Physical AssessmentPhysical AssessmentPhysical AssessmentPhysical Assessment

Ball & BindlerBall & Bindler

Donna Hills RN EdDDonna Hills RN EdD

Parts of the Physical Exam

• History• Physical• Developmental Assessment• Parent/Child Interaction• Immunizations

History• Birth History incl. Prenatal Care• Past medical history incl.

Injuries/accid/hosp• Well child care: Immuniz/illnesses• G & D Milestones

– primitive reflexes

• Nutrition/Sleep/Elimination/Socialization• Dental health/fluoride

History (cont.)• Home environment:lead risk/basic

resource availability• Parent’s perceptions of the child• Safety: car sears/helmets• Social hx: peers/group

activities/after school care/day care

History (cont.)• Responsibilities:chores in the

home/job• Family hx: risks and concerns• Review of lab data: assess what is

needed

Physical Assessment in the Ambulatory Care

Setting• general approaches accd to dev.level.• Height/weight/head circ./plot on the growth

curve• observe the general behavior of the

infant/parent• assessment by systems(or problem oriented)

– neurologic assessment– chest to toes then head.

Developmental Assessment in the Acute

Hospital Setting• vital signs at assigned times;move

often as needed• assess pain Q1-2hr as appropriate• body system assessment (s) as

related to the pt’s condition• assessments to determine nursing

diagnoses/interventions

Developmental Assessment

• multiple tools to assess parameters of development

• Denver II:fine/gross motor, lang., personal/social

• Ballard Scale assesses gestational maturity• Preterm infant growth charts for

gestational age and for corrected age for premies<2yr.

Parent/Child Interaction• How does the parent respond to

the child’s needs?• Is there eye-contact?• Is there communication with sibs?• Do the parents communicate to

each other/pt with sensitivity and respect?

• Does the parent handle and respond to the child in a developmentally appropriate way?

FIGURE 8–2 Children are not just small adults. There are important anatomic and physiologic differences between children and adults that will change based on a child’s growth and development. Can you identify which of these differences are of greatest concern for the hospitalized child and why?

Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families

© 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458

All rights reserved.

How are children different?

• See figure 8-2 p. 236 (B&B)• proportionately greater body surface

area for weight• large tongue, short narrow trachea• myelinization (mostly) completed by

1st yr• higher BMR, O2needs, caloric needs

Measurement• Head circumference

– Technique– Measure until age 2 yrs or closure of

anterior fontanel.• Length: lying until age 2yr

– Then standing.• Weight: consistency for time and

clothing.

Skin• Mongolian Spots

– Variation of normal coloration in the skin.– Misinterpreted as bruises.

• Turgor and Capillary Refillnormal skin is elastic; dehydrated skin will tent.

• Lice– inspect the hair shaft for nits that adhere

to the hair.

HEENT• Fontanels; should be flat. Bulging indicates

increased intracranial pressure. Sunken indicates dehydration. – Posterior closes 2-3 mos of age– Anterior closes 12-18 mos of age.

• Down Syndrome facies• Strabismus; ocular asymmetry due to muscle

imbalance.• Red Reflex: indicates clear lens (lack of

cataracts)

Chest• Inspection: observe for increased

work of breathing, retractions, respiratory rate.

• Auscultate: R and L; anterior and posterior.– Crackles/rales– Course breath sounds or wheezes – Listen (with ear) for stridor with

inhalation

Heart• Auscultate with diaphragm and then bell

at 4th intercostal interspace in infants and 5th intercostal interspace in older children.

• Determine rate per minute• Determine if rate is regular and WNL for

age and activity level.• Try to identify the heart sounds S1 and S2.• Obtain BP using approp.size cuff.

Abdomen• Inspection: shape and contour• Auscultation: presence or absence of

bowel sounds• Palpation: soft/ firm/ hard

– Lightly first to assess for pain in all quadrants, then deeper.

– Palpate liver along R costal margin– Palpate for spleen (if applic) under L costal

area.

Genitalia• In acute care setting, will probably

not be part of your assessment unless condition requires it or changing a diaper.

• Be aware of Tanner stages of pubertal development.

Musculoskeletal• Spine: screen for posture and

scoliosis• Muscle strength and tone• Hip range of motion Fig.8-60 p.287• Gross motor milestones Table 8-18

p.284.

Neurologic• Cognitive function for age• Language development for age

– Table 8-19 p.287

• Gait and balance milestones Table 8-20 p.288

• Fine motor milestones Table 8-21 p. 289• Primitive reflexes Table 8-23 p.291-4.

Case Study #1• Adam is a 4mo old admitted for 3 days of

fever, 8 diarrhea stools per day, and vomiting with each feeding. His mother reports 3 wet diapers in past 24 hrs. He cries alot and has to be wakened to be fed.

• What would your assessment of Adam include?

• What would you list for nursing diagnoses?

Adam• Assess:

• Nursing Diagnoses:

Case Study #2• Cassie is a 9 yr old, first day post-

op with a ruptured appendectomy.• What would your assessment of

Cassie include?• What would you list for nursing

diagnoses?

Cassie: s/p appendectomy

• Assess:

• Nursing Diagnoses:

Case Study #3• Jarod is an 8yr old admitted with

acute asthma exacerbation.• What would your assessment of

Jarod include?• What would you list for nursing

diagnoses?

Jarod: asthma• Assess:

• Nursing Diagnoses:

Case Study #4 • Brian is 9yrs old and admitted to

R/O meningitis.• What would your assessment of

Brian include?• What would you list for nursing

diagnoses?

Brian: meningitis• Assess:

• Nursing Diagnoses: