Physical Assessment of the Child

1. Physical Assessment of the Child Ricci, Chapter 32

2. General Approaches Toward Examining the Child • Head-to-toe sequence not always appropriate. • Understand child’s perception of painful procedures. • Expect success. • Private room decorated according to age. • Have toys and games available if possible.

3. Preparation of the Child • Use non-threatening approach. • Provide time for play and to become acquainted. Do as much as possible without touching. • Tell child what will happen within their understanding. • Cooperation enhanced with parent’s presence unless teen. Infants and toddlers may be examined in parent’s lap. • Begin with games and non-invasive procedures. Examine painful, invasive, and private areas last.

4. Signs of readiness • Making eye contact • Allowing touching • Talking to nurse • Accepting offered equipment • Sitting on exam table instead of parent’s lap

5. If child is not showing readiness…. • Talk to parent for a while. • Talk to child by way of transition object. • Make complimentary remarks about child (consider cultural differences.) • Tell funny story or do a magic trick.

6. If that doesn’t work……. • Assess what the reason is • . • Try to involve the parent and child. • Avoid prolonged explanations of the procedure. • Use firm, direct approach with a calm and gentle voice. • Gently restrain the child. • Proceed as quickly as possible.

7. Assessing growth • Recumbent length for infants up to age 36 months + weight and head circumference • Standing height and weight after 36 months • Plot height, weight, and head circumference on growth chart by gender and adjust for prematurity if appropriate. May also need to do BMI. • Growth spurts are expected. • Less than 5th or greater than 95th percentile is considered outside expected parameters. HCP usually considers ethnic and genetic differences or nutrition issues as possible causes.

8. Temperature, pulse, respirations • Methods vary including oral, axillary, rectal, tympanic, and temporal. Do whatever is available and is preferred by parent and HCP. If rectal, safety is of utmost importance. • Normal temps are same as adults • Apical pulse x 1 min for kids under 10 yrs. Radial acceptable over 10 yrs. • Rapid pulse is easier to count if you close your eyes and tap your fingers. • Infants have abdominal respiratory movements. Take x 1 min due to normal irregularity. • Normal rates Table 32.3, p. 1098.

9. Blood pressure • Baseline during first 3 years unless child meets criteria on p. 1098. Do at each checkup after age 3. • May use Dinamap or auscultated. • Proper fit includes 40% of MAC; length 80-100%. • Norms in Appendix H. Average for 1 yr old is approx 80/40; lowest normal adult BP of 90/60 is achieved by an average of 8 yrs old. • If upper extremities are higher than lower extremities, or if pulse pressure is less than 10 or more than 50, may indicate cardiac defec.t • Prehypertension is risk in obese children.

10. Proper vs sequence for infants/toddlers • Respirations first while child is quiet. • Apical HR second. May do if child is sleeping. • Temp is third unless it is rectal. If rectal, do blood pressure third and temp last.

11. General appearance and skin • Facial expression • Behavior • Speech • Extremity movements, coordination • Hair, nails, and hygiene may give clue to care of child or presence of stress. • Assessing color variations 1104, 1105. • Note rashes or injuries

12. Head and neck • Note head shape and size. Head circ is important. • Palpate anterior and posterior fontanels. Posterior closes first at 2 months. Anterior closes between 9-18 months. Should be flat, not bulging or sunken. • Head control by 4 months • Neck should be supple, not stiff (nuccal rigidity). • Lymph nodes are larger in children but should be movable and non-tender. Tender, enlarged nodes usually indicate infection or inflammation close to their location. Hard, immovable, non-tender nodes usually indicate neoplasm.

13. eent • Check for eye slant, folds, symmetry, redness • Vision screening—make sure to have correct Snellen chart • Color vision established between 6 and 12 months • Check ear placement and shape • Internal ear exam is invasive • Check for deviated septum, nasal drainage • Inspect lip and palate • Check condition of teeth. Number of teeth = age of child in months minus 6 • Mucous membranes • Tongue protrusion • Tonsils bigger than adults

14. Chest and lungs • Size, shape of chest; symmetry of chest movements; assess for worker breathing. • Check breasts for Tanner staging, if age appropriate (1115) • Barrel or pigeon chest indicates respiratory condition • Lung sounds are vesicular; inspiratory sounds are easier to hear • Ask child to play blowing games to get them to deep breathe

15. heart • PMI at 4th intercostal until about age 7 yrs, then 5th • May listen while child is sleeping • S1 synchronous with carotid or brachial • Sinus arrhythmia is normal. Heart speeds up with inspiration; slows down with expiration. • Split S2 is normal • Refer all murmurs to HCP. Some may be innocent, but it is not within the nurse’s scope of practice to decide.

16. abdomen • Inspect, auscultate, and palpate • May auscultate while child is sleeping • Minimize tickling sensations by having child put hand on top of yours • Report visible peristaltic waves • Report umbilical and inguinal hernias • Inspect umbilical stump, if applicable • Give infant a bottle or pacifer during exam to enhance your ability to hear

17. genitalia • Assess Tanner stages (1118, 1120) • Check for testicular descent (cryptorchidism) • Is male urinary meatus at midline? • Circumcised? If not, do not force back foreskin • Look for abuse by bruising, fissures, redness, swelling, discharge • No internal female exam unless sexually active • Note symmetry of gluteal folds • Check for anal reflex

18. Back and extremities • Check for spinal curvature • County fingers and toes to detect polydactyly or syndactyly • Bow-legs (genu varum). Feet together—knees 2 or more inches apart • Knock-knees (genu valcum); knees together—ankles 3 or more inches apart • Check for pigeon toe (toeing in) • Check for symmetrical folds in thighs

19. neurological • Use fun games • Assess level of consciousness • Sensory testing • Check reflexes • Patellar, triceps, biceps, achilles • Primitive reflexes • Test cerebellar function (balance and coordination): • Balance on 1 foot • Finger-to-nose test • Heel to toe walk • Romberg • Finger to nose test • Rapid alternating movements