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					                                                                             Pediatric assessment    1

                           MENNONITE COLLEGE OF NURSING
                              AT ILLINOIS STATE UNIVERSITY
                      Diagnostic Reasoning for Advanced Practice Nursing 431

                         Assessing Children: Infancy through Adolescence

Difference between pediatric and adult examination
    With Pediatric assessment the approach to the patient and the sequence of the exam differ
       according to the child’s age and developmental level

Types of visits:
    Complete (head-to-toe)
          o New to the practice
          o Regular health maintenance visits
          o School physicals
          o Sports physicals
    Focused – concentrates on chief complaint and includes a focused history

Child development
    Predictable pathway governed by maturing brain
          o Cephalocaudal – head to foot development; examples are brain/head development earlier
              coordination than in arms and legs; head larger relative to rest of body
          o Proximodistal – central to peripheral development; examples are brain/spinal cord in
              trunk develop before arms and legs; motor control of trunk and head before arms and legs
    Characterized development as normal or abnormal based on achievement of age-specific
       milestones
    Affected by physical, social, and environmental factors, as well as diseases
          o Chronic illness
          o Child abuse
          o Poverty
    Child’s developmental level affects how you conduct the medical history and physical
       examination

Focus on Pediatric Health Promotion: Key Components
    Age-appropriate developmental achievement of the child
          o Physical
          o Motor (gross and fine motor skills)
          o Cognitive
          o Emotional
          o Social
    Health supervision visits (periodic assessment of medical and oral health)
    Integration of physical exam findings with health lifestyles
    Immunizations – see CDC site for latest recommendations
    Screening procedures
          o Growth parameters
          o Developmental screenings (DDST) – early detection/intervention
          o B/P, vision, hearing
          o High-risk patients; testing for lead poisoning, TB exposure, anemia, cholesterol, UTIs
             and STDs
    Anticipatory guidance
                                                                                Pediatric assessment      2

                                               History
Approach the family and child
   Family-centered approach
   Address the parent & child’s concerns
   Realistic recognition of limitations in self, patient, time, and environment
   Effective planned use of time

Communication skills
   Boost self-esteem of child
   Enhance sense of parents confidence
   Consider the family as partners in problem solving
        o Explore family’s value system
        o Use the families resources
        o Respect family’s agenda and solutions
        o Respect family needs, expectations, concerns and resource limitations
   Be open-ended
   Be non-judgmental
   Make advise finite, practical, and concrete
   Have FUN with the child and family

Gathering Information/History (see Bright Futures website for visit templates at
http://brightfutures.aap.org/tool_and_resource_kit.html)
     Parent or guardian needs to accompany the child to the visit unless documentation from
        responsible party that indicates another adult has permission to make health care decisions!
    A. Chief Complaint - reason for visit
    B. History of Present Illness: OLDCART
    C. Past Medical History (pregnancy, birth, newborn→ current age, illness, accident, preventative
        care)
            a. Perinatal
                     i. Mother’s general health during pregnancy;
                           1. Complications of pregnancy - bleeding, falls, swelling of hands and feet,
                                high blood pressure, unusual weight gain, substance abuse, medications
                                during pregnancy
                           2. Ultrasound results or genetic testing results
                           3. Emotional status, during pregnancy and post-partum
                    ii. Pregnancy history; Para, Gravida, Abortions, Miscarriages
                   iii. Planned pregnancy?
                   iv. Father’s attitude
            b. Labor & Delivery
                     i. Date, Place of birth
                    ii. Complications
                   iii. Anesthesia used
                   iv. Type of delivery
            c. Newborn (first 28 days)
                     i. Gestation
                    ii. Weight
                   iii. Length
                   iv. Apgars
                    v. Nutrition
                   vi. Sleep
                                                                                Pediatric assessment    3

