NR328 Pediatric Nursing - ATI Skills Module - Physical Assessment of the Child GRADED A VERIFIED

Accepted Practice Equipment Stethoscope - Stethoscopes are used to auscultate, or listen to, a variety of sounds generated within the body. They come in several styles and levels of quality. In general, higher quality stethoscopes allow better transmission of sound. Choose an infant, child, or adult size if available. Disposable stethoscopes are provided in some practice settings. In any case, the diaphragm should achieve sufficient skin contact to minimize environmental sounds. Clean stethoscopes (the diaphragm, bell, and earpieces) before and after each use, especially if used for more than one patient. - Most nurses use acoustic stethoscopes. With this type, the stethoscope’s head picks up sounds that are transmitted through hollow tubing to your ears. Many stethoscopes have rotating heads, thus you can listen either with the diaphragm, which is better for listening to high-pitched sounds, or with the bell, which is useful for hearing low-pitched sounds. Stethoscope tubing that is thick, fairly heavy, and no longer than 18 inches is best for transmitting sound. The earpieces are attached to bendable metal tubing, so that you can insert the earpieces at an angle toward your nose. This allows the sound to be projected in the direction of your tympanic membranes. The earpieces should be soft, comfortable, and large enough to fill your ear canal and block outside sounds. - To use the stethoscope, place the earpieces in your ears, making sure that they are directed toward your nose. Rub the stethoscope’s diaphragm with warm, clean or gloved hands so that it will feel warm on the patient’s skin. To listen to high-pitched sounds, such as heart or lung sounds, use the diaphragm. Gently rub the diaphragm to ensure that your stethoscope’s head is rotated correctly. Apply the diaphragm firmly to your patient’s skin, using your index and middle fingers to apply pressure. Be sure that nothing rubs against the tubing because that will generate distracting sounds. When listening for low-pitched sounds, such as checking blood vessels for bruits, use the stethoscope’s bell. Use light pressure, but be sure that the entire rubber ring around the bell is in contact with the patient’s skin. Blood Pressure Cuff - Blood pressure cuffs come in a variety of sizes and are either aneroid or electronic. The cuff is made of various materials, typically cloth or other synthetic material, which covers an inflatable rubber bladder. The bladder of the cuff should be selected by size and not by the age of the patient. The length of the bladder should be at least 80% to 100% of the circumference at the midpoint of the upper arm. The width of the bladder should be at least 40% of the circumference at the midpoint of the upper arm. Critical to an accurate blood pressure is using the proper size cuff for the size of the client. A too large or too small cuff will provide either false high or low readings. Penlight - Use a penlight for better visualization when you examine body orifices, such as the mouth, or in skin folds where you need extra illumination. Penlights are also used to check pupillary responses. Otoscope With Speculum - In some practice settings, you’ll use an otoscope to examine your patient’s ear canals and perhaps the tympanic membranes. Make sure the handle of the otoscope is charged; otherwise, the light source will not work. Attach the otoscope’s head to the handle and then a disposable speculum to the head. Specula are most commonly available in two sizes: 2-mm for pediatric exams, and 4-mm for adult exams. The larger speculum affords a wider view of the inner ear. Twist the speculum onto the head and be sure it is firmly attached. Turn on the light by pressing the small button and rotating the ring at the top of the otoscope’s handle. Handle the otoscope carefully and safely and, at the end of the examination, discard the speculum. Ophthalmoscope - An ophthalmoscope is used to examine your patient’s internal eye structures. It is composed of a lens-and-mirror system and a bright light. Different lens powers are on a disk that rotates on the head of the ophthalmoscope. The black plus numbers magnify images and the red minus numbers reduce them in a range of powers. The lenses are changed by turning the disk with your forefinger. - To use the ophthalmoscope, make sure the handle of the ophthalmoscope is charged; otherwise, the light source will not work. Once the ophthalmoscope head is attached to the handle, turn it on and set the lens power at zero. To stabilize the ophthalmoscope during the examination, rest the top against your eyebrow and the handle against your cheek. To stabilize the patient’s head, place your hand on top of it. To best visualize the eye, use your right eye to examine the patient’s right eye and your left eye to examine the patient’s left eye. Percussion Hammer - A percussion hammer can be made from a variety of materials. Generally the hammer will have a rubber head, which is triangular in shape, with a metal or plastic handle. Use a percussion hammer to test deep tendon reflexes. Thermometers - There are many different types of thermometers that are available for measuring temperature through various routes. Some are mercury free glass, or electronic. Temperature can be measured orally, rectally, axillary, temporally and tympanic. Tongue Depressors - Use a tongue depressor to hold down your patient’s tongue while you visualize the throat or to check the gag reflex. Use another tongue depressor for sharp/dull discrimination in the neurologic examination. Simply break it, and then use the half with the sharpest point to test sensation. Cotton Ball - Use a cotton ball to test sensation to light touch, both on the face during cranial nerve testing, and on the extremities as part of the neurologic examination. Fragrance (orange or mint) - Testing the first cranial nerve, the olfactory nerve, is often omitted from physical examinations. But you can test it easily by asking your patient, with his eyes closed, to identify a non-noxious odor, such as orange or mint (as in as toothpaste). These smells are preferred rather than irritating odors such as alcohol, which can stimulate the trigeminal nerve and produce an incorrect response. Measuring Devices - A disposable ruler is handy for measuring a variety of skin lesions, areas of redness, and incisions. Use a measuring tape for determining head circumference and edema. Pediatric Perspective - When conducting physical examinations of children from birth through adolescence, there are quite a few unique considerations to keep in mind. Approach these differences by first establishing a rapport with the child and the family. Take some time to get acquainted with them. Establish a warm, safe, cheerful, and private environment. Remember that parents and other adults provide a critical link to understanding a child’s health. They are the primary source of information about the child and often help the child accept and cooperate with the examination. Listen to them when collecting data. It is essential to remember that parents will be responsible for carrying out the plan of care; therefore, they must know and understand that plan. For families who speak another language, include adequate interpretive skills or an appropriate interpreter in your physical examination “tool kit.” - Engage the parent and the child. Talk with the parent about how the child copes with new or stressful situations. Find out if the child has any experience with healthcare situations. Ask what the parents have told the child to expect at a healthcare visit, then observe the child carefully for readiness to engage with you during the examination. Include the child in the conversation to whatever extent is appropriate. Allow the parent to participate at whatever level is comfortable for the parent and for the child. - Organize your examination. Consider the sequence of the steps of your examination and the attention span of the child. Perform the least invasive procedures first and the steps that might feel strange or uncomfortable for the child last. If the child will not participate in the conversation, talk with the parent. Try complementing the child for information the parent shares or for things the child can do to help draw the child into the experience. - Involve the child. Sometimes, playing a game will help a child relax and work with you. Try speaking in the third person, for example (for young children), “Little boys sometimes think it tickles when I listen to their tummy.” Explain each part of the examination to the child (and to the parent). Use concrete terms to describe what you are doing. Say, “I’m going to look in the back of your throat,” not, “I need to see your tonsils.” Encourage the child to ask questions during the examination, but do not pressure him. Take every opportunity to “teach” the child and parent about the human body in language that is simple and suitable for the child’s developmental level. Do not give the child more than three pieces of information about what you are going to do at any one time. - Keep a steady pace. Do not make rushed movements during the examination, especially toward the child. Work at a pace that is comfortable for the child. If he is anxious about one part of the examination, move on and return to that part later. If examining more than one child at a time (siblings), start with the most cooperative child and include the other children in the conversation as you perform the examination. - Be honest. Be clear and honest about your expectations. Do not offer choices if there are none. Say, “I need for you to lie very still while I look into your ears,” not, “If you are ready, I’d like to look in your ears.” And, if necessary, ask for the child’s cooperation. If the child does not cooperate, see if the parent can help. Be sure to praise the child before, during, and after each step, even if the child had difficulty cooperating. Age by age… - Especially for infants. A primary form of communication with infants involves nonverbal activities such as holding, rocking, and patting. Also important is talking to the infant in a quiet, unhurried, nonthreatening tone of voice. Watching the parents interact with the infant can give you examples of established communication patterns that you can use during the examination. Older infants have strong stranger and separation anxiety, so you might be more successful doing the examination when a parent holds the child. If you do hold an older infant, do it securely to convey a sense of confidence. As much as possible, perform the examination in a manner that allows the infant to see the parent at all times. Have the infant hold a favorite object (toy, stuffed animal, doll, blanket, pacifier) during the examination. Use the distraction of a bright object or a rattle to gain cooperation, if needed. A quiet, higher-pitched voice and smiling and engagement with the infant help promote a quick, efficient, thorough, and nontraumatic examination. - When the child is a toddler. Children in this age group are concrete thinkers who interpret your statements literally. If you tell toddlers you can see all the way through their ears to the other side, they will believe you. A toddler expresses herself through a broad range of nonverbal actions; observe these and take cues from the parent-toddler interaction you observe early in the visit. Monitor the toddler for signs of fear or anxiety and address it immediately in a quiet, soft, relaxed manner while also involving the parent. With this age group, misunderstanding generates an abnormal response of fear or anxiety. To prevent this, use short, concrete instructions and repeat them several times as you prepare to do the examination. Or, make up engaging scenarios, such as checking to see if a little boy has the muscles to be a superhero. Toddlers love dolls and puppets, so incorporate these props into the examination, demonstrating each step on the doll and letting the toddler practice on the doll. It is very helpful to let a toddler touch and play with the equipment before performing the examination. If the child remains uncooperative despite your best efforts, perform the examination as quickly as possible. - Preschooler pointers. Many of the communication skills used for toddlers work well for this age group. Because of ever-expanding verbal communication skills, it is somewhat easier to gain a preschooler’s cooperation for various parts of the examination. Children in this age group like to please and conform, and that makes examining this age group somewhat easier. Again, enlist parental assistance if the child becomes resistant or frightened by the examination. Most preschoolers know the names of quite a few body parts, and you can use this both to gain cooperation and to teach. Preschoolers are very modest, so give them the opportunity to undress themselves for the examination. Encourage them to ask questions during the examination. Make your responses short, specific, and in simple language the child can understand. This is an ideal opportunity to begin to introduce proper terminology as the child demonstrates knowledge of various body parts. Rewards (stickers, small toys) are also effective and can help set the stage positively for future healthcare visits. - Working with school-age children. At this stage, children remain concrete thinkers but are becoming more sophisticated. Many have had prior experience with healthcare staff, and it is particularly important to know whether these experiences have been positive or negative before you begin the examination. Do not attempt to rush through your examination. School-age children are sensitive to embarrassment and may fear injury. Explain every step of the examination, especially if the child has not had any prior experience in this type of setting. Children in this stage often respond well to reassurance and praise (for allowing the examination, for cooperation with the examination). Talking in the third person to younger children in this group can be very effective in reducing their anxiety and gaining their cooperation. Explain in simple terms the various parts of the examination and why you are doing each step. This group responds very well to discussion about what you are doing as you do it. - Communicating with adolescents. In this stage, verbal skills are often more sophisticated than behavioral skills. It is important to understand what an adolescent’s prior experiences with healthcare have been as you approach the examination. Following the adolescent’s cues, address fears verbally and directly. Expect the adolescent to use monosyllabic responses plus a wide range of nonverbal expressions, such as anger, reticence, or other behavior that is considered inappropriate in other settings. Be patient and avoid prying, confrontation, continuous and repetitive questioning, and judgmental attitudes. Start the discussion, or refocus it if the examination is not proceeding well, with nonthreatening subjects such as school, friends, sports, or other extracurricular activities. Respect the adolescent’s privacy and emphasize confidentiality. Whenever appropriate, do at least part of the examination and history taking without the parent in the room. This gives the adolescent an opportunity to convey any sensitive issues. However, be aware of any specific state laws about children’s confidentiality and be clear with the adolescent about what you are required to share with parents and others before he discloses anything in confidence. Determine the adolescent’s comprehension level and attempt to confirm understanding throughout the visit. Share your findings as you proceed through the examination and ask him to reiterate what you have said in his own words to confirm accuracy of understanding. General Patient & Anthropometric Measurements Components include: ● Observe body characteristics and check body mass index, or BMI. ● Note facial expression and the presence or