Physical Assessment

Physical Assessment Professor Debora Halloran Azusa Pacific University

Pediatric Physical Assessment • Neonate and Infant • The Young Child • School Age and Adolescent

Infant Health History • Developmental History • Home Safety • Immunizations • Review of Systems • This review will help you identify normal physiologic changes as well as alert you to abnormal

The Neonate and Infant • The 1 minute and 5 minute Apgar results will give you important data on the neonates immediate response to extrauterine life. • The following slides depicts a standard sequence • You may reorder sequence as the infant’s sleep and wakefulness state or physical condition warrants • The infant is supine on a warming table or examination table with an overhead heating element. The infant may be nude.

Neonate and Infant • Vital Signs • Note pulse, respirations and temperature • Measurement • Weight, length and head circumference are measured and plotted on growth curves for the infant’s age.

Neonate and Infant • ABNORMAL FINDINGS • Greater than normal head circumference - hydrocephalus • Smaller - microcephaly • Measurements deviating from normal may be caused by underlying disease or inadequate eating or nutritional pattern • Axillary tem range is 35.9 C - 36.7 C • Low temperature suggests hypothermia • High temperature can cause seizures

Neonate and Infant • GENERAL APPEARANCE • Body symmetry, spontaneous position, flexion of head and extremities and spontaneous movement • Skin color and characteristics, any obvious deformities • Symmetry and positioning of the facial features • Alert and responsive affect • Strong lusty cry

Neonate and Infant • ABNORMAL FINDINGS • Eczema • Cradle cap • Depressed fontanels associated with dehydration • Bulging fontanels associated with intracranial pressure • Persistent cyanosis in a warm infant is never normal and requires immediate referral

Neonate and Infant • CHEST AND HEART • Inspect the skin condition over the chest and abdomen, chest configuration, and nipples and breast tissue • Note movement of the abdomen with respirations and any chest retraction • Palpate apical impulse and note its location; chest wall for thrills; tactile fremitus if the infant is crying • Auscultate breath sounds, heart sounds in all locations, and bowel sounds in the abdomen and in the chest • HR RANGE 80 - 160 • CAP REFILL < 1 SECOND • PULSES PRESENT

Neonate and Infant • ABNORMAL FINDINGS • Abnormal HR range requires attention • Murmurs accompanied by cyanosis may indicate congenital heart disease • Cap refill times longer than 2 seconds may indicate dehydrate or hypovolemic shock • Evaluate newly discovered murmurs • Infant eating poorly may have cardiovascular

Neonate and Infant • ABNORMAL FINDINGS - RESPIRATORY • Stressful breathing with flaring nares and sighing with each breath are signs of respiratory distress and require immediate attention • Inspiratory stridor, expiratory grunts, retractions, paradoxical breathing (seesaw) asymmetrical or decreased breath sounds, wheezing and crackles are abnormal • Depressed sternum may affect normal respiration

Neonate and Infant • ABDOMEN • Inspect the shape of the abdomen and skin condition • Inspect the umbilicus, note condition of cord or stump, any hernia • Palpate skin turgor • Palpate lightly for muscle tone, liver, spleen tip, and bladder • Palpate deeply for kidneys, any mass • Palpate femoral pulses, inguinal lymph nodes • Percuss all quadrants

Neonate and Infant • ABNORMAL FINDINGS • Umbilical hernias > 2 cm wide may require further evaluation • Abdominal pain may indicate childhood diseases • Enlarged liver or spleen may indicate disease

Neonate and Infant • HEAD AND FACE • Note any molding after delivery, any swelling on cranium, bulging of fontanel with crying or at rest • Palpate fontanels, suture lines and any swelling • Inspect positioning and symmetry of facial features at rest and while the infant is crying.

Neonate and Infant • EYES • To open the neonates eyes, support the head and shoulders and gently lower the baby backward, or ask the parent to hold the baby over his or her shoulder while you stand behind parent • Inspect the lids(edematous in the neonate), palpebral slant, conjunctivae, any nystagmus and any discharge • Using a penlight; elicit the pupillary reflex, blink reflex and corneal light reflex, assess tracking of moving light • Using an ophthalmoscope, elicit the red reflex

Neonate and Infant • ABNORMAL FINDINGS • Continued strabismus after 6 months is abnormal • Lack of tears after 2 months may be caused by clogged lacrimal ducts and requires medical attention • Fixed or dilated pupils indicate neurological problem

Neonate and Infant • EARS • Inspect size, shape, alignment of auricle, patency of auditory canals, any extra skin tags or pits • Note the startle reflex in response to a lound noise • Palpate flexible auricles • Defer otoscopic examination until the end of the complete examination

Neonate and Infant • ABNORMAL FINDINGS • Lack of response to noise may indicate hearing problem

Neonate and Infant • NOSE • Determine patency of nares • Note the nasal discharge, sneezing and any flaring with respirations

Neonate and Infant • ABNORMAL FINDINGS • Flaring of nares is sign of respiratory distress • Bloody discharge or large amount of nasal secretions may obstruct nares

