Physical Assessment

Physical Assessment 150 150 Tony Guo

Physical Assessment

  • Anthropometric Measurements
    • Height, weight, and circumference
      • Weigh the child, taking two measurements and averaging them
    • Calculate BMI
      • BMI= weight (kg)height (m)2
    • BMI under the 5th percentile indicated the child is underweight
    • BMI over the 85th percentile correlates with overweight
    • Measure the infant’s head circumference (up to age 2 to 3 years)
  • Examination techniques
    • Inspection
      • Purposeful observation of the child’s physical features and behaviors during the entire physical examination
      • Physical feature characteristics include size, shape, color, movement, position, and location.
      • Adequate lighting is essential
      • Detection of odors is also a part of inspection
    • Palpation
      • Use of touch to identify characteristics of the skin, internal organs, and masses.
      • Characteristics include texture, moistness, tenderness, temperature, position, shape, consistency, and mobility of masses and organs
      • The palmar surface of the fingers and the fingertips pads are used for determining position, size, consistency, and masses
      • The ulnar surface of the hand is best for detecting vibrations
    • Auscultation
      • Listening to sounds produced by the airway, lungs, stomach, heart, and blood vessels to identify their characteristics
      • Auscultation is usually performed with a stethoscope to enhance the sounds heard in the chest and abdomen
      • Speech is also assessed during auscultation
    • Percussion
      • Striking the surface of the body, either directly or indirectly, to set up vibrations that reveal the density of underlying tissues and borders of internal organs in the chest and abdomen
      • As the density of the tissue increases, the percussion tone become quieter
      • The tone over air is the loudest, and the tone over solid areas is soft
  • Physiological and growth measurements
    • Temperature by age
Expected Level Recommended Routes
3 Months 37.5° C (99.5° F)
  • Axillary
  • Rectal (if exact measurement necessary)
6 Months
1 Year 37.7° C (99.9° F)
3 Years 37.2° C (99.0° F)
  • Axillary
  • Tympanic
5 Years 37.0° C (98.6° F)
  • Oral (if child cooperative)
  • Rectal (if exact measurement necessary)
7 Years 36.8° C (98.2° F)
  • Oral
  • Axillary
  • Tympanic
9 Years 36.7° C (98.1° F)
11 Years
13 Years 36.6° C (97.9° F)

 

  • Temperature measurement in pediatrics
    • Ask the Question
      • PICOT Question: In infants and children, what is the most accurate method for measuring temperature in febrile children?
    • Search for the Evidence
      • Search Strategies
        • Clinical research studies related to this issue were identified by searching for English publications within the past 15 years for infant and child populations; comparisons with gold standard: rectal thermometry.
      • Databases Used
        • PubMed, Cochrane Collaboration, MD Consult, Joanna Briggs Institute, National Guideline Clearinghouse (AHRQ), TRIP Database Plus, PedsCCM, BestBETs
    • Critical Appraisal of the Evidence
      • Rectal temperature: 
        • Rectal measurement remains the clinical gold standard for the precise diagnosis of fever in infants and children compared with other methods.
        • However, this procedure is more invasive and is contraindicated for infants younger than 1 month of age due to risk for rectal perforation
        • Children with recent rectal surgery, diarrhea, or anorectal lesions, or who are receiving chemotherapy (cancer treatment usually affects the mucosa and causes neutropenia) should not undergo rectal thermometry.
      • Oral temperature (OT): 
        • OT indicates rapid changes in core body temperature, but accuracy may be an issue compared with the rectal site.
        • OTs are considered the standard for temperature measurement, but they are contraindicated in children who have an altered level of consciousness, are receiving oxygen, are mouth breathing, are experiencing mucositis, had recent oral surgery or trauma, or are younger than 5 years of age
        • Limitations of OTs include the effects of ambient room temperature and recent oral intake
      • Axillary temperature: 
        • This is inconsistent and insensitive in infants and children older than 1 month of age
        • A systematic review of 20 studies concluded that axillary thermometers showed variation in findings and are not a good method for accurate temperature assessment 
        • In neonates with fever, the axillary temperature should not be used interchangeably with rectal measurement. 
        • It can be used as a screening tool for fever in young infants
      • Ear (aural) temperature: 
        • This is not a precise measurement of body temperature. A meta-analysis of 101 studies comparing tympanic membrane temperatures with rectal temperatures in children concluded that the tympanic method demonstrated a wide range of variability, limiting its application in a pediatric setting
        • Other published reviews continue to find poor sensitivity using infrared ear thermometry.
        • Diagnosis of fever without a focus should not be made based on tympanic thermometry, because it is not an accurate measure of core temperature
      • Temporal artery temperature (TAT): 
        • TAT is not predictable for fever in young children but can be used as a screening tool for detecting fever less than 38° C (100.4° F) in children 3 months to 4 years of age

 

  • Pulse Rate
    • Grading of Pulses
Grade Description
0 Not palpable
+1 Difficult to palpate, thready, weak, easily obliterated with pressure
+2 Difficult to palpate, may be obliterated with pressure
+3 Easy to palpate, not easily obliterated with pressure (normal)
+4 Strong, bounding, not obliterated with pressure