absence of distress. ● Observe hygiene, grooming, and dress. ● Check for any odors. ● Evaluate affect (bright, pleasant, anxious, apprehensive, depressed, angry, hostile). ● Measure weight, height, head circumference, and body mass index. General Patient Survey: - As you greet your patient, begin your general patient survey. The information you obtain from this survey can provide valuable information about the child’s well-being and about the relationship between the child and the parent. Start the survey by taking note of the child’s general appearance and behavior. She should appear well nourished and developed for her age. Note body posture and movement. Be sure to note the child’s facial expression as well. Are there any signs of pain or distress? - Note the behavior and tone of voice the parent uses with the child. Is the interaction between the two warm and caring and appropriate for the situation? Does the parent reassure the child and encourage her to interact with you? - Observe hygiene, grooming, and dress. Is the child dressed appropriately for the season and the situation? Pay attention to any noticeable odors as well. - Finally, note the child’s mood, or affect. Is he smiling and pleasant? Does he appear anxious or apprehensive? Depressed? Is he angry or hostile? Anthropometric Measurements - Growth measurements are an important component of pediatric care. Children are unique and grow at variable rates, thus it is important to measure and plot their weight, height, and head circumference on the appropriate standardized growth charts. The Centers for Disease Control and Prevention has made these charts available for boys and girls, ages 0 to 36 months and 2 to 20 years of age, for height and length, weight, and weight to length and height. For children who are less than 24 months, growth should be plotted on the World Health Organization (WHO) charts. There are also special growth charts for children with specific genetic disorders such as Down syndrome. - Each child’s growth is plotted on a curve, and the child should follow the curve consistently through adolescence. Measurements that fall within the 5th to 95th percentiles are considered within the normal range for growth. Standardized growth charts help clinicians assess for trends and compare growth to previous measurements and to that of the child’s peers. - Although standardized charts are valuable, body mass index (BMI) is now used more often in practice today. An indirect measure of body fat, BMI provides a better picture of the child’s growth status. Clinicians use BMI measurements to predict the potential for obesity and to determine whether or not a child is growing adequately. Calculated using a formula that compares height to weight, BMI is included on gender-specific growth charts for children between the ages of 2 and 20 years. Weight - Infants. Weigh infants on a platform-type scale with clothes and diaper removed. To obtain an accurate weight, be sure to calibrate the scale prior to placing the infant on the scale. Cover the platform of the scale with a clean cloth or a disposable pad before calibrating the scale. For safety while the infant is being weighed, stand next to the scale at all times to make sure the infant cannot roll off, and keep the parent close to the infant to help reduce the infant’s anxiety. Weigh to the nearest ½ ounce and record the weight on the appropriate flow sheet. - Toddlers/Preschoolers/School-age children. For children who are able to stand and cooperate with the procedure, use an upright scale. To obtain the most accurate weight possible, the child should only wear underwear. However, because scales are not often in a private area and children may be uncomfortable taking their clothes off to be weighed, this is not always appropriate. Under these circumstances, have them take off their shoes and jacket or coat and record the weight on the appropriate flow sheet. - Adolescents. Use an upright scale to obtain an adolescent’s height. Again, having the adolescent wear as little clothing as possible facilitates obtaining an accurate weight. Because some adolescent girls become preoccupied with their weight and body image, it is important to be aware of the signs and symptoms of eating disorders, such as anorexia nervosa or bulimia nervosa. Provide education and resources to patients and their parents when you detect any possibility of these disorders. Height/Length - Infants. To measure the height or length of a child up to the age of 24 months, use a horizontal measuring board. If you are using a birth-to-36-months length-for-age chart, use the board for children up to 36 months of age. If a board is not available, use a measuring tape, but keep in mind that it is less accurate. If you do use a measuring tape, place the infant on a paper-covered surface, with the legs fully extended and the head midline. Mark the end points of the top of the head and the heels of the feet on the paper sheet. Pick up the infant and measure between the head and heel marks to obtain the length. For the most accurate measurement, place the infant in a supine position with the head at midline and the legs flat on the table. Because this is not a normal position for an infant, gently hold the infant in place until the measurement is taken. - Toddlers/Preschoolers/School-age children. Measure height using a stadiometer and be sure to use the appropriate grid (stature for height) chart. Encourage the child to stand straight and tall and to look straight ahead. Make sure the child’s head, shoulders, and heels touch the wall. The measuring device should sit gently on the top of the child’s head. The number just under the measuring device is the child’s height; measure to the nearest 1/8 inch. - Adolescents. Use a stadiometer to measure an adolescent’s height. As with toddlers and preschoolers, encourage the adolescent to stand straight and tall with his head, shoulders, and heels touching the wall. The number just below the measuring device is the height to record. Head Circumference - Infants. Head circumference should be measured at birth and at every check-up up to 36 months of age and the measurements plotted on the appropriate growth grid. Place the tape measure around the widest part of the infant’s head, which is slightly above the eyebrows and the pinna of the ears and around the occipital prominence at the back of the skull. Head circumference is noted to increase by 1.5 cm/month in the first 6 months and then drops to 1.25 cm/month. Be sure to measure to tenths of a centimeter, because the percentile charts have grids with 0.5 cm. - Toddlers/Preschoolers/School-age children. Head circumference is generally measured up to 36 months of age, and beyond if the child’s head size is questionable or the child has physiologic problems such as hydrocephalus. When measuring head circumference, place the tape measure around the widest part of the child’s head, which is slightly above the eyebrows and the pinna of the ears and around the occipital prominence at the back of the skull. A toddler’s head circumference generally increases by about 1 inch during the second year and about 1.25 cm/year until age 5. - Adolescents. Measuring head circumference is not a routine part of the physical examination for this age group. Vital Signs Components include: ● Measure temperature. ● Assess pulse. ● Evaluate respiration. ● Measure blood pressure. Overview - After conducting a general survey, take the physiologic measurements essential for the data-collection portion of the physical assessment of your pediatric patient. Many clinicians begin by measuring height (or for infants, length), head circumference for children up to the age of 3 years, and a body mass index. (For more information about growth measurements, see the accepted practice section that covers this area of physical assessment.) In some healthcare settings, pain and oxygen saturation are also considered vital signs and may also be measured depending on the reason the child needs healthcare. (These