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PC12 Child Health CheckPart 2 - Physical Assessment workbook

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PC122 Physical Assessment - Child Health Check

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PaRROT Program - Child Health Check: Part 2 | A primary health care approach


Contents

PC122 Child Health Check - Part 2: Physical Assessment 5

PC122 Pre-Session Survey 7

PC1221-1 Introduction to Skin 8

PC1221-1 Learning Activity 16

PC1221-2 Rashes 17


PC1221-3 Infections 22


PC1221 Quiz 27

PC1222-1 Introducing Ears and Hearing 29


PC1222-2 Otoscopy 41


PC1222-3 Tympanometry 49


PC1222-4 Audiometry 53


PC1222 Quiz 57

PC1223-1 Introducing Eyes and Vision 60


PC1223-2 Eye Checks 67


PC1223-3 Abnormal Findings 74


PC1223-3 Quiz 82

PC1224-1 Oral Health Introduction 84


PC1224-2 Screening 88


PC1224-3 Prevention 101


PC1224-3 Quiz 105

PC122 Theory to Practice Activity 107

PC1221-1 Learning Activity Feedback 117



PC1221 Quiz Feedback 120






PC1222 Quiz Feedback 126




PC1223-3 Quiz Feedback 131




PC1224-3 Quiz Feedback 135

PC122 Theory to Practice Activity Feedback 143

PC122 Post-Session Survey 146

PC122 References 147

5PaRROT Program - Child Health Check: Part 2 | A primary health care approach

PC122 Child Health Check - Part 2: Physical Assessment

Introduction

A comprehensive child health check includes conducting routine physical assessment which will assist in the identification of risk factors for poor health outcomes.

A physical check includes inspecting the skin for rashes and infections, viewing the physical components of the ears and eyes and evaluating vision and hearing and examining and assessing oral health.

This course considers the various elements of a physical check, identifies potential issues with the skin, ears, eyes and oral environment and discusses interventions that may be taken to prevent further issues.

Learning Objectives

On completion of this course participants will be able to:

• Discuss the structure, physiology and function of the skin, ears, eyes and mouth• Describe the differences between normal healthy and unhealthy skin, ears, eyes and mouth• Provide simple prevention and treatment interventions for problems of the skin, ears, eyes and mouth• Clearly and accurately document findings on screening of the skin, ears, eyes and mouth

Topics

• The first topic introduces and explores the basic anatomy and physiology of skin, its function and somecommon skin problems we may see as part of the child health check. It reviews rashes including allergies,eczema and those associated with infectious diseases and discusses skin infections including fungal,impetigo and infected scabies.

• Topic two introduces the child health ears and hearing check and provides some information on the ear andthe reasons for checking ears and hearing routinely. It provides information on otoscopy, tympanometry andaudiometry, discusses normal and abnormal findings and provides information on intervention and followup should it be needed.

• Topic three introduces the eye, reviews the structures within the eye and discusses how the eye works. Itprovides information on screening the eyes and explains the different tests that are included in the eyecheck. The topic identifies and explains potential normal and abnormal findings and discusses sometreatment and management options.

• The final topic introduces and discusses factors that contribute to the healthy and unhealthy oralenvironment. It reviews the screening process for infants and children from 0 to 14 and strategies forensuring a healthy oral environment.

Pre and Post Session Surveys

Before you commence, we ask you to complete a quick survey to identify current knowledge base. This will provide a baseline you can refer to once you have completed this topic.

When you have completed this session, we ask you to complete another quick survey to determine if we have met your learning needs.

6 PaRROT Program - Child Health Check: Part 2 | A primary health care approach

Learning activities / Quiz

An ungraded, interactive learning activity and graded quiz is included in each module and an ungraded theory to practice activity for the course is included and must be completed in order to receive your certificate.

Certificate

Once the quiz is completed you are eligible to receive a personalised certificate which provides evidence of your training. Included on this is the average time the course takes which can be used for professional development points.

If this course is completed using the workbook it will need to be forwarded to the PaRROT team who will issue the certificate.


PC122 Pre-Session Survey

Before you commence this session we ask you to take a few moments to complete the pre-session survey for this topic. This will give us some indication what your learning needs might be.

At the end of this session we will also ask you to complete another survey to see how well we have met your needs.

Please indicate the degree to which you agree to the following, by ticking the box most relevant.

I am able to discuss the structure, physiology and function of the skin, ears, eyes and mouth

I can describe the differences between normal healthy and unhealthy skin, ears, eyes and mouth

I am able to provide simple prevention and treatment interventions for problems of the skin, ears, eyes and mouthI can clearly and accurately document findings on screening of the skin, ears, eyes and mouth

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PC1221-1 Introduction to Skin

Learning Objectives

On completion of this module learners will be able to:

• Describe the structure of the skin• Discuss the physiology of the skin • Describe the function of the skin• Define normal healthy and unhealthy skin

Skin

Skin is our largest organ – this diagram shows a cross section of skin. Within the structure there are various components which all work together to ensure the skin functions as it should. The outer layer is waterproof, and if intact protects the body from microscopic organisms and foreign bodies.

When the skin surface is broken, these microorganisms can enter the body and create infections within the skin, bloodstream and other structures.

The skin has three layers - the epidermis, dermis, and fat layer (also called the subcutaneous layer).

Each layer performs specific tasks.


Cross section of Skin

Structure Purpose

Hair Shaft • Temperature regulation, protection, sensation

Pores • Waterproof and when undamaged prevents bacteria, viruses and foreign bodies from entering the body

• Drains oils and other impuritiesSkin surface / Sweat Pore • Drains sweat

Capillaries • Blood Flow

Pilo Erectile Muscle • Moves hair follicle if cold or frightened

Sweat Gland • Cools body

Venule / Arteriole • Blood Flow

Adipose Tissue (fat) • Cushioning and insulation

Nerve Ending • Sensitive to pain, temperature and itch

Matrix • Tissue regeneration and healing

Connective Tissue • Binds the structures together

Sebaceous Gland • Produce oil to moisturise

Epidermis • Pigmentation (colour) protection and immune response

Dermis or True Skin • Skin elasticity and body temperature regulation

Subcutaneous Tissue • Cushioning and insulation


Skin Epidermis

The epidermis is the thin, tough, outer layer of the skin.

The outermost portion of the epidermis is relatively waterproof and, when undamaged, prevents most bacteria, viruses, and other foreign substances from entering the body.

The epidermis (along with other layers of the skin) also protects the internal organs, muscles, nerves, and blood vessels against trauma.

Scattered throughout the basal layer of the epidermis are cells called melanocytes, which produce the pigment melanin, one of the main contributors to skin colour.

Melanin’s primary function, however, is to filter out ultraviolet radiation from sunlight which can damage DNA, resulting in numerous harmful effects, including skin cancer.

The epidermis also contains Langerhans’ cells, which are part of the skin’s immune system.

Although these cells help detect foreign substances and defend the body against infection, they also play a role in the development of skin allergies.

Skin - Dermis

The dermis, the skin’s next layer, is a thick layer of fibrous and elastic tissue that gives the skin its flexibility and strength. The dermis contains nerve endings, sweat glands and oil glands, hair follicles, and blood vessels.

The nerve endings sense pain, touch, pressure, and temperature. Some areas of the skin contain more nerve endings than others. For example, the fingertips and toes contain many nerves and are extremely sensitive to touch.

The sweat glands produce sweat in response to heat and stress. Sweat is composed of water, salt, and other chemicals. As sweat evaporates off the skin, it helps cool the body.

The sebaceous (oil) glands secrete sebum into hair follicles. Sebum is an oil, that keeps the skin moist and soft and acts as a barrier against foreign substances.

Hair follicles provide a layer of protection and help in regulation of body temperature and facilitation of evaporation of perspiration.

Blood vessels – carry blood to the extremities.


Skin – Subcutaneous

Below the dermis lies a layer of fat that helps insulate the body from heat and cold, provides protective padding, and serves as an energy storage area.

The fat is contained in living cells, called fat cells, held together by fibrous tissue.

The fat layer varies in thickness, from a fraction of an inch on the eyelids to several inches on the abdomen and buttocks in some people.

Skin

• These layers all come together to form the skin, which weighs about 11 kg and is the largest human organ.

• It protects the body from harm by preventing germs and chemicals entering the body and causing problems with the internal systems.

• Skin regulates body temperature by sweating to cool the body down and shivering to warm it up. • It assists with fluid balance and provides a means to feel the environment through the sense of touch and

feeling.

Normal healthy skin is smooth, clean, slightly oily and free from sores or wounds. Rashes, infections and lesions are all signs of skin problems.

An inflammatory response (inflammation) occurs when tissues are injured by bacteria, trauma, toxins, heat, or any other cause.

The damaged cells release chemicals which cause blood vessels to leak fluid into the tissues, resulting in swelling and redness.

If the skin is infected there is pain, swelling, redness, fever, throbbing and discharge which may be malodorous and purulent.


Problems of the Skin

An important component of the child health check is to observe, report and manage problems of the skin.

Skin infections need to be treated as soon as possible to prevent further ongoing health problems from the microorganism entering into the bloodstream and causing more infection in the internal body structures.

With skin infections, one of the greatest risk is glomerulonephritis which will be discussed later in this session.

Other issues include:

• Excess oil production• Histamine responses• Injury• Viral infections• Birth marks• Metabolic issues

The following pages provide information on potential findings of a skin check.

Cradle CapCradle cap is common in small babies and is the result of excessive oil production that dries causing a scaly, crusty mass.

It is treated using oil or moisturiser. Regular gentle massaging of the baby’s head is a good way to prevent the development of cradle cap, as it disperses the oil.


Nappy Rash

Nappy rash is found in the perineum region.

It is an inflammatory response to acid burns from urine (and sometimes faeces).

Nappy rash is red, raw and swollen and can be very painful and itchy.

Nappy rash can be prevented by more regular nappy changes, leaving the nappy off and using treatments such a pawpaw ointment or lanolin.

If left untreated, it can become infected or develop into a fungal rash which is very painful and itchy and will need prescription medication for treatment.

Sunburn

Sunburn is caused by overexposure to ultraviolet (UV) radiation from the sun.

This burns the skin, causing an inflammatory response that includes redness, swelling, pain and in severe cases, blistering. Injury can start within 30 minutes of exposure.

Sunburn is a common problem for young children that can be easily prevented by using UV protective shirts, sunscreens and hats when the baby or child is in the sun.

The best treatment is cool water and moisturisers and it will heal fully within 1 to 2 weeks


Bruises

Bruises are common in young children and generally appear when they first start moving.

Bruises are caused when tiny blood vessels are damaged or bro-ken as the result of a blow to the skin from falling or knocking into things, and usually appear over hard surfaces like shins, knees or foreheads.

The raised area of a bump or bruise results from blood leaking from these injured blood vessels into the tissues or into the top layers of skin and as part of the body’s response to the injury.

Bruises can be black, blue, yellow or green, depending on the age of the injury. Bruises will often disappear after a couple of weeks.

When observing bruises be mindful of where they are and the story behind how they occurred as they can be the result of child abuse.

Birthmarks

Birthmarks are quite common in babies and children.

They include: • Mongolian Blue Spot which looks like a large bruise

usually over the back and buttocks of darker skinned children

• Strawberry mark which is a small raised and rough red mark

• Port wine stain which is a flatter, larger red mark often on the face and upper body

• Café au lait spot or stork marks which are a small brown spot on the forehead or neck

• Most birth marks will fade or disappear over time.


Jaundice

Jaundice develops when the liver is unable to rid the body of bilirubin which is a brownish yellow substance found in bile.

When bilirubin levels are high, the skin and whites of the eyes may appear yellow (jaundice).

