Physical Assessment of the Child Ricci, Chapter 32

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.

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.

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

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.

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.

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.

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.

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.

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.

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

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.

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

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

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.

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

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

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

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