parameters will also be covered in more depth in this and other skills modules.) - How you measure a child’s vital signs varies to some extent with the age of the child. For example, when your patient is an infant, it is best to count respirations first. If you take the infant’s temperature first, you have to “disturb” him, and, if he cries in response to that procedure, you won’t obtain an accurate baseline respiratory rate. If your patient is a preschooler, it is important to be as noninvasive as possible. At this stage, children fear intrusive procedures, so an axillary or a tympanic temperature measurement is usually a better choice than a rectal measurement. - It is essential to use critical thinking when evaluating vital sign numbers with normal ranges for age and correlating them with your general physical assessment of the health status of the patient. The normal ranges for heart or respiratory rate might not be appropriate for an acutely ill patient and vital signs within those ranges could actually reflect deterioration. For example, a 3-year-old child with asthma who has had a heart rate of 150 and a respiratory rate of 44 but on retake of vital signs has a normal heart rate of 100 and a respiratory rate of 20 may be “tiring out” and respiratory failure might be imminent. Vital sign numbers alone have little meaning; you must analyze them critically for individual patients. Findings such as a rapid heart rate may be related to pain, fever, or anxiety. An elevated skin temperature may be due to excessive bundling or overdressing of an infant. It is also important to compare your findings with measurements documented at previous assessments, as well as with the normal ranges of vital signs for the particular age group. Temperature - Body temperature is more variable in infants and children than it is in adults. There is some controversy about the optimal method of measuring temperature in children. Core body temperature provides the most accurate and useful data, and the rectal route is most reflective of core temperature. It can be used for children of all ages (although it is no longer standard procedure for newborns), but it is not without risks. It is invasive, and therefore can be upsetting for many children, so you have to weigh the need for absolute accuracy against the potential for losing the child’s cooperation early in the exam. Also, there is the potential for injury, especially if the child “fights” the procedure. And, of course, it would be a poor choice for a child who has diarrhea or any rectal or anal irritation or disorder. - The oral route is convenient but often inaccurate, unless the child is old enough to understand the need to keep the device under the tongue with the lips sealed around it and has clear nasal passages. Remember not to measure temperature orally right after the child has just had food or fluids. Tympanic temperatures are convenient and safe and are often the preferred route; however, researchers do not concur on the accuracy and advisability of this route when precise measurement and correlation with core body temperature are imperative. Likewise, axillary temperatures are convenient and safe, but are not necessarily the most useful when precise measurement of core body temperature is critical. Various skin sensors are also available, but again, their usefulness when a precise measurement is warranted is uncertain. - Infants. If you take an infant’s rectal temperature, you might want to make this the last step of your vital-signs assessment, since it is invasive. The technique, however, is relatively simple. With the infant lying prone and preferably on the parent’s lap, separate the buttocks with the thumb and index finger of one hand while inserting the tip of a well-lubricated rectal thermometer probe at no more than about 0.6 inches, or 1.5 centimeters, in depth. If it is an electronic thermometer, keep it in place until the device signals that the temperature is recorded. Some clinicians advise taking a rectal temperature only when absolutely necessary due to the discomfort and the risk of trauma. Axillary and tympanic routes are appropriate for this age group as well. The usual temperature range for infants up to 1 year of age is 99.4° F to 99.7° F (37.5° C to 37.7° C). - Toddlers/preschoolers. For this age group, use the method that makes the most sense considering the degree of precision of measurement the child’s condition warrants. If you measure axillary temperature, place the covered temperature probe under the child’s arm in the center of the axilla. Lower the patient’s arm over the probe and hold the child’s arm across the abdomen. Leave the thermometer probe in place, close to the skin, until the audible signal indicates that the temperature has been measured. The usual temperature range for children between the ages of 1 year and 5 years is 98.6° F to 99.7° F (37.0° C to 37.7° C). - School-age children. Again, use the method that makes the most sense considering the degree of precision of measurement the child’s condition warrants. When you use a tympanic thermometer, remember the principles for inserting eye drops or an otoscope into a child’s ear: Straighten the ear canal by pulling the pinna up and back for children 3 years of age and older (as in this age group) and down and back for children younger than 3 years of age. Place the covered tip at the external opening of the ear canal and wait 2 to 5 seconds after you press the scan button for the temperature display. To obtain an accurate reading from a tympanic thermometer, it is important to place the probe at the proper angle for sealing the ear canal. Do not use the tympanic site if the child has ear pain or has excessive earwax, drainage from the ear, or sores or injuries in or around the ear. The usual temperature range for children between the ages of 5 years and 11 years is 98.0° F to 98.6° F (36.7° C to 37.0° C). - Adolescents. Likewise, use the method that makes the most sense considering the degree of precision of measurement the child’s condition warrants. If you measure an adolescent’s temperature orally, place the covered temperature probe under his tongue in the posterior sublingual pocket. Instruct him to close his lips gently around the probe and to keep his mouth closed until the temperature has been measured. Remind him not to bite down on the temperature probe. Leave it in place until you hear the signal that indicates that the temperature has been measured. The usual temperature range for children between the ages of 11 years and above is 97.8° F to 98.0° F (36.6° C to 37.0° C). Pulse - Assessing the rhythm, strength, and rate of a child’s pulse is an important part of a pediatric physical assessment, as it provides essential information about cardiovascular function. Until the age of 2 years, the apical pulse is typically used, and the radial pulse can be used for children above 2 years of age to adulthood. However, if the radial pulse is irregular or the child has a cardiac issues, an apical pulse for a full minute should be taken. - Infants. Heart rate varies quite a bit in infants and is especially sensitive to the effects of illness and activity. For infants and children under the age of 2 years, the most reliable way to measure pulse is to auscultate the apical impulse. Place the warmed bell or diaphragm of your stethoscope over the child’s chest at the apex of the heart. It is best to count for 1 full minute because of the possibility of irregular rhythms. If you have established that the rhythm is regular and you must measure pulse repeatedly, count for 30 seconds and multiple by 2. Keep in mind that you will obtain the most accurate measurement while the child is asleep. - Toddlers/preschoolers. For this age group, radial pulse measurement is appropriate. The radial pulse point is easily accessible and easy to locate. Just apply light pressure with the pads of the fingers in the groove along the radial or thumb side of the child’s inner wrist. - School-age children. For this age