                vii.   Elimination
               viii.   Growth and development
                 ix.   Hospitalizations; ER or Urgent care visits
                  x.   Surgeries
                 xi.   Illness
                xii.   Immunizations
               xiii.   Allergies
               xiv.    Medications
          d. Infant
                  i. Key areas – nutrition, sleep, elimination, dentition, illness, hospitalization,
                     surgery, accidents, immunizations, growth and development, allergies,
                     medications, habits
                 ii. Informant is the parent or guardian
         e. School-age
                  i. Key additional areas – family, friends, school, activities
                 ii. Interview parent and child
         f. Adolescent – Key principles of interviewing
                  i. Adolescent is primary informant, interview alone
                 ii. Discuss findings and recommendations with parents
                iii. Confidentiality must be ensured, explain to adolescent and parent that unless
                     serious problems emerge that is a threat to teen’s life or health, interview with
                     adolescent will be strictly confidential
                iv. Use HEADSS interview approach (Home, Education, Activities, Drugs, Sex, and
                     Suicide)
   D. Family History (developmental, personal and social)
         a. Composition of household
         b. Health of family members; heart problems, cancer, developmental delays, learning
             problems, genetic disorders, asthma, allergies, seizure disorders, hypertension, sickle cell
             anemia, blindness, endocrine disorders, kidney disorders, birth defects, infant deaths
         c. Marital status, educational background, and occupation of parents
         d. Outcomes of any previous pregnancies
         e. Availability and nature of support for the family
   E. Social History
         a. Living situation – including sleeping arrangement
         b. Who is in the home and any smoking, use of alcohol, firearms, safety issues, etc?
         c. Who is the primary care giver and other care givers - daycare
   F. Review of Systems
         a. All systems - age appropriate questions and much shorter
         b. Focus will vary a bit by age, should include nutrition, elimination, sleep, behavior,
             physical activity, growth & development, school, and home

Areas of Physical examination
   • Physical development
          – Assessed in depth at each visit
   • Cognitive development
          – Assessed generally at each visit
   • Social and emotional development
          – Assessed generally at each visit
          – Observe parent-child interaction – evidence of mutuality and reciprocity
          – Behavioral assessment
                                                                           Pediatric assessment   4

Stages of Development
   • Newborn (birth)
   • Infancy (0 to 12 months)
   • Early childhood (1 to 4 years)
   • Middle childhood (5 to 10 years)
   • Adolescence (11 to 20 years)
           – Early
           – Middle
           – Late

Vital Signs Throughout Development (important to know normal ranges and evaluate each visit)
   • Height – at birth & every visit – plot on growth chart
   • Weight – at birth & every visit – plot on growth chart
           – Calculate BMI (body mass index) at every visit & plot on growth chart
   • Head circumference – birth to 36 months & plot on growth chart
   • Blood pressure – start measuring at age 2, unless CVD
   • Pulse – higher in infancy; slows down with aging
   • Respiratory rate – higher in infancy; slows down with aging
   • Temperature
           – < 2 months of age: rectal temperature
           – > = 2 months of age: tympanic temperature

Newborn Assessment
  • General assessment – Apgar score
  • Sequence of examination:
        – Careful observation of activity
        – Head, neck, heart, lungs, abdomen, genitourinary system
        – Lower extremities, back
        – Ears, mouth
        – Eyes whenever they open spontaneously
  • Skin (throughout the exam)
        o Vernix caseosa: present at birth
        o Lanugo: shed within the first few weeks of life
        o Meconium staining
        o Texture
        o Color – cyanosis, jaundice, pink, pale
        o Lesions
                 Secondary to trauma - forceps marks, subcutaneous fat necrosis, sucking blisters,
                   scalp
                 Vascular – nevus simplex, port wine nevus, strawberry hemangioma, cavernous
                   hemangioma
                 Infectious lesions – Candida diaper dermatitis, Herpes
  • Head and Neck
        o Head and face shape, circumference, symmetry; molding, caput succedaneum (edema
            crosses suture lines), cephalhematoma
        o Suture lines, anterior and posterior fontanelles
        o Neck mobility, torticollis, length, webbing
        o Dislocation of clavicle
  • Nose and Mouth
        o Nasal patency, discharge, sneezing, flaring, flattened nasal bridge
                                                                          Pediatric assessment   5

