1. Physical Assessment of the Child
Chapter 34

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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.

10. 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

11. 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:
3 mo—2 yr:

12. 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

13. 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

14. 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 %
See how to use tables in Appendix E in Guidelines box on p. 900

15. 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

16. 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)

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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 In addition to vision and hearing, III, V, VII, X, XI, and XII are most commonly tested.

25. 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