PHYSICAL EXAMINATION

OF CHILDREN

SARA ABU SHHADEH

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INTRODUCTION

Diagnosis

Investigation

History

Examination

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HISTORY❑demographic data

❑ chief complain

❑history of present illness

❑Past History

✓Medical history.

✓( Childhood illness&

injuries)

✓perinatal history

✓History surgical

✓ Family history

✓ immunization history

✓ Medication history

✓ Allergy history

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PHYSICAL EXAMINATION

Sequence of the examination

The sequence of children examination

follows head-to-toe direction.

Alterations are made to accommodate the

child’s developmental needs and

chronological age.

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KEEP IN MIND:

1. Choose appropriate, non-threatening area.

2. Have room well light and warm.

3. Have some toys, dolls, stuffed animals, and games available for child.

4. Provide privacy, especially for school-age children and adolescents.

5. Provide time for play and becoming acquainted.

6. Perform examination as quickly as possible.

7. Involve child in examination process.

8. Discuss findings with family at end of examination.

9. Praise child for cooperation during examination; give reward such as a small toy or sticker.

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INCREASING A CHILD’S

READINESS

✓Talk to parent while essentially ignoring the child, gradually focus on the child or his favorite object.

✓Make complementary remarks about the child.

✓Tell a funny story or a simple magic trick.

✓Avoid prolonged explanation about examining procedures.

✓Minimize any disruptions or stimulation.

✓Limit no. of people in the room.

✓Use quite, calm, confident voice.

✓Use paper-doll technique.

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PEDIATRIC PHYSICAL EXAMINATION

❑Physical Growth measurements.

❑Physiologic measurements.

❑General appearance.

❑Skin - Head and neck - Eyes - Ears - Nose -Mouth and throat - Chest - Lungs - Heart -Abdomen - Genitalia - Anus - Back and extremities - Neurological assessment.

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PHYSIOLOGICAL MEASUREMENTS

1. Respiration

•Observe rate of breathing for 1 full

minute.

•In infant and young children observe

abdominal movement.

•In older children Observe thoracic

movement.

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•In infant and young children count the apical pulse for 1 full minute because of possible irregularities in rhythm .

• For greater accuracy, measure the apical rate while the child is sleep.

•Can be taken radially in children older than 3 years

2.PULSE

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3.BLOOD PRESSURE

•Appropriate sized cuff; the width of the rubber bladder should cover

two thirds ( or 40%) of the circumference of the arm, and the length

should encircle 80%-100% of the arm circumference.

•Crying can cause inaccurate blood pressure reading.

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BLOOD PRESSURE

Guidelines for Measuring blood pressure:

oUse appropriate sized cuff

oPosition limb at level of heart

oRapidly inflate cuff to about 20 mmHg above point at which radial

pulse disappears.

oRelease cuff pressure at rate of about 2 to 3 mmHg /sec during

auscultation of the artery

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Temp. measures at several

body sites via (oral, rectal ,

axillary, ear canal, skin rout,

tympanic).

▪ 7 min for oral.

▪ 4 min for rectal( 1 degree ↑

than oral).

▪ 5 min for an axillary reading (1

degree ↓than oral).

Normal range → ( 36.5-37.5 C)

4.TEMPERATURE

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GROWTH

PARAMETERS

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Head circumference

•Measure head circumference in children

up to 36 months of age.

•In any child whose head size is

questionable.

•Place the measuring tape slightly above

the eyebrows, pinna of the ears, and

around occipital bone

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Chest circumference

▪ measure the size of chest by placing

the measuring tape around the rib

cage at the nipple line

▪Take measurement during

inspiration and expiration and

record the average values.

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Length▪ Length :- until 3 years

▪Measure from the crown of the head

to the heel recumbent.

▪ holding the head in midline.

▪ grasping the knees together gently.

▪ pushing down on the knees against

the table to fully extended and flat of

the legs .

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HeightHeigth:- older than 3 year old

•Stand straight without shoes Head in

midline and the line of vision parallel

to the ceiling or floor.

•The heels, buttocks, and back of the

shoulders touching the wall and the

medial malleoli touching if possible

•correct bending of the knees,

slumping of the shoulders, or raising

of the heels of the feet.

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WEIGHT; UNTIL 3YEARS

Use platform-type scale

Weigh infants and older

children in under wear

Scale should be balanced

•Protect infant by placing hand

over body to prevent falling off

scale.

•Cover scale with Clean sheet

of paper for each child.

•Use platform- standing type

scale

•Plot on growth chart

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نشاط

GROWTH CHARTS

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GROWTH CHART

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GENERAL APPEARANCE

•Alertness and level of consciousness.

•Facial features (Symmetric. Dysmorphic).

•Assess skin color.

•Facial expression ( ex: pain, difficulty breathing, frightened,

unhappy, mentally delayed).

• Posture, position, and types of body movements (perception!,

self-esteem, in pain).

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GENERAL APPEARANCE

•Behavior (personality, activity level, reaction to stress,

interaction).

•Distress signs (respiratory ,cardiac , pain).

•Nutrition.

•Hygiene & groom.

• Developmental assessment.

•Assess the speech

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SKIN

❖Skin Color ( cyanosis, acrocynosis, pallor, erythema,

ecchymosis, jaundice ).

❖Texture, Moisture, & Temperature.

❖Mobility and turgor (on abdomen)

❖ Lesion(Size, shape, Color, Color &Characteristics).