Jaundice may be caused by liver disease, blood disorders, or blockage of the bile ducts that allow bile to pass from the liver to the small intestine.

Too much bilirubin (hyperbilirubinaemia) in a newborn occurs when the baby’s immature liver has not started to function fully.

It can cause brain damage, hearing loss, problems with the eye muscles, physical abnormalities, and even death.

Some babies who develop jaundice may need be treated with special lights (phototherapy) which breaks down the bilirubin, or a blood transfusion to lower their bilirubin levels.

If it hasn’t cleared after 2 weeks, the baby should be reviewed by a medical officer.


PC1221-1 Learning Activity

1. Which of the following statements about normal healthy skin are true?

Tick Answer

Dry

Smooth

Scaly

Lesion free

Slightly oily

2. Arrange the layers of skin in order from inner to outer

1. Epidermis 2. Subcutaneous 3. Dermis

Answer


PC1221-2 Rashes

Learning Objectives


• Describe the various types of rashes that may be found on screening• Identify rashes associated with infectious diseases• Discuss simple prevention and treatment of rashes

Rashes - Allergies

The most common rash on children is an allergy, which is the result of an overactive immune response generated in the Langerhans’ cells in the epidermis.

These rashes are often large raised welts, wheals or hives.

They are itchy, red and swollen and are caused by contacting an allergen, an insect bite or a food allergy.

They are usually of short duration, but can be severe and may need treatment.

Rashes - Eczema

Atopic dermatitis, or eczema, is a skin condition that usually appears in early childhood and affects people with a genetic susceptibility.

Damage to the skin barrier allows moisture to escape and allergens and infection to enter, causing an inflammatory response including redness and itchiness.

Once the skin barrier is disrupted, moisture leaves the skin and it becomes dry and scaly.

Treatment for eczema includes:

• Moisturisers • Anti-inflammatory ointments – either topical corticosteroids or non-steroidal anti-inflammatory ointment • Coal tar – to reduce the itch • Dietary changes• Ultraviolet radiation therapy (phototherapy)


Slapped cheek / fifths disease

Slapped cheek or fifths disease is a harmless viral infection. The rash starts on the cheeks, but quickly appears on the body and arms and legs.

A child usually presents with a defined red rash on the cheeks, abdomen or limbs, which forms after the infectious period of the virus.

Children with this rash do not need to be isolated as the infectious period passes before the rash appears.

The rash is bright red and slightly raised. It gives the characteristic look of slapped cheeks on the face, followed by a lacy appearance which gives a blotchy look to the rash.

The rash is not usually itchy.

Hand, foot and mouth disease

Hand, foot and mouth disease is a mild viral infection that begins with a slight fever, tiredness, no appetite, and sorethroat.

It develops into flat or raised red spots, which may form blisters. It affects the palms of the hands and soles of the feet.

Small red mouth sores form painful blisters, and may turn into ulcers which need to be treated.

The virus is highly contagious and is spread by coughing and sneezing and close contact that gets better in a few days without treatment.


Molluscum

Molluscum is commonly found on young children.

It is a round lesion with a dimple in the middle and is filled with watery white fluid.

It can last for months and although harmless, it is highly infectious, with gross infection related to bathing.

Treatment varies but may include removal of heads, agitation of lesion etc.

Chicken Pox

Chicken pox is a viral infection that is spread through coughing, sneezing, and direct contact.

It is not a mild infection as it can cause meningitis and death – it is recommended that children are immunised against the disease when they are babies.

The rash starts with small, flat red spots which become raised and form multiple small watery filled blisters (vesicles) form over the entire body after exposure to virus.

Chicken pox is contagious for 1-2 days before the rash begins up until blisters have become scabs.

Chickenpox rash evolves through 3 stages, and a person may have examples of each type of spot at any one time. New crops of spots appear over a period of 2 to 4 days.

The rash starts with small, flat red spots. These flat red spots then become raised and very itchy and form round, fluid-filled blisters (called vesicles) against a red background.

The vesicles crust over forming dry crusty lesions that are intensely itchy.

The rash starts on the trunk (body) and then later appears on the face, arms and legs. It is unusual for the rash to affect the palms and soles.

Chickenpox spots (lesions) can sometimes be found on the eyelids and inside the mouth and the vagina.


Measles

Measles is a dangerous viral disease that is spread through coughing and sneezing.

Severe cases of measles can cause brain inflammation and pneumonia which can result in brain damage and death.

The measles virus can remain latent following infection and represent as Subacfe Sclerosing Pan Encephalitis (SSPE) in adolescence which causes rapid neurological deterioration and eventually death.

It causes a high fever, cough and rash and is diagnosed usually through the Koplik (white scaly) spots found in the throat, a spreading rash and bilateral conjunctivitis.

The measles rash starts around the ears and hairline after the Koplik’s spots disappear.

After 1-2 days the rash may spread to the trunk, arms and legs and start to fade on the face.

The ‘spots’ are separate flat red areas to start with, they become raised and join together as rash spreads.

Measles rash may be slightly itchy. Measles can be prevented through child hood immunisation.

Rubella

Rubella, which is commonly known as German measles, is caused by the rubella virus.

It is caught in the same way as measles.

An infected person coughs or sneezes and so spreads droplets containing the virus, which other people breathe in and, if they are not immune, become infected with rubella.

The incubation period for Rubella is 12 to 23 days — that is the time lag between being exposed to the virus and developing a rash.

The rash is pink and flat. The spots are very small, giving the rash a fine appearance. It is similar to the measles rash but less extensive and fades more quickly. The rash starts around the hairline and affects the face and neck first. It will then spread to the body and the arms and legs.



1. Which of the following are signs of an allergic rash? (More than one possible answer)

Risk Answer

Welts

Crusty lesions

Lesions in the mouth

Lesions with fluid filled centre

Itchy lesions

2. Which of the following can be used to manage eczema? (More than one possible answer)

Risk Answer

Moisturisers

Antibiotics

Ultraviolet radiation

Antifungal creams

Dietary changes


PC1221-3 Infections

Learning Objective


• Describe some of the common skin infections found on screening• Discuss the importance of treating skin infections• Define impetigo• Discuss potential outcomes of untreated skin infections

Fungal Infections

Skin infections are common, but not normal in the tropics.

Fungal infections such as tinea, ring worm and ‘double skin’ can be found on most skin surfaces.

They are dry, scaly and itchy and are usually defined to a specific area.

The infections develop in hot moist environments.

Treatment options include creams such as Miconazole or Clotromazole, ointments, lotions including Selenium Sulphide (Selsun Gold) or tablets which are prescribed by Medical Officers if all else fails .

If fungal conditions are not treated they will spread and can become infected.

Scabies

Scabies is a parasitic infection that thrives in warm temperatures, where there is poor water supply,overcrowding and issues with accessing good hygiene.

They usually present as pus filled itchy blisters and sores and are found in skin folds.

Scabies is caused by a mite that burrows into the skin.An allergic reaction to the presence of the mite is responsible for the signs and symptoms.

It is usually spread by skin to skin contact, although clothing and bedding can be a source of infestation.

The mite can live away from the skin for 1-2 days or, if near a host (e.g. in bed linen) for up to 4 days.


Scabies - continued

Multiple family members / householders tend to be affected and need to be treated if someone in the home has a scabies infection.

Scabies is treated with scabies cream and requires the washing of clothes and linen with hot soapy water and drying them in the sun.

All contacts of a person, especially family sharing the house will need to be treated or it will continue to spread.

If left untreated, scabies can develop into bacterial skin infections which may also infect the heart and kidneys.

Dog scabies is a different species to human scabies, and it is very unlikely that dogs play any significant role in maintaining scabies transmission in humans.

Impetigo

One of the most common infections of the skin is Impetigo also

known as school sores. They are yellow crusty lesions commonly found around the mouth and on the limbs.

Impetigo is a highly infectious bacterial skin infection that occurs in children 2 years and over. They are spread by close contact.

Impetigo needs to be treated with soap and water and antibiotics if they become infected.

Impetigo may also be found with other skin conditions such as Infected scabies; eczema; infected fungal infections; insect bites and minor abrasions.

Impetigo begin as a tiny blister (vesicle ) which is sometimes surrounded by a red, hot area that becomes filled with pus. The blisters pop easily and when they dry they form a golden crust.

Each blister is no bigger than 1-2cm but sometimes they join to form larger blisters.

It is not uncommon for infected sores to form after the blister has burst.

These sores become red, hot and painful and if left unattended can cause infections that spread to the internal structures.


Streptococcus Aureus

The bacteria that causes impetigo is called Streptococcus.

Streptococci are a normal part of the environment of the mouth, skin, intestine, and upper respiratory tract of healthy people.

When a person’s health is compromised, streptococci multiply and invade body structures that do not usually contain streptococci.

Most common and most dangerous is Streptococcus Aureus or Strep A.

Strep A can cause severe infections and has high incidence in Aboriginal and Torres Strait Islander communities of Australia.

Streptococcus is known to cause infections of the brain, heart, lungs, upper respiratory tract, joints, throat, skin and kidneys.

Streptococcal infections are a major concern in some communities, and need to be treated immediately with antibiotics.

Untreated streptococci infections cause major health problems in some communities in Australia.

Acute Post Streptococcal Glomerulonephritis (APSGN) is one of themajor causes of ill health in children which leads to severe chronic disease in adults.

APSGN

Acute Post Streptococcus Glomerulonephritis (APSGN) is a common side affect of untreated skin infections. When broken down into its components it means a severe infection of the kidney which occurs following a streptococcus infection.

Acute Severe

Post After

Streptococcus Streptococcus bacteria

Glomerular Structure within the kidney

Nephritis Kidney infection

APSGN is the result of recurrent untreated streptococcal skin or throat infections.


APSGN – Infection Progress

The bacteria travels with blood to kidney for filtering and the Glomeruli become infected and stop working properly.

If left untreated, kidney function may become compromised and chronic kidney disease may occur.

Chronic disease causes kidneys to fail which may lead to dialysis for filtering.

Untreated Infection

Streptococcus bacteria travels in the blood

Blood reaches kidney for cleaning

Kidneys function becomes compromised

Kidney Disease Infected glomeruli stop working

Prevention

An effective way of preventing APSGN is the check the skin folds, mouth and throat carefully when doing a child health check.

If a skin problem is identified it needs to be treated appropriately and not just recorded as being checked.

The adoption of consistent screening helps identify skin problems and by taking action when problems are identified our children will have a better chance of a healthy future.

Skin Describe skin: Healthy Intact Jaundice Sores Rash

Bites Scars Bruises Itchy

Prevention is also possible if health professionals encourage personal hygiene.

Clothes and bed sheets (for whole family) should be washed in the hottest water possible and dried in sunlight.

Finger nails need to be kept cut and clean and everyone taught good hand washing techniques.

If a child has impetigo they need to avoid contact with other children until pustules cease and dry up.

The use of penicillin to treat the infection should be included in the care of the child.



1. Which of the following skin conditions need to be treated as soon as possible?

Tick Answer

Scabies

Fungal infections

Insect bites

Sores

Impetigo


PC1221 Quiz

1. Match the type of rash with its most likely cause (5 marks)

1. Allergy 2. Hand, Foot and Mouth Disease 3. Chicken Pox 4. Eczema 5. Fifth’s Disease

Rash Cause

Hives

Dry scaly skin

Lacy rash

Lesions around mouth

Fluid filled blisters

2. Which of the following statements are incorrect? (1 marks)

Tick Answer

The family of a person with scabies needs to be treated

Streptococcus is usually a harmless natural occurring bacteria

Scabies can be found in conjunction with impetigo

Fungal infections will clear up on their own

Impetigo is a bacterial infection


3. APSGN could be the consequence of which of the following conditions (5 marks)

Tick Answer

Scabies

Impetigo

Eczema

Insect bites

Minor abrasions

4. Strep A is the most common and dangerous of the streptococcal infections (1 mark)

Tick Answer

True

False

5. Fungal infections are normal in the tropics so do not need to be treated (1 mark)

Tick Answer

True

False


PC1222-1 Introducing Ears and Hearing

On completion of this module learners will:

• Describe the function of the ear• List 5 causes of ear problems• Discuss the importance of checking ears and hearing• Accurately document child health ear and hearing checks

The Ear

The ear is a complex organ made up of many complementary parts. It is used for both hearing and balance. The pinna is made up of cartilage which is the outer section of the ear which catches and funnels sound (which is in fact a vibration).

