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Physical Assessment Professor Debora Halloran Azusa Pacific University 7/21/2015 1 Pediatric Physical Assessment 7/21/2015 Neonate and Infant The Young Child School Age and Adolescent 2 Infant Health History Developmental History Home Safety Immunizations Review of Systems 7/21/2015 This review will help you identify normal physiologic changes as well as alert you to abnormal 3 The Neonate and Infant 7/21/2015 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. 4 Neonate and Infant Vital Signs Measurement 7/21/2015 Note pulse, respirations and temperature Weight, length and head circumference are measured and plotted on growth curves for the infant’s age. 5 Neonate and Infant ABNORMAL FINDINGS 7/21/2015 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 6 Neonate and Infant GENERAL APPEARANCE 7/21/2015 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 7 Neonate and Infant ABNORMAL FINDINGS 7/21/2015 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 8 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 7/21/2015 HR RANGE 80 - 160 CAP REFILL < 1 SECOND PULSES PRESENT 9 Neonate and Infant 7/21/2015 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 10 Neonate and Infant 7/21/2015 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 11 Neonate and Infant 7/21/2015 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 12 Neonate and Infant 7/21/2015 ABNORMAL FINDINGS Umbilical hernias > 2 cm wide may require further evaluation Abdominal pain may indicate childhood diseases Enlarged liver or spleen may indicate disease 13 Neonate and Infant 7/21/2015 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. 14 Neonate and Infant 7/21/2015 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 15 Neonate and Infant 7/21/2015 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 16 Neonate and Infant 7/21/2015 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 17 Neonate and Infant 7/21/2015 ABNORMAL FINDINGS Lack of response to noise may indicate hearing problem 18 Neonate and Infant 7/21/2015 NOSE Determine patency of nares Note the nasal discharge, sneezing and any flaring with respirations 19 Neonate and Infant 7/21/2015 ABNORMAL FINDINGS Flaring of nares is sign of respiratory distress Bloody discharge or large amount of nasal secretions may obstruct nares 20 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 7/21/2015 Note the nasal discharge, sneezing and any flaring with respirations 21 Neonate and Infant 7/21/2015 ABNORMAL FINDINGS Protruding tongue associated with congenital disorders such as Down’s syndrome or hypothyroidism 22 Neonate and Infant 7/21/2015 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 23 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 7/21/2015 24 Neonate and Infant ABNORMALFINDINGS Inadequate range of motion may indicate congenital malformation or birth injury or may result from pulling or lifting infant 7/21/2015 25 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 7/21/2015 26 Neonate and Infant 7/21/2015 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 27 Neonate and Infant ABNORMAL FINDINGS Ambiguous genitalia abnormal Male Female 7/21/2015 Phimosis - tight foreskin Weak urine stream Solid scrotal mass Hernias present as scrotal mass Undecended testicles Swollen scrotum - hydrocele 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 28 Neonate and Infant 7/21/2015 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 29 Neonate and Infant 7/21/2015 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 30 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 7/21/2015 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 31 Neonate and Infant ABNORMAL FINDINGS 7/21/2015 Dimpling in spine may be associated with neural tube defects Watery stools and explosive diarrhea indicate infection. Constipation or hard stools indicate inadequate hydration 32 Neonate and Infant 7/21/2015 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. 33 Neonate and Infant 7/21/2015 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 34 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) 7/21/2015 Collect the history, including developmental data During the history, note data on general appearance 35 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” 7/21/2015 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 36 The Young Child Neurological check: Test balance coordination and accuracy of movements. 7/21/2015 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 37 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 7/21/2015 Height, Weight, head circumference ((may been to defer until later in the examination) 38 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: 7/21/2015 Lesions such as tinea capis or ringworm need treatment Pediculosis is common among preschoolers 39 The Young Child 7/21/2015 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 40 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 7/21/2015 Note: if you detect a murmur, refer patient for follow up and rule out pathology 41 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 7/21/2015 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. 42 The Young Child 7/21/2015 GENITALIA Inspect the external genitalia On males, palpate the scrotum for testes. If masses are present, trans-illuminate 43 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 7/21/2015 44 The Young Child 7/21/2015 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 45 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: 7/21/2015 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 46 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 7/21/2015 47 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 7/21/2015 48 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. 7/21/2015 49 The Young Child 7/21/2015 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 50 The Young Child 7/21/2015 SUMMARY Toddlers and preschoolers have their own unique developmental and psychosocial issues Understanding these issues and knowing how to communicate honestly and effectively with children and parents will help you conduct a thorough assessment and develop an effective plan of care Inspect and palpate the auricle. Note any discharge for the auditory meatus 51 The School Age Child and the Adolescent Sequence is the head to toe described in the adult format. Be aware of developmental considerations 7/21/2015 52