group, radial pulse measurement is also appropriate. The usual pulse rate doesn’t change much during this stage. - Adolescents. Measuring the pulse rate of children in this age range doesn’t vary much from measuring an adult’s pulse. Respiration - Accurate assessment of respiration is another important component of your physiologic measurements. It involves observing the rate, depth, and rhythm of chest-wall movement during inspiration and expiration. Changes in respiratory rates from normal parameters can potentially indicate a respiratory issue such as bronchiolitis, pneumonia, or a heart condition. - Infants. Measure respiratory rate early in your assessment; it will not be accurate if the infant is crying, in fact, a sleeping rate is best. Infants’ respirations are primarily diaphragmatic, so, when counting their respirations, observe abdominal movements. Infants typically breathe irregularly, so be sure to count for a full minute. The usual range for respiratory rates of infants up to 1 year of age is 30 to 35 breaths per minute. - Toddlers/ preschoolers. For this age group, count the respiratory rate just as you would for an adult. It is always best to count respirations without the child knowing what you are doing. Just as for adults, when a patient knows you are counting breaths, that awareness of breathing often alters the rate and pattern. The usual range for respiratory rates of children between the ages of 2 and 5 years is 22 to 25 breaths per minute. - School-age children. Your technique in evaluating respiration won’t vary much for children past infancy. The usual range for respiratory rates of children between the ages of 5 and 12 years is 19 to 22 breaths per minute. - Adolescents. Assessing respiration in this age group is the same as for adults. The usual range for respiratory rates of children 12 years old and above is 16 to 19 breaths per minute. Blood Pressure - Measuring blood pressure, the force that blood exerts against the vessel wall, is just as important for children as it is for adults. Children may experience hypertension or hypotension from a variety of conditions. Essential hypertension is also seen in children, with evidence indicating that both genetic and environmental factors play a role in its development. - The most important factor in obtaining an accurate blood-pressure measurement is using a cuff of the appropriate size. The cuff’s bladder width should be about 40% of the child’s arm circumference, measured at a point halfway between the olecranon and the acromion. The cuff’s bladder length should cover 80% to 100% of the arm’s circumference. A cuff that is too small can yield falsely high blood-pressure readings; a cuff that is too large can yield falsely low blood-pressure readings. In order to ensure validity in ongoing comparisons of blood pressure readings, the same process, cuff size, and measuring instrument should be used. Interpretation of blood pressure should be compared to the published tables with norms for blood pressure by age and height percentile. - When using an automatic blood-pressure device, use the correct setting (neonatal, pediatric, adult) so that the pressure generated to occlude the artery isn’t too high for a younger patient. The initial pressure on an adult setting may be much higher (200 mm Hg) than the pressure on a pediatric or neonatal setting. If this is a concern, use a manual pressure cuff for better control of maximal occlusion pressure. - In children 3 years of age and older, blood pressure should be measured annually. Blood pressure in the upper extremities should be compared at least once with blood pressure in the lower extremities to detect problems such as coarctation of the aorta. This disorder results in a lower-extremity blood pressure lower than that of the upper extremities. - Normal blood pressure readings for children vary not only with age, but with gender and height. - Infants. Unless there are any special indications, blood pressure is not routinely measured for infants, although it should be measured at least once during the first year of life. To measure an infant’s blood pressure, it is probably best to use a Doppler device. It detects arterial blood-flow vibrations and converts them to systolic readings. Another electronic method is oscillometry, where pressure changes are transmitted through the arterial wall to the cuff. Average readings from the newborn period up to the age of 2 years via oscillometry range from a mean of 65/41 mm Hg for newborns to 95/58 mm Hg for a child age 1 month to 2 years. - Toddlers/preschoolers. It is especially important to prepare this age group for the procedure. The tightening of the cuff can be intimidating; to allay anxiety (which can increase blood pressure), explain that it will feel like an “arm hug.” When measuring blood pressure, position the limb at heart level, rapidly inflate the cuff to about 20 mm Hg above the point at which the radial pulse disappears, and release the cuff at the rate of about 2 to 3 mm Hg per second while using a pediatric stethoscope to listen to the Korotkoff sounds. - School-age children. Measure blood pressure of school-age children as you would measure an adult’s blood pressure. Record the first Korotkoff sound as the systolic pressure and the last Korotkoff sound as the diastolic pressure. - Adolescents. Measure adolescents’ blood pressure as you would measure an adult’s blood pressure. For children between the ages of 12 and 18, record the first Korotkoff sound as the systolic pressure and the last Korotkoff sound (the disappearance of sound) as the diastolic pressure. Integument Examination Components Include: ● Inspect the skin systematically and head to toe for color (pink, tanned, pale, ruddy, jaundiced, cyanotic, mottled, and consistent with ethnicity), hair distribution, and lesions. ● Palpate and inspect the skin head to toe for temperature, texture, and moisture. ● Palpate and inspect the skin overall for skin turgor, edema, and lesions. ● Assess any lesions for location, distribution, size, shape, color, texture, surface characteristics, exudate, and tenderness. ● Inspect and palpate the hair for quantity, distribution, texture, color, and parasites. ● Inspect and palpate the nails for color, shape, thickness, adhesion to the nailbed, lesions, clubbing, and capillary refill. Overview - Assessing your patient’s integument involves inspecting and palpating the skin, hair, and nails. The skin typically is assessed within the context of each body system; however, for this section it is discussed as a focused assessment. Have clean gloves available to use during the examination in case you encounter any open skin or body fluids and a measuring device to help you document the size of any incisions, wounds, or lesions. Before completing the integument examination, be sure to inspect the skin on all posterior surfaces. Note any dimples, sinus tracts, or tufts of hair. Inspection - Starting with the patient’s head and scalp, inspect the skin for color, hair distribution, and any lesions. Be sure to inspect for the presence of any infestations such as lice or nits. After inspecting the head and scalp, systematically inspect all of the child’s skin, uncovering one body part at a time. Use a measuring device to document any wounds or lesions. If you note bruising on several parts of the body, in various stages of healing, or in places where bruises are not normally found, inquire about how the child got them. It is also important to be aware of any cultural practices (such as coining) that might cause skin alterations. Some culturally acceptable “lesions” could be mistaken for burns or non accidental, trauma-inflicted lesions. - Infants. For light-skinned infants, the overall color of the skin should be pink. Skin folds may appear red or irritated, though, since these areas are often moist. Infants, especially during the newborn period, might have tiny white papules called milia on the cheeks, forehead, nose, and chin. Let the parents know that milia will go away on their