The sound travels into the auditory canal and hits the tympanic membrane (ear drum), which vibrates onto the three ear bones known as the incus (anvil), malleous (hammer) and stapes (stirrup) or ossicular chain.

This vibration causes fluid to move in the cochlea which sends a message to the auditory nerve to interpret the sound.

The semi-circular canals hold fluid which helps with balance and knowing where the body is in relation to gravity – the vestibular nerve carries the balance message to the brain.

The eustachian tube allows for ventilation and drainage of the middle ear. The eustachian tube is connected from the middle cavity to the back of the nose.


If the eustachian tube is free of fluid, the tympanic and ear bones are able to vibrate and hearing and balance function correctly. If it is full of fluid, hearing and balance are impaired.

It is important to check ears and hearing from birth.

Hearing loss is a common but preventable problem for children so abnormal results need to be documented and the child referred for specialist assessment. Brief intervention education on ear health is an essential com-ponent of the all hearing checks.

Rationale for assessment

Regular assessment is recommended because:

• Ear disease is a common illness in all populations • The Aboriginal and Torres Strait Islander population have the highest rates of severe and persistent ear

disease as described in medical literature, generally in rural and remote Indigenous communities.

The high rate of ear disease affects a child’s communication, speech and language development and play and learning.

If hearing loss is left undetected and untreated, it can impact heavily on social and emotional wellbeing, education, unemployment outcomes.

Causes of Ear Problems

Causes of ear and hearing problems are many. Some of these are:

• Frequent upper respiratory tract infections causing recurrent ear infections• Foreign objects in the ear canal including wax• Swimming in dirty water• Loud noises• Prop bottle feeding to sleep


Ear Assessment

Otoscopy from 2 months

Audiometry from 5 years

Tympanometry from 6 months

Ear checks are included for all ages of children.

Otoscopy (Visual checks ) are conducted on all children from birth.

Tympanometry (describes normal and abnormal middle function) from 6 months and at specific ages.

Audiometry (hearing tests) are conducted from 5 years.

At ages where there are no specific checks, parents or children should be asked questions about ears and hearing.

Any concerns should be followed up and a full check conducted.

Referral

A child is referred for further review if:

• They report pain or discomfort• There is visible discharge• The tympanic membrane is perforated or bulging• The ear canal is blocked by wax or foreign body• They complain of sudden hearing loss with tinnitus and/or dizziness (urgent)• They fail the audiometry test • There are any abnormal tympanometry results


Questions birth to 4 months

Questions Procedure

1 - 6 weeks

Is your baby startled by loud noises such as a loud clap?Has your baby been free of ear infections or discharge?

2 months

Do you think your baby can hear you?Has your baby been free of ear infections or discharge?

Otoscopy

4 months

Are you happy about your baby’s hearing?Does your baby turn towards sound or voices?Does your baby settle with familiar sounds or voices?Has your baby been free of ear infections or dischage?

Otoscopy

All ear and hearing checks should be proceeded with questions appropriate to the child’s age.

At 1 to 6 weeks questions include a baby’s response to loud noises. At 2 months parents and carers are asked if they think their baby can hear them.

At 4 months questions are around the parent or carers perception of their baby’s ability to hear and if the baby is responding to sounds and voices.

A history of ear infections is asked at all ages.


1 to 6 weeks

Startled by loud noises such as a clap?

Eye appearance

*Red eye reflex

Yes No

Normal Abnormal

Present Not present

Hearing and visionPrint name: Signature: Date:

At 1 to 6 weeks very basic checking begins.

Parents are asked if their baby jumps or wakes at a loud noise.

If answer is no, baby is referred.

2 months

• Ask the questions• Perform the otoscopy

Do you think your baby can hear you?

Otoscopy

Yes No

Normal Refer

Present Refer

Ears and hearingPrint name: Signature: Date:

Left ear:

Right ear:

Comments:

At 2 months all parents and family will know if their baby jumps or wakes at a loud noise and will have an idea if the baby can hear.

Parents are asked if they have any concerns. Otoscopy (viewing ears ) commences at 2 months of age.

The baby is referred if there are any concerns.


4 months

• Ask the questions• Perform the otoscopy

Are you concerned about your child’s hearing?

Does the baby settle with familiar sounds or voices?

Does the child look towards sound?

Otoscopy

Yes No

Healthy Refer

Healthy Refer


Left ear:

Right ear:

Comments:

Yes No

Yes No

6 and 12 months

Questions Procedure

6 months

Are you happy about your baby’s hearing?Does your baby turn towards sound or voices?Has your baby been free of ear infections or discharge?

Otoscopy andtympanometry

12 months, 18 months and 2 years

Has your child been free of ear infections or discharge in the last 6 months?Are you happy about your child’s ears and hearing?Are you happy with your child’s speech and language development?


At 6 months questions are asked about a child’s hearing and their response to sound or voices.

From 12 months to 2 years, parents are asked about their child’s speech and language development.

Questions continue to be asked about ear infections.


6 months

• Ask the questions• Perform otoscopy and tympanometry

Has your child had any ear infections or ear discharge in the last 6 months?

Are you concerned about your child’s ears or hearing?

Otoscopy

Tympanometry

Yes No

Healthy Refer

Healthy Refer


Left ear:

Right ear:

Comments:

Yes No

Healthy (Type A) Refer (Type B or C)


Left ear:

Right ear:

At 6 months otoscopy and tympanometry are performed.

If a child has normal otoscopy in both ears they are reviewed at their next regular check.

From 6 months tympanometry, which measures ear canal size, if the ear drum moves, and if the middle ear is working is included in hearing checks.

If the result is abnormal in one or both ears they are referred to a Medical Officer.


12 months to 4 years

Questions Procedure

12 months, 18 months and 2 years



3 and 4 years


Otoscopy andtympanometry plus audiometry for 4 year olds

From 12 months to 4 years parents and carers are asked if they are happy about their child’s ears and hearing and it their speech and language development appears to be normal.

Questions continue to be asked about ear infections in the last 6 or 12 months – depending on how frequently the child is being reviewed.


12 months to 4 years

• Ask the questions• Perform the otoscopy, tympanometry



Otoscopy

Tympanometry

Yes No

Healthy Refer

Healthy Refer


Left ear:

Right ear:

Comments:

Yes No



Left ear:

Right ear:

Between 12 months and 4 years otoscopy and tympanometry are performed.

If the otoscopy and tympanometry are normal the child should be reviewed at their next age appropriate check.

If the results are abnormal, the child is reviewed again in 3 months and if results remain the same they are referred to a Medical Officer.

If there are some doubts the child is referred to the Medical Officer.


Age appropriate questions

Questions Procedure

5 and 12 years

Otoscopy, tympanometry and audiometry

6, 7, 8, 9,10, 11, 13 and 14 year olds

Family history of genetic hearing loss?History of frequent ear, nose and throat infections?Speaks in loud or monotone voice?Does not respond to name?Watches others continuously?Asks for statements to be repeated?Withdraws from group?Has learning problems in class?Has disruptive and impulsive behaviour?Teacher reports hearing difficulty?Parent / carer reports hearing difficulty?

If yes to any questions or Aboriginal or Torres Strait Islander descent then perform otoscopy, tympanometry and audiometry

From 5 years onwards, children have audiometry testing as well as otoscopy and tympanometry.

If there are no evident issues with the child’s ears or hearing, the checks only need to be done at 5 and 12 years of age.

However, if parents, carers and teachers report hearing difficulties, tests should be conducted at that time.

Although official testing may not need to be conducted, whenever a child presents for a health check a number of questions are asked.

These include:

• Family history of hearing loss and a history of ear, nose and throat infections in the child.• If the child speaks in a loud or monotone voice, if they respond to their name or asks for statements to be

repeated.• Questions about behaviour including watching others closely, withdrawing in a group, having learning

problems and displaying disruptive and impulsive behaviour are also asked.


5 and 12 years

• Ask the question • Perform otoscopy, tympanometry and audiometry

Is the child aged 5 or 12 years?

Possible ear or hearing problem?

Otoscopy

Tympanometry

Audiometry

Yes (perform full ears & hearing screen) No (continue to next question)

Healthy Refer

Healthy Refer

Ears and hearing - Refer to ‘Ears and Hearing Criteria for Referral’ list

Print name: Signature: Date:

Left

Right

Yes (perform full ears & hearing screen) No (continue to next question)



Left

Right

Left

Right

4000Hz/25dB Refer

4000Hz/25dB Refer

Pass

Pass

1000Hz/25dB Refer

1000Hz/25dB Refer

Pass

Pass

At 5 and 12, and otoscopy, tympanometry and audiometry are routinely tested.

If there are some concerns about a child’s hearing or if the child is Aboriginal or Torres Strait Islander the tests are conducted annually, regardless of the child’s age.

If results are normal the child is reviewed at their next routine child health check.

If results are abnormal, the child is reviewed in 3 months and if results remain the same they are referred to a Medical Officer.

If there are some doubts about the health of the child’s ears or hearing, they are referred to a Medical Officer.



1. Match the procedure with what it is checking for

1. Otoscopy 2. Tympanometry 3. Audiometry

Procedure Checking for

Measure canal volume

Visualise ear canal and tympanic

Test hearing


PC1222-2 Otoscopy


• Define otoscopy• Discuss the rationale for otoscopy• Identify a normal ear canal and ear drum using Otoscopy• Recognise an abnormal ear canal and ear drum and refer for treatment• List 8 abnormalities of the ear drum and ear canal

Definition

Otoscopy is a visual examination that involves looking into the ear with an otoscope (or auriscope).

This is performed in order to examine the external auditory canal and inspection of the eardrum which provides information about what’s happening within the middle ear and other anatomical structures associated with ears, nose and throat.

Otoscopy Procedure

The Chronic Disease Guidelines outlines the procedure to perform and otoscopy. It is important to check that the battery is charged and the light works.

The correct sized ear piece for the child is chosen. Pull the child’s ear up and backwards and slowly insert the otoscope.

Always brace the hand against the child’s head to prevent the otoscope tip perforating the ear drum if any sudden movement.

The clinician must brace the otoscope before otoscopy is commenced. The two styles of holding the otoscope are pencil grip and pistol grip.

Note the colour of the canal and tympanic membrane, observe for foreign bodies, fungus, infection and discharge.

Look for bulges and holes in the tympanic membrane and debris in the canal.

Record findings.

Otoscopy is performed on all children to 5 years of age and at 12 years unless there is pain or notable discharge.

If there are problems the child should be referred to the Medical Officer or Nurse Practitioner.

The Primary Clinical Care Manual (PCCM) – Ear problems provides more information.


Referral process for Otoscopy

YES Refer to MO, NP or PCCM - Ear Problems

Review in 3 months

Otoscopy result abnormalStructural defect of ear

was occlusion of ear canalforeign body

blood or dischargeinflammation or perforationfluid or pus behind ear drum

bulging eardrum

NO Proceed to Otoscopy

Otoscopy result normal Eardrum intact and free of bulgingear canal clean and free of debris

PASS

Proceed with tympanometry and audiometry

Does the child have ear pain or discharge?

