Pediatric Physical ExamPediatric Physical Exam

Philadelphia UniversityPhiladelphia UniversityFaculty of NursingFaculty of Nursing

11stst Semester, 2008/2009 Semester, 2008/2009Clinical Pediatric NursingClinical Pediatric Nursing

IntroductionIntroduction

Key elements.Key elements. Times:Times: Every month in the 1Every month in the 1stst year. year. Every 3 month of the 2Every 3 month of the 2ndnd and 3 and 3rdrd year. year. Each 6 month of 4Each 6 month of 4thth and 5 and 5thth year. year. Yearly after the 6Yearly after the 6thth year. year.

Avoid touching painful areas until Avoid touching painful areas until confidence has been gained.confidence has been gained.

Begin exam without instruments.Begin exam without instruments. Allow child to determine order of Allow child to determine order of

exam if practical.exam if practical. Use the same format as adult Use the same format as adult

physical exam.physical exam.

Physical ExamPhysical Exam

Infant ExamInfant Exam

Examine on parent lap.Examine on parent lap. Leave diaper on.Leave diaper on. Comfort measures such as pacifier or Comfort measures such as pacifier or

bottle.bottle. Talk softly.Talk softly. Start with heart and lung sounds. Start with heart and lung sounds. Ear and throat exam last.Ear and throat exam last.

Toddler ExamToddler Exam

Examine on parent lap if Examine on parent lap if uncooperative.uncooperative.

Use play therapy.Use play therapy. Distract with stories.Distract with stories. Let toddler play with equipment / BP.Let toddler play with equipment / BP. Call by name.Call by name. Praise frequently.Praise frequently. Quickly do exam.Quickly do exam.

History TakingHistory Taking

Personal Hx.Personal Hx. Life styles.Life styles. Health Hx. (past and current).Health Hx. (past and current). Family Hx.Family Hx.

Growth MeasurementsGrowth Measurements

Wt.Wt. Ht.Ht. HC.HC. CC.CC. Mid arm C.Mid arm C. SFT.SFT.

Head, chest, and abdominal Head, chest, and abdominal circumferencecircumference..

Physiological MeasurementsPhysiological Measurements

Temp. (sites).Temp. (sites). Pulse.Pulse. RR.RR. BP.BP.

Physical Exam TechniquePhysical Exam Technique

Inspection- eye only.Inspection- eye only. Palpation- tip of finger.Palpation- tip of finger. Percussion- use. . .Percussion- use. . . Dullness (solid organ), resonance Dullness (solid organ), resonance

(over solid organ or filled air), (over solid organ or filled air), tympanic (hollow organ).tympanic (hollow organ).

Auscultation- stethoscope.Auscultation- stethoscope.

Physical AssessmentPhysical Assessment

General appearance & behavior:General appearance & behavior:• Facial expression.Facial expression.• Posture / movement.Posture / movement.• Hygiene.Hygiene.• Behavior.Behavior.• Development: grossly fits guidelines for Development: grossly fits guidelines for

age.age.

SkinSkin

Color, texture, turgor, lesion and Color, texture, turgor, lesion and pigmentation (jaundice, cyanosis, pigmentation (jaundice, cyanosis, pale).pale).

Palpate: moisture and dryness.Palpate: moisture and dryness. Temp.Temp. Edema: extremities and buttocks.Edema: extremities and buttocks. Lesions: primary and secondary.Lesions: primary and secondary.

HairHair

Texture, color, distribution.Texture, color, distribution.

NailsNails

Shape and contour, surface, edgeShape and contour, surface, edge Capillary refill: howCapillary refill: how

Lymph NodesLymph Nodes

Sites, ch.ch, enlarged, warmthSites, ch.ch, enlarged, warmth

HeadHead

Fontanels: shapeFontanels: shape Assess symmetry of both sides.Assess symmetry of both sides. Palpate for size and closure.Palpate for size and closure. 1- anterior closed 18-24 M.1- anterior closed 18-24 M. 2- posterior closed at 0-2 M.2- posterior closed at 0-2 M. Sunken fontanel –Dehydration.Sunken fontanel –Dehydration. Bulging- increase ICP (cough, Bulging- increase ICP (cough,

vomiting, crying).vomiting, crying).