       o Palate intact, uvula midline, frenulum of tongue and upper lip, Epstein pearls, thrush
           (candidiasis)
       o Reflexes; gag, sucking, rooting
       o Vigorous cry, receding chin
•   Ears and auditory
       o Symmetry, shape, position
       o Preauricular sinus, preauricular skin tag, poorly formed helix, malformed ear, low placed
           ears
       o Startle reflex to noises
•   Eyes
       o Red light reflex, nasolacrimal duct patency
       o Blink reflex, rudimentary fixation on objects and ability to follow to midline
       o Epicanthal folds, nystagmus or strabismus, scleral hemorrhages
•   Chest and Lungs
       o AP and lateral diameters equal, pectus excavatum (funnel chest), pectus carinatum
           (pigeon chest)
       o Breasts – enlargement, secretion, supernumerary nipples
       o Respirations primarily abdominal, cough reflex
•   Heart
       o Apex – 4th to 5th intercostal space, lateral to left sternal border
       o S2 slightly sharper and higher in pitch than S1
       o Check for murmurs and coarctation of aorta (check pulses)
•   Abdomen
       o Cylindrical shape - abdominal masses, hepatosplenomegaly, diastasis recti
       o Liver palpable 2-3 cm below right costal margin
       o Kidney palpable 1-2 cm above umbilicus
       o Umbilical cord (AVA), umbilical hernia
•   GU
       o Male – testes palpable in scrotum, penis, smegma, urethral opening at tip of glans penis,
           hypospadias, inguinal hernia, hydrocele
       o Female – labia majoria and clitoris usually edematous, vernix caseosa between labia,
           patency of vagina, ambiguous
       o Urinates in 24 hours
       o Anus patent, anal wink, meconium within 36 hours
•   Neuromuscular
       o Spine intact, no openings or masses
       o Check for hip dislocation
       o Reflexes; Moro and Plantar (up going toes until about 18 months)
•   Extremities
       o 10 fingers and toes, ROM, symmetry, pulses, syndactyly (webbing/fused toes),
           polydactyly (extra digits)
•   Reflexes
       o Blinking, pupillary, doll’s eyes
       o Sneeze, Glabellar (touch middle of forehead and eyes close)
       o Sucking, gag, rooting, extrusion, yawn, cough
       o Grasp, plantar, ankle clonus, Moro, startle, Perez, tonic neck, Galant, step, crawling,
           placing
                                                                                 Pediatric assessment     6

General Assessment of a child (as appropriate for developmental stage)
   • General appearance - facies, posture, hygiene, nutrition, behavior, development, state of
      awareness
   • Skin, hair, nails, lymph nodes, head, neck, trachea, thyroid, carotid arteries
   • Eyes – Palpebral slant, Epicanthal fold, lids, pupils, lens, fundus, corneal light reflex, cover test,
      alternate cover test, peripheral vision, color vision-Ishihara or Hardy-Reand Rittler test
   • Ears –
          o Until age 3 insert speculum between 3 and 9 o’clock position in a downward and forward
              slant, pull pinna down and back to the 6 and 9 o’clock range
          o Over age 3 pull pinna up and back toward a 10 o’clock position
          o Rinne test
          o Weber test
   • Nose, mouth, throat. Lungs
   • Heart
          o Aortic area – 2nd ICS right sternum
          o Pulmonic area – 2nd ICS left sternum
          o Erb point – 2nd and 3rd left ICS sternum
          o Tricuspid area – 5th right and left ICS sternum
          o Mitral area – 5th ICS, left MCL
   • Abdomen, genitalia
   • Back and extremities
          o Assess gait
          o Genu valgum (knock-knees) from 18 months to 4 years of age
          o Genu varum (bowleg)
          o Pes planus (flat foot) – normal finding in infancy, may be a result of muscular weakness
              in older child
          o Pes valgus – eversion of entire foot, sole rests on ground
          o Pes varus – inversion of entire foot, sole rests on ground
          o Metatarsus valgus – eversion of forefoot, heel remains straight (toeing out or duck walk)
          o Talipes valgus – eversion (turning outward of foot, inner side of foot rests on ground)
          o Talipes varus – inversion (turning inward of foot, outer side of foot rests on ground)
          o Talipes equines – extension or plantar flexion of foot, ball and toes rest on ground,
              commonly occurs with talipes varus (most common club foot deformity)
          o Talipes calcareous – dorsal flexion of foot, heel rest on ground
   • Neuro
          o Mental status
          o Cranial nerves
          o Motor function (finger-nose-finger, heel-to-shin, Romberg test, touch tip of finger to
              thumb)
          o Reflexes
          o Sensory – vision and hearing