Diagram 1: Referral and review process for otoscopy

Performing Otoscopy

All health professionals should perform otoscopy on children presenting to clinics.

Otoscopy is part of a comprehensive physical assessment.

The more ears are looked at, the more health professionals will see a normal ear, making it easier to identify abnormal findings.

The rest of this module provides images that may be seen when performing otoscopy.


Normal Tympanic Membrane

These are normal, healthy tympanic membrane. Look for the land marks – cone of light and handle of the malleus.

Retracted Tympanic Membrane

Retracted tympanic membrane usually associated with a problem of pressure and drainage of the Eustachian tube.


Foreign Body

These pictures clearly show a foreign body in the canal.

Otitis Media

These two pictures indicate otitis media also known as glue ear which is an infection of the inner ear.


Perforated Tympanic Membrane

These membranes are perforated, either from trauma or multiple infections of the middle ear.


Otitis Externa

These two illustrations are of an infection in the canal also known as Otitis Externa which is the result of excessive moisture in the canal.

Further examples of otitis externa.


Bulging Tympanic

These are examples of a bulging tympanic membrane caused by a build up of fluid and pressure behind the ear drum.

Grommets

These are grommets which are inserted to assist in the drainage of pus to allow drum movement which is

essential for hearing.



1. Match the type of problem you may see with the part of the ear anatomy it affects.

1. Ear canal 2. Ear Drum 3. Pinna 4. Middle Ear 5. Eustachian Tube

Problem Anatomy

Fungal infection

Perforation

Red, itchy and dry skin

Bulge in the ear drum

Retracted eardrum


PC1222-3 Tympanometry


• Define tympanometry• Discuss the rationale for tympanometry• Read and interpret tympanometry graphs• Recognise abnormal results and refer for treatment• Clearly document results

Definition

• Tympanometry is not a hearing test but it is used in addition with the results of otoscopy and audiometry to assess the ear function.

• Tympanometry measures any obstruction of sound through the middle ear. • Tympanometer calculates

» The size of the ear canal. » Movement of the ear drum. » If the eustachian tube is open

Tympanometry measurements

Tympanometry measures:

• Ear canal volume (ECV) (normal between 0.2 and 2.0cm)• Middle ear pressure (normal between -150 and +100 daPa) and• Middle ear compliance or movement (normal between 0.2 and 1.4 cm)

Conducting Tympanometry

Tympanometry is performed on children from 6 months of age. It should not be performed if child has had recent surgery, pain, a perforation or if there is discharge from ears.

If there is ear discharge the child needs to be referred to the Medical Officer or Nurse Practitioner.

The Primary Clinical Care Manual (PCCM) provides information under the heading Chronic suppurative otitis media.


Conducting Tympanomety

Before commencing a tympanometry, it is important to check to see if the battery is charged and the correct sized ear piece is available.

Before proceeding it is important to view the canal and ensure there is no discharge in the child’s ear.

To proceed, pull the child’s ear up and backwards, insert the Tympanometer ensuring there is a good seal.

Press the button corresponding to the ear that is being checked.

Record results and refer if needed.

There are a number of potential results from tympanometry.

These are identified as curves with peaks. The most common curves are:

• Type A – normal peak• Type B – flat line• Type C – left peak

The following pages demonstrates these peaks

Type A


Type B

This type B flat line shows a low ear canal and no middle ear movement or pressure.

Otitis Media is the most common cause for this result, however, other causes may include:

Otosclerosis (stiff middle earbones due to bony growths); Badly scarred eardrum; Eardrum perforation (hole); Grommet; Ear canal blockage; Wax

Type C

This is a type C peak. It shows normal ear canal volume and middle ear movement. However it also shows a negative middle ear pressure which may be the result of a eustachian tube not draining properly.

An upper respiratory tract infection causing excessive fluid production in the sinuses.

Fluid not moving into the middle ear.



1. Match the image to its definition

Type A Type B Type C

Type - A, B or C Definition

• Normal ear canal volume• Normal middle ear movement• Negative middle ear pressure

• No middle ear movement• No middle ear pressure

• Normal ear canal volume• Normal middle ear movement • Normal middle ear pressure


PC1222-4 Audiometry

Learning Objectives


• Define audiometry• Discuss the rationale for conducting audiometry• Explain the findings on Audiometry• Discuss abnormal results and refer for treatment• Clearly document hearing assessment results

Definitions

• Audiometry tests a child’s ability to hear sound.• Sounds vary based on loudness (intensity) and speed of sound wave vibrations (tone).• Hearing occurs when sound waves stimulates the nerve of the inner ear and travels along nerve pathways

to the brain.• Sound intensity is measured in decibels – a whisper is 20 decibels, loud music is 80 to 120 decibels and

a jet engine is 140-180 decibels.• Tone is measured in cycles per second (cps) or hertz. Low based tones are around 50 to 60 hertz and

shrill, high pitched tones range around 10,000 hertz or higher.• Normal range of human hearing is from 20 to 20,000 hertz. Human speech is between 500 and 3,00

hertz.

Audiometry Test

• Audiometry checking follows a set sequence• The right then the left ear is tested at set and

decreasing levels of intensity (dB) and tone (Hz)• Results at each level are recorded as a pass or

fail before moving to the next level• An overall pass or fail is recorded on completion

of the test.


Audiometry Test - continued

Before an audiology is performed, the procedure needs to be explained to the child.

Advise the child to raise a finger or drop a rock in a cup when they hear a noise.

Put the ear phones on, ensuring the red side is on the right ear.

Set the hertz dial to 4000Hz and the decibel level to 50dB.

Before the test begins do a sound test and practice – when the child demonstrated understanding begin the test.

Once the child indicates they are ready to do the test it commences on the right ear first.

The hertz is set to 4000Hz and the decibels to 50dB then press the sound button. Reduce the decibels to 35dB then 25dB. If the child hears the sounds down to 25dB they pass the test. If they do not hear a sound, increase the decibels by 5dB until they do.

Record this as their result on the child health check form.

Set Hertz to 2000Hz and follow the above procedure with 50dB, 35dB, then 25dB.

Set Hertz to 1000Hz and follow the same procedure with 50dB, 35dB and 25dB.

If child indicates they can hear the sounds at 4000Hz, 2000Hz and 1000Hz then they pass the test.

If they do not pass then increase by 5dB stages until the child responds.

Record the results on the Hearing Health form.

Repeat the same procedure for the left ear.

Once the right ear is tested, change over and test the left ear. Repeat the test on both ears starting at 4000Hz and 55dB.

A child passes the test if they hear 25dB in both ears and respond at 1000Hz, 2000Hz and 4000Hz for both ears.

If the child does not pass the test they need to be referred to the medical officer/audiologist for follow up.


Audiometry Flow Chart

FAILaudiometry in one or both ears or B and

C type tympanometry

MO, NP or Audiologist

No further action Review next

scheduled as-sessment or in 6 months if Hx of

OM

PASSaudiometry in both ears and

A type tympanometry

Audiometry > 40dB?

Review in 3 months

PASSaudiometry in both ears and

A type tympanometry

FAILaudiometry in one or both ears or B

and C type tympanometry

Things to remember

Clinicians need to be aware that a child may pre-empt the sound if the intervals are regular. They should ensure the sound button is pressed irregularly to prevent this.

If a child doesn’t appear to hear, the positioning and sealing of the ear phones should be checked.

Children need to understand what is required of them.

The test should be conducted in a quiet (preferably sound proof) room and the child encouraged using praise. The audiometer must never go above 80dB.

Brief Intervention

Brief interventions for children for ears and hearing include ensuring the child understands the need to:

• Blow their nose• Wash their hands• Stay away from loud noises• Stay away from smoke• Swim in running water or swimming pools• Eat healthy foods• Don’t put anything in their ears



1. What is the minimum sound intensity a child has to respond to in both ears to pass a hearing test?

Tick Answer

25 dB

10dB

30 dB

45 dB

50 dB

2. Which of the following measurements returning a positive response indicates a child is hearing tone correctly?

Tick Answer

1000 Hz

6000 Hz

4000 Hz

2000 Hz

5000 Hz


PC1222 Quiz

Please complete the gradable quiz for this session. You can complete this quiz as many times as you like until you are happy with your results.

1. Otoscopy checks canal volume

Tick Answer

True

False

2. Which of the following indicates a child may require follow up?

Tick Answer

Bulging tympanic membrane

Perforated tympanic

Canal volume between 0.2 and 2.0

Failed Audiometry at 55dB and 1000 Hz

Type A peak on Typanometry

Middle ear pressure above 100 daPa

Middle ear movement between 0.2 and 1.4


3. Which of the following requires urgent referral?

Tick Answer

Visible perforation

Ear canal blocked by wax

Sudden hearing loss or dizziness

Abnormal Typanometry results

Visible discharge

Failed Audiometry



1 2

3 4

Tick Answer

Which image shows a fungal infection?

Which image shows a retracted drum?

Which image shows a bulging tympanic?

Which image shows a perforation?


PC1223-1 Introducing Eyes and Vision

On completion of this module participants will be able to:

• Identify the normal eye• Identify the different structures of the eye• Describe how the eye works

Function of the Eye

The main function of the eye is sight which includes near, far and peripheral vision. It helps to differentiate colours and receives and sends images to the brain for interpretation.

Structure of the Eye

Lacrimal GlandDucts

Pupil

ScleraIris

Lacrimal puncta Inferior Lacrimal Canal

Lacrimal Duct

Lacrimal Sac

Superior Lacrimal Canal

EyelidLacrimal Gland

The eye is made up of a number of structures that work together to produces images which help us to interpret our environment

• Eyelid – protects eye from injury and distributes lubrication over eye• Eyelashes – protect eyes from foreign bodies• Lacrimal glands – produce tears to moisturize and wash away foreign substances• Cornea – outermost layer of eye sensitive to pain• Sclera – white of the eye which gives eye its shape• Pupil – located in centre of iris which controls the amount of light entering retina• Lens – the disc that lies behind pupil, through which light and images pass. It changes shape for near and

far vision• Retina – contains rods and cones that transform light and colour impulses to brain• Iris – coloured part of the eye


How the Eye works

The eye works similar to a camera. Each part plays a vital role in providing clear vision.

As with the camera, if the “film” is bad in the eye (i.e. the retina), no matter how good the rest of the eye is, you will not get a good picture.

The human eye accommodates to changing lighting conditions and focuses light rays originating from various distances from the eye.


Light Entry

The cornea, behaves much like a lens cover.

As the eye’s main focusing element, the cornea takes widely diverging rays of light and bends them through the pupil, the dark, round opening in the centre of the coloured iris.

The iris and pupil act like the aperture of a camera. The lens acts like the lens in a camera, helping to focus light to the back of the eye.


Light Transmission

The vitreous humour comprises a large portion of the eyeball. It is a clear gel that occupies the space behind the lens and in front of the retina at the back of the eye.

The main functions of the vitreous are to transmit light to the retina, and to exert enough pressure to keep the retinal layers tightly pressed together.

This pressure helps maintain the round shape of the eye so the lens can focus sharp images on the retina.

Because the eye must process visual data, this liquid must be clear enough that light can easily pass through.


Light Receptors

The very back of the eye is lined with a layer called the retina which acts like the film of the camera.

The retina is a membrane containing photoreceptor nerve cells that change the light rays into electrical impulses.

These impulses are sent to the optic nerve (which is tested as part of the red eye reflex).

The centre 10% of the retina is called the macula. This is responsible for sharp and reading vision.

The peripheral retina is responsible for the peripheral vision.


Light to Image

The electrical impulses formed by the light rays travel through the optic nerve to the brain.

The lateral geniculate nucleus (LGN) is the primary relay centre for visual information received from the retina.