EyesEyes

Examine external structure of the:Examine external structure of the: 1- Conjunctiva- glassy1- Conjunctiva- glassy 2- Sclera- clear2- Sclera- clear 3- Cornea- cover the iris and pupil3- Cornea- cover the iris and pupil 4- pupils- compare for size, shape, 4- pupils- compare for size, shape,

test for reaction.test for reaction. 5- Iris- color, size and clarity. 6-12 M.5- Iris- color, size and clarity. 6-12 M.

NoseNose

Assess for symmetry, deformity, skin Assess for symmetry, deformity, skin lesion.lesion.

Palpate for septal deviation.Palpate for septal deviation. Smooth and moist, with pinkish color.Smooth and moist, with pinkish color.

Mouth and throatMouth and throat Lips: color, moisture, lesion.Lips: color, moisture, lesion. Teeth: #, sequence, eruption and Teeth: #, sequence, eruption and

occlusion.occlusion. Gum: color, inflammation or swelling.Gum: color, inflammation or swelling. Tongue: color, shape, deformity, Tongue: color, shape, deformity,

ulceration.ulceration. Oropharynx: use tongue blade, color.Oropharynx: use tongue blade, color. Tonsils: pink, inflammation or Tonsils: pink, inflammation or

inspection.inspection.

EarsEars

External shape and size.External shape and size. Pinna: line, low set ear (retardation).Pinna: line, low set ear (retardation). Internal structure.Internal structure.

Ear ExamEar Exam

Pinna is pulled down and back to straighten ear canal in children under 3 years.

Otitis MediaOtitis Media

Most common reason children come Most common reason children come to the pediatrician or emergency to the pediatrician or emergency room.room.

Fever at ear.Fever at ear. Often increases at night when they Often increases at night when they

are sleeping.are sleeping. History of cold or congestion.History of cold or congestion.

Why a problemWhy a problem??

Infection can lead to rupture of ear drum.Infection can lead to rupture of ear drum. Chronic effusion can lead to hearing loss.Chronic effusion can lead to hearing loss. OM is often a contributing factor in more OM is often a contributing factor in more

serious infections: mastoiditis, cellulitis, serious infections: mastoiditis, cellulitis, meningitis, bacteremia.meningitis, bacteremia.

Chronic ear effusion in the early years may Chronic ear effusion in the early years may lead to decreased hearing and speech lead to decreased hearing and speech problems.problems.

ChestChest

Anatomy. Anatomy. Inspection: symmetry, movement of Inspection: symmetry, movement of

chest wall.chest wall. Breathing pattern- abdominal breathing.Breathing pattern- abdominal breathing. Palpation:Palpation: 1- light palpation: in light circular 1- light palpation: in light circular

motion to detect lesion and massesmotion to detect lesion and masses 2- deep palpation: palpate for internal 2- deep palpation: palpate for internal

organ like liver and spleen.organ like liver and spleen.

Start from breast, lymph nodes, and Start from breast, lymph nodes, and pulses.pulses.

Use back of hand to assess temp.Use back of hand to assess temp. Use palm to assess vibration.Use palm to assess vibration. Assess respiratory excursion during Assess respiratory excursion during

insp. and exp.insp. and exp. Posterior assessment at the level of Posterior assessment at the level of

spinal column at the level of 10spinal column at the level of 10thth ribs. ribs. Assess tactile fremitus.Assess tactile fremitus.

Percussion of the chest: put patient Percussion of the chest: put patient in supine position, or in side.in supine position, or in side.

Percussion technique: record what Percussion technique: record what you hear.you hear.

Auscultation: used to assess the flow of air Auscultation: used to assess the flow of air through the bronchial tree and to evaluate the through the bronchial tree and to evaluate the presence of fluid or solid in lung structure.presence of fluid or solid in lung structure.

Anterior-axillary line.Anterior-axillary line. Mid-clavicular line.Mid-clavicular line. Mid-sternal line.Mid-sternal line. Posterior axillary line.Posterior axillary line. Scapular line.Scapular line. Vertebral line.Vertebral line. Use stethoscope and move from side to side.Use stethoscope and move from side to side.

Chest AssessmentChest Assessment

RetractionsRetractions• SubcostalSubcostal• IntercostalIntercostal• Sub-sternalSub-sternal• Supra-clavicularSupra-clavicular

Red flags: grunting / nasal flaringRed flags: grunting / nasal flaring

Possible Sites of RetractionsPossible Sites of Retractions

Observe whileinfant or childis quiet.