Infancy: 28 days to 12 months
   • Most rapid rate of growth
          – Birth weight triples, height increases by 50% by the end of year one
   • Sequence of examination
          – Perform non-disturbing maneuvers early
          – Perform potentially distressing maneuvers near the end; e.g., ears, mouth, and abdomen
          – If quiet listen to heart, lungs, abdomen, then reflexes; perform traumatic procedure and
              Moro reflex last
                                                                           Pediatric assessment   7

•   Tips for Examining an Infant
       – Use a reassuring voice throughout the examination
       – Let the child see and touch the examination tools you will be using
       – Avoid asking permission to examine a body part because you will do the examination
           anyway; instead, ask the child which body part he or she would like to have examined
           first
       – Examine the child in the parent’s lap around 4-6 months
       – Allow the parent to undress the child; leave in diaper
       – If unable to console the child, allow a short break
       – Make a game out of the examination
•   Head
       – Inspect for symmetry, shape, circumference (look from above)
       – Palpate:
                o Anterior fontanelle – closes between 4 and 26 months of age
                o Posterior fontanelle – closes by 2 months of age




•   Eyes:
       – Inspect sclera, pupils, irises, extraocular movements, and presence of red reflex
•   Ears:
       – Inspect position, shape, landmarks, patency of ear canal Acoustic blink reflex
•   Nose and paranasal sinuses:
       – Infants are obligate nasal breathers for first the 2 months of life
       – Only the ethmoid sinuses are present at birth
       – Inspect for position of nasal septum
•   Mouth/pharynx:
       – Inspect mucosa, tongue, gums, palate, uvula, tonsils, and posterior pharynx
       – Palpate gums and teeth
              o Teeth: 6 to 26 months of age, 1 tooth per month
              o Central and lateral incisors erupt first, molars last
       – Reflexes – gag, sucking, rooting
•   Neck:
       – Inspect for masses
       – Palpate for presence of adenopathy: unusual in infancy
                                                                                 Pediatric assessment      8

Question
A mother presents to the pediatrician concerned that her 8-month-old child is not developing
appropriately. She bases this concern on the fact that the posterior fontanelle closed 6 months ago, but
the anterior fontanelle is still open and soft. Your response to this concern is based on which fact?
            a. The anterior fontanelle closes between 4 to 26 months of age
            b. Both fontanelles should close within 2 to 4 months of each other
            c. The posterior fontanelle has closed early
            d. None of the above are true
Answer –

   •   Thorax:
          – Inspect respiratory rate, color, nasal component of breathing, and listen for audible breath
               sounds
          – Palpate tactile fremitus if infant is crying or making noise
          – Percussion is not helpful in infants
                  o Thorax is more rounded in infants than in older children and adults
   •   Lungs - auscultation:
          – Generally, sounds are louder and harsher
          – Distinguish between upper and lower airway sounds
                  o Upper airway: loud, symmetric transmission throughout the chest - loudest as
                      stethoscope is moved upward; coarse during inspiratory phase
                  o Lower airway: loudest over site of pathology; asymmetric; often has an expiratory
                      phase
   •   Heart
          – Inspect for cyanosis
          – Palpate:
                  o Peripheral pulses, especially brachial
                  o PMI is not always palpable; 1 interspace higher than in adults
                  o Thrills
          – Auscultate:
                  o S1, S2 (split is normal but fuse together as single sound during deep expiration)
                  o S3 is frequently heard and is normal
                  o Murmurs – functional murmurs vs. pathologic
                  o Mitral area – 3rd to 4th ICS and lateral to left MCL
   •   Breasts
          – Inspect
          – Palpate for masses
   •   Male genitalia
          – Inspect
          – Palpate for descent of testes into scrotal sac
   •   Female genitalia
          – Inspect
   •   Abdomen
          – Inspect – umbilical cord remnant is gone by 2 weeks of age
          – Auscultate bowel sounds
          – Palpate - liver edge 1-2 cm below costal margin is normal; palpable spleen tip is normal
          – Rectal – generally not done
   •   Musculoskeletal
          – Inspect the spine
          – Palpate the clavicle, hips, legs, and feet
                                                                             Pediatric assessment     9

