1. Pediatric Physical Assessment: The Differences
Hannah O’Handley RN, MSN, CPNP

2. Basic Information LOOK AT THE CHILD!!!! ABCs Safety: Side rails!!!!
Family present in room?
Survey the room
- Who is who??
Caregivers mental state (alert, oriented, sleeping, sober)
Child’s mood

3. Know your “norms” before entering room!!!
Remember your growth & development when approaching patient.
Ideal time to do exam: sleeping and not aware
Assess a lot by just observing!
Make exam fun!!!
- blow out your penlight
(Table on anatomical & physiological characteristics of child)

4. Approaching the Pediatric Patient
Newborns/<6 months old
- Easiest to examine, no resistance
- use pacifier, hold patient
- warm hands, stethoscope
- order of assessment varies depending on patient’s
mood.

5. Approaching the Pediatric Patient (continue)
Infants >6 months old
- Keep with parent d/t separation anxiety
- Toys for distraction
- Start at feet but may need to vary assessment due
to mood.

6. Approaching the Pediatric Patient (continue)
Toddlers
- Demonstrate instrument use on parent
- Parents hold patient if possible
- Don’t ask patient if you can do something: “NO” will be the answer!!!
- Speak with confidence, explaining
each step

7. Approaching the Pediatric Patient (continue)
Preschooler
- Allow them to touch/play with equipment
- Listen to stuff animals first
- Give positive feed back
- Use distraction with talk

8. Approaching the Pediatric Patient (continue)
School-Age Children
- If older school age, ask if ok if parents present
- Head – to – toe assessment
- Offer as many choices as possible
- Demonstrate how to use equipment & let them
use it
- Teach about how body works

9. Approaching the Pediatric Patient (continue)
Adolescents
- Cover body parts not being examined
- Offer privacy when changing – if safe!!!!
- Ask if ok if parents present during perineal/
genital area exam/care.

10. Vital Signs & Measurements
Miscellaneous Facts re: Vital Signs
- Respirations: observe/feel abdomen < 6 years old
- Pulse: Auscultate apical pulse 1 full minute
- BP: Appropriate cuff size
Use same extremity (if possible) every time
- Temperature:
Oral: 1 minute
Axillary: 3 minutes
< 7 years old axillary method preferred
* Notify if <97 or >100.5
*Oral, axillary, or rectal – which is most accurate??

11. Vital Signs & Measurements BLOOD PRESSURE
Correct cuff
- Too large = low BP
- Too small = high BP
Cuff 50-75% length of extremity
Cuff bladder 40% of circumference of extremity
Check all extremities if cardiac issues
Toddler’s/preschoolers – take BP last
- Tell child your giving arm a squeeze

12. Vital Signs & Measurements (Continue)
Height: cm (2.4cm in an inch)
- >2 yo: Feet flat on floor if standing (straight), no
shoes
- < 2 yo: Top of head to sole of feet (laying flat)
Rules of thumb:
Average newborn length: Males: 20 inches
Females: 19.5 inches
Birth length increases 50% by end of 1st year
Birth length takes 4 years to double
Birth length triples by adolescent years

13. Height (continue)

14. Vital Signs & Measurements (Continue)
Weight: kg (0.45kg in 1 pound)
- Clean scale before/after use
- Lay sheet down if weighing on table scale
- Zero out scale after sheet application
Rules of thumb:
Average newborn weight: Males 7.5#
Females 7#
Weight doubles by 5-6 months
Weight triples by 1 year old

15. Vital Signs & Measurements (Continue)
Head circumference – done until age 2
- Wrap around head at supraorbital prominence, above ears & around occipital prominence

16. Vital Signs & Measurements (Continue)
Anterior Fontanel – Closes approximately 8-18 months
Posterior Fontanel – Closes approximately 1-2 months
* Assess through at least 2 years of age

17. Assessment - HEENT
Head circumference
Symmetry of face
Hair distribution
Trachea midline
Nasal passage patent
Lymph nodes
Light reflux – pupils
Eye size, spacing, color, drainage/discharge
Ear placement
Mouth – lips, teeth, gums, tongue, odor

18. Respiratory Assessment
Observe/touch abdomen to obtain respiratory rate if <6 yo – 1 full minute
Look: color, cap refill, chest expansion/retractions, nasal flaring
Check ease and depth: affected by emotion
Respirations irregular in infants/toddlers
- Newborn 30-50/minute
- Apnea in newborn (no breathing 20 seconds)
EMERGENCY!!!

19. Respiratory Assessment (continue)
Infants – nose breathers
Diaphragm (major muscle) – abdomen bulge with respirations
Intercostal & sternal retractions: TROUBLE!!!
Little thoracic expansion in infants
Color: cyanosis??

20. Respiratory Assessment (continue)
Little Lungs:
- 28 weeks: airway blood vessels development adequate
for gas transfer
weeks: sufficient surfactant
- Respiratory rate decrease with age d/t aveoli
development resulting in > lung volume
* Most codes/arrests at NCH are respiratory!

21. Respiratory Assessment (continue)
Adult stethoscope fine – diaphragm hears more high pitched sounds better
Listen after looking at chest
Rhonci – course continuous low pitched bronchial secretions
Wheezing – higher pitched (expiratory)
Rales – alveolar fluid
One side absent breath sounds??
One sided wheezing??? Foreign body??

22. Cardiovascular Assessment
Best to assess while asleep/mom’s lap
Assess color of body, pulses, edema
PMI:
Newborn – 7 years old (3-4th ICS)
> 7 years old (5th ICS)
Infant’s heart more horizontal in thorax

23. Cardiovascular Assessment (continue)
Apical – full minute (note activity)
Heart rate fluctuates with crying, eating, etc.
Check tachycardia when sleeping
Assess as much as possible as quietly as possible before awakes
Newborn /bpm Infants-2 years old /bpm
Listen with bell and diaphragm
Warm stethoscope!
Listen recumbent & then sitting up

24. Cardiovascular Assessment (continue)
Assess all pulses – radial hard to palpate in kids
Brachial/femoral most important: femoral usually stronger
- Weak femoral pulse: coarctation aorta
Quality – distinct vs. muffled
Intensity – loud vs. weak

25. Cardiovascular Assessment (continue)
Murmurs
Blowing, swishing d/t disruption of blood flow
* Takes practice to assess murmurs in children
Many innocent murmurs in children

26. Abdomen Assessment Assess shape Assess abdominal movement
-Infants – 6 years old breath with diaphragm
Auscultation (diaphragm) x 4 quadrants
Percussion (Supine)
- Dullness over organs
- Tympany over stomach/intestines
- Resonance
Palpation

27. Genital/Perineal Assessment
**** PRIVACY****
Often deferred
Explain what going to do
Assess:
Swelling
Bruising
Testicle – descended?
Discharge
Tanner Stage

28. Musculoskeletal Assessment
Assess upper/lower extremities for leg length discrepancies, skin fold asymmetry
ROM – active/passive
Muscle strength – meeting developmental milestones good indication of muscle strength/tone.

29. Nervous System Behavior: - calm, anxious, lack of interest
- does it correlate with developmental milestones
Communication skills:
- appropriate for age/developmental stage
Balance
Sensory Function:
- numbness, tingling, altered sensation

30. Infant reflexes Moro/Startle:

31. Palmer Grasp:

32. Plantar Reflex:

33. Stepping:

34. Tonic Neck/Fencing:

35. Rooting Reflex:

36. Skin assessment Temperature Moisture Turgor Mottling Mongolian spots
Café au late spots
Moles/birth marks
Acne
Eczema
Diaper rash
Burns/bruises
Pressure ulcer
Thrush
Cellulites
Stork bites
Port wine stains

37. Skin assessment (continue)

38. Skin assessment (continue)

39. Skin assessment (continue)

40. Skin assessment (continue)

41. Communication Speak clearly & simply - BUT APPROPRIATE FOR AGE!!!!
Don’t use to many wordy words or medical terms
Use simple sentences
Give genuine compliments
HONESTY!!!!!!

42. Honesty ** Be honest with children, especially regarding pain **
Each time you talk honestly with kids, trust develops
Be POSITIVE!!!!
- ie: Hold still like a statue vs. Don’t move
Keep promises
Answers to questions you don’t know – Say “I don’t know but will try & find out for you!”

43. Health Promotion
Anticipatory Guidance

44. Safety First Side rails Equipment concerns Medication risks
Parent/visitor badges
Equipment/supplies in bed
Car seat/safety harness

45. THE END – GOOD LUCK!!!!
While we try to teach our children all about life, our children teach us what life is all about.
Angela Schwindt