Wheeze or StridorWheeze or Stridor

Wheezes occur when air flows rapidly Wheezes occur when air flows rapidly through bronchi that are narrowed through bronchi that are narrowed nearly to the point of closure. nearly to the point of closure.

Wheezes is lower airwayWheezes is lower airway• Asthma = expiratory wheezesAsthma = expiratory wheezes

A stridor is upper airwayA stridor is upper airway• Inflammation of upper airway or FBInflammation of upper airway or FB

Breathing soundsBreathing sounds

1- bronchial: over trachea1- bronchial: over trachea 2- vesicular breath sound: entire 2- vesicular breath sound: entire

surface of the lung (soft, swishing surface of the lung (soft, swishing noise).noise).

3- broncho-vesicular: over manubrium 3- broncho-vesicular: over manubrium and upper intra-scapular region.and upper intra-scapular region.

Best heard in 5Best heard in 5thth ICS at the MCL and ICS at the MCL and AAL.AAL.

Heart examinationHeart examination Palpation over four area:Palpation over four area: 1- Aortic area: felt in the 21- Aortic area: felt in the 2ndnd ICS to ICS to

the Rt. Of sternum.the Rt. Of sternum. 2- Pulmonary area: felt in the 22- Pulmonary area: felt in the 2ndnd ICS ICS

to the Lt. of the sternum.to the Lt. of the sternum. 3- Rt. Ventricular or Tricuspid area- 3- Rt. Ventricular or Tricuspid area-

felt in 5felt in 5thth ICS. ICS. 4- Mitral area: felt in the 54- Mitral area: felt in the 5thth ICS to ICS to

the Lt. of the sternum under nipple.the Lt. of the sternum under nipple.

Apical impulse best felt in the lateral Apical impulse best felt in the lateral to the MCL and 4to the MCL and 4thth ICS for child under ICS for child under 77thth year. year.

At the Lt. MCL and 5At the Lt. MCL and 5thth ICS for child ICS for child above 7above 7thth year. year.

PMI: at apical impulse.PMI: at apical impulse.

Auscultation of the heart: S1, S2, S3.Auscultation of the heart: S1, S2, S3. Percussion of heart to detect ??Percussion of heart to detect ??

Heart SoundsHeart Sounds

Abdomen examAbdomen exam

Use supine position with pillow under Use supine position with pillow under the head and knee flexed.the head and knee flexed.

Divide abd. to 4 Quadrant, and Divide abd. to 4 Quadrant, and examine from button to top.examine from button to top.

Examination of the abdomen involve Examination of the abdomen involve the inspection, auscultation, the inspection, auscultation, palpation and percussion.palpation and percussion.

Abdominal GirthAbdominal Girth

Abdominal girth should be measured over the umbilicusWhenever possible.

InspectionInspection

For contour, symmetry, ch.ch of For contour, symmetry, ch.ch of umbilicus, skin pulsation and umbilicus, skin pulsation and movement.movement.

Tense board is a serious sign of Tense board is a serious sign of paralytic illus and intestinal paralytic illus and intestinal obstruction.obstruction.

AuscultationAuscultation

Listen for peristalsis or bowel sounds Listen for peristalsis or bowel sounds for full minute.for full minute.

Listen for bruit of the major arteries.Listen for bruit of the major arteries. Listen around the umbilicus and Listen around the umbilicus and

epigastric region for venous hum epigastric region for venous hum (soft low pitched and con.).(soft low pitched and con.).

Bowel SoundsBowel Sounds

Normally occur every 10 to 30 seconds.Normally occur every 10 to 30 seconds. Listen in each quadrant long enough to Listen in each quadrant long enough to

hear at least one bowel sound.hear at least one bowel sound. Absence of bowel sounds may indicate Absence of bowel sounds may indicate

peritonitis or a paralytic ileus.peritonitis or a paralytic ileus. Hyperactive bowel sounds may indicate Hyperactive bowel sounds may indicate

gastroenteritis or a bowel obstruction.gastroenteritis or a bowel obstruction.

PalpationPalpation

Put patient in comfortable position.Put patient in comfortable position. Warm your hands.Warm your hands. Teach to be calm.Teach to be calm. Start in superficial to deep.Start in superficial to deep. Late any tender area.Late any tender area. Palpate LQ and upward, for liver and Palpate LQ and upward, for liver and

spleen.spleen. Kidneys.Kidneys.

GenitaliaGenitalia

Inspect genitalia for size, shape, and Inspect genitalia