Chapter 32 Health Assessment Part E

Performing a Physical Examination Genitalia and anus Male Female Anus

Genitalia: Male: circumcised?, meatus, scrotum, testes (avoid cremasteric reflex; use of translumination), inguinal hernia, stage of development Female: labia, clitoris, meatus, vaginal orifice, stage of development Anus: may be examined for reflex and patency

male genitalia: full term newborn, uncircumcised

Palpating Testes Normally felt as small Palpating Testes Normally felt as small. Ovoid bodies in each scrotal sac. May take time to descend. in Figure 06-38.   A, Preventing cremasteric reflex by having child sit in “tailor” position. B, Blocking inguinal canal during palpation of scrotum for descended testes. Circumcised male

To prevent the testes from retracting during the exam, place fingers over inguinal canal.

absence of the testicles in the scrotum few rugae in the scrotum in the preterm newborn

Stages of development for male genitalia.

Stages of female development for pubic hair.

Female Genitalia

Anatomic structures of the female genital and perineal area

Sexual maturity rating: These scales are used to rate sexual maturity in males and females.

Performing a Physical Examination Musculoskeletal Clavicles and shoulders Spine Extremities Neurologic Level of consciousness Balance and coordination Sensory testing Reflexes

Back, Extremities and Joints 8 months: sits without support; spine is straight Normal spine is straight Marked curvatures, like scoliosis (lateral) are abnormal

Figure 06-40.  Bowleg (genu varnum) Toddlers may be bowlegged after beginning to walk but will correct. If present beyond 2-3 years (space between knees greater than 2”/5cm) will need treatment with a brace.

Knock-knee (genu valgum) Normal in children 2-7 years. Figure 06-41.    Knock-knee (genu valgum) Normal in children 2-7 years. May need treatment if persists with correction braces worn day & night

Examining Hips of Infant equal hip abduction with knees nearly touching exam table = normal

Joint Assessment Ortolani-Barlow maneuver: position infant as shown, knees pressing together, downward pressure on one femur at a time Allis Sign: flex the infant’s hips and knees heels close to buttocks, place feet on exam table a difference in knee height

Reflexes of the Newborn/Infant Blinking: to bright lights or object coming close to eyes Sneeze: present throughout life Sucking: sucking movements of circumoral area to stimulation Gag and rooting Yawn and Cough Grasp Remember these reflexes in the newborn? When assessing the newborn/infant, check for these reflexes if appropriate for age.

More Newborn Reflexes Plantar reflex: Plantar flexion = normal after 2 y.o. Babinski response normal in children under 2 y.o., abnormal after. Moro: extension and abduction of extremities with jarring Startle: abduction of arms with elbow flexion with noise Tonic Neck: when head turned to one side, arm and leg on that side extend, opposite arm and leg flex

Neurologic Assessment: Cerebellar Function and Reflexes Test balance and coordination Finger-to-nose test Coordination tests: can be done with cooperative 6 y.o. and older Finger-to-finger test Heel-to-Shin test

stand with feet together, eyes Romberg procedure: stand with feet together, eyes closed, arms by side Remain close to child in case they fall Overall Function Watch for balance, coordination, gait and fine and gross motor skills as child moves

Reflexes as Child gets Older Figure 06-42. Testing for triceps reflex Reflexes as Child gets Older Figure 06-42.   Testing for triceps reflex. Child is placed supine, with forearm resting over chest, and triceps tendon is struck. Alternate procedure: child's arm is abducted, with upper arm supported and forearm allowed to hang freely. Triceps tendon is struck. Normal response is partial extension of forearm.

Figure 06-43. Testing for biceps reflex Figure 06-43.   Testing for biceps reflex. Hold child's partially flexed elbow in palm of hand with your thumb over antecubital space. Strike thumbnail with hammer. Normal response is partial flexion of forearm.

Figure 06-44.   Testing for patellar (knee jerk) reflex using distraction. Child sits on edge of examining table (or on parent's lap) with lower legs flexed at knee and dangling freely. Patellar tendon is tapped just below kneecap. Normal response is partial extension of lower leg.

Figure 06-45. Testing for Achilles reflex Figure 06-45.   Testing for Achilles reflex. Use same position for eliciting knee jerk reflex. Support foot lightly in your hand and strike Achilles tendon. Normal response is plantar flexion of foot (foot pointing downward, or “planting” toward floor).

The ability to Assess our patients is one of the most important skills a nurse can develop. Nurses are with the patient more than any other health professional, so it is vital we know the normal parameters for the child based on age and recognize signs and symptoms that indicate the need for interventions and referral. Our goal is to keep children healthy and safe or return them to a state of maximum health. I LOVE pictures of children – can you tell!

The End