The neurons of the LGN send the stimuli through to the visual cortex of the brain where where visual information is processed and turned into an image.

Both hemispheres of the brain contain a visual cortex and a LGN.

The left visual cortex receives signals from the right visual field and the right visual cortex from the left visual field.



1. List in order the structures of the eye in which light travels to produce an image.

Cornea | Lens | Vitreous | Pupil | Optic Nerve | Retina

Order Answer

1

2

3

4

5

6

2. Now match the structure of the eye with its role in the process of creating an image from light rays.


Structure Function

Controls the amount of light going through the eye

Takes wide diverging rays and bends them

Transmits light to the retina

Focuses light to the back of the eye

Transfers electrical impulses to the brain

Changes light rays into electrical impulses


PC1223-2 Eye Checks


• Undertake a reliable eye assessment at relevant ages and stages of development• List the types of eye tests and describe the procedure• Describe near and far sightedness• Define visual acuity

Eyes and Vision

Checking a child’s eyes and vision commences at birth and continues until they are 14 years old.

Checks include observing the eye, red eye reflex, corneal light reflex, cover tests and visual acuity.

Parents, teachers and children should always be asked if there are any concerns before routine checks are conducted.

If concerns are reported, extra checks should be conducted, recorded and the child referred as needed.

Screening 6 weeks, 2 and 4 months

Eye and vision checks at 6 weeks, 2 and 4 months involve inspecting the eye for symmetry, the presence of infection or lesions, conjunctiva colour and movement and a red eye reflex.

Print Name: Signature: Date:Eyes and Vision

Eye Appearance

*Red Eye reflex

Normal Abnormal

Present Not present


Appearance

The eye is checked for evidence of deformity and disease.

Both eyes should move evenly and freely with symmetrical pupils (shape and size) which constrict and dilate when light is shone in the eyes.

The conjunctiva should be white and free of discharge, lids and lashes clear of lesions and discharge and the iris uniformly shaped and free of lesions.


Red eye reflex

Normal Response Problem

Problem Problem

The red eye reflex test is usually performed by a medical officer or trained child health nurse.

While the child is looking at a distant object, the light of an ophthalmoscope is directed at the pupil from 30 centimetres away.

A red reflex from the retina should be observed.

An uneven response is cause for concern and the child needs to be referred to a specialist.

Screening 6 months

At 6 months the corneal light reflex is added to the well child health eye check.

Parents are asked parents if they have any concerns and test the child to see whether they fixate and follow an object with their eyes.

Red eye and corneal light reflex should be equal in both eyes.

Print Name: Signature: Date:Eyes and vision

Child fixates and follows an object with eyes at the following distance

*Red eye reflex

Corneal light reflex equal

30cm (near) Yes No

6m (distant) Yes No

Present Not present Yes No


Corneal Light Reflex

To check the corneal light reflex a bright light is held centrally but level with the eyes at about 30 cm from the eyes. Light will reflect in both eyes. If both eyes are properly fixing, the reflection should fall centrally on each cornea. If there is a squint, the light will not fall centrally on the corneas.

This test is a preliminary step to the cover test which better identifies squints and other eye problems.

Screening 12 to 18 months

At 12 months, Parents are still asked questions about any concerns and the red eye and corneal light reflex is still checked.

The fixation (focus) and following of eyes are tested for near and distant objects.

Print Name: Signature: Date:Eyes and vision

Child fixates and follows an object with eyes at the following distance

*Red eye reflex

Corneal light reflex equal

30cm (near) Yes No

6m (distant) Yes No

Present Not present Yes No


Following near and distant objects

To check if a child is following near and distant objects an object is held at arms length then moved away from

them (other side of room).

The child is observed to see if they follow the object.

Parents can also be asked if they noticed if their child focuses on things in the distance and nearby - children who do not focus close or distant objects may have vision problems.

Far and Short sightedness

Children who are far sighted have trouble focusing on objects that are close by as the image falls be-yond the optic nerve.

Those who are short sighted have problems seeing things in the distance as the image falls short of the optic nerve.

Screening 5 - 14 years

From 5 to 14 years, vision is only checked if problems are reported EXCEPT at 6 and 12 years when a child has a full check including cover tests and visual acuity.

Print Name: Signature: Date:Eyes and vision - Refer to ‘Vision Criteria for Referral’ list

Is the child aged 6 or 12 years?

Possibly eye or vision problem?

Cover test Left: Right:

Visual acuity (with prescription glasses if worn)

Yes (perform full eye and vision screen) No (continue to next question)

Yes (perform full eye and vision screen) No (continue to next question)

Near Movement No movement Distant Movement No movement Near Movement No movement Distant Movement No movement Left / Right /


Near and Far Cover Tests

Near and far cover tests are conducted by asking a child to focus on a near (30 cm away) object and on a distant (more than 6 metres away).

The tests are always started on the right eye first.

The child is asked to fixate on the distant object first and encouraged to keep the eye still. The right eye is covered and the left observed for movement.

Any corrective movement of the left eye may suggest a squint.

The right eye is then uncovered and observed for movement as well – any movement of either eye when the right eye is uncovered may also suggest a squint.

The test is repeated on the left eye using the distant object then a near object.

Visual Acuity

Vision is dependent on how sharp the retina can focus an image and how well the brain can interpret the information. Visual acuity is the most common clinical measurement for assessing clarity of vision which is checked using a Snellen or Tumbling E chart.

It determines how clearly a child can identify black symbols on a white background at a certain distance.

Visual acuity is checked at 6 and 12 years only, unless a teacher, parent or child expresses concerns about vision.

To check visual acuity the child stands 6 metres (3 metres if using mirror and reverse chart) away from the eye chart.

The left eye is fully occluded and the child asked to read the letters or indicate the way the E is facing using 3 fingers, with their right eye.

The check is then repeated by occluding the right eye and reading using the left eye.

Each line has a number that refers to the distance in metres from which the child can clearly see the row of letters.

The results are recorded as ‘the line number the child can read clearly’ /6 (the distance to the chart).

The second number is the distance from which most children with normal vision would be able to see the letters clearly.

By 7 years old all children should be 6/6 in both eyes. If a child’s result is not 6/6 they should be referred for follow up.



1. Which of the following are included in the 12 month old eye check? (More than one answer)

Tick Answer

Visual acuity

Red eye reflex

Corneal light reflex

Near cover test

Far cover test


PC1223-3 Abnormal Findings


• Recognise and describe potential problems and appearance of the eye• Define Strabismus and amblyopia• Recognise abnormal results and refer for treatment

Appearance of the Eye

Children’s eyes that are of no concern move evenly and freely with symmetrical pupils (shape and size) which constrict and dilate when light is shone in the eyes. The conjunctiva should be white and free of discharge, lids and lashes clear of lesions and discharge and the iris uniformly shaped and free of lesions.

Ptosis or drooping eyelid is caused by weakness of the muscles that raise the eyes, damage to the nerves that control the muscles or looseness of the skin on the upper eyelid.

In children this is usually caused by a congenital abnormality, injury or disease.


Infections of the Eye

Herpes simplex causes ocular herpes and cold sores. Usually the cornea is infected and in most cases just in the superficial layer (epithelial keratitis).

Infection of the deeper layers (stromal keratitis) is more serious as it may cause scarring of the cornea.

A minor and temporary inflammation of the conjunctiva (conjunctivitis), eyelids (blepharitis) and deeper structures such as the retina or iris may also occur with active infection, often at the same time as the cornea is infected.

Blepharitis is usually caused by seborrhoeic dermatitis, a bacterial or viral infection or allergies.

The eyelids become red, swollen, itchy, burning and may be dry and crusty.

Treatment involves bathing the eyes daily and applying ointments and creams to treat infection.

Conjunctivitis

Viral conjunctivitis Bacterial conjunctivitis

Conjunctivitis could be either a viral or bacterial infection or the result of allergies affecting the conjunctiva. It causes redness in the sclera, stickiness, discomfort and light sensitivity.

Viral Conjunctivitis is very contagious, so children should be avoid close contact with others while they have an infection.

Bacterial conjunctivitis may require antibiotic treatment so a medical officer should be consulted and allergic conjunctivitis can be treated by anti-histamines.


Infections of the Eye - continued

A stye is a small lump that occurs on the eyelid. It develops when an oil gland becomes blocked.

Styes can become infected and quite painful. They can be treated using warm compresses, gentle massage and antibiotic drops, ointment or tablets if it becomes infected.

A nasolacrimal duct cyst occurs when the tear duct becomes blocked - usually the result of a congenital abnormality.

Treatment includes gentle daily massages and in some cases surgicalintervention to open the duct.


Conditions of the Eye

Trachoma is caused by a bacterial infection (Chlamydia trachomatis) of the eye.

It is spread through direct contact with infected eye, nose or throat secretions or contact with contaminated objects like towels and clothes.

In Australian remote communities the infection is carried by flies.

Trachoma starts out as an infection that causes a cloudy cornea, discharge, swelling of the lymph nodes, swollen eyelids and turned-in eyelashes.

Treatment with antibiotics is essential if complications such as scarring, permanent eyelid damage and blindness are to be prevented.

Glaucoma is the result of increased pressure in the eye which damages the optic nerve.

Childhood glaucoma is the result of abnormal development of the eye drainage system or disorders of the body of the eye that may or may not be genetic.

Paediatric glaucoma usually requires surgery early in the baby’s life – if left untreated permanent vision loss will occur.


Strabismus

Strabismus is a condition in which the eyes are not properly aligned with each other.

It typically involves a lack of coordination between the extra ocular muscles that prevents bringing the gaze of each eye to the same point in space.

This prevents proper binocular vision, which may affect depth perception.

Strabismus can be either a disorder of the brain coordinating the eyes or a disorder of one or more muscles of the eye.

Strabismus is most commonly described by the direction of the eye misalignment; common types of strabismus are esotropia, exotropia, hypotropia, and hypertropia.

Esotropia is inward turning of the eyes (crossed eyes). Types of esotropia include infantile esotropia, accommodative esotropia, and sixth nerve palsy.

Exotropia is the term used to describe outward turning of the eyes (wall-eyed)

Esotropia – abnormal eye turned in Exotropia – abnormal eye turned out

The terms hypertropia and hypotropia are used to describe vertical misalignment. Hypertropia is an abnormal eye higher than the normal eye.

Hypotropia is when the abnormal eye is lower than the normal eye.

Hypertropia - abnormal eye higher than the normal one

Hypotropia – abnormal eye is lower than normal eye


False / Psuedo Squint

A false or pseudo squint can be mistaken for strabismus. The eye appears turned because of a broad bridge of the nose. In this picture strabismus can be ruled out as the corneal light reflexes fall evenly on the eye.

Sometimes young babies may appear to have a squint as a result of immature eye muscles.

This usually disappears by 6 months.

Broad bridge of nose Immature eye muscles

Latent Squint

A latent squint is not a true strabismus. It occurs in some children who squint when they are tired.

The only way to determine this is to conduct a cover test when the child is not tired to exclude strabismus.

Occurs if child is tired Can be excluded with a cover test


Amblyopia

Amblyopia also known as a lazy eye is a vision development disorder that may be the result of

• An undiagnosed or poorly treated strabismus (squint).• Deprivation of visual experience caused by a blockage on the visual pathway e.g. child hood cataracts.• Refractive problems (poor eyesight due to poor focusing of light through the lens) e.g. one eye is more

near or farsighted than the other.

Amblyopia occurs when the brain stops forming an image from one eye to maximise the vision in the other.

This may lead to a perceptive “blindness” (blindness not caused by structural problems) and poor depth perception.

Amblyopia is diagnosed by conducting a cover test, if a child fails a cover test, it is essential they are referred for specialist follow up, in order to prevent long term vision problems.

Lazy eye May lead to poor depth perception

Treating Squints

Early detection and treatment of squints impacts on the chances of successful intervention and prevention of long term complications including amblyopia.

Treatment of squints involves patching, glasses, exercises, eye drops, or surgery.

Success of the treatment depends on the child’s compliance.



1. Match the eye abnormality with its definition

1. Conjunctivitis 2. Blepharitis 3. Stye 4. Amblyopia 5. Strabismus

Abnormality Definition

Vision development disorder

Eyes not properly aligned

Small infected lump on eyelid

Infection of the conjunctiva

Swollen, red, itchy eyelid


PC1223-3 Quiz

1. Amblyopia and Strabismus are the same thing (1 mark)

Tick Choice

True

False

2. Match the test with what it is checking for (5 Marks)

1. Cover test 2. Corneal light reflex 3. Visual acuity 4. Red eye reflex 5. Eye inspection


Amblyopia

Strabismus

Retinal function

Ability to see from certain distances

Conjunctivitis


3. Which of the following requires follow up by a specialist? (More than one answer) (4 marks)

Tick Choice

Stye

Amblyopia

Strabismus

Blepharitis

Conjunctivitis

4. Which of the following conditions has the potential to lead to vision loss or blindness in one or both eyes? (More than one answer) (4 marks)

Tick Choice

Nasolacrimal duct cyst

Glaucoma

Trachoma

Untreated Strabismus

Amblyopia


PC1224-1 Oral Health Introduction

Learning Objectives


• Discuss the importance of oral health• Define plaque and causes of tooth decay • Discuss influences of diet on oral health• Identify the foods that are most likely to harm the oral environment.

Oral Environment

The health of teeth is dependent on the environment of the mouth.

Teeth will remain healthy as long as they are in contact with fluoride from toothpaste or water, are flushed by a good flow and quantity of saliva and there is sufficient calcium in the diet to ensure they remain strong.

Teeth become weaker when they are not exposed to fluoride, the quality and amount of saliva is reduced, there is insufficient calcium and water and a high sugar content in diet, there is poor or no dental care.

Plaque is made up of germs (bacteria) and food debris. Everyone has plaque but some people have “worse” bacteria than others.

Plaque bacteria is only found in the mouth – brushing teeth reduces the build up of plaque, but it continues to develop again soon after.

It takes 12-24hrs for the full plaque amount to return.

When a baby is born there is no bacteria in their mouth, a baby gets their bacteria from the mouths of their parents.

If the parents have poor oral health they will pass on bad bacteria to their child.

Sucking dummies or milk bottle teats to “clean” them is a common root of bacteria transfer so this practice needs to be strongly discouraged.


A poor oral environment is the culmination of a high sugar diet and plaque bacteria in the mouth building up over time and affecting a susceptible tooth.

Plaque Bacteria

Susceptible tooth

Time

High sugary diet

Plaque Bacteria

Susceptible tooth

Time

High sugary diet

Plaque Bacteria

Susceptible tooth

Time

High sugary diet

The combination of sugary drinks and food, if not cleaned from the teeth results in the development of plaque bacteria. This produces acid which attacks the teeth causing tooth decay.

Sugary drinks and food

Plaque bacteria

Makes acid which attacks the teeth

Influences of Diet

Plaque bacteria reproduces in sugar that’s left on your teeth after food or drinks are consumed.

Sugar can come from fruit, milk, lollies, biscuits and bread – in fact any food group could have a sugar content.

The more these foods are eaten, without cleaning the teeth after, the more the bacteria produces the acid which causes decay.


Liquid Sugar

The worst sugars are liquid and sticky sugars which get into all the small places where its harder to clean.

Fluids containing sugar include: soft drink; cordial; fruit juice; sports drinks; Ribena; sweetened tea/coffee; flavoured milk.

Sticky Sugar

Sticky sugars which come from confectionary like roll-ups, muesli bars, chewing gum, lollies and toffee all adhere to the tooth surface and are harder to clean off.

If left on the tooth surface they will begin to damage the enamel which results in tooth decay.

Soft Drinks

Soft drinks also cause tooth decay.

• Full sugar soft drink contains sugar and acid which leads to tooth decay.• Diet soft drink contains acid which leads to tooth decay.

Plain water has no sugar or acid which leads to healthy intact teeth.

It is recommended that water instead of soft drink is consumed.



1. Which of the following factors contribute to a healthy oral environment?

Tick Answer

Good water supply

Access to fluoride

High sugar diet

Dental check-ups every 2 years

Good oral hygiene


PC1224-2 Screening

Learning Objectives


• Discuss the oral health screening process • Conduct oral health screening • Identify degrees of tooth decay• Make recommendations to reverse tooth decay

Introduction

Checking oral health on every child health check is essential.

Poor dental health is an extremely common problem amongst children.

There is an association between periodontal disease and the risk of heart disease, coronary artery disease, inadequate nutrition and otitis media.

There is also an association between periodontal disease and diabetes, obesity and diets high in sugar and fatInfections and decay may result in the loss of teeth which impacts on nutrition, psycho-social health and life outcomes.

If poor oral health practices are present, parents and carers should to be educated and supported to make good choices.


0-12 months

Prior to commencing an oral health check, parents, carers are asked a series of questions.

At 6 months the parents are asked if the child has any teeth and if they are cleaning the teeth and gums.

The baby’s teeth, gums, cheeks and tongue are visually checked.

Questions Intervention

6 months

Does the child have any teeth?Does the parent clean the child’s teeth and gums?

Brief Intervention

Are teeth present?

Do you clean your child’s teeth and gums?

Yes No

Oral HealthPrint name: Signature: Date:

Yes No


12 months - 4 years


12 months, 18 months, 2,3 and 4 years

Does the child have any teeth?Does the parent clean the child’s teeth and gums using a small soft toothbrush with a pea sized amount of low fluoride toothpaste twice a day?

Brief InterventionVisual Oral Check

Are teeth present?

Do you clean the child’s teeth and gums using a small soft toothbrush with a pea sized amount of low fluoride toothpastetwice a day?

Oral examination of teeth

Oral examination of gums

Yes No


Yes No

Healthy Decay Malalignment No exam

Healthy Bleeding Swelling No exam

Between 12 months and 4 years parents are asked if they are cleaning their child’s teeth with a toothbrush and toothpaste.

The child’s teeth, gums, cheeks and tongue are checked. If there are any concerns the child should be referred to a medical officer or dentist.


5 to 14 years


5 to 14 years

How often do you brush your teeth?Have you had any toothache or bleeding gums in the last 4 weeks?Have you had a dental checkup in the last 12 months?

Brief InterventionVisual Oral Check

How often do you brush your teeth?

Have you had any toothache or bleeding gums in the last 4 weeks?

Have you had a dental checkup in the last 12 months?



Twice daily Once daily


Yes No



Occasionally Never

Yes No

Children aged between 5 and 14 are asked if they brush their teeth, if so how often, if they have any pain or bleeding and if they have had a dental check in the past year.

The child’s teeth, gums, cheeks and tongue are checked. If there are any concerns the child should be referred to a medical officer or dentist.

Screening

Parents/carers or children should be asked questions about their dental hygiene and nutrition practices prior to examining the teeth and gums.

Oral health checks involve a full mouth check including:

• Cheeks for grazes, ulcers and infections• Teeth for plaque and decay • Gums for boils and gingivitis• Tongue for ridges, ulcers and other abnormalities

Education about healthy habits, brushing and flossing daily is an integral part of the check.


Checking the mouth

To check the mouth good lighting or a torch is essential. A gloved hand and tongue depressor makes the process easier.

The child is asked to open their mouth, and with teeth clenched and lips parted, the outside of the front teeth is checked.

The child is then asked to open mouth fully so the molars, gums, cheeks and gum can be checked.

Tooth Decay

Tooth decay is one of the most common problems with oral health.

It is a consequence of bottle feeding that continues into toddlerhood, excessive juice intake especially with pop-top bottles and excessive consumption of soft drinks – full sugar and diet.

Poor dental hygiene and a poor diet with high sweet and sugar intake causes plaque build up which may result in decay.

Healthy Teeth

Healthy teeth are clean, unstained and have no holes or cavities.


Early Decay - Frosting

Early decay or frosting is indicated by discolouration and spots on the tooth enamel.

It is reversible with improved oral health and decreasing exposure to sugars.

Without change decay will continue, holes will form and teeth will need fillings or, if the decay is bad enough, require extraction.

Small hole already formed

Active Decay

Early decay or frosting is indicated by discolouration and spots on the tooth enamel.

It is reversible with improved oral health and decreasing exposure to sugars.

Without change decay will continue, holes will form and teeth will need fillings or, if the decay is bad enough, require extraction.


Severe Active Decay

Severe active decay leads to loss of tooth structure and is not reversible.

All teeth may need to be extracted which will cause difficulty with speech and eating.

If habits do not change NOW this child will have severe dental problems into adult life.

Less Active Decay

If oral health habits change early enough, the damage to the tooth can be halted. In this image damage has occurred but is now less active.

The darker (black) colour is inactive decay and the lighter brown areas are more active meaning decay has recommenced.


Misaligned Teeth

Misaligned teeth have both cosmetic and health impacts.

Cross bite is when the upper front teeth should be in-front of the lower teeth – usually caused by lower jaw anat-omy which can be corrected by orthodontic intervention.

Crowding occurs when there is insufficient space in the jaw- resulting in overlapping or crooked teeth.

Misaligned teeth can impact on a child’s ability to chew and if very crowded can cause problems with teeth cleaning and potential decay.


Misaligned Teeth - continued

The above images show misalignment as a result of thumb sucking.

This space is caused from thumb sucking which is quite normal for young children.

It should be stopped by the time the child begins to lose their baby teeth.

Healthy Gums

When checking for oral health it is important to take note of the gums.

Healthy gums are pink or coral coloured and have ridges above the teeth.

The top of the tooth is clean and free of plaque and the gums are not puffy or red.

The attachment to the tooth is firm and the gum is clean.


Unhealthy Gums

This image shows unhealthy gums. There is plaque at the top of the teeth.

Between the teeth are red puffy sections which will build easily when cleaned with a toothbrush.

There are no clear ridges above each tooth and the teeth are likely to be loose.

It is very easy to return these gums to good health by cleaning teeth and gums with a soft toothbrush, using a mouthwash and rinsing after eating or drinking.

Floss should also be used daily.

Causes of Unhealthy Gums

Gums become unhealthy if a person is brushing too roughly or they are using a hard or medium toothbrush.

They may not be brushing near the gums which results in build-up of plaque which causes gum infections.

When infected gums are touched with a toothbrush bleeding occurs.

This can be fixed by regularly brushing the gums gently to remove the plaque and reversing the infection.


Inflamed Gums

Inflamed gums indicate infection.

They become inflamed at the base of the teeth as a result of plaque build up – if the infection is not managed, it spreads to the whole gum.

Gums will be sensitive and will bleed when brushing teeth. Correcting brushing technique, flossing and using mouthwash are all good ways to manage gum infections.

Gum Boils and Abscesses

Gum boils and abscesses occur as a result of poor oral hygiene – the decay moves beyond the tooth into the gum causing infection.

Gum boils can be very painful and may need antibiotic treatment.

Tooth decay needs to be halted by practising good hygiene, if this is not possible teeth may need to be extracted.


Ulcers and Lumps

Ulcers and lumps which can be found on gums, cheeks and lips may be caused by a number of different conditions including:

Herpes; warts; biting; burns; poor nutrition; hand foot and mouth and other diseases.



