1. Physical Assessment of Children Depending of Age

2. Physical Assessment of Infant
Assessment is NOT in the head-to-toe manner
When quiet, auscultate heart, lungs, abdomen
Assess heart & respiratory rates before temperature
Palpate and percuss same areas
Perform traumatic procedures last
Elicit reflexes as body part examined
Elicit Moro reflex last
Encourage caretaker to hold infant during exam
Distract with soft voice, offer pacifier, music or toy
Rooting-Touch/stroke cheek side of mouth-3-4 months; Extrusion-touch tongue force outward-4 months, plantar, Grasp-touch palms of hand/soles of feet/flexion 3-8months, Babinski-Stroke outer sole of foot upward from heel and across ball of foot- 1 yr, Tonic neck on back-1 arm and leg flexed on one side of body, other extended; Dance – Hold under arms and let feet touch hard surface-3-4 months, Crawl- place on abdomen-6 weeks, Moro-Sudden jarring/change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers ; 3-4 months; “startle”-Sudden loud noise causes abduction of arms with flexion of elbows/hands clenched – 4months

3. Physical Assessment of Toddler
Inspect body areas through play – “count fingers and toes”
Allow toddler to handle equipment during assessment and distract with toys and bubbles
Use minimal physical contact initially
Perform traumatic procedures last
Introduce equipment slowly
Auscultate, percuss, palpate when quiet
Give choices whenever possible
Photo Source: Del Mar Image Library; Used with permission

4. Physical Assessment of Preschooler
If cooperative, proceed with head-to-toe
If uncooperative, proceed as with toddler
Request self undressing and allow to wear underpants
Allow child to handle equipment used in assessment
Don’t forget “magical thinking”
Make up “story” about steps of the procedure
Give choices when possible
If proceed as game, will gain cooperation
Photo Source: Del Mar Image Library; Used with permission

5. Physical Assessment of School-Age Child
Proceed in head-to-toe
May examine genitalia last in older children
Respect need for privacy – remember modesty!
Explain purpose of equipment and significance
Teach about body function and care of body

6. Physical Assessment of the Adolescent
Ask adolescent if he/she would like parent/caretaker
present during interview/assessment
Provide privacy
Head-to-toe assessment appropriate
Incorporate questions/assessment related to
genitals/sexuality in middle of exam
Answer questions in a straightforward, non-
condescending manner
Include the adolescent in planning their care

7. Pain Assessment

8. Pain
“Pain is whatever the experiencing person says it is, existing whenever the person says it does.”
McCaffery and Pasero, 1999
This includes VERBAL and NONVERBAL expressions of pain

9. Pain Facts and Fallacies
FACT: Children are under treated for pain
FACT: Analgesia is withheld for fear of the child becoming addicted
FALLACY: Analgesia should be withheld because it may cause respiratory depression in children
FALLACY: Infants do not feel pain

10. Principles of Pain Assessment in Children: QUESTT
Question the child
Use a pain rating scale
Evaluate behavioral and physiologic changes
Secure parent’s involvement
Take the cause of pain into account
Take action and evaluate results

11. Pain Rating Scales
Not all pain rating scales are reliable or appropriate for children
Should be age appropriate
Consistent use of same scale by all staff
Familiarize child with scale

12. Pain Scales FACES pain rating scale Numeric scale FLACC scale
Facial expression
Legs (normal relaxed, tense, kicking, drawn up)
Activity (quiet, squirming, arched, jerking, etc)
Cry (none, moaning, whimpering, scream, sob)
Consolability (content, easy or difficult to console)

13. Nonpharmacologic Interventions
Based on age
Swaddling, pacifier, holding, rocking
Distraction
Relaxation, guided imagery
Cutaneous stimulation

14. Anesthetics: Topical and Local
Major advancement for atraumatic care
EMLA
NUMBY stuff
Intradermal local anesthetics
Importance of timing

15. Analgesics Opioids NSAIDs “Potentiators”
Lytic cocktail (DPT)—Demerol, Phenergan, and Thorazine
Co-analgesics, amnesics, sedatives, etc.
Role of placebos

16. Dosage of Analgesia Based on body weight up to 50 kg
Concept of “titration”
Ceiling effect of non-opioids
First pass effect
PCA

17. Fears of Bodily Injury and Pain
Common fears among children
May persist into adulthood and result in avoidance of needed care

18. Pain Assessment: Infants
Assessment of pain includes the use of pain scales that usually evaluate indicators of pain such as cry, breathing patterns, facial expressions, position of extremities, and state of alertness
Examples: FLACC scale,
NIPS scale

19. Young Infant’s Response to Pain
Generalized response of rigidity, thrashing
Loud crying
Facial expressions of pain (grimace)
No understanding of relationship between stimuli and subsequent pain

20. Older Infant’s Response to Pain
Withdrawal from painful stimuli
Loud crying
Facial grimace
Physical resistance

21. Pain Assessment: Toddlers
Toddlers may have a word that is used for pain (“owie,” “boo-boo,” “ouch” or “no”); be sure to use term that toddler is familiar with when assessing.
Can also use FLACC scale, or Oucher scale (for older toddlers)

22. Young Child’s Response to Pain
Loud crying, screaming
Verbalizations: “Ow”, “Ouch”, “It hurts”
Thrashing of limbs
Attempts to push away stimulus

23. Pain Assessment: Preschoolers
Think pain will magically go away
May deny pain to avoid medicine/injections
Able to describe location and intensity of pain
FACES scale, poker chips and Oucher scale may be used
Photo Source: Del Mar Image Library; Used with permission

24. School-Age Child’s Response to Pain
Stalling behavior (“wait a minute”)
Muscle rigidity
May use all behaviors of young child

25. Pain Assessment: Older Children
Older children can describe pain with location and intensity
Nonverbal cues important, may become quiet or withdrawn
Can use scales like Wong’s FACES scale, poker chips, visual analog scales, and numeric rating scales

26. Adolescent Less vocal protest, less motor activity
Increased muscle tension and body control
More verbalizations (“it hurts”, “you’re hurting me”)
Start pg 674

27. Let’s Review
The nurse begins a full assessment on a 10 year-old patient. To ensure full cooperation from this patient it is most important for the nurse to:
A. Approach the assessment as a game to play.
B. Provide privacy for the patient.
C. Encourage the friend visiting to stay at the
bedside to observe.
D. Instruct the child to assist the nurse in the
assessment.

28. Let’s Review
During a routine health care visit a parent asks the nurse why her 10 month-old infant is not walking as her older child did at the same age. Which response by the nurse best demonstrates an understanding of child development?
A. “Babies progress at different rates. Your infant’s
development is within normal limits.”
B. “If she is pulling up, you can help her by holding her
hand.”
C. “She’s a little behind in her physical milestones.”
D. “You can strengthen her leg muscles with special
exercises to make her stronger.”

29. Let’s Review
When assessing a toddler identify the order in which you would complete the assessment:
Ear exam with otoscope
Vital signs
Lung assessment
Abdominal assessment

30. Let’s Review
When assessing pain in an infant it would be inappropriate to assess for:
Facial expressions
Localization of pain
Crying
Extremity movement