chapter 33 peds physical assessment

Involve parents and allow pt to handle safe equipment

Head to toe

In parent's lap

No

Last

• Males - diaper
• Females - nothing

They feel stranger anxiety

They do not cooperate

Least to most invasive, be flexible and allow them to hold toys or medical equipment and explain things for them

Parent because their soothing techniques are familiar

• Allow them to participate
• Because they like showing what thy can do

Ask them questions they can answer

Drape over underpants or a colorful exam gown

School agr

Head to toe

The body and personal care

Straightforward and not condescending

Not usually

Ask the pt

Head to toe

In the middle of the exam

Puberty, normal development, and answer questions

Gown

Inspection, palpation, percussion, auscultation

Nurse uses their own sight and hearing

Nurse uses tools to see and hear

Like otoscope

Locating structures and masses

Warmth, texture, size, tenderness, mobility

Pads of fingers

Finger tips

Back of the hand

Palm

Apply pressure with fingertips and depress skin 1/2 to 3/5" and move fingers in a circular motion

• Surface depressed 1&1/2 to 2 "
• After light palpation

Identifying abdominal structures and masses

Use 2 hands to trap a mass or organ between them

Quick tapping of fingers or hands to produce sounds

To locate the position, size, and density of underlying structures

• Mediate/indirect
• Immediate
• Fist percussion

Finger of one hand placed against the body and finger of other hand acts as a hammer

Strike finger of one hand directly against the body?

Ulnar aspect of the fist is used to deliver firm blow directly to are

Diaphragm

Heart and breath sounds

Bell

Vascular sounds and BP

Pitch, intensity, duration, and quality

Hygiene, infection, some conditions

General survey

Get general info through observation about child's behavior, sex, race, physical appearance

Observe their interactions with child

Taking an accurate history

1. Complete/ initial history- data gathered from conception to current

2. Well/ interim history - data gathered from last well visit to current visit

3. Episodic/ problem oriented - info gathered about a current problem

• Statistical info
• Patient profile- regular habits
• Health history
• Family history
• Lifestyle and patterns - interactions with environment and social
• Review of systems

• 97.7 - 99.1 axillary
• 120-160 BPM
• 30-60 breaths/ minute
• 65/30 - 95/60

• Temp- 97.5 to 98.6 axillary
• Pulse - 80-125
• RR- 20-30
• BP- 91/52 - 104/66

• Temp - 97.5- 98.6 oral
• Pulse - 70-110
• RR 16- 22
• BP- 102/60 - 115/74
• BP-

Like adults

• 1. Chief complaint in child's words
• 2. Location on body
• 3. Quality- what problem is like for the child
• 4. Quantity - intensity of prob
• 5. Chronology - when began, frequency, course
• 6. Setting - where prob occurs
• 7. Aggravating and alleviating factors
• 8. Associated manifestations- other related info
• 9. Treatment- what has.been used to treat it

Axillary

Because of risk for injury, feces retains heat long after fever has go e, and invasive

What side it is taken from

Children around age 5 and up

Children younger than 2 years and those with irregular heart beat or known heart prob

3

• One minute
• To compensate for normal irregularities

Palpating the apical pulse

• Acute care settings
• All ages

Femoral, radial, and carotid

Anterior fontanel.

• Not abnormal
• Usually response to changes in respiration

Rate, depth, ease of respirations

• Infant- ABD excursion
• Toddler and up- thoracic excursion

One minute

Crowing noise heard on inspiration and louder over the neck

Croup or eppiglotitis

Partial Obstruction of airway

Delayed dev of cartilage in trachea or small larynx

Beginning at age 3

At least every day

Must be confirmed

Avg of 3 abnormal BP taken at Esperanto occasions

> 120/80

Elevated/ low BP reading

The cuff will squeeze/ give the arm a hug

Using dev appropriate pain assessment tool

Measuring human body and assessing nutrition, growth, and dev

Head circumference, height, and weight

Weight(lb) x 703 / height in inches squared.

Mid arm muscle circumference, ski fold thickness, weight

Rate of growth

When the child's height/ weight drops off their own growth chart

Lying down on flat measuring board

When the child is able to stand aline

• Measuring board- head is held to board a d footboard is moved to touch heels
• More accurate

Lay on paper and mark where heels and top of head are and measure with measuring tape

Same as adult

May be slightly differnet

Zeroed or balanced

Naked on a baby scale

Like adults in nothing but underwear

All age birth to 36 months and all above 3 with questionable head size macrocephaly or microcephaly

No stretch measuring tape around largest part of head/ forehead

1.2

Rate of dev, nutritional status, hydrocephalus

Abnormal accumulation of CSF

Chest

1 year

Tape measure around chest at nipple line and measurement taken b/t inspiration and expiration

Total body fat

Calipers

Muscle and fat

Measure midpoint between acromion and olecranon and record in cm

With arms loosely at sides grasp skin gold at posterior midpoint of arm , ask child to flex muscle, take reading with. Alipet

When the child flexes the it is felt

• WHO 0-2 years
• CDC children 2 & over

Because WHO charts are based on breasted infants and show what growth should be

Girls and boys

Length, weight, head circumference, and length to weight relationship

Overweight/ obesity

Height, weight, and BMI

2-20

Premature, down syndrome, other conditions that affect growth

• Horizontal
• Vertical

• 97th
• 3rd

Serial head circumference measurements

85th to below 95th

95th

Inspection and palpation

Color, texture,turgor, and lesions

• dusky red or violet
• Black
• Diffusely darker

Determine normal skin color and compare

Acanthosis nigricans

Darker, thicker skin in folds (posterior neck, behind knees and elbows, and in armpits )

Areas of depigmentation

Areas of increased pigmentation

• Yellow skin
• Sclera/ whites of eyes

• Blue skin
• Mucous membranes of the mouth especially under tongue

• Orange skin
• Palms and soles of feet

Loss of skin color?

Red skin

Discolored areas of skin

Moisture, temp, texture, turgor, edema, and lesions

Because it is more sensitive to temp

Compare 2 sides of the body

Abdomen and upper arm

Extremities and buttocks

On the eyelids

Configuration, distribution, color, and size

Primary- arise from normal skin ( freckle)

Secondary - results Tom an alteration in primary lesion (scab)

Arrangement/position of several lesions in relation to each other or arrangement of a single lesion

Location on body and symmetry or asymmetry of lesions

Palms, soles of feet, genitalia

Texture, changes in color, unusual distribution, cleanliness

• Endocrine
• Nutrition

Excessive hair growth

Unusual hair loss

Scratching

Observe index finger for bulging up of nail

Put nails together and see diamond

160

• < 2 seconds
• Anemia
• Peripheral edema
• Vasoconstriction
• Decreased cardiac output

Inspection and palpation

Head and neck, supraclavicular, axillary, arms, inguinal

Enlarged, warm, firm, and fluctuant

• Sentinel node
• Wilms tumor or other neoplasticism disease

the abnormal proliferation of benign or malignant cells. neoplastic

Inspection and palpation

Symmetry, paralysis, weakness, and movement

Palpate

Around 6 mo

Paralysis and weakness of neck muscles

Infant in supine position

Pulling infant up by arms

Several seconds

Weak neck muscles

6 mo

Neuromuscular probs/ cerebral palsy

Full ROM - up, down, side to side

Size, tenseness, and pulsation

2-3 mo

5

12-24

Dehydration

Increased intracranial pressure.

Premature closure of the anterior fontanel

Cannot palpate it

Coughing, crying, vomiting

Inspection and palpation

Symmetry, size, and shape

Related to use/ disuse of neck muscles

Some chromosomal disorders

Down syndrome, trisomy

Identify the isthmus of the thyroid across the trachea

Displace thyroid gland and palpate with other hand

Having the child swallow

Inspection and palpation

Dysmorphic features

Size, position, and configuration

Eyes are wide spaced

Eyes close together

Shallow crease or absence of crease below nose

Auricle of the ear does not cross or touch the eye- occupy line

10

• V- trigeminal nerve
• VII- facial nerve

Trigeminal nerve- face sensations, chewing, and biting

Observe chewing and sucking / touch child's cheeks and forehead with a cotton ball & child should move head or bat it away

Facial nerve- motor control of most muscles of facial expression

Ask child to frown, smile, or make a face / have child puff out cheeks or whistle