1. Number the sequence of events that may result in the development of an oral health emergency

Sequence

Gum boil

Poor tooth brushing techniques

Infected gums

Gum abscess

Plaque build up

High sugar diet

Inflamed gums (gingivitis)


PC1224-3 Prevention

Learning Objectives


• Describe good oral health habits• Discuss ways to maintain a healthy oral health environment• Explain process of teeth brushing and flossing for adults and children• Discuss the benefits of regular dental checks• Identify what issues require referral and to whom.

Good Oral Health Habits

Good oral health is the result of drinking plenty of water and milk and eating fruit and vegetables. Brushing teeth twice daily with a soft, well maintained toothbrush, daily flossing and regular visits to the dentist will ensure oral hygiene is maintained.

Teeth Cleaning

Good oral hygiene includes regular teeth cleaning starting in infancy.

Up to 12 months of age teeth should be wiped with a clean, soft cloth after eating or drinking.

From 12 months of age children’s teeth need to be cleaned twice a day.

Parents should clean and floss children’s teeth up until they are 8 years old. Flossing needs to be done daily, preferably at night.

Brushing Teeth

The best way to keep the mouth healthy is for adults and children to brush their teeth twice a day.

Children under 8 need adult help with teeth brushing as it is difficult for them to do it correctly.

Children over 8 are able to brush their teeth but need to be supervised to ensure they do it correctly.

A thorough brushing should take two to three minutes to complete, less than that is less then optimal.

Toothbrushes

Teeth should be brushed with a soft toothbrush – not medium or hard as they do not clean as well as they are not flexible and they can cause damage to the teeth enamel and gums. Toothbrushes with smaller heads are more able to reach the back of the mouth.


Replacing Toothbrushes

Toothbrushes should be changed regularly – they begin to look scraggy after about three months so should be replaced. Toothbrushes should not be shared as this will transfer germs.

Toothpaste

Toothpaste must contain fluoride which helps strengthen teeth to resist, reverse or slow down decay.

It is preferable to use a toothpaste that suits taste.

Children’s Toothpaste

Children between 2 and under 6 should use a child’s toothpaste which has less fluoride that adult toothpaste.

Toothpaste should no be swallowed and needs to be spat out of the mouth.

Mouths, however do not need to be rinsed following teeth cleaning because leaving the teeth in contact with the fluoride longer is good for the teeth.

Using Toothpaste for Children

Toothpaste is not required for children under 2 years of age. For children between 2 and 6 a smear is sufficient and for children over 6 a pea sized amount of adult toothpaste is recommended.

Flossing

Flossing is the only way to clean between the teeth. Flossing should be done daily - preferably at night time and before brushing.

There are a number of different types of floss available, some are like string and others similar to small plastic toothpicks.

All styles are effective and preferences are based on personal choice and budget.

Effective flossing takes practice but should be part of the daily routine.

Dental Checks

All children should have an annual check up with the dentist.

Dentists are trained to diagnosis and treat dental disease.

Problems with teeth and gums could be painless, making it more important for the annual check up.

If problems are left untreated, ongoing issues with oral health will occur.


Dental Visits

Once a child starts to feel pain, the dental problem has escalated.

The longer it takes for the problem to be treated the worse it will become.

If pain stops, it is still important to see a dentist, as this does not necessarily mean the problem has gone away.

Medical Referral

A child requires a medical referral if they complain of moderate to severe pain, and have abscesses, unusual lumps, swelling or ulcers.

Abscesses with associated facial swelling requires urgent follow up.

Young children with severe dental decay should also be referred to a medical officer for a more thorough check and treatment.

Dental Referrals

Children with dental pain, tooth trauma, swollen bleeding gums, crooked teeth, tooth decay and lumps, swelling and ulcers should be referred to a dentist.



1. Which of the following statements are true?

Tick Answer

Flossing is best way to clean between teeth

Flossing needs to be done twice daily

Flossing is an optional element of oral hygiene

The best product for flossing is the string

A variety of flossing products can be used


PC1224-3 Quiz

1. Which of the following statements are true? (More than one answer) 2 marks

Tick Answer

Gingivitis is inflamed or infected gums

Teeth should be cleaned with a hard toothbrush

A tooth abscess is a dental emergency

Babies teeth should be cleaned with a soft toothbrush and fluoride toothpaste

White discolouration of the tooth indicates active decay

2. Which of the following occurs when the lower teeth protrude over the upper teeth? (1 mark)

Tick Answer

Cross bite

Crowding

Crooked teeth

Gum boil

Gingivitis


3. Match the problem with its best definition (5 marks)

1. Gingivitis 2. Ulcer 3. Plaque 4. Active Decay 5. Non-active Decay

Problem Definition

Cement like structures between teeth

Black discolouration on tooth

Inflamed or infected gums

Small open lesion on the gums or cheek

Brown discolouration on tooth

4. It is best to use a medium toothbrush for teeth cleaning (1 mark)

Tick Answer

True

False

5. With appropriate intervention, active decay is reversible (1 mark)

Tick Answer

True

False


PC122 Theory to Practice Activity

Tommy who is 4 ½ years old has been brought to the clinic for a check. His mother says he has been unwell over the last week and she is worried about his health in general. When you talk to Mum she tells you:

• Tommy is often unwell. • He seems to always have a cold and runny nose and complained recently of a very sore throat. • He is having trouble weight bearing on his right ankle.• This is the second time in 6 months that he has had joint pain, although the last time it was in his left

knee which she thought was growing pains.• He has also had many ear infections in the past and she is worried he may have some hearing loss. • He has not had his four (4) year old immunisations yet, as each time Mum was going to bring him in he

had a cold.• Tommy is a fussy eater; he refuses to eat meat and all vegetables but loves mashed potato, fish and fruit.

He drinks juice and soft drink but refuses milk and water.• He is very clumsy and is having problems with his speech and playing with other children at preschool.• Mum is very worried as Tommy seems to be ‘just not right’ – he was very premature and had had health

problems as a baby.

You complete a child health check on Tommy and find:

• He weighs 13.5 kg and is 100 cm tall.• He has a bulging tympanic and a fungal infection in his right ear. • He is also lethargic and has a slight fever.• He has active caries on his 4 front teeth. • He has infected lesions on his elbows and hands with signs he has been scratching.

Please complete Tommy’s Child Health Check form, his growth chart and his BMI chart, then complete the following quiz.

HE

ALTH

CH

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K - 4 Y

EA

RS

Legend: Indicates a health risk that requires brief intervention, follow up or action.

Patient’s actual age:

Indigenous status: Aboriginal but not Torres Strait Islander origin Torres Strait Islander but not Aboriginal origin Both Aboriginal and Torres Strait Islander origin Neither Aboriginal or Torres Strait Islander origin Not stated / unknown

Parent / carer’s name: Relationship: Signature (consent for health check): Date:

Has the carer / parent been advised of the process and benefits of health check? Yes No

Medical historyAllergies:

Family history:

Medical history:

Current problems / concerns:

Examination (*MO’s note: examination requirements on following pages):

Medications:

Immunisations due at 4 years of age:

Immunisations current: Yes No (proceed to consent and immunise child)

Evidence of 4 year old immunisation sighted? Yes No (child must be vaccinated to claim ‘Healthy Kid’ check)

Evidence of immunisation sighted by (print name): Signature: Date:

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Health Check4 Years

Medicare Item No. 715 or ‘Healthy Kid’ check

(Affix identification label here)

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Body measurements Print name: Signature: Date:

Weight kg ( ..................................... %le) Healthy Abnormal

Height cm ( ..................................... %le) Healthy Abnormal

Body Mass Index (BMI) Underweight Healthy Overweight Obese

Clinical measurements Print name: Signature: Date:

Breathing

*Heart sounds

Normal Noisy Coughing Wheeze Breathless

Normal Abnormal

General appearance Print name: Signature: Date:

Movement

Limbs

Joints

Normal Abnormal

Normal Abnormal

Normal Abnormal

Skin Describe skin: Healthy Intact Jaundice Sores Rash

Bites Scars Bruises Itchy

Developmental milestones Print name: Signature: Date:

Hops on one foot

Catches and throws ball

Runs and turns corners without over balancing

Draws a person with 2 or more parts (e.g. eyes, arms)

Is able to name drawing (e.g. drawing of dog, parent)

Uses a pencil grip

Plays with other children

Able to have a conversation

Is fluent in conversation

Is easily understood

Asks questions

Understands opposites

Achieved Not Achieved












Ears and hearing Print name: Signature: Date:



Otoscopy

Tympanometry

Yes No

Yes No

Left ear: Healthy Refer

Right ear: Healthy Refer

Left ear: Healthy (Type A) Refer (Type B or C)

Right ear: Healthy (Type A) Refer (Type B or C)

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Health Check4 Years



URN:

Family name:

Given name(s):

Address:

Date of birth: Sex: M F I

Tommy

Nutrition Print name: Signature: Date:

Healthy food

Unhealthy food

If your child was hungry are you always able to provide food?

Cereal with iron Vegetables Meat Fruit Fish

Water Milk

Coke / soft drink Junk food Juice Tea Cordial

Yes No

Continence / elimination Print name: Signature: Date:

Is the child independent in toileting?

Is the child incontinent of urine or faeces?

Does the child wet the bed?

Yes No

Yes No

Yes No

Oral health Print name: Signature: Date:

Are teeth present

Do you clean your child’s teeth and gums using a soft toothbrush with a low fluoride toothpaste, twice per day?



Yes No

Yes No



Social emotional well-being Print name: Signature: Date:

Does the parent / carer have concerns about any of the following

Observe: is interaction between mother / carer and child positive?

Coping: Yes No

Relationships (family and social): Yes No

Support available: Yes No

Violence: Yes No

Child’s behaviour: Yes No

Yes No

Environment Print name: Signature: Date:

Is the child exposed to cigarette smoke?

How many people live in the house?

Yes No

Topics for discussion / education Cross infection Injury prevention

Comments:

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Health Check4 Years



URN:

Family name:

Given name(s):

Address:


■

■

■

■

■

●

■

■

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Tommy

Action plan for good healthRisks identified Referrals / actions Initial Date

Actions to be taken by patient / carer

All risks, outcomes and results discussed and explained to carer / parent by MO?

Yes No

Medical Officer signature: Date:

Written feedback report provided to carer / parent? Yes No

Carer / parent signature: Date:

Care plans / follow up assigned on PHCIS? Yes No

Medicare Item No. 715 Aboriginal and Torres Strait Islander Child Health Check (all Item 715 can be claimed every 9 months if items complete)

Yes No Date:

Healthy Kid check claimed (701, 703, 705, 709 MO or 10986 Nurse or Health worker)

‘Get Set for Life’ book provided (must be provided for Healthy Kids check claim)

Yes No

Yes No

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Health Check4 Years



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Family name:

Given name(s):

Address:


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4 ye

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3 ye

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3 ye

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4 ye

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PC122 Theory to Practice Activity

1. There are a number of health concerns and Tommy needs to be reviewed as soon as possiblet

Tick Answer

True

False

2. What immediate follow up does Tommy require

Answer


3. Tommy’s weight is on which centile curve?

Tick Answer

20th centile

Between 95th and 98th centile

98th centile

Below the 3rd centile

5th centile

4. Tommy’s BMI is on which centile curve?

Tick Answer

20th centile


98th centile

Between the 3rd and 15th centile

5th centile

5. Are there any concerns with Tommy’s weight? If so, what are they?

Answer


6. What longer term followup does Tommy require?

Answer


PC1221-1 Learning Activity Feedback

1. Which of the following statements about normal healthy skin are true?

Tick Answer

Dry

Smooth

Scaly

Lesion free

Slightly oily

2. Arrange the layers of skin in order from inner to outer

1: Epidermis 2. Subcutaneous 3. Dermis

Answer

1 Subcutaneous

2 Dermis

3 Epidermis



1. Which of the following are signs of an allergic rash? (More than one possible answer)

Tick Choices

Welts

Crusty lesions

Lesions in the mouth

Lesions with fluid filled centre

Itchy lesions

2. Which of the following can be used to manage eczema? (More than one possible answer)

Tick Choices

Moisturisers

Antibiotics

Ultraviolet radiation

Antifungal creams

Dietary changes



1. Which of the following skin conditions need to be treated as soon as possible?

Tick Choices

Scabies

Fungal infections

Insect bites

Sores

Impetigo

All skin conditions should be treated as soon as possible to prevent complications such as systemic infection e.g.