 

  • Newborn: 110 to 160/min (depending on activity)
  • 1 week to 3 months:107 to 180/min (depending on activity)
  • 2 to 10 years: 70 to 110/min (depending on activity)
  • 10 years and older: 50 to 90/min (depending on activity)
  • Respirations
    • Count the respiratory rate in children in the same manner as for adult patients
    • However, in infants, observe abdominal movements, because respirations are primary diaphragmatic
      • Newborn to 1 year: 30 to 35/min
      • 1 to 2 years: 25 to 30/min
      • 6 to 12 years: 19 to 21/min
      • 12 years and older: 16 to 19/min
  • Blood pressure
    • Should be measured annually in children 3 years of age through adolescence and in children with symptoms of hypertension, children in emergency departments and intensive care units, and high-risk infants.
    • Orthostatic Hypotension
      • Also called postural hypotension or orthostatic intolerance
      • Manifests as syncope (fainting), vertigo (dizziness), or lightheadedness and is caused by decreased blood flow to the brain (cerebral hypoperfusion)
      • Normally blood flow to the brain is maintained at a constant level by several compensating mechanisms that regulate systemic BP.
      • When one assumes a sitting or standing position from a supine or recumbent position, peripheral capillary vasoconstriction occurs, and blood that was pooling in the lower vasculature is returned to the heart for redistribution to the head and remainder of the body.
      • Leading to vertigo or syncope
      • One of the most common causes of OH is hypovolemia
        • May be induced by medications, such as diuretics, vasodilator medications, and prolonged immobility or bed rest.
      • Other causes of OH include: 
        • Dehydration
        • Diarrhea
        • Emesis
        • Fluid loss from sweating and exertion
        • Alcohol intake
        • Dysrhythmias
        • Diabetes mellitus
        • Sepsis
        • Hemorrhage
    • Width of cuff should cover 40% of the arm and 80-100% of the upper arm without overlapping 
Female Males
Systolic (mmHg) Diastolic (mmHg) Systolic (mmHg) Diastolic (mmHg)
Infants 65 to 78 41 to 52 65 to 78 41 to 52
1 Year 83 to 114 38 to 67 80 to 114 34 to 66
3 Years 86 to 117 47 to 76 86 to 120 44 to 75
6 Years 91 to 122 54 to 83 91 to 125 53 to 84
10 Years 98 to 129 59 to 88 97 to 130 58 to 90
16 Years 108 to 138 64 to 93 111 to 145 63 to 94

 

  • General Appearance
    • Appears undistressed, clean, well-kept, and without body odors
    • Muscle tone: Erect head posture is expected in infants after 4 months of age
    • Make eye contact when addressed (expect infants)
    • Follows simple commands as age-appropriate
    • Uses speech, language, and motor skills spontaneously
  • Skin
    • Assess skin for color, texture, temperature, moisture, turgor, lesions, acne, and rashes. 
    • Examination of the skin and its accessory organs primarily involves inspection and palpation. 
    • Touch allows the nurse to assess the texture, turgor, and temperature of the skin. 
    • The normal color in light-skinned children varies from a milky white and rose to a deeply hued pink. 
    • Dark-skinned children, such as those of Native American, Hispanic, or African descent, have inherited various brown, red, yellow, olive green, and bluish tones in their skin. 
    • Asian persons have skin that is normally of a yellow tone. Several variations in skin color can occur, some of which warrant further investigation
    • Difference in color changes of racial group
Description Appearance in Light Skin Appearance in Dark Skin
Cyanosis: bluish tone through skin; reflects reduced (deoxygenated) hemoglobin
  • Bluish tinge, especially in palpebral conjunctiva (lower eyelid), nail beds, earlobes, lips, oral membranes, soles, and palms
  • Ashen gray lips and tongue
Pallor: paleness; may be sign of anemia, chronic disease, edema, or shock
  • Loss of rosy glow in skin, especially face
  • Ashen gray appearance in black skin
  • More yellowish-brown color in brown skin
Erythema: redness; may be result of increased blood flow from climatic conditions, local inflammation, infection, skin irritation, allergy, or other dermatoses or may be caused by increased numbers of red blood cells as compensatory response to chronic hypoxia
  • Redness easily seen anywhere on body
  • Much more difficult to assess; rely on palpation for warmth or edema
Ecchymosis: large, diffuse areas, usually black and blue, caused by hemorrhage of blood into skin; typically result of injuries
  • Purplish to yellow-green areas; may be seen anywhere on skin
  • Very difficult to see unless in mouth or conjunctiva
Petechiae: same as ecchymosis except for size: small, distinct, pinpoint hemorrhages ≤2 mm in size; can denote some type of blood disorder, such as leukemia
  • Purplish pinpoints most easily seen on buttocks, abdomen, and inner surfaces of arms or legs
  • Usually invisible except in oral mucosa, conjunctiva of eyelids, and conjunctiva covering eyeball
Jaundice: yellow staining of skin usually caused by bile pigments
  • Yellow staining seen in sclerae of eyes, skin, fingernails, soles, palms, and oral mucosa
  • Most reliably assessed in sclerae, hard palate, palms, and soles

 

  • Hair and scalp
    • Hair should be evenly distributed, smooth, and strong
      • Manifestations of nutritional deficiencies include hair that is stringy, dull, brittle, and dry
      • Hair loss or balding spots on infants can indicate the child is spending too much time in the same position
    • Scalp should be clean and absent from any scaliness, infestations, and trauma.
    • Assess children approaching adolescence for the presence of secondary hair growth
  • Head and Neck
    • Head
      • The shape of the head should be symmetric
      • Fontanels should be flat.
        • The posterior fontanel usually closes by 8 weeks of age
        • The anterior fontanel usually closes between 12 and 18 months of age
    • Face
      • Symmetric appearance and movement
      • Proportional features
    • Neck
      • Short in infants
      • No palpable masses
      • Midline trachea
      • Full range of motion present whether assessed actively or passively
    • Eyes
      • Eyebrows
        • Symmetrical and evenly distributed from the inner to the outer canthus
      • Eyelids
        • Close completely and open to allow the lower border and most of the upper portion of the iris to be seen
      • Eyelashes
        • Curve outward and be evenly distributed with no inflammation around any of the hair follicles
      • Conjunctiva
        • Palpebral fissures and conjunctiva are pink
        • Bulbar conjunctiva are transparent
      • Lacrimal apparatus
        • Without excessive tearing, redness, or discharge
      • Sclera
        • Should be white
      • Corneas
        • Should be unclear
      • Pupils
        • Should be:
          • Round
          • Equal in size
          • Reactive to light
          • Accommodating
      • Irises
        • Round with the permanent color manifesting around 6 to 12 months of age
      • Visual acuity
        • Can be difficult to assess in children younger than 3 years of age
        • Visual acuity in infants can be assessed by holding an an object in front of the eyes and checking to see whether the infant is able to fix on the object and follow it
        • Use he tumbling E or HOTV test to check visual acuity of children who are unable to read letters and numbers
        • Older children should be tested using a Snellen chart or symbol charts
      • Peripheral visual fields
        • Should be:
          • Upwards 50°
          • Downward 70°
          • Nasally 60°
          • Temporally 90°
      • Extraocular movements
        • Might not be symmetric in newborns
        • Corneal light reflex should be symmetric
        • Cover/uncover test should demonstrate equal movement of the eyes
        • Six cardinal fields of gaze should demonstrate no nystagmus
      • Color Vision
        • Should be assessed using the Ishihara color test or the Hardy-Rand-Rittler test
        • The child should be able to correctly identify shapes, symbols, or numbers
      • Internal exam
        • Red reflex should be present in infants
        • Arteries, veins, optic discs, and maculae can be visualized in order children and adolescents
  • Ears
    • During the tympanic membrane exam:
      • In infants – Pull pinna down and back
      • In children older than 3 – Pull pinna up and back
      • The ear canal should be pink with fine hairs
      • The tympanic membrane should be pearly pink, or gray
      • The light reflex should be visible
    • Alignment
      • The top of the auricles should meet in an imaginary horizontal line that extends from the outer canthus of the eye
    • External ear
      • The external ear should be free of lesions and nontender
      • The ear canal should be free of foreign bodies or discharge 
      • Cerumen is an expected finding
    • Hearing
      • Newborns
        • Have intact acoustic blink reflexes to sudden sounds
      • Infants
        • Turn towards sound
      • Older children
        • Can be screened by whispering a word from behind to see whether they can identify the word
  • Nose
    • The position should be midline
    • Patency should be present for each nostril without excessive flaring
    • Smell can be assessed in older children
    • Internal structure
      • The spectrum is midline and intact
      • The mucosa is deep pink in light-skinned clients and various shades of brown or gray in dark-skinned clients
      • The mucosa should be moist without evidence of discharge
  • Mouth and throat
    • Lips
      • Darker pigmented than facial skin
      • Smooth, soft, moist, and symmetrical
    • Gums
      • Coral pink in light-skinned clients, and various shades of brown or gray in dark-skinned clients
      • Tight against the teeth
    • Mucous membranes
      • Without lesions
      • Moist, smooth, and glistening
      • Pink in light-skinned clients and various shades of brown or gray in dark-skinned clients
    • Tongue
      • Infants can have white coating on their tongues from milk that can easily removed
      • Oral candidiasis coating is not easily removed
      • Children and adolescents should have pink, symmetric tongues that they are able to move beyond their lips
    • Teeth
      • Infants should have six to eight teeth by 1 year of age
      • Children and adolescents should have teeth that are white and smooth, and begin replacing the 20 deciduous teeth with 32 permanent teeth
    • Hard and soft palates
      • Intact, firm, and concave
    • Uvula
      • Intact and moves with vocalization
    • Tonsils
      • Infants: Might not be able to visualize
      • Children: Barely visible to prominent, same color as surrounding mucosa
    • Voice
      • Infants: Strong cry
      • Children and adolescents: Clear and articulate
    • Atraumatic Care
      • Encouraging Opening the Mouth for examination
        • Perform the examination in front of a mirror.
        • Let the child first examine someone else’s mouth, such as the parent, the nurse, or a puppet, and then examine the child’s mouth.
        • Instruct the child to tilt the head back slightly, breathe deeply through the mouth, and hold the breath; this action lowers the tongue to the floor of the mouth without the use of a tongue blade.
        • Lightly brushing the palate with a cotton swab also may open the mouth for assessment.
  • Chest and Lungs
    • Chest shape
      • Infants: Shape is almost circular with anteroposterior diameter equaling the transverse or lateral diameter
      • Children and adolescents: The transverse diameter to anteroposterior diameter changes to 2:1
    • Rib and sternum
      • More soft and flexible in infants; symmetric and smooth, with no protrusions or bulges
    • Movement 
      • Symmetric, no retractions
      •  Infants: Irregular rhythms are common
      • Children younger than 7 years: More abdominal movement is seen during respirations
    • Breath sounds
      • Inspiration is longer and louder than expiration
      • Vesicular, or soft, swishing sounds, are heard over most of the lungs
    • Breasts
      • Newborn: Breasts can be enlarged during the first few days
      • Children and adolescents: nipples and areolas are darker pigmented and symmetric.
        • Females: Breasts typically develop between 10 to 14 years of age. The breasts should appear asymmetric have no masses and be palpable.
        • Males can develop gynecomastia, which is unilateral or bilateral breast enlargement that occur during puberty
    • Classification of Normal Breath Sounds
      • Vesicular Breath Sounds
        • Heard over the entire surface of the lungs with the exception of the upper intrascapular area and area beneath the manubrium.
        • Inspiration is louder, longer, and higher pitched than expiration.
        • The sound is a soft, swishing noise.
      • Bronchovesicular Breath Sounds
        • Heard over the manubrium and in the upper intrascapular regions where the trachea and bronchi bifurcate.
        • Inspiration is louder and higher pitched than in vesicular breathing.
      • Bronchial Breath Sounds
        • Heard only over trachea near suprasternal notch.
        • The inspiratory phase is short, and the expiratory phase is long.
    • Effective Auscultation
      • Make certain the child is relaxed and not crying, talking, or laughing. Record if the child is crying.
      • Check that the room is comfortable and quiet.
      • Warm the stethoscope before placing it against the child’s skin.
      • Apply firm pressure on the chest piece but not enough to prevent vibrations and transmission of sound.
      • Avoid placing the stethoscope over hair or clothing, moving it against the skin, breathing on the tubing, or sliding fingers over the chest piece, which may cause sounds that falsely resemble pathologic findings.
      • Use a symmetric and orderly approach to compare sounds.
    • Atraumatic Care
      • Encouraging Deep Breaths
        • Ask the child to “blow out” the light on an otoscope or pocket flashlight; discreetly turn off the light on the last try so the child feels successful.
        • Place a cotton ball in the child’s palm; ask the child to blow the ball into the air and have parent catch it.
        • Place a small tissue on the top of a pencil and ask the child to blow the tissue off.
        • Have child blow a pinwheel, a party horn, or bubbles.
    • Various Pattern of Respiration
      • Tachypnea: Increased rate
      • Bradypnea: Decreased rate
      • Dyspnea: Distress during breathing
      • Apnea: Cessation of breathing
      • Hyperpnea: Increased depth
      • Hypoventilation: Decreased depth (shallow) and irregular rhythm
      • Hyperventilation: Increased rate and depth
      • Kussmaul respiration: Hyperventilation, gasping and labored respiration; usually seen in diabetic coma or other states of respiratory acidosis
      • Cheyne-Stokes respiration: Gradually increasing rate and depth with periods of apnea
      • Biot respiration: Periods of hyperpnea alternating with apnea (similar to Cheyne-Stokes except that depth remains constant)
      • Seesaw (paradoxic) respirations: Chest falls on inspiration and rises on expiration
      • Agonal: Last gasping breaths before death
    • Description of selected adventitious sounds and their cause
Type Description Cause
Fine crackles High-pitched, discrete, noncontinuous sound heard at end of inspiration; does not clear with coughing

(Rub pieces of hair together beside your ear to duplicate the sound)

Air passing through watery secretions in the smaller airways (alveoli and bronchioles)
Coarse crackles Loud, lower pitched, more moist or bubbly sound heard during inspiration; does not clear by coughing Air passing through thicker secretions in the airway
Sibilant wheezing Higher pitched, musical, squeaking, or hissing noise usually heard continuously during inspiration or expiration, but generally louder on expiration; does not clear with coughing Air passing through mucus or fluids in a narrowed lower airway (bronchioles) as with asthma
Rhonchi (sonorous wheezing) Coarse, low-pitched sound like a snore, heard during inspiration or expiration; may clear with coughing Air passing through thick secretions that partially obstruct the larger bronchi and trachea
Stridor High-pitched, piercing sound most often heard during inspiration without a stethoscope Whistling sound as air passes through a narrowed trachea and larynx, associated with croup

 

  • Circulatory System
    • Heart
      • Inspection
        • Precordial activity
        • Shape and symmetry
          • Heave: an obvious lifting of the chest wall during contraction, may indicate an enlarged heart
      • Palpation
        • Apical impulse
        • Thrills
      • Auscultation
        • Rate and rhythm
Age Heart Rate range (Beats/min) Average Heart Rate (Beats/min)
Newborns 100-170 120
Infants to 2 years 80-130 110
2-6 years 70-120 100
6-10 years 70-110 90
10-16 years 60-100 85

 

  • Heart sounds
    • Auscultation should be done in both sitting and reclining position
    • S1 and S2 heart sounds should be clear and crisp. S1 is louder near the base of the heart. Physiological splitting of S2 and S3 heart sounds are expected findings in some children. Sinus arrhythmias that are associated with respirations are common
Auscultatory Site  Chest Location  Characteristics of Heart Sounds
Aortic area  Second right ICS close to sternum
  • S2 heard louder than S1; aortic closure heard loudest
Pulmonic area Second left ICS close to the sternum
  • Splitting of S2 heard best, normally widens on inspiration; pulmonic closure heard best
Erb’s point  Second and third left ICSs close to sternum
  • Frequent site of innocent murmurs and those of aortic or pulmonic origin
Tricuspid area Fifth right and left ICSs close to sternum
  • S1 heard as louder sound preceding S2 (S1 synchronous with carotid pulse)
Mitral or apical area Fifth ICS, LMCL (third to fourth ICS and lateral to LMCL in infants)
  • S1 heard loudest; splitting of S1 may be audible because mitral closure is louder than tricuspid closure
  • S1 heard best at beginning of expiration with child in recumbent or left side-lying position; occurs immediately after S2; sounds like word S1 S2 S3: “Kentuck-y”
  • S4 heard best during expiration with child in recumbent position (left side-lying position decreases sound); occurs immediately before S1; sounds like word S4 S1 S2: “Ten-nes-see”

 

  • Heat Murmurs
    • Intensity, location, radiation, timing, quality
    • Venous hum
      • Caused by turbulent blood flow through the jugular veins
    • Types:
      • Innocent: No anatomic or physiologic abnormality exists.
      • Functional: No anatomic cardiac defect exists, but a physiologic abnormality (such as, anemia) is present.
      • Organic: A cardiac defect with or without a physiologic abnormality exists.
Grade  Description
Very faint; often not heard if child sits up
II  Usually readily heard; slightly louder than grade I; audible in all positions
III  Loud, but not accompanied by a thrill
IV Loud, accompanied by a thrill
Loud enough to be heard with a stethoscope barely touching the chest; accompanied by a thrill
VI  Loud enough to be heard with the stethoscope not touching the chest; often heard with the human ear close to the chest; accompanied by a thrill

 

  • Pulses
    • Infants: Brachial, temporal, and femoral pulses should be palpable, full, and localized
    • Children and adolescents: Pulse locations and expected findings are the same as those in adults
  • Abdomen
    • Without tenderness, no guarding. Peristaltic waves can be visible in thinner children.
    • Shape: Symmetric and without protrusions are around the umbilicus
      • Infants and toddlers have rounded abdomens
      • Children and adolescents should have flat abdomens
    • Bowel sounds should be heard every 5 to 30 seconds
    • The sections are named:
      • Left upper quadrant
      • Left lower quadrant
      • Right upper quadrant
      • Right lower quadrant
    • Atraumatic Care
      • Promoting relaxation during abdominal palpation
        • Position the child comfortably, such as in a semi reclining position in the parent’s lap, with knees flexed.
        • Warm your hands before touching the skin.
        • Use distraction, such as telling stories or talking to the child.
        • Teach the child to use deep breathing and to concentrate on an object.
        • Give an infant a bottle or pacifier.
        • Begin with light, superficial palpation, and gradually progress to deeper palpation.
        • Palpate any tender or painful areas last.
        • Have the child hold the parent’s hand and squeeze it if palpation is uncomfortable.
        • Use the non-palpating hand to comfort the child, such as placing the free hand on the child’s shoulder while palpating the abdomen.
        • To minimize the sensation of tickling during palpation:
          • Have the child “help” with palpation by placing a hand over the palpating hand.
          • Have the child place a hand on the abdomen with the fingers spread wide apart and palpate between his or her fingers.
  • Genitalia
    • Anus
      • Surrounding skin should be intact with sphincter tightening noted if the anus is touched. 
      • Routine rectal exams are not done with the pediatric population
    • Male:
      • Hair distribution is diamond shaped after puberty in adolescent males. 
      • No public hair is noted in infants and small children
        • Penis
          • Should appear straight
          • Urethral meatus should be at the tip of the penis.
          • Foreskin might not be retractable in infants and small children
          • Enlargement of the penis occurs during adolescence
          • The penis can look disproportionately small in males who are obese because of skin folds partially covering the base
        • Scrotum
          • Hangs separately from the penis
          • The skin on the scrotum has a rugose appearance and is loose
          • The left testicle hangs slightly lower than the right
          • The inguinal canal should be absent of swelling
          • During puberty, the testes and scrotum enlarge with darker scrotal skin
    • Female
      • Hair distribution over the mons pubis should be documented in terms of amount and location during puberty.
      • Hair should appear in an inverted triangle.
      • No pubic hair should be noted in infants or small children
        • Labia
          • Symmetric, without lesions, moist on the inner aspects
        • Clitoris
          • Small, without bruising or edema
        • Urethral meatus
          • Slit-like in appearance with no discharge
        • Vaginal orifice
          • The hymen can be absent, or it can completely or partially cover the vaginal opening prior to sexual intercourse
  • Musculoskeletal system
    • Length, position, and size of extremities are symmetric
    • Joints
      • Stable and symmetric with full range of motion and no crepitus or redness
    • Spine
      • Infants
        • Spines should be without dimples or tufts of hair. 
        • They should be midline with an overall C-shaped lateral curve
      • Toddlers
        • Appears squat with short legs and protuberant abdomen
      • Preschoolers
        • Appear more erect than toddlers
      • Children
        • Should develop the cervical, thoracic, and lumbar curvatures like that of adults
      • Adolescents
        • Should remain midline (no scoliosis noted)
    • Gait
      • Toddlers and younger children
        • A bowlegged or knock-knee appearance is a common finding
        • Feet should face forward while walking
      • Older children and adolescents
        • A steady gait should be noted with even war on the soles of shoes
  • Neurological system
    • Tests for cerebellar function
      • Finger-to-nose test: 
        • With the child’s arm extended, ask the child to touch the nose with the index finger with the eyes open and then closed.
      • Heel-to-shin test: 
        • Have the child stand and run the heel of one foot down the shin or anterior aspect of the tibia of the other leg, both with the eyes opened and then closed.
      • Romberg test: 
        • Have the child stand with the eyes closed and heels together; falling or leaning to one side is abnormal and is called the Romberg sign.
    • Infant reflexes
Expected Finding Expected Age
Sucking and rooting reflexes
  • Elicited by stroking an infant’s cheek or the edge of an infant’s mouth
  • The infant turns their head towards the side that is touched and starts to suck
Birth to 4 months
Palmar Grasp
  • Elicited by placing an object in an infant’s palm
  • The infant grasps the object
Birth to 4 months
Plantar Grasp
  • Elicited by touching the sole of an infant’s foot
  • The infant’s toes curl downward
Birth to 8 months
Moro Reflex
  • Elicited by allowing the head and truck of an infant in a semi-sitting position to fall backward to an angle of at least 30°
  • The infant’s arms and legs symmetrically extend, then abduct while fingers spread to form C shape
Birth to 6 months
Tonic Neck Reflex (Fencer Position)
  • Elicited by turning an infant’s head to one side
  • The infant extends the arm and leg on that side and flexes the arm and leg on the opposite side
Birth to 3 to 4 months
Babinski Reflex
  • Elicited by stroking the outer edge of the sole of an infant’s foot up toward the toes
  • The infant’s toes fan upward and out
Birth to 1 year
Stepping
  • Elicited by holding an infant upright with his feet touching a flat surface
  • The infant makes stepping movement
Birth to 4 weeks
  • Cranial Nerves
    • I—Olfactory Nerve
      • Olfactory mucosa of nasal cavity (Smell)
        • With eyes closed, have child identify odors, such as coffee, alcohol from a swab, or other smells; test each nostril separately.
    • II—Optic Nerve
      • Rods and cones of retina, optic nerve (Vision)
        • Check for perception of light, visual acuity, peripheral vision, color vision, and normal optic disc.
    • III—Oculomotor Nerve
      • Extraocular muscles of eye:
        • Superior rectus: moves eyeball up and in
        • Inferior rectus: moves eyeball down and in
        • Medial rectus: moves eyeball nasally
        • Inferior oblique: moves eyeball up and out
          • Have child follow an object (toy) or light in six cardinal positions of gaze
      • Pupil constriction and accommodation
        • Perform PERRLA (Pupils Equal, Round, React to Light, and Accommodation).
      • Eyelid closing Check for proper placement of eyelid.
    • IV—Trochlear Nerve
      • Superior oblique (SO) muscle: moves eye down and out
        • Have child look down and in
    • V—Trigeminal Nerve
      • Muscles of mastication 
        • Have child bite down hard and open jaw; test symmetry and strength.
      • Sensory: face, scalp, nasal and buccal mucosa
        • With child’s eyes closed, see if child can detect light touch in mandibular and maxillary regions.
        • Test corneal and blink reflex by touching cornea lightly with a whisk of cotton ball twisted into a point (approach from side so the child does not blink before cornea is touched).
    • VI—Abducens Nerve
      • Lateral rectus (LR) muscle: moves eye temporally
        • Have child look toward temporal side
    • VII—Facial Nerve
      • Muscles for facial expression 
        • Have child smile, make funny face, or show teeth to see symmetry of expression.
      • Anterior two-thirds of tongue (sensory)
        • Have child identify sweet or salty solution; place each taste on anterior section and sides of protruding tongue; if child retracts tongue, solution will dissolve toward posterior part of tongue.
    • VIII—Auditory, Acoustic, or Vestibulocochlear Nerve
      • Internal ear
      • Hearing and balance
        • Test hearing; note any loss of equilibrium or presence of vertigo.
    • IX—Glossopharyngeal Nerve
      • Pharynx, tongue 
        • Stimulate posterior pharynx with a tongue blade; child should gag.
      • Posterior third of tongue (Sensory)
        • Test sense of sour or bitter taste on posterior segment of tongue.
    • X—Vagus Nerve
      • Muscles of larynx, pharynx, some organs of gastrointestinal system, sensory fibers of root of tongue, heart, and lung
        • Note hoarseness of voice, gag reflex, and ability to swallow.
        • Check that uvula is in midline; when stimulated with tongue blade, it should deviate upward and to stimulated side.
    • XI—Accessory Nerve
      • Sternocleidomastoid and trapezius muscles of shoulder
        • Have child shrug shoulders while applying mild pressure; with examiner’s palms placed laterally on child’s cheeks, have child turn head against opposing pressure on either side; note symmetry and strength.
    • XII—Hypoglossal Nerve
      • Muscles of tongue 
        • Have child move tongue in all directions; have child protrude tongue as far as possible; note any midline deviation.
        • Test strength by placing tongue blade on one side of tongue and having child move it away.
  • Expected findings
Infants Children and Adolescents
I Olfactory
  • Difficult to test
  • Identifies smells through each nostril individually
II Optic
  • Looks at face and tracks with eyes
  • Has intact visual acuity, peripheral vision, and color vision
III Oculomotor
  • Blinks in response to light
  • Has pupils that are reactive to light
  • Has no nystagmus and PERRLA is intact
IV Trochlear
  • Looks at face and tracks with eyes
  • Has the ability to look down and in with eyes
V Trigeminal
  • Has rooting and sucking reflexes
  • Is able to clench teeth together
  • Detects touch on face with eyes closed
VI Abducens
  • Looks at face and tracks with eyes
  • Is able to move eyes laterally toward temples
VII Facial
  • Has symmetric facial movements
  • Has the ability to differentiate between salty and sweet on tongue
  • Has symmetric facial movements
VIII Acoustic
  • Tracks a sound 
  • Blinks in response to a loud noise
  • Does not experience vertigo
  • Has intact hearing
IX Glossopharyngeal
  • Has an intact gag reflex
  • Has an intact gag reflex
  • Is able to taste sour sensations on back of tongue
X Vagus
  • Has no difficulties swallowing
  • Speech clear, no difficulties swallowing
  • Uvula is midline
XI Spinal Accessory
  • Moves shoulders symmetrically
  • Has equal strength of shoulder shrug against examiner’s hands
XII Hypoglossal
  • Has no difficulties swallowing
  • Opens mouth when nares are occluded
  • Has a tongue that is midline
  • Is able to move tongue in all directions with equal strength against tongue blade resistance
  • Deep tendon reflexes
    • Deep tendon reflexes should demonstrate the following
      • Partial flexion of the lower arm at the bicep tendon
      • Partial extension of the lower arm at the triceps tendon
      • Partial extension of the lower leg at the patellar tendon
      • Plantar flexion of the foot at the Achilles tendon
  • Physiologic Data
    • Current health status
      • Health maintenance pattern and last visit
      • Up to date?
      • Safety
      • Activity and exercise
      • Nutrition
      • Sleep
      • Family history
        • Health background
        • Changes in family or family life
          • Separation, divorce, or death of a parent
          • Who lives in the household?
      • Age-specific issues
        • Newborns
        • Children
          • Daily routines
        • Adolescents
          • HEEADSSS
            • Home environment, education & employment, eating, activities, drugs, sexualities, suicidal thoughts, safety
    • Medication
      • Prescribed and over the counter (OTC)
    • Allergies
    • Immunization status

 

Pain Assessment

  • Intensity
    • Assessment includes behavioral measures, multidimensional, and self-report.
    • Self-report is used for children 4 years or older. Children under 4 are unable to accurately report their pain
    • Multiple tools have been developed and researched as reliable
    • Choose an appropriate pain tool that will adequately assess the infant or child’s pain
    • Assess the location, quality, and severity of pain
  • Satisfaction with treatment
  • Symptoms and adverse events
  • Physical recovery
  • Emotional response
  • Behavioral pain measures
    • FLACC (2 months to 7 years)
      • Pain rated on a scale of 0 to 10
      • Assess behaviors of the child
Ages of Use  Reliability and Validity Variables Scoring Range
FLACC Postoperative Pain Tool
2 months of age to 7 years of age Validity using analysis of variance for repeated measures to compare FLACC scores before and

after analgesia; preanalgesia FLACC scores significantly higher than postanalgesia scores at

10, 30, and 60 minutes (p <0.001 for each time)

Correlation coefficients used to compare FLACC pain scores and OPS pain scores; significant

positive correlation between FLACC and OPS scores (r = 0.80; p <0.001); positive correlation also

found between FLACC scores and nurses’ global ratings of pain (r[47] = 0.41; p <0.005)

Face (0–2)

Legs (0–2)

Activity (0–2)

Cry (0–2)

Consolability (0–2)

0 = no

pain; 10 = worst pain

FLACC Scale
FLACC 0 1 2
Face No particular expression or smile  Occasional grimace or frown, withdrawn, disinterested Frequent to constant frown, clenched jaw, quivering chin
Legs Normal position or relaxed  Uneasy, restless, tense Kicking, or legs drawn up
Activity Lying quietly, normal position, moves easily  Squirming, shifting back and forth, tense Arched, rigid, or jerking
Cry No cry (awake or asleep)  Moans or whimpers, occasional complaint Crying steadily, screams or sobs, frequent complaints
Consolability  Content, relaxed Reassured by occasional touching, hugging, or talking to; distractible Difficult to console or comfort
  • Numeric scale: 5 years and older
    • Pain rated on a scale of 0 to 10
    • Explain to the child that 0 means “no pain” and 10 means “worst pain”
    • Have the child verbally report a number or point to their level of pain on a visual scale
  • FACES
    • Pain rated on a scale of 0 to 5 using a diagram of six faces.
    • Substitute 0,2,4,6,8,10 for 0 to 5 convert to the 0 to 10 scale
    • Explain each face to the child; ask the child to choose a face that best describes how they are feeling
      • 0: No hurt
      • 1: Hurts a bit
      • 2: Hurts a little more
      • 3: Hurts even more
      • 4: Hurts a whole lot
      • 5: Hurts worst
  • Oucher: 3 to 13 years
    • Pain rated on a scale of 0 to 5 using six photographs
    • Substitute 0,2,4,6,8,10 for 0 to 5 convert to the 0 to 10 scale
    • Have the child organize the photographs in order of no pain to the worst pain; ask the child to choose a picture that best describes how they are feeling.
      • 0: No hurt
      • 1: Hurts a bit
      • 2: Hurts a little more
      • 3: Hurts even more
      • 4: Hurts a whole lot
      • 5: Hurts worst
  • Non-communicating children’s pain checklist: 3 years and older
    • Behavior are observed for 10 min
    • Six subcategories are each scored on a scale 0 to 3
      • 0: Not at all
      • 1: Just a little
      • 2: Fairly often
      • 3: Very often
    • Subcategories
      • Vocal
      • Social
      • Facial
      • Activity
      • Body and limbs
      • Physiological
    • Cutoff scores
      • 11 or higher indicates moderate to severe pain
      • 6 to 10 indicates mild pain
  • IM injections are not recommended for pain control in children
  • Intranasal medications are not recommended for children younger than 18 years
  • Rectal medications have variable absorption rates, and children dislike them
  • Intradermal medications are used for skin anesthesia prior to procedure

 

  • Children’s responses to pain at various ages
    • Newborn and young infant
      • Uses crying
      • Reveals facial appearance of pain (brows lowered and drawn together, eyes tightly closed, and mouth open and squarish)
      • Exhibits generalized body response of rigidity or thrashing, possibly with local reflex withdrawal from what is causing the pain
      • Shows no relationship between what is causing the pain and subsequent response
    • Older Infant
      • Uses crying
      • Shows a localized body response with deliberate withdrawal from what is causing the pain
      • Reveals expression of pain or anger
      • Demonstrates a physical struggle, especially pushing away from what is causing the pain
    • Young Child
      • Uses crying and screaming
      • Uses verbal expressions, such as “Ow,” “Ouch,” or “It hurts”
      • Uses thrashing of arms and legs to combat pain
      • Attempts to push what is causing the pain away before it is applied
      • Displays lack of cooperation; need for physical restraint
      • Begs for the procedure to end
      • Clings to parent, nurse, or other significant person
      • Requests physical comfort, such as hugs or other forms emotional support
      • Becomes restless and irritable with ongoing pain
      • Worries about the anticipation of the actual painful procedure
    • School-Age Child
      • Demonstrates behaviors of the young child, especially during actual painful procedure, but less before the procedure
      • Exhibits time-wasting behavior, such as “Wait a minute” or “I’m not ready”
      • Displays muscular rigidity, such as clenched fists, white knuckles, gritted teeth, contracted limbs, body stiffness, closed eyes, wrinkled forehead
    • Adolescent
      • Less vocal with less physical resistance
      • More verbal in expressions, such as “It hurts” or “You’re hurting me”
      • Displays increased muscle tension and body control
  • Patient-centered care
    • Nursing care
      • Reassess the child’s pain level frequently
      • Use nonpharmacological, pharmacological, or both approaches to manage pain
      • Ask parent or caregiver to reassess the child’s pain level
      • Ask the parent or caregiver their satisfaction of the pain management
      • Assess the child for adverse reactions to pain medications
      • Review laboratory reports
      • Assess the child’s physical functioning following pain management intervention
      • Assess for negative effects or distress the child might experience related to pain (anxiety, withdrawal, sleep disruption, fear, depression, or unhappiness)
    • Atraumatic measures
      • Use a treatment room for painful procedures
      • Avoid procedures in “safe places” (the playroom or the child’s bed)
      • Use developmentally appropriate terminology when explaining procedures
      • Offer choices to the child
      • Allow parents to stay with the child during painful procedures
      • Use play therapy to explain procedure on a doll or toy

 

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