own, and encourage them not to rub vigorously or break the intact skin. Another irregularity you might note on the forehead or the back of the neck is a “stork bite,” a telangiectatic nevi that is irregularly shaped and red or pink. This type of lesion typically fades during the first year. Lastly, note the condition of the peri-anal skin in the diaper area for any redness, rashes, or open lesions. - Infants and children of certain ethnicities who are dark-skinned or Asian may have Mongolian spots. Assess for these bluish-gray macular areas on the sacrum or buttocks. These spots usually fade over the first year. It is important to recognize Mongolian spots as such and not mistake them for bruises. Café au lait spots are another skin color variation common in infants. They are usually large round or oval patches that are light brown in color and are a normal finding unless they are larger than 1.5 cm and there are more than 6 present. This finding requires further evaluation. - Inspect the nails of the infant’s feet and hands, looking at color and shape. The nails should be firmly attached. To assess capillary blood flow, raise the child’s extremity at or above the level of the heart, press gently over a finger’s nailbed (or the heel of the foot) to cause blanching of the skin and occlusion of blood flow, release the pressure, and count the time it takes for a full return of blood to the blanched tissue. Pressing on a central site such as the forehead can also assess capillary refill. Normal capillary refill time is less than 2 seconds. Delayed capillary refill indicates poor blood flow. - Toddlers/Preschoolers/School-age children. In this age group, a light-skinned child’s skin should be pink and without dryness, rashes, or lesions. Bruising on the knees, shins, and lower arms is common. If you see bruises elsewhere, try to determine how the child got them. Keep in mind that it is very difficult to determine the age of bruises. It is better to describe the bruises’ color, size, and location than to try to note the stage of healing. If the bruising is on soft tissues or of a concerning shape or placement, it is important to document your findings on a body diagram. - Inspect the nails of both the feet and the hands, looking at color and shape. The nails should be firmly attached. As for infants, assess capillary blood flow by raising the child’s extremity at or above the level of the heart, pressing gently over a finger’s nailbed (or the heel of the foot) to cause blanching of the skin and occlusion of blood flow, releasing the pressure, and counting the time it takes for a full return of blood to the blanched tissue. Normal capillary refill time is less than 2 seconds. - Adolescents. Inspect for acne on the face, chest, shoulders, and back. If the patient does have acne or is at the age where he may start developing acne, use this opportunity to discuss hygiene with the patient. It is also important to note when pubic and axillary hair develops, as this is part of the assessment of pubertal development and sexual maturation (Tanner stages). - Inspect the nails of both the feet and the hands, looking at color and shape. The nails should be firmly attached. Note the presence of thickening, yellowing, and ragged nail edges, which suggest a fungal infection. Check capillary refill by pressing over a nail to cause blanching or by pressing on a central site such as the forehead. The pink color should return to the nail within 2 seconds. Palpation - Palpate the skin for temperature, texture, moistness, and resilience. Use your fingertips to assess the texture and moisture of the skin and the back of your hand to feel temperature. A normal finding is for the skin to be smooth, warm, and dry with no tenting of the skin when you test turgor, or resilience. - Infants. Because an infant has difficulty controlling body temperature and can become cold rather quickly, be sure to uncover only one area at a time. The infant’s skin should feel soft, smooth, dry, and warm. If the infant has been crying, the skin may feel slightly damp. - Over the infant’s abdomen, gently pinch a skin fold to check skin turgor, which reflects hydration status. Well-hydrated skin in this area is resilient and returns quickly to its original position, while poorly hydrated skin retains the “tent” shape of the pinched skin. If the infant is dehydrated, estimate the degree of dehydration based on the time it takes the skin to return to its normal position. - Toddlers/Preschoolers/School-age children. The child’s skin should feel warm, dry, and smooth. Note any areas of roughness or thickening, as abnormalities in the texture of the skin can be associated with endocrine disorders, chronic irritation (as with eczema), and inflammation. - To evaluate the skin turgor of children in this age group, gently pinch a skin fold over the abdomen. Once you release the skin, it should return quickly to its original position. If it doesn’t, assess your patient for other signs and symptoms of dehydration. - Adolescents. Adolescents’ skin should feel warm, dry, and smooth. If you note excessive sweating without exertion, further evaluation is warranted. The child may have something as simple as a fever or as critical as an uncorrected congenital heart defect. - Evaluate skin turgor by gently pinching a skin fold over the clavicle or on the abdomen. If the adolescent is well hydrated, the skin should return quickly to its original position. With dehydration, the “tent” shape of the pinched skin will remain after it is released. Estimate the degree of dehydration by noting the time it takes the skin to return to its normal position. - Even though it is uncommon for healthy children to have edema, note if you leave a thumbprint, or dent, in the skin surface. This finding could be indicative of edema. Head, Face, & Neck Examination (HFN) Components Include: ● Inspect and palpate the face and the skull. ● Test cranial nerves V (trigeminal) and VII (facial). ● Inspect the neck for contour and tracheal position. ● Evaluate the neck's range of motion. ● Palpate the carotid arteries. ● Palpate the cervical lymph nodes. ● Check cranial nerve XI (spinal accessory). ● Palpate the trachea and the thyroid gland. Head Inspection - When examining a child’s head and skull, keep in mind that what is normal for an infant may not necessarily be normal for an older child. It is also important to keep in mind when completing an examination on a newborn that the head might be somewhat asymmetric due to trauma during birth. For all age groups, assess for general shape and symmetry. Note head control in infants and head posture in older children. - Infants. The normal shape of the head during infancy and early childhood is round with a prominent occipital area that becomes less prominent as the child gets older. With the practice of "back to sleep," a flattening of one part of the head (and hair loss in one area) may indicate that the infant lies on one side in a particular position. Assess head asymmetry with asymmetry of facial features and fontanels. Any abnormal finding should have further evaluation. For the newborn who has swelling and ecchymosis of the presenting part of the head likely has what is called caput succedaneum. This area feels soft and may extend across suture lines. It usually resolves on its own in the first few days of life. Another head abnormality in newborns is a cephalhematoma. Caused by a subperiosteal hemorrhage, it usually reabsorbs within the first few weeks of life without treatment. The soft, spongy hemorrhage is usually only over one bone. Because both of these can look frightening to new parents, it is important to reassure them that they can happen during birth but that they are not life-threatening and will resolve without any intervention. Inspect and palpate the infant's scalp for crusting suggestive of seborrhea (cradle cap). By 4 months of age, most infants should be able to hold the head erect and in midline when in a vertical (sitting up) position. - Toddlers/Preschoolers/School-age children. A young child’s head is usually rounded with a prominent occipital area that becomes less prominent as he gets older. Head circumference should be measured annually until about 3 years of age to determine whether or not growth is adequate for proper brain development. A larger-than-normal head is associated with hydrocephalus, while a smaller-than-normal head is associated with microcephaly or various genetic factors. - Adolescents. At this stage, the head no longer has a prominent occipital area, and it should be of normal shape and size for the child’s age. Be sure to observe the adolescent’s head for appropriate positioning. Palpation - Palpating the skull is an important part of this examination, especially in infants, to assess the suture lines and fontanels. For older children, palpate for any deformities or masses. - Infants. During early childhood (prior to 36 months of age), the skull’s sutures permit expansion for brain growth. Palpate each of the infant’s suture lines gently using the pads of your fingers. You should feel the edge of each bone in the suture line. However, there is usually no separation between the two bones. If you feel more bone edges, the infant might need further evaluation to rule out a problem. Suture lines are usually palpable up to 18 months. - Palpate the fontanels where the suture lines intersect. They should feel flat and firm inside the bony edges. A bulging fontanel can be a sign of increased intracranial pressure. A sunken fontanel is typically associated with dehydration. At 6 months of age, the anterior fontanel is about 2 inches (4-5 centimeters) in diameter with a diamond shape and then becomes smaller as the infant gets older. It usually closes by 12 to 18 months of age (the average being 14 months). The posterior fontanel may not be palpable at birth, but if it is, it is usually less than ½ inch (1 centimeter) in diameter and closes between 2 and 3 months of age. Abnormalities noted in fontanel size and closure may indicate a disorder that requires further evaluation. - Toddlers/Preschoolers/School-age children. The child’s head should feel symmetric and smooth. You should not feel any lumps, depressions, or abnormal protrusions. While inspecting and palpating the child’s head, note the color, distribution, and cleanliness of the hair. The shaft of the hair should be evenly colored, shiny, and either curly or straight and distributed evenly over the scalp. Part the hair in several spots, then palpate for any lesions and inspect the hair shafts for nits. Note any unusual hair growth patterns, such as an unusually low hairline on the neck or forehead, as a possible indication of a congenital disorder and would require further evaluation. - Adolescents. The child’s head should be round, symmetric, and appropriately sized in relation to the rest of the body. Palpate the cranial bones that have normal protrusions, which include the forehead, the lateral edge of the parietal bone, the occipital bone, and the mastoid process behind the ear. The adolescent should not feel any pain or tenderness, and you should not feel any lumps, depressions, or bone abnormalities. The hair should be clean, soft, and evenly distributed. Part the hair in several spots, then palpate for any lesions and inspect the hair shafts for nits. Face Inspection - When inspecting the child’s face, look for symmetry and movement of facial features. This is easier if you focus on the palpebral fissures, or eye openings, and the nasolabial folds between the nose and the corner of the mouth. Symmetrical movement demonstrates that cranial nerve VII is intact. Significant asymmetry is an abnormal finding and should be evaluated further. Be sure to note the skin of the face as well, checking skin color and noting dryness, presence of rashes, birthmarks, or other lesions, plus any involuntary movements, such as tremors, tics, or twitching of facial muscles, which are sometimes associated with seizure disorders. - Infants. Inspect the face for symmetry when the infant cries or smiles. Both sides of the forehead should wrinkle, and both sides of the lips should turn up. Be sure to inspect for any rashes, birthmarks, or lesions. - Toddlers/Preschoolers/School-age children. Inspect the child’s face for symmetry when the child is at rest, when he is smiling, and when he is frowning. Inspect for parotid enlargement by asking the child to look up at the ceiling. If there is inflammation, the swelling will appear below the angle of the jaw. Test cranial nerve V by asking the child to bite down and feeling for contraction of the temporal muscle (at the temple) and the masseter muscle (just in front of the ear). Be sure to check the sensory branch of cranial nerve V as well by asking the child to close her eyes and report when she feels light touch as you touch her forehead, each cheek, and her chin with cotton. - Adolescents. Inspect an adolescent’s face for symmetry just as you would for a younger child. Test cranial nerve V by asking the child to bite down and feeling for contraction of the temporal muscle (at the temple) and the masseter muscle (just in front of the ear). Be sure to check the sensory branch of cranial nerve V as well by asking the child to close her eyes and report when she feels light touch as you touch her forehead, each cheek, and her chin with cotton. Neck Inspection - Examine the child’s neck, checking its contour and symmetry. Note for the presence of lumps or masses. Visible distended neck veins may indicate increased pressure from a respiratory or cardiac disorder. - Infants. The infant’s neck is quite short, which can make inspection somewhat difficult. To see the neck better, support the infant’s shoulders and tilt the head slightly back. Look for rashes or irritation due to increased moisture from drooling. - Check the neck’s range of motion. Hold a toy in front of the infant and move the toy in all four directions. As you move the toy, note the movement of the infant’s head and neck. If the child is unable to follow an object, cradle the infant’s head in your hand and gently turn it side to side and test for flexion, extension, and rotation. - Toddlers/Preschoolers/School-age children. By 3 to 4 years of age, the neck has lengthened, making inspection easier. Look for any webbing, or extra skin folds, on each side of the neck. If you see any, it may indicate a genetic disorder which requires further evaluation. - Check range of motion of the neck. Ask the child to look up, and then look down, and then turn her head to each side. The child should be able to move her head freely in all directions and without pain. If the child is unable to move her head voluntarily, passively move it through the expected range of motion. Limited horizontal range of motion may indicate an injury or strain to the sternocleidomastoid muscle. Complete the assessment of the neck by checking cranial nerve XI, the spinal accessory nerve. Ask the child to turn her head to each side while you provide resistance with the palm of your hand. Then ask her to elevate or “shrug” her shoulders against resistance. If she can complete both of these actions, cranial nerve XI is intact. - Adolescents. Inspect the neck for any swelling or abnormalities. Check range of motion as for younger children. The adolescent should be able to move her head freely in all directions without pain. If she cannot move her head on her own, passively move it through the normal range of motion. If she feels pain with flexion, evaluate for a possible injury or infectious process. - Complete the assessment of the neck by checking cranial nerve XI, the spinal accessory nerve. Ask the child to turn her head to each side while you provide resistance with the palm of your hand. Then ask her to elevate or “shrug” her shoulders against resistance. If she can complete both of these actions, cranial nerve XI is intact. Palpation - Palpate the groove between the trachea and the sternocleidomastoid muscle. Look at position of the trachea; it should be