question about pediatric/adolescent physicals

AmericanRN · Feb 9, 2008

good morning everybody i hope you all are having a good weekend so far, i still do have a few more questions i know at the office where i work when our pediatric/adolescent patients come to the office for their annual physical we ask them to bring a urine sample with them i was wondering if that was ok to do or they should give a sample right in the office just prior to their physical? should the child give a sample every year they come for their physical or just every few years? i also know at the office for our female patients who are going into 7th grade since it is mandated by new york state where i live that kids going into 7th and 10th grades are required to get physicals before school starts we ask them to undress to their underpants and have the females patients take their bra off as well because as the doctor i work for wants to get a baselinebreast exam done on them to make sure nothing is abnormal and no lumps are starting to grow in their breasts.Is this exam really neccessary at this point in the childs development or is the physician going over borard with this? the child is given a gown to cover up with after they change? since being a new nursing student i got these questions. i hope to get some responses back and if i should mention something to the physician about this. hope everybody has a good rest of their weekend and go new england lol.

When I lived in Staten Isalnd NY I was an adolescent and I remember my doc (female) having me take my bra off when I was about 12 or 13 and doing a breast exam. This was back in the 80's too so it's not completely unheard of. I beleive at the time she was making sure that the breast tenderness I was feeling was from developing and not some other issues. I was a late bloomer and also did not menstruate until I was older so I think they were making sure I wasn't anorexic as well, I was just very skinny in the arms and legs but once they saw I was developing normally in other areas they ruled out an eating disorder, etc.

There could possibly be more that your doc wants to check for then lumps, he/she may also be looking for bruising/cutting/etc.

My friend's 11 year old daughter was found to be a cutter and if they had not made her take her clothes off during a physical required for cheerleading it never would have been caught since she was cutting her upper thighs and breast area. She is now receiving the proper counseling for this. I am not sure wheter I agree or disagree with the nudity issue with kids and pre teens but there are many factors that could be at work for some of the doctors who decide on this.

SCUnursie06 · Feb 19, 2008

I work in a peds office. I weigh babies with diaper on unless it's soaked. All kids for a physical undress except for underwear & bras and put on a gown. Some teenage boys are uncomfortable with undressing & gown so we let them stay in street clothes.

twahls65 · Feb 20, 2008

Thank you so much for your responses, i dont understand what the advantages and the disadvantages of weighing a baby with their diaper on or off? if someone could explain that to me please i would be greatly appriciated. you mentioned that you work in a peds office do u usually get a new nursing student in the office who wants to study office based medicine? Do the girls act all embarrassed when you tell them that they have to undress to their underwear and bra's and to put on a gown? When you give them a gown is it one of those basic hosital exam gowns that is cloth or is it one of those blue paper gowns? I know in the office where i am a student we have animal print gowns to give to the kids when they have to undress. Do u usually have the parent step out of the room for a minute while the child is undressing or does the parent stay in the room with the child? I hope i am not going overboard with these questions, i just cant get a straight answer at the office where i work. i hope to get some good responses and i thank you for your help.

lpnstudentin2010, LPN · Feb 27, 2008

Here is my personal experience:

I basically have 2 physicals a year. One with my PCP one with a geneticist. Until a year ago I went to my pediatrician. And my geneticist is a pediatric one.

At the PCP's office I would stay in my cloths. She would unbutton my pants and take a quick look down there to make sure all looked ok and would have me pull down my pants so she could check for moles (one of her things that she was REALLY careful about). She never did a breast exam. I gave a urine sample every year at the office. Every year she also got a report from my geneticist about my visit there. My mom came in with my to my pcp till I was about 14.

At my geneticist, I have always changed into a gown. Everything except underpants off. She checked everywhere. She has always done a breast exam on me, since I was little, due to the fact that my disorder has caused a tumor (benign) on my left breast. Office staff tried to say that by law my mom needed to come in until I was 18 but my doctor stood up for me and said for the exam I could come in alone, this was when I was 15. My mom then came in to discuss her what she found and any concerns my mom had about things she noticed since the last visit.

twahls65 · Mar 10, 2008

thank you for those that have responded to my question, i am still looking for other nurses experince dealing with pediatrics and adolescents in the office setting. My main duties in the office are to call the patient to the back and do their height,weight, vision check and also ask them to give a urine sample. Then i escort them to the exam room and do their bp. While i wait for them to give their urine sample i go to the exam room and pull a paper gown from the exam table drawer and have that laying on the table when the patient comes in. Is this basically what it is like at other pediatric practices for the nurses their? Or do the nurses do other things at the office as well when you are dealing with a patient? Any more responses would be appriciated. I thank you in advance for your responses.

girlr6RN · Apr 8, 2008

I worked in a peds office for a year, and yes, that's the way it went in our office. Same routine. As far as the diaper on vs off- we weighed our kids with no diaper (more accurate) on the baby scale, until they were about 15-18 months old and can stand on the regular scale. When kids are small enough to weigh on a infant scale, the weights should reflect more accurately what it really is. This is because of medication dosages the practicioner is prescribing. Remeber when figuring out peds doses, it generally goes kilo/mg-mcg-ml/time. (the smaller the kid, the more important the accuracy is. And as far as doing a breast exam on the girls in adolescence, I've been in the room as a chaparone for the practicioner for that. I find nothing wrong with it- it is important to know what Tanner stage the adolescent is in related to the age. If the child isn't showing any signs of development, or advanced development in some cases, there's cause for concern and it would indicate a need for a referral to a endocrinologist. Remeber, although the majority of patients who have breast cancer are older, there can still be the exception to anything, until proven otherwise. If I were you, I'd write down your questions and concerns and ask the nurse manager or whomever. And about the developing/deveolped girls not giving a gown to use, that's not right. If the kid is aware, it's time to give a gown.