Acute Post Streptococcal Glomerulo Nephritis.


PC1221 Quiz Feedback

1. Match the type of rash with its most likely cause (5 marks)

1. Allergy 2. Hand, Foot and Mouth Disease 3. Chicken Pox 4. Eczema 5. Fifth’s Disease

Rash Cause

Hives Allergy

Dry scaly skin Eczema

Lacy rash Fifth’s Disease

Lesions around mouth Hand, Foot and Mouth Disease

Fluid filled blisters Chicken Pox

2. Which of the following statements are incorrect? (1 marks)

Tick Answer

The family of a person with scabies needs to be treated

Streptococcus is usually a harmless natural occurring bacteria

Scabies can be found in conjunction with impetigo

Fungal infections will clear up on their own

Impetigo is a bacterial infection


3. APSGN could be the consequence of which of the following conditions (5 marks)

Tick Answer

Scabies

Impetigo

Eczema

Insect bites

Minor abrasions

4. Strep A is the most common and dangerous of the streptococcal infections (1 mark)

Tick Answer

True

False

5. Fungal infections are normal in the tropics so do not need to be treated (1 mark)

Tick Answer

True

False



1. Match the procedure with what it is checking for

1. Otoscopy 2. Tympanometry 3. Audiometry

Procedure Checking for

Otoscopy Visualise ear canal and tympanic

Tympanometry Measure canal volume

Audiometry Test hearing



1. Match the type of problem you may see with the part of the ear anatomy it affects.

1. Ear canal 2. Ear Drum 3. Pinna 4. Middle Ear 5. Eustachian Tube

Problem Anatomy

Fungal infection Ear canal

Perforation Ear drum

Red, itchy and dry skin Pinna

Bulge in the ear drum Middle ear

Retracted eardrum Eustachian tube



1. Match the image to its definition

Type A Type B Type C

Type - A, B or C Definition

Type A• Normal ear canal volume• Normal middle ear movement• Negative middle ear pressure

Type B• No middle ear movement• No middle ear pressure

Type C• Normal ear canal volume• Normal middle ear movement • Normal middle ear pressure



1. What is the minimum sound intensity a child has to respond to in both ears to pass a hearing test?

Tick Answer

25 dB

10dB

30 dB

45 dB

50 dB

2. Which of the following measurements returning a positive response indicates a child is hearing tone correctly?

Tick Answer

1000 Hz

6000 Hz

4000 Hz

2000 Hz

5000 Hz


PC1222 Quiz Feedback

Please complete the gradable quiz for this session. You can complete this quiz as many times as you like until you are happy with your results.

1. Otoscopy checks canal volume

Tick Answer

True

False

2. Which of the following indicates a child may require follow up?

Tick Answer

Bulging tympanic membrane

Perforated tympanic

Canal volume between 0.2 and 2.0

Failed Audiometry at 55dB and 1000 Hz

Type A peak on Typanometry

Middle ear pressure above 100 daPa

Middle ear movement between 0.2 and 1.4



Tick Answer

Visible perforation

Ear canal blocked by wax

Sudden hearing loss or dizziness

Abnormal Typanometry results

Visible discharge

Failed Audiometry


4.

1 2

3 4

Tick Answer

2 Which image shows a fungal infection?

4 Which image shows a retracted drum?

1 Which image shows a bulging tympanic?

3 Which image shows a perforation?



1. List in order the structures of the eye in which light travels to produce an image.


Order Answer

1 Cornea

2 Pupil

3 Lens

4 Vitreous

5 Retina

6 Optic nerve

2. Now match the structure of the eye with its role in the process of creating an image from light rays.


Structure Function

Pupil Controls the amount of light going through the eye

Cornea Takes wide diverging rays and bends them

Vitreous Transmits light to the retina

Lens Focuses light to the back of the eye

Optic nerve Transfers electrical impulses to the brain

Retina Changes light rays into electrical impulses



1. Which of the following are included in the 12 month old eye check? (More than one answer)

Tick Answer

Visual acuity

Red eye reflex

Corneal light reflex

Near cover test

Far cover test


1. Match the eye abnormality with its definition

1. Conjunctivitis 2. Blepharitis 3. Stye 4. Amblyopia 5. Strabismus


Amblyopia Vision development disorder

Strabismus Eyes not properly aligned

Stye Small infected lump on eyelid

Conjunctivitis Infection of the conjunctiva

Blepharitis Swollen, red, itchy eyelid


PC1223-3 Quiz Feedback

1. Amblyopia and Strabismus are the same thing (1 mark)

Tick Choice

True

False

2. Match the test with what it is checking for (5 Marks)

1. Cover test 2. Corneal light reflex 3. Visual acuity 4. Red eye reflex 5. Eye inspection


Corneal light reflex Amblyopia

Cover test Strabismus

Red eye reflex Retinal function

Visual acuity Ability to see from certain distances

Eye inspection Conjunctivitis


3. Which of the following requires follow up by a specialist? (More than one answer) (4 marks)

Tick Choice

Stye

Amblyopia

Strabismus

Blepharitis

Conjunctivitis

4. Which of the following conditions has the potential to lead to vision loss or blindness in one or both eyes? (More than one answer) (4 marks)

Tick Choice

Nasolacrimal duct cyst

Glaucoma

Trachoma

Untreated Strabismus

Amblyopia



1. Which of the following factors contribute to a healthy oral environment?

Tick Answer

Good water supply

Access to fluoride

High sugar diet

Dental check-ups every 2 years

Good oral hygiene


1. Number the sequence of events that may result in the development of an oral health emergency

Sequence

6 Gum boil

2 Poor tooth brushing techniques

5 Infected gums

7 Gum abscess

3 Plaque build up

1 High sugar diet

4 Inflamed gums (gingivitis)



1. Which of the following statements are true?

Tick Answer

Flossing is best way to clean between teeth

Flossing needs to be done twice daily

Flossing is an optional element of oral hygiene

The best product for flossing is the string

A variety of flossing products can be used


PC1224-3 Quiz Feedback

1. Which of the following statements are true? (More than one answer) 2 marks

Tick Answer

Gingivitis is inflamed or infected gums

Teeth should be cleaned with a hard toothbrush

A tooth abscess is a dental emergency

Babies teeth should be cleaned with a soft toothbrush and fluoride toothpaste

White discolouration of the tooth indicates active decay

2. Which of the following occurs when the lower teeth protrude over the upper teeth? (1 mark)

Tick Answer

Cross bite

Crowding

Crooked teeth

Gum boil

Gingivitis


3. Match the problem with its best definition (5 marks)

1. Gingivitis 2. Ulcer 3. Plaque 4. Active Decay 5. Non-active Decay

Problem Definition

Plaque Cement like structures between teeth

Non-active Decay Black discolouration on tooth

Gingivitis Inflamed or infected gums

Ulcer Small open lesion on the gums or cheek

Active Decay Brown discolouration on tooth

4. It is best to use a medium toothbrush for teeth cleaning (1 mark)

Tick Answer

True

False

5. With appropriate intervention, active decay is reversible (1 mark)

Tick Answer

True

False


PC122 Theory to Practice Activity Feedback

1. There are a number of health concerns and Tommy needs to be reviewed as soon as possiblet

Tick Answer

True

False

2. What immediate follow up does Tommy require

Answer

Tommy needs an urgent medical referral to exclude Acute Rheumatic Fever (See PCCM Paediatric Section - Immune Complications).

The Medical Officer should also conduct a thorough clinical assessment to determine Tommy’s general state of health.

Tommy needs to have his 4 year old immunisations as soon as possible and to be seen by a dentist.

His ear and skin infections need to be treated. It is possible he has infected scabies so the whole family and house hold needs to also be treated.

Tommy needs to continue to be monitored closely.


3. Tommy’s weight is on which centile curve?

Tick Answer

20th centile


98th centile

Below the 3rd centile

5th centile

4. Tommy’s BMI is on which centile curve?

Tick Answer

20th centile


98th centile

Between the 3rd and 15th centile

5th centile


5. Are there any concerns with Tommy’s weight? If so, what are they?

Answer

Tommy’s weight is below the third centile and his BMI is between the 3rd and 15th centile.

It is important to remember that a single, stand-alone measurement cannot be viewed in isolation; it needs to be reviewed over a period of time.

When viewed over time, Tommy’s weight and BMI centile have steadily dropped.

This is a concern, particularly because Tommy has had several bouts of poor health recently.

Tommy is at risk of ongoing poor health including failure to thrive which, if left untreated, may result in serious longer term complications.

6. What longer term followup does Tommy require?

Answer

Tommy’ growth is of concern and he has some developmental delays.

He requires specialist review and follow up and needs to continue to be monitored closely including:

• Regular child health checks• Paediatric follow up• Hearing health follow up. • Medical care if he has had Acute Rheumatic Fever.

Tommy’s food intake is also of a poor quality with little variety. This will further impact on his growth and development.

Mum would benefit from some education on good nutrition and some hints on how to get Tommy to eat foods that are healthy and nutritious.


PC122 Post-Session Survey

Now that you have completed this session we ask you to take a few moments to complete the post-session survey for this topic. This will give us some indication about how well we have met your learning needs. Once submitted you will be eligible to receive your certificate.

Please indicate the degree to which you agree to the following, by ticking the box most relevant.

Stro

ngly

Agr

ee

Agre

e

Neu

tral

Dis

agre

e

Stro

ngly

Dis

agre

e

I am able to discuss the structure, physiology and function of the skin, ears, eyes and mouth

I can describe the differences between normal healthy and unhealthy skin, ears, eyes and mouth

I am able to provide simple prevention and treatment interventions for problems of the skin, ears, eyes and mouthI can clearly and accurately document findings on screening of the skin, ears, eyes and mouth

What, if anything could have been added to this session?


PC122 References

1. Queensland Health, Child and Youth Health Practice Manual. 2007, Queensland Health.

2. Queensland Health, The Royal Flying Doctor Service (Queensland Section), Apunipima Cape York Health Service. Chronic Disease Guidelines. 3rd ed. 2010. Cairns.

3. Queensland Health and the Royal Flying Doctor Service (Queensland Section), Primary Clinical Care Manual 8th Edition 2013. Cairns.

4. Western Australian Health (2013) Community Health Manual Procedure- 6.3.1 Otoscopic examination 5. Western Australia Health (2013) Community Health Manual Procedure – 6.3.2 Screening Audiometry

6. Western Australia Health (2013) Community Health Manual Procedure – 6.3.3 Tympanometry

7. Queensland Health - Deadly Ears Program

http://www.pmh.health.wa.gov.au/general/CACH/docs/manual/6%2520Procedures/6.3/6.3.1%2520Otoscopic%2520examination.pdf

http://www.pmh.health.wa.gov.au/general/CACH/docs/manual/6%2520Procedures/6.3/6.3.2%2520Screening%2520Audiometry%2520-%2520update.pdf

http://www.pmh.health.wa.gov.au/general/CACH/docs/manual/6%2520Procedures/6.3/6.3.3_Tympanometry.pdf

http://www.health.qld.gov.au/deadly_ears/default.asp

Documents

PC122 Child Health Check - Home | Queensland Health · PC122 Child Health Check - Part 2: Physical Assessment Introduction ... The first topic introduces and explores the basic anatomy