❖ Hair (color, texture, quality, distribution, cleanliness, lesions,

infestation).

❖Nails (color, shape, texture, quality, &hygiene).

❖Palm creases (Transpalmar crease!).

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NAILS

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HEAD AND NECK

oHead (shape, symmetry, size). (macrocephalic, microcyphalic,

normocephalic).

oHead control and posture

oSkull ( fontanels, fractures, swelling).

oEvaluate range of motion

oAssess lymph nodes

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EYES

▪ Visual acuity

Snellen E chart for preschooler from 3 to 6 years of age

Standard snellen alphabet chart by 7 to 8 years

▪ Extraocular muscle function

Test strabismus ( corneal light reflex, cover test )

▪ Inspection of external structure (eyelids, palpebral fissures,

conjunctiva, lacrimal punctum , sclera, pupils, iris).

▪ Inspection of internal structures

(ophthalmoscope, red reflex).

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EYES

▪ Visual reflexes( test light perception)

▪ Attending behaviors:Birth to 2 weeks – refusal to reopen

eyes after exposure to bright light; increasing

▪ alertness to object; infant may fixate on an object

By 2 to 4 weeks– infant can fixate on an object

By 1 month – infant can fixate and follow a light or bright toy

By 3 to 4 month – infant can fixate, follow and reach for the

toy

By 6 to 10 months– infant can fixate and follow the toy in all

directions

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EARS

•Inspection of external structures (pinna):

•Location (Measure height alignment of the pinna)

•Assess Skin for small openings, sinuses, tags.

•Assess hygiene.

•Inspection of Internal structures (otoscopic examination: walls of the

canal, signs of irritation, foreign bodied, infection color of the tympanic

membrane, light reflex, landmarks).

•Pull pinna down and backward in children ˂3 yrs. old

•up backward in children ˃ 3 years old.

•Auditory testing (CN vIII).

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EARS

Skin tag

NOSE

▪Inspection of external structures ( placement, alignment,

symmetry, deviation).

▪Inspect nasal cavity (color, any swelling, discharge, dryness, or

bleeding).

▪Assess Olfactory nerve(smell).

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MOUTH AND THROAT

▪Inspection of external structure (lips: color, moisture,

texture, symmetry; buccal mucosa).

▪Inspection of internal structure (mucosal lining, gums, teeth,

tongue, palate, uvula, tonsils)

▪ color, ulceration, bleeding, moisture.

▪Assessment for cleft lip or palate.

▪Assess CNlX ,CNX

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HOLDING TODDLER FOR MOUTH EXAM

Parent can hold the child closely to

the chest with legs between the

parent's legs

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CHEST LANDMARKS

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CHEST AND LUNGS

▪ Assess bony landmarks (rib cage, sternum,

costal angle, ICS).

▪ Shape &size( measure chest circ),

▪ Assess respiration for rate ( 1min),

rhythm (regular, irregular, or periodic), depth

(deep or shallow), quality(effortless,

automatic,difficult, or labored) & chest movement.

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CHEST AND LUNGS

▪ Note the character of breath sounds,

such as noisy, grunting, snoring, or

heavy.

➢Percussion over lungs field

➢Auscultation of breath sounds (vesicular,

bronchovesicular, bronchial).

▪ Note addition breathing sounds such as

Crackles vs wheezes.

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CHEST AND LUNGS

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CHILD RIB CAGE

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AUSCULTATE THE

BREATHING SOUND

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HEART

•Distended neck veins, clubbing of fingers, peripheral cyanosis, edema, blood pressure, respiratory status, capillary refill.

•Inspection. Distress sings

•Palpation: Apical impulse:

I. Just lateral to the left MCL and fourth ICS in children younger than 7 years old .

II. At the left MCL and fifth ICS in children older than 7 years old.

III. Auscultate heart sound.

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ASSESS HEART SOUND

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PERIPHERAL

PULSES

Assess peripheral

pulses bilaterally

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ABDOMEN

Anatomic landmarks;

placement of the

abdominal organs.

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ABDOMEN

➢ Examination orders: inspection, auscultation, palpation.

➢ Inspection (contour, skin, stretch marks, hernias: umbilical, inguinal, femoral, & abd. movement).

➢ Auscultation → Bowel sounds.

➢Palpation

➢superficial → skin, tenderness, muscle

tone, and superficial lesions

➢deep → Organs

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INFANT'S ABDOMINAL

PALPATION

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GENITALIA

Signs of puberty.

Urethral meatus (hypospadias, epispadias)!.

Undescended testes!.

Ambiguous genitalia!.

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BACK AND EXTREMITIES

•Spine: examine for curvature (scoliosis).

•Inspection of the back (tufts of hair, dimples, discoloration).

•Inspect the extremity for symmetry of length and size.

•Count the fingers and toes to be certain of

normal number ( polydactyly, syndactyly).

•Bowleg VS knock-knee.

•Joints;Evaluate range of motion &mucsle strength.

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NEUROLOGIC

ASSESSMENT

▪ Level of consciousness & orientation

▪ Cerebellar Functioning ; balance &coordination

✓ Finger-to-nose test.

✓ Heel-to-shin test.

✓ Romberg test.

▪ Deep tendon reflexes

▪ Assess cranial nerves

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REFERENCE

Hockenberry, M. J., & Wilson, D. (2017). Wong's Essentials of Paediatric. Nursing. (10th ed.). Elsevier Health Sciences.