Never stop asking questions- when you do, the other guys have won.

jemrn56 · May 2, 2008

In our practice, LPN's did Ht, Wt, hearing, vision, immunizations, and asked brief history dealing with food/formula/urination/BM and if had any concerns for the provider. We had one RN, sometimes LPN on the phone all day doing phone triage. We had 3-4 providers seeing kids so the staff hopped all day to keep the flow moving. Babies weighed without diapers and all infants/toddlers remained undressed in diapers for the exam. As child got older, we provided paper gowns (preschoolers love em). We followed AAP guidelines for routine screenings: UA, Hct and Pb. Adolescents (male and female) were down to underwear with a gown. Breast exams were done on teens; its a good opportunity to teach self breast exams. We did not perform gyn services for sexually active teens (decision that was made by the Medical Director.) Every office seems to have there own system in place. Ask questions!! :wink2:

dansingrn · May 3, 2008

I just completed my last clinical rotation for my pediatric nurse practitioner master's. I was in the outpatient adolescent clinic of a large children's hospital. Every girl received a breast exam if she was there for a full physical. As mentioned by another poster, it is a good idea to Tanner stage a younger adolescent, this documentation can be helpful if later there are questions about her progression ( or lack) through puberty. Older teens learn breast self exams, and we talked about breast health during the exams. Finding suspicious moles, nipple discharge, and evidence of cutting are also reasons. These things are not likely to be brought up by the patient or parent as concerns.

The genital exam is important as well to check for development, the presence of adhesions, any abnormal moles or other growths.

These exams were performed with the utmost care being given to the girls' privacy and sense of modesty. Patients were always examined with a cloth gown and an additional sheet for cover. Only the part being examined was exposed, then quickly covered. The girls learn that it is okay to form a trusting relationship with their healthcare providers and hopefully that its okay to discuss any questions or concerns, now or in the future. They learn (gradually) to assume some responsibility for their own healthcare. The provider's office is not a place for embarrassment, but for promotion of optimum health. It was always gratifying to see the look of relief on their faces when they heard how "normal" they were. Often these exams led to the patients opening up about things they otherwise wouldn't have mentioned.

The physical exams were always done with the parents out of the room, unless of course the patient wanted them there. This provided an opportunity to let the patients know that their confidentiality would always be respected, unless they revealed that they were planning to harm themselves or others. I was amazed at the things these kids would reveal, and the questions they would ask without their parents present.

By the way, the boys also received full exams with gowns. It is very important to teach testicular exams, as late adolescence and early 20's are the peak time for testicular cancer.

As long as modesty issues are handled with respect, the physical exam is no place for embarrassment; after all, excellent healthcare cannot be provided without full information. Providing teens with a respectful experience during the exam just might set the stage for more open relationships with providers in the future, when it may mean life or death to be forthcoming with details.

CaDad · Dec 8, 2009

I find it interesting that the children were not given any choice in whether they wanted a female or male nurse or Doctor. Why Not? Just in case you forgot-wasn't there a time when you were the most sensitive on modesty issues?

Apparently not, because I noted a complete lack of empathy for the PT. I can assure you the embarrassment and humiliation stays with kids and continues through adulthood. Both my Daughter and son will have nothing to do with the opposite sex when it comes to nurses or Doctors because of what happened to them getting physicals, and that includes me. My wife finally came around after she heard what happened to them. I find it appalling that intelligent, professional people like yourselves, who save peoples lives every day, work your butts off, sacrifice all you have for the general public, give up your personal lives and family time are so naive as to not understand a basic human condition called modesty .You defend your intrusive, calloused holier than thou behavior and perceptions on the presumption that " you have seen it all anyways" notion and essentially alienate the very clients you so wish to serve and leave them with emotional scars that quite simply could have been avoided. All this because you think we, the general public should give up our childish preoccupation with our sensitivities. This is precisely the reason this controvercy will not go away and I dare say eventually ,you will be made to listen. Sooner or later enough lawsuits will happen to change your ways-no matter what you say or happen to believe I am sorry to say. How utterly unfortunate.

Care4U391 · Dec 10, 2009

I work in a peds office and we do not have the older kids undress, unless they have a rash and it needs to be looked at, but even then we do not usually do this. The babies get down to a dry diaper and we provide a blanket for them to be covered with. We want the older kids 4years old and up to urinate at our office if they can at the time of the exam. I have never heard of a breast exam on a 7th grader unless they are sexually active then they would be referred to a gyno.

zone9 · Apr 8, 2010

I still remember my pediatric physical exams. Modesty was thrown out the window.

BabyLady, BSN, RN · Apr 8, 2010

hi everybody i work in a doctors office as a nurse and wonder if it is really necessary to have the child undress for their physical and if they do do you give them a gown to put on to cover up? i am just wondering if other pediatricians offices do this for their patients or do you have your patients keep their clothes on? what is the procedure at other pediatricians offices for when a child/adolescent comes in for their annual physical. i look forward to hearing back about this from everybody. let me just mention that i am a student nurse presently and working in a pediatricians office working with the regular nurses there. i hope this does not seem like a stupid question for everyone i am just wondering the protocol at other pediatricians offices. i hope to get some good responses back.

At my children's Peds office, it depends on what type of exam is being done.

If you go in for a sore throat, respiratory, etc...they are not going to ask you to get undressed.

But for something like GI, abdominal, etc..they may ask you to gown.

Our Peds is very good, especially the male physicians, on educating young female, newly self-conscious children, that it's ok for a physician to look at their bodies but ONLY if Mommy or Daddy are there.

My daughter is extremely self conscious and they are ok with only the female Ped examining her.