                 o  Barlow’s and Ortolani’s test – identifies unstable hip that lies in the reduced
                    position and can be passively dislocated (see handout)
                 o Bowlegged growth to age 18 months is normal
   •   Nervous system
          – Inspect motor tone
          – Palpate motor tone through passive ROM of major joints
          – Normal reflexes
                 o Newborn:
                        Palmar grasp, plantar grasp, Moro reflex, asymmetric tonic neck reflex,
                            positive support reflex, anal reflex, positive plantar
                 o Infancy:
                        Triceps, brachioradialis, and abdominal reflexes present starting at age 6
                            months


Early Childhood (1 to 4 years): Physical Examination Features
   • Rate of growth slows to 50% of that of infancy
   • Tips for examination sequence:
          – Toddler
                 o Start with the child seated or standing by the parent
                 o Inspect the body through play
                 o Introduce equipment slowly
                 o Have parents remove outer clothing
                 o Praise for cooperative behavior
                 o Ask the parent for assistance if restraint is needed
                 o First examine the eyes, palpate neck, percuss/auscultate
                 o Move child to supine position – examine abdomen, musculoskeletal, nervous
                    system; examine genitalia last
                 o End the examination with the patient upright; look at the throat and ears
          – Preschooler
                 o Prefer standing or sitting
                 o Proceed head-to-toe
                 o Request self-undressing
                 o Demonstrate equipment
                 o Give choices when possible; expect cooperation
   • General appearance – facies, posture, hygiene, nutrition, behavior, development, state of
       awareness
   • Early Childhood: Unique Physical Examination Features
          – Vital signs:
                 o Measure blood pressure starting at age 2
          – Neck:
                 o Palpate for lymph nodes; adenopathy is common
          – Eyes:
                 o Cover and uncover test for position and alignment of eyes
          – Ears:
                 o Visualization of tympanic membrane is the greatest challenge
          – Nose/sinuses:
                 o Maxillary sinuses present by age 4
          – Heart
                 o Brachial pulses still easier to feel than radial
                                                                              Pediatric assessment    10

           –   Abdomen
                  o Protuberant abdomen still normal
                  o Liver span 1-2 cm below costal margin is still normal
                  o Spleen edge 1-2 cm below costal margin is normal
                  o Use the scratch test to palpate for the liver size
           –   Male genitalia:
                  o Testes undescended in scrotal sac by age 1 is abnormal and need to refer
           –   Musculoskeletal system:
                  o Inspect spine for scoliosis in any child who can stand
Question
You enter the room of a 2-year-old female who is visibly upset and afraid of being at the clinic. To
facilitate the examination, which of the following actions would be most appropriate?
             a. Leave the room and return when the child is calm
             b. Have the parent leave the room since his or her presence is making the “acting out” worse
             c. Ask the child’s permission to examine a body part
             d. Examine the child in the parent’s lap
Answer –


Middle Childhood (5 to 10 years): Physical Examination Unique Features
   • Tips for examinations
         – Prefer sitting
         – Proceed head-to-toe as with adults
         – Request self-undressing; give gown to wear
         – Teach about body functions
   • Nose and paranasal sinuses
         – Sphenoid sinuses present by age 8
         – Frontal sinuses present by age 6-7
   • Tonsils
         – Peak growth is between ages 8-16 years
   • Breasts
         – Development in girls is the first sign of puberty; may start as early as age 6
   • Musculoskeletal system
         – Inspect legs and feet
         – Inspect spine for scoliosis

Adolescence: Unique Features
  • Tips on examination
         – Offer privacy; give a gown
         – Emphasize normalcy of development
         – Examine genitalia as any body part, may leave until end
  • Assessments
         – Height, weight, blood pressure, pulse
         – Vision screen
         – Hearing screen
         – Skin
         – Teeth, gums
         – Neck – thyromegaly or adenopathy
         – Abdomen – hepatosplenomegaly
         – Tanner staging (below)
                                                                        Pediatric assessment   11