Neonate and Infant • MOUTH AND THROAT • Inspect the lips and gums, high-arched intact palate, buccal mucosa, tongue size and frenulum of tongue; note absent or minimal salivation in neonate • Note the rooting reflex • Insert a gloved little finger, note the sucking reflex and palpate palate • Note the nasal discharge, sneezing and any flaring with respirations

Neonate and Infant • ABNORMAL FINDINGS • Protruding tongue associated with congenital disorders such as Down’s syndrome or hypothyroidism

Neonate and Infant • NECK • Lift the shoulders and let the head lag to inspect the neck; note midline trachea, any skin folds and any lumps • Palpate the lymph nodes, the thyroid and any masses • While the infant is supine, elicit the tonic neck reflex; note a supple neck with

Neonate and Infant UPPER EXTREMITIES • Inspect and manipulate, noting ROM, muscle tone, and absence of scarf sign (elbows should not reach midline) • Count fingers, count palmar creases, and note color of of hands and nail beds • Place your thumbs in the infants palms to note the grasp reflex, then wrap your hand around infant’s hands to pull up and note the head lag

Neonate and Infant ABNORMALFINDINGS • Inadequate range of motion may indicate congenital malformation or birth injury or may result from pulling or lifting infant

Neonate and Infant LOWER EXTREMITIES • Inspect and manipulate the legs and feet, noting ROM, muscle tone and skin condition • Note alignment of feet and toes, look for flat soles and count toes; note any syndactyly • Test Ortolani’s sign for hip stability

Neonate and Infant • GENITALIA • Females: Inspect labia and clitoris (edematous in the newborn), patent vagina • Males: Inspect position of urethral meatus (do not retract foreskin), strength of urine stream if possible, and rugae on scrotum • Palpate the testes in the scrotum

Neonate and Infant • ABNORMAL FINDINGS • Ambiguous genitalia abnormal • Male • Phimosis - tight foreskin • Weak urine stream • Solid scrotal mass • Hernias present as scrotal mass • Undecended testicles • Swollen scrotum - hydrocele • Female • Vaginal discharge or labial redness or itching may be cuase by diaper or soap irritation or sexual abuse • Blood tinted fluid from vagina after first week abnormal

Neonate and Infant • NEUROMUSCULAR Lift infant under the axillae and hold the infant facing you at eye level • Note shoulder muscle tone and the infant’s ability to stay in your hands without slipping • Rotate the neonate slowly side to side; note the doll’s eye reflex • Turn the infant around so his or her back it to you’ elicit the stepping reflex and the placing reflex against the edge of the examination table

Neonate and Infant • ABNORMAL FINDINGS Note shoulder muscle tone and the infant’s ability to stay in your hands without slipping • Delays in motor or sensory activity may indicate brain damage, mental retardation, illness, malnutrition or neglect • Asymmetrical posture or spastic movements need further evaluation • Maintenance of infant reflexes past usual age is

Neonate and Infant • SPINE AND RECTUM Turn the infant over and hold him or her prone in your hands, or place the infant prone on the examination table • Inspect the length of the spine, trunk incurvation reflex and symmetry of gluteal folds • Inspect intact skin; note any sinus openings, protrusions, or tufts of hair • Note patent anal opening. Check for passage of meconium stool during the first 24 - 48 hours

Neonate and Infant • ABNORMAL FINDINGS • Dimpling in spine may be associated with neural tube defects • Watery stools and explosive diarrhea indicate infection. • Constipation or hard stools indicate inadequate hydration

Neonate and Infant • FINAL PROCEDURES • With an otoscope, inspect the auditory canal and tympanic membrane • Elicit the Moro reflex by letting the infant’s head and trunk drop back a short way, by jarring crib sides or by making a loud noise.

Neonate and Infant • SUMMARY • Is a fundamental component in health promotion and disease prevention • Baby clinic visit may be the only access to the healthcare system for the family • BC infant health depends on family health, incorporating the total family is critical in your approach to health assessment • Encourage parents to keep all scheduled visits and take every opportunity to make necessary referrals for the family members

The Young Child • Review Developmental Considerations when preparing for examination of the toddler and young child • A young child during this time goes between independence and dependence on parent • Is aware and fearful of a new environment, has a fear of invasive procedures, dislikes being restrained, and may be attached to a security object • Focus on the parent as the child plays with a toy • Health History (bio data, current health status, past health history, family history, review of systems, psychosoical profile) • Collect the history, including developmental data • During the history, note data on general appearance

The Young Child • General Appearance • Note child’s ability to amuse himself or herself while the parent speaks • Note parent/child interaction • Note gross motor and fine motor skills while child plays with toys GRADUALLY FOCUS ON AND INVOLVE YOURSELF WITH THE CHILD AT FIRST IN A “PLAY PERIOD” • Evaluate developmental milestones by using a Denver II test; gait, jumping, hopping, building a tower and throwing a ball • Evaluate posture while the child is sitting and standing. Evaluate alignment of the legs and feet while the child is walking • Evaluate speech acquisition • Evaluate vision, hearing ability • Evaluate social interaction

The Young Child Neurological check: Test balance coordination and accuracy of movements. • Toddlers usually can walk alone by 12 - 13 months. • Balance is unsteady with wide base of support • The preschoolers gait is more balanced, smaller base of support; child walks, jumps and climbs by age 3 • Strength increases during preschool years • Balance and coordination improve with refinement of fine motor skills

The Young Child ASK THE PARENT TO UNDRESS THE CHILD TO THE DIAPER OR UNDERPANTS. POSITION THE OLDER INFANT AND YOUNG CHILD 6 MONTHS TO 2 OR 3 YEARS, IN THE PARENTS LAP. A 4 OR 5 YEAR OLD USUALLY FEELS COMFORTABLE ON THE EXAMINATION TABLEFINAL PROCEDURES • Measurement • Height, Weight, head circumference ((may been to defer until later in the examination)

The Young Child • For your general inspection note toddler general appearance • Pot belly and wide base of support • Note delays or premature maturation • As you continually inspect the skin: • Lesions such as tinea capis or ringworm need treatment • Pediculosis is common among preschoolers

The Young Child • CHEST AND HEART • Auscultate breath sounds and heart sounds in all locations, count respiratory rate, count heart rate, and auscultate bowel sounds • Inspect size, shape and configuration of chest cage. Assess respiratory movement • Inspect pulsations on the precordium. Note nipple and breast development • Palpate apical impulse and note location, chest wall for thrills, any tactile fremitus

The Young Child • ABNORMAL FINDINGS • Toddlers and preschoolers have a high incidence of respiratory infections • Children often have sinus arrhythmia and split second heart sound that both change with respiration This is a normal variation • Systolic innocent murmurs and venous hum are common findings • Note: if you detect a murmur, refer patient for follow up and rule out pathology

The Young Child THE CHILD SHOULD BE SITTING UP IN THE PARENT’S LAP OR ON THE EXAMINATION TABLE, DIAPER OR UNDERPANTS IN PLACE • ABDOMEN • Inspect the shape of abdomen, skin condition and periumbilical area • Palpate skin turgor, musle tone, liver edge, spleen, kidneys and any masses • Palpate the femoral pulses. Compare strength with radial pulses • Palpate inguinal lymph nodes • NOTE: Pot belly normal for toddler disappears as abdominal muscles strengthen.

The Young Child • GENITALIA • Inspect the external genitalia • On males, palpate the scrotum for testes. If masses are present, trans-illuminate

The Young Child LOWER EXTREMITIES • Test Ortolani’s sign for hip stability • Note alignment of legs and skin condition • Note alignment of feet. Inspect toes, and longitudinal arch • Palpate the dorsalis pedis pulse • Gain cooperation with reflex hammer. Elicit plantar, Achilles and patellar reflexes

The Young Child • UPPER EXTREMITIES • Inspect arms and hands for alignment, skin condition; inspect fingers and note palmar creases • Palpate and count the radial pulse • Test biceps and triceps, reflexes with a hammer reflex • Measure blood pressure

The Young Child • HEAD AND NECK • Inspect the size and shape of the head and symmetry of facies • Palpate the fontanels and cranium. Palpate the cervical lymph nodes trachea, and thyroid gland. • Measure the head circumference Note: • Head size growth slows to 1 inch a year by end of age 2; then 1/2 inch a year until 5 • Anterior fontanel closes by 18 months • Enlarged lymph nodes may indicate infection or lymphoma

The Young Child • EYES • Inspect the external structures. Note any palpebral slant • With a penlight, test the orneal light and pupillary light reflexes • Direct a moving penlight for cardinal positions of gaze • Inspect conjunctivae and sclerae • With ophthalmoscope, check the red reflex. Inspect the fundus as much as possible Note: visual acuity is normally 20/40 during toddler years. Begin vision screening between 3 and 4

The Young Child • NOSE • Inspect the external nose and skin condition • With a penlight, inspect the nares for foreign body, mucosa, septum and turbinates Abnormal finding: Boggy, bluish-purple or gray turbinates: Chronic rhinorrhea which can result from allergic rhinitis Note: when inspecting nares or external ear canal, be alert for foreign objects

The Young Child • MOUTH AND THROAT • With a penlight, inspect the mouth, buccal mucosa, teeth and gums, tongue, palate and uvula in midline. Use tongue blade as the last resort Note: Generally tonsils are large Eruption of primary teeth is usually complete by 2.5 years. Note any baby caries.

The Young Child • EARS • Inspect and palpate the auricle. Note any discharge for the auditory meatus • Check for any foreign body • With an otoscope, inspect the ear canal and tympanic membrane. Gain cooperation throug the use of a puppet, encouraging the child to handle the equipment or to look in the parent’s ear as you hold the otoscope. You may need to have the parent help restrain the child Note: Test hearing by age 3 or 4. Hearing deficits warrant follow up. Toddlers and preschoolers have a high incidence of otitis media

Physical Assessment