Gloves

Color, amount, consistency

Occlude one side and have them sniff

Allergies

I - olfactory

Close eyes, occlude one nostril, have them ID a familiar smell

Color and moisture

Smooth, moist, & bright pink

Pale and boggy

Erythematous and swollen

Yellow or green

Frontal and maxillary

Swelling and color

Inflammatory response

Press over sinus under eyebrow

Pressing upward with thumbs under the maxillary bones

At the end because it may stress them

From anterior structures to interior

• Notch b/t nose and
• Mouth

Gloves

Tongue blade and pen light

Inspection, palpation, and sense of smell

Symmetry, color, moisture, cracking, and lesions

Attaches lips to gums

Hold cheeks open with tongue blade

Color, nodules, and lesions

Buccal mucosa opposite the upper second molar

Number, cavities, formation, and occlusion

6 mo

30 mo

Excessive ingestion of fluoride

Color and swelling

Sublingual frenulum, sublingual ridge, & wharton's ducts

Hold child's cheeks

Hypoglossal nerve- to the movement

Stick out tongue as though licking a lollipop and observe for sideways movement

Put finger on cheek and have them press tongue against it

Should be equally strong on both sides

Allow infant to suck on gloved finger while palpating hard palate

Glossopharyngeal nerve- swallowing, taste on back of to gue

Vagus nerve- breathing, speech, gag reflex

• Ask child to say ah
• Soft palate and uvula should rise symmetrically & phonation of ah is understood

Depress tongue with blade

Slide along side of to tongue until reach soft palate then compress tongue to elicit gag reflex and observe back of throat

Enlarged tonsils

Inspection, palpation, visual accuity, extraocular muscle function

Black and white images, contrasting figures, or faces

4 weeks

3

Lea chart, tumbling E, HOTV matching test

3-5

Amblyopia

Loss of one eye's ability to see details

" lazy eye"

Use HOTV matching- stand 10 feet back, give child cards and have them match them to the chart

• 20/40
• 20/30

Correctly ID 4 of 5 letters

Snellen chart- 20 feet away, both eyes, then one at a time, begin at the line for 40 feet unless child is known to have vision problems

Do test without them then with

Until child misses half plus one of the letters

Correctly ID letters for 20 feet at a distance of 20 feet

Can see at 20 feet what the avg child sees at 40 ft

5

Recessive x-linked trait

Only one x chromosome

Ishihara charts- have patterns that cannot be seen by color blind

Optic nerve- vision

Cover one eye and bring an object from behind until child is able to see it in peripheral vision

Corneal light reflex/hirschberg

Field-of-vision test

Cover/uncover test

Test binocular vision and presence of strabismus

Shine light directly onto irises from 16 in away, reflection of light should appear in same spot on both eyes

Eyes are malaligned

May give false malalignment

• Normal
• Oscillation of eye

May not cooperate

Kids < 5

III, IV, & VI

Abducent nerve- abducts eye

Trochlear nerve

Downward and inward movement of the eye

Oculomotor nerve- most eye movements, pupil construction, keeping eyelid open

Movement of the eye

Amblyopia & strabismus

Asian

Have child look down, palpate outer part of upper lid along bony prominence for swelling or redness

Tear duct

Infants

Not unless there is a problem

Shine a light across them

Shine a light across the eye from temporal side,

Contract or expand

CNS injury

Dim the lights

Hearing, external exam, otoscope exam

At time of birth & before discharge

Have parent stand behind them and speak and observe their response

4

Tests hearing with beeping noise

• Hearing losses
• Extent of loss

Preschool and school age

Stand 2 ft behind child & whisper numbers/ letters (or a sentence for preschoolers) and have them repeat it

Preschool- adolescents

Tuning fork test

>

Determines whether air conduction is greater than bone conduction

Determines ability to hear by bone conduction

Inspect for abnormalities, note any discharge, pull auricle to see any discomfort, palpate mastoid process

Tympanic membrane

Largest that will comfortably fit

• Pinna down and back
• Pinna up and back

All 4

Abnormal breath sounds, sputum, RR & pattern,

Rounder

Pectus carinatum/ pigeon Chest

Pectus ecavatum / funnel chest

Scoliosis- s curve of thoracic and lumbar vertebrae

Posterior chest

Stay in view

Tenderness, tactile fremitus, and chest excursion

Airway alterations

Intensity, pitch, quality, & duration

Upright

To the side of pt

Head bent forward and hands folded in front

Open mouth and breathe in and out, blow bubbles, pretend to blow out candles

Fluid in airways, discontinuous, crackling heard during inspiration and not cleared with coughing


Rales, crepitation

Like rubbing leather together.

Musical squeaking mostly on expiration , coughing may change the sound

Narrowing of air passages for fluid, swelling, spasm, or tumors

Musical snoring moaning sounds

More predominant on expiration

May clear some with coughing

Sonorous wheeze

Inspection, palpation, and auscultation

Aortic area, pulmonic area, right ventricular area, apex, and epigastric area

Right second IC space

Left second intercostal space

Left sternal boarder

Fifth left IC space in midclavicular line

below the xiphoid process

more horizontal in thorax, apex is 1 - 2 IC spaces above the 5th IC space and lateral to the midclavicular line

second rib is attached to sternum just below or at the sternal angle so locate the sternal angle

anterior chest overlying the heart and great vessels

bulges, lifts, heaves, and apical impulse

7

presence of pulsations at each area

point of maximal impulse / apical pulse

at the 4th IC space lateral to the midclavicular line

palmar

palpable vibrations of the heart

supine, lateral recumbent, and sitting up

at the apex of the heart in the tricuspid and mitral area

at the base in the aortic and pulmonic area

closing of the mitril and tricuspid valves

closing of the aortic and pulmonic valves

considered normal in children

pulmonic area

• 1. rate and rhythm
• 2. ID S1 and S2
• 3. Assess S1 & S2 separately & determine
•      where they are best heard
• 4. Listen for extra sounds
• 5. ID murmurs

inspiration

expiration

have the pt hold breath during heart auscultation if possible

opening snaps, ejection clicks, midsystolic to systolic clicks, and murmurs

short, high-pitched sounds heard with valve disorders that are not affected by respirations

lowing, swooshing sounds that occur because of turbulence of the blood flow in the heart

bell of stethoscope

innocent or functional heart murmurs

along the left sternal boarder

do not radiate, & change with position

rate, rhythm, elasticity of vessel wall, & equal force of bilateral pulses

opposite side to side and lower extremity to upper

Z

aortic, pulmonic, tricuspid, mitral

estrogen crossing placenta

breast development

beginning of puberty in girls

as early as age 7

if it has just occurred

once they have reached menarche

3 to 4 days after menses because less tender

enlargement of breast tissue

adolescent boys during puberty

empty bladder, warm hands, and supine position with knees flexed

inspection, auscultation, percussion, palpation

contour, symmetry, umbilicus & skin condition, pulsations or movement, and hair distribution

profile of the abd from rib margin to the pubic bone

looking across the abdomen

• scaphoid - emaciated or malnourished
• flat - thin
• rounded - normal appearance of abd in young child
• protuberant - distention with flatus, obesity, pregnancy if old enough

protruberant

no

diaphragm

lower right

aortic, renal, iliac, and femoral arteries

bell

epigastric region and around the umbilicus

ID mass or tenderness & determine size, consistency, and location of organs

Have them help with the palpations, have them breathe deeply

• 1. lightly palpate abd no more than 1 cm deep
• 2. Repeat with deep palpation 5 - 8 cm beginning in right lower quadrant

Wait for the child to breathe and should go away if voluntary

acute inflammation of the peritoneum

skin turgor, femoral pulses, and inguinal lymph nodes

rebound tenderness test

place hand perpendicular to the abd away from tender area, push down deeply and lift quickly

will cause severe pain with peritoneal inflammation

tell child what you are going to do, get parent's permission, inspect peniscompress glans between thumb and forefinger and evaluate meatus, inpect scrotum, palpate scrotum,

no, need further oppurtunities for communication

gloves

5 to 6

infant/young - proximal is wider and distal narrower

adolescent is opposite

have the boy sit cross legged

testes withdrow into the inguinal canal

 testicular self examination

drape pt, gloves, visual inspection and gentle palpation

bones, muscles, joints, ligaments, cartilage

observe them playing and doing physical activities and ROM

Denver Developmental Screening Test II (DDST - II)

head to toe

varus deformity - medial adduction or turning inward

valgus deformity - medial abduction or turning outward

• overuse injuries like sprains
• sports requiring repetitive motions - swimming, gymnastics, skating, and running

skull, extremities, and ribs

scoliosis, kyphosis, and lordosis

2 mo

compare leg lengths

baby's feet placed flat on table and knees flexed up - top of knees should be same height

lordosis

pronation

child walks on the lateral side of the foot

usually corrects itself by age 3 years

bowleg - space of more than 2.5 c is measured b/t knees as the ankles are held together

• walk
• 3

more than 2.5 cm remains b/t medial maleoli (ankles) when knees are held together

 between ages 2 and 3 1/2

should stay level

• spine
• kyphosis

excessive inward curvature of the spine

• bowing / rounding of spine
• hunchback

poor posture

9 - 15

child bends forwrd with shoulders dropping and arms hanging and nurse looks for unilateral elevation of the lower thoracic ribs and flank

observe them moving, do passive ROM if problem is observed, How is the motor segment of cranial nerve V / trigeminal nerve evaluated?

apply pressure to temporalis muscle while child clenches the teeth

assessing the strength of the sternocleidomastoid and trapezius muscles during rotation of the head from side to side and chin to shoulder

measure the muscle

at greatest circumfernce

temp, tenderness, crepitation, swelling, and masses

fatigue, stiffness or weakness, heat and redness

2 wks - 2 months

2 mo

3 - 6 mo

3 - 6 mo

3 - 6 mo

by 7 months

by 9 mo

6 to 9 mo

by 11 mo

by 12 mo

walks holding onto something or supported by something

12 mo

15 mo

stance - heel strikes the floor, weight is transferred to the ball of the foot, and toes push off the floor

swing- foot is off the floor

degree, type, and location of NS lesions

DDST - II

apnea, loss of consciousness, and seizures

very young children may have nonspecific symptoms - irritability, recurrent vomiting, fever, and loss of appetite

cerebral function, cranial nerves, and cerebellar functioning

cognitive function - appearnce, behavior, orientation, speech patterns, memory, logic, and affect

history of behavior etc from caregiver

evaluation of older child/ adolescent LOC, thought, and communication

alert, lethargic, obtunded, stuporous, or comatose

awake and aware of surroundings

sluggish and drowsy and has to work to focus on surroundings

unconscious and only able to be aroused with strong physical stimuli - loud noises/pain

unconscious and unable to be aroused

sleep-like state and cannot be aroused

attention span, communication, perceptual problems, and emotional withdrawal and depression

proprioception, balance, and coordination

have child perform specific movements

first without resistance then with

corresponding muscles on 2 sides are compared

in the first year of life

findings that indicate child is unable to perform activities r/t its age

learning disorders

because children with med, mental, or emotional probs may have same signs

ask parent/child if there are any questions

document findings

• short att span
• poor motor coordination
• clumsiness
• frequent falling
• hyperkinesis
• uneven perceptual development
• no dominant side
• language disturbances
• movements involving more muscles than intended

absence of the sense of smell

loud, high-pitched sounds normally heard over trachea and large bronchi

medium - pitched and quieter sounds heard over the main-stem bronchi

blowing or swishing sounds = turbulent blood flow through a BV

membrane of the eylids and sclera of the eye

• 1.  bulbar - covers cornea and front part of sclera
• 2. palpebral - lines eyelids and appears red b/c of vascularity

dry, crackling or grating sound

• 1. fluid in the alveoli of the lungs
• 2. bone rubbing against bone
• 3. air in SQ tissue

scratching or squeaking sound during I & E and does not clear with coughing

posture, position, & build of the body

portion of an organ protrudes through somewhere it isn't supposed to

convex curvature of the thoracic spine

hunchback

chest rises with heart beat (systole/contraction)

enlarged heart possible

AKA heave

contraction

heart sound caused by vascular turbulence usually

narrowed or leaking heart valves

skin crevice b/t nose and mouth

involuntary rhythmic rapid movement of eyeball

opening b/t 2 eyelids

anterior surface of the body over heart and stomach

(epigastric region + inferior thorax)

drooping of the upper eyelid

discontinuous, usually inhalation, from fluid in alveoli or collapsed alveoli popping open

fine crackles

backflow of blood through heart valves due to abnormal closing of the valves

snore in throat or bronchial tubes due to partial obstruction/ secretions

shaped like a boat

lateral deviation of the spine

sinus dysrhythmia

enlarges passage in body

abnormal narrowing of a body passage or BV

stridor

walking a straight line

pointing a light at something from an angle

vibration felt on palpation

contracture of the neck/cervical muscles

bell-like sound heard during percussion of an area that contains air or gas such as stomach or intestines

vesicular

CG

to the nearest half ounce

to the nearest 1/4

body image and eating disorders

nearest 1/8

infants up to 36 months old and beyond if there is a reason

32-38 in

33%

body temp is usually higher in infants and slowly lowers with age

1. hypoxia

2. hypothermia

apical rate

• 2 mo 90-100
• 6 mo 80-180
• 1 year - 75-155

2

70 - 110

55-90

pneumonia

10

35-35

22-25

19 - 22

12

hold arm above level of heart and press nailbed or press on heal

spots on bottom of dark-skinned infants that are harmless

abd

18 months