midline or slightly to the right. Are the carotid pulses palpable? Be sure to palpate only one carotid artery at a time. Applying pressure to both carotid arteries can disrupt cerebral blood flow. Palpate the lower half of the neck. There are many chains of lymph nodes in the head and neck. Lymph nodes in young children are more prominent until adolescence. Assess them in the same way for each age group in the following sequence: around the ears (preauricular, posterior auricular), under the jaw (tonssilar, submandibular, sub-mental), in the occipital area (occipital), and in the cervical chain of the neck (anterior, posterior, deep cervical). If you detect any masses in the neck, refer the child for further evaluation. - Infants. To palpate the lymph nodes, press gently with your fingertips making small circular motions over the lymph nodes. In an infant, the lymph nodes in the cervical chain of the neck are not palpable even if they are inflamed. - Toddlers/Preschoolers/School-age children. Palpate the lymph nodes by pressing gently with your fingertips making small circular motions. In young children cervical lymph nodes are palpable. Lymph nodes are should be round, with defined edges, move easily and should not be tender. Lymph nodes that are greater than 1 cm may require further evaluation. In response to infection lymph nodes may become enlarged, firm, and tender. - Adolescents. Palpate the neck as for the previous age group. Again, you should not feel any lymph nodes, the trachea should be at midline, and unless the thyroid is enlarged, you should not be able to feel it. Eye Examination: Components Include: ● Inspect the appearance of the structures of the eyes. ● Check pupillary response and extraocular movements. ● Perform vision screening. ● Use an ophthalmoscope to check for the red reflex. Inspection - Assess the appearance of the child’s eyes when you inspect the face and its features. During inspection, note the distribution of the child’s eyebrows and eyelashes. The eyebrows normally extend the full width of the eye, and the eyelashes should curve outward from each lid. Look for any drooping of the upper lids or sagging of the lower lids. Note the color of the sclera, or white part of the eye, and look for defects or inflammation of the bulbar conjunctivae, the thin membranes that cover the sclerae. Gently retract the lower lids to note the palpebral conjunctivae. Inspect each iris and note the size and shape of the pupils, which should be round, clear, and equal in size. Because eye abnormalities are common with chromosome disorders, take care to observe, record, and make the appropriate referral if the child has any deviation from the expected norms. - Infants. It is not always possible to examine a newborn’s eyes right after birth because of swelling of the lids from trauma during birth and from the prophylactic agent instilled in the infant’s eyes at birth. A thorough eye examination should be performed a few days after birth and at every well-child check-up. - When inspecting the external structures of the infant’s eye, you might note an epicanthal fold, an extra skinfold that extends over the inner corner of the eye. This finding is especially common in Asian children. In other children, the epicanthal fold disappears by about 10 years of age. A newborn’s conjunctivae may appear irritated due to the prophylactic agent routinely instilled just after birth. This irritation usually disappears within 24 hours. Note for swelling or signs of inflammation of the lacrimal punctum which is located at the inner edge of the upper and lower lids. The punctum can become obstructed, thus requiring referral for further evaluation. The sclerae should be white. At birth, the irises of light-skinned infants are usually blue, gray, or light-colored and may change in color, usually within 6 months. At birth, the irises of dark-skinned infants are usually brown. Inspection of the internal structure in infants is limited to eliciting a red reflex. The red reflex should be bright and uniform. - Toddlers/Preschoolers/School-age children. Begin by inspecting the external structures of the eye. When the child’s eyes are open, the upper and lower eyelid should cover a portion of the iris but not any portion of the pupil. When the child closes his eyes, the eyelids should cover both the iris and the cornea. Also, inspect for the palpebral slant. The eyelids of most children open horizontally. An upward or Mongolian slant is normal in Asian children; however, it might also be seen in children who have Down syndrome. The sclerae should be white or ivory-colored in children with darker skin. If the sclerae are a different color, such as yellow, suspect an underlying disorder. The bulbar conjunctivae should be clear. Redness can develop with eye strain, allergies, or irritation. - In addition to inspecting the external eye structures, test pupillary response to light and accommodation. With your patient looking in the distance, use your penlight to shine light obliquely onto each pupil. The pupils should constrict in response to light. Note both the direct response, that of the same eye, and the consensual response, that of the opposite eye. Observe for the red reflex, which should be uniform. Next, hold your finger a few inches from your patient’s eyes and ask her to look at your finger or a toy and then at an object, such as a picture or a wall, in the distance. Observe the pupils for accommodation. They should dilate with far gaze and constrict with near gaze. A patient whose pupils are equal, round, and reactive to light and accommodation (documented as PERRLA) has intact cranial nerves II and III. - Adolescents. Examine an adolescent’s eyes in the same manner. Inspect the eyelid, iris, pupil, and sclera of both eyes. Check pupillary response to light and accommodation and red reflex. Be sure to note any abnormalities. Eye Muscles - When examining the eyes, it is important to check for non-binocular vision, or crossed eyes. If this condition is not detected early and is left untreated, vision can be impaired permanently. To check for muscle problems that can lead to non-binocular vision, test extraocular movement (EOM) and the corneal light reflex and perform the cover-uncover test. Checking extraocular movements also confirms that cranial nerves III, IV, and VI are intact. Vision Screening - Since vision is an important component of how children learn, it is essential to begin assessing vision at an early age to identify problems and initiate treatment immediately. Consider how you will gain the infant or child's cooperation. Make a game of the procedures with preschoolers and toddlers. The age of the child determines the screening tool to use. To help ensure accuracy and consistency, test vision using a standardized vision chart, such as the Snellen E chart. - Infants. At birth, the infant has limited eye function. Often, infants will open their eyes if held in an upright position over the parent’s shoulder. In this situation, you can examine the infant’s eyes behind the parent and use the ophthalmoscope as a penlight to assess external structures and movement. You can also test the child’s response to light and accommodation, the corneal light reflex, and the red reflex. Visual acuity in infants is tested through checking for light perception and response to the light. Note the infant’s ability to fix and follow an object. The infant should follow a light to midline at birth and by age 3 months will follow 180 degrees to the periphery. If an infant is unable to fix and follow by 4 months further evaluation is needed. Test the infant’s blink reflex by moving your hand quickly toward the infant’s eyes. A quick blink is the normal response. Or, shine a bright light in the infant’s eyes. Again, the infant should blink. - Toddlers/Preschoolers/School-age children. Several types of vision screening tools are available for this age group. The Snellen E, Lea symbols or Allen can be used. In general the screening tools used should be appropria