Physical Assessment of the Child Chapter 34

Goals of Pediatric Assessment Minimize stress and anxiety associated with assessment of various body parts. Foster trusting nurse-child-parent relationships. Allow for maximum preparation of child. Preserve security of parent-child relationship. Maximize accuracy of assessment findings.

General Approaches Toward Examining the Child Head-to-toe sequence for assessing adult clients; however, sequence for pediatric assessments generally altered to accommodate child’s developmental needs Understand child’s perception of painful procedures Save invasive and painful procedures for last Expect success Room should be private and decorated acc’d to age Have toys and games available if possible

Preparation of the Child Use non-threatening approach Tell child what will happen within their scope of understanding Cooperation usually enhanced with parent’s presence unless an adolescent, then give choice Provide time for play and to become acquainted Begin with games and non-invasive procedures

Preparation of Child cont’d Allow child to handle or hold equipment and encourage child to use equipment on doll, family member or examiner Perform exam in parent’s lap if necessary Do as much as possible first without touching Examine painful, invasive, and private areas last

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

Lack of Readiness Talk to parent for a while Talk to child by way of a transition object Make complimentary remarks about the child (consider cultural differences) Tell a funny story or do a magic trick

Lack of Cooperation Assess what the reason is Try to involved the parent and child Avoid prolonged explanations of the procedure Use a firm, direct approach with a calm and gentle voice Gently restrain the child Proceed as quickly as possible

Growth Recumbent length for infants up to age 36 months + weight and head circumference Standing height + weight after age 36 months Plot on growth chart by gender and prematurity if appropriate <5th or >95th percentile considered outside expected parameters for ht, wt, head circ.

Growth Ethnic differences Expected growth spurts at various ages Use of skin fold thickness and arm circumference for evaluation of body composition of muscle and adipose tissue Significance of head circumference measurements

Temp and Pulse Temp not outside adult parameters. EBP shows that rectal is gold standard Should do apical x 1 min <2 years. Radial acceptable over 2 years. Rapid pulse—close eyes and tap fingers Grading scale is slightly different (897). Absence of femorals is significant. Normal rates (other ages not outside adult parameters): NB—3 mo: 100-200 3 mo—2 yr: 70-150

Respirations Respirations: infants are abdominal. Should be taken for 1 min due to irregularity in infancy and childhood. NB 35; 1 yr 30; 2 yr 25; 4 yr 23; 6 yr 21; Reaches adult rate of 20 by age 8 yrs

Blood Pressure Do one for baseline during first 3 years, comparing upper and lower extremities to rule out defects. Usually not done routinely under 3 unless child has cardiac condition. Do annually from 3 to 18, unless child is high-risk Prehypertension is risk in obese children Normal ranges are based on gender, age, and height

Blood Pressure cont’d Average BPs are found in first column of Table 34-5 p. 898 Dinamaps are best to eliminate errors and hearing probs Fit and proper size in Figure 34-11—most important criterion for accuracy. Cuff selection—bladder width 40% of MAC; length 80-100% See how to use tables in Appendix E in Guidelines box on p. 900

Sequence of Infant/Toddler VS Measurement Count respirations FIRST (before disturbing the child) Count apical HR SECOND Measure BP (if applicable) THIRD Measure temperature LAST—especially if rectal Temp and BP order may be interchangeable if route is not rectal

General Appearance and Skin Facial expression Behavior Speech Motor, coordination Hair, nails, hygiene give many clues to care of child Skin: assessing color differences (901)

Head and Neck Fontanels—posterior closes 2 months; anterior between 12 and 18 months Neck suppleness vs nuccal rigidity Head lag—control by 4 months Lymph nodes—larger in children; small, nontender, movable nodes usually normal. Tender enlarged nodes usually indicate inflammation or infection close to their location. Hard, immovable, nontender nodes usually ominous sign

EENT Eye slant, folds, symmetry, redness, vision (cranial nerve II); color established between 6 and 12 months Ear placement, restrain for internal ear exam; hearing test (cranial nerve VIII) Deviated septum Inspect palate and lip for cleft Teeth condition; number = age of child in months minus 6 Mucous membranes Tongue protrusion Tonsils bigger than adults

Chest and Lungs Chest—size, shape, symmetry, movement, breasts. Barrel or pigeon chest indicates respiratory condition Lungs—generally vesicular; inspiration easier to hear; ask child to play blowing games

Heart Think of perfusion issues All murmurs should be reported to HCP PMI at 4th ICS until 7 yrs, then 5th S1 synchronous with carotid Sinus arrhythmia, physiologic split S2 and venous hum are all normal

Abdomen Inspection, auscultation, palpation (see Atraumatic Care) Inspect for umbilical and inguinal hernias Minimize tickling sensations by having child put hand on top of examiners Give infant bottle or pacifier during exam

Genitalia Check for development—hair distribution Descent of testicles (cryptorchidism) Meatus—midline? Circumcision—if not, do not force foreskin back Abuse—bruising, tearing, fissures, redness, swelling, discharge No internal exam unless sexually active Note symmetry of gluteal folds Check for anal reflex

Back and Extremities Check for curvature of spine Count fingers and toes to detect polydactyly or syndactyly Bow-legs (genu varum); feet together—knees 2” apart Knock-knees (genu valgum); knees together—ankles 3” apart Check for pigeon toe (toeing in) Check for symmetrical folds in thighs

Neurological Assessment can be done using fun games Cerebellar function (balance and coordination): balancing on 1 foot; heel to toe walk; finger-to-thumb test; Romberg; finger-to-nose test Reflexes: patellar, triceps, biceps, achilles Cranial nerves: Table 34-13. In addition to vision and hearing, III, V, VII, X, XI, and XII are most commonly tested.

Sequence of Examination Do non-invasive, fun things first Vision, hearing testing and neuro exam first Other things that do not require undressing (extremities, VS, etc) Save ears, throat, rectal temps, genitalia for last