       – Breast and testes self-examination
       – Pelvic exam
       – Scoliosis screen
•   Puberty
       – Reproductive physiology
            • Males may produce sperm before first ejaculation
            • Males usually are fertile by age 14-15 years
            • Males are able to cause pregnancy at any time after they begin producing sperm,
                 but have diminished fertility the first 1-2 years
            • Females may not produce eggs (ovulate) for 1-2 years after menarche
            • It is impossible to predict which females will be fertile soon after menarche and
                 which may take months to years to become fertile, although earlier menarche is
                 associated with earlier ovulation
            • Pregnancy is possible whenever there is intercourse
            • Pregnancy is most likely when intercourse occurs halfway between menstrual
                 periods
            • The earlier a boy or girl enters puberty, the earlier he/she is likely to be fertile
       – Major physical events
            • Gonads and reproductive organs mature and secondary sex characteristics develop
                 (breasts, pubic hair, facial hair, testes, penis, scrotum)
            • Skeletal growth increases, then slows before finally ceasing (growth spurt)
            • Alterations of body composition as well as the altered distribution of fat
            • Increased strength and endurance
            • Maturation of the anatomic and biochemical factors which coordinate and initiate
                 these processes
       – Major outcomes
            o Adult size, shape and appearance
            o Clear physical distinction between sexes
            o Ability to reproduce
       – Features
            o Sequence of changes is very similar for all persons
            o May be a wide variation in tempo (when it starts and how long it takes)
            o Physical changes (secondary sex characteristics, fertility, changes in endocrine
                 glands, brain and body composition) reflex underlying hormonal changes
       – Typical ages of pubertal events
            o Start
                      Boys: 11-12 years (range 9-14 years) – testicular growth and pubic hair
                      Girls: 10-11 years (range 8-13 years) – breast development and pubic hair
            o Growth spurt
                      Boys: 14 years (range 12-16 years)
                      Girls: 12-13 years (range 10-14 years)
            o Spermarche/menarche
                      Boys: 13-14 years (range 12-16 years) – first ejaculation
                      Girls: 12-13 years (range 10-16 years) – first menstrual period
            o Length
                      Boys: 3-4 years
                      Girls: 4-5 year
       – Typical sequence of events
            o Boys
                      Growth of testicles
                                                           Pediatric assessment   12

         Pubic hair appears
         Growth of penis, scrotum
         Axillary hair
         1st ejaculation, growth spurt, facial hair - may occur simultaneously
         Adult height
o Girls
      oBreast buds appear or in ½ of girls pubic hair
      oPubic hair appears and/or growth spurt
      oPubic hair matures
      oBreast mature
      oAxillary hair
      oMenarche
           Average age is 12-13 years – signals the end of rapid growth phase
           Usually occurs 2-3 years after breast development begins
           Growth rate usually slowing down before menarche
           Bleeding usually not regular in amount or number of days for first
              1-2 years
           Menarche may be delayed by poor health, intense exercise
              (athletes), low body weight (anorexics), emotional stress, and poor
              nutrition
     o Adult height
Pediatric assessment   13
                                                                       Pediatric assessment   14

•   Common concerns about puberty
      – Beginning late – discuss normal variations or underlying cause
      – Beginning early – discuss normal variations (more common in girls) and associated stress
      – Partial early
            o Premature thelarche – isolated breast development
            o Premature adrenarche – isolated pubic hair development
      – Unexpected events
            o Breast asymmetry in girls
            o Gynecomastia – breast tissue development in boys (if unilateral check tests due to
                increase testicular cancer rate)
            o Excessive or insufficient body hair
            o Nipple discharge (check prolactin level)
      – Expected events
            o Acne
            o Body odor
            o Spontaneous erections
            o Nocturnal emissions
            o Masturbation
            o Sexual urges
      – Typical concerns
            o “I’m not normal.”
            o “I don’t look like my friends.”
            o “I’m too tall, too fat, etc.”

				
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