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

9. Blood pressure
Baseline during first 3 years unless child meets criteria on p Do at each checkup after age 3.
May use Dinamap or auscultated.
Proper fit includes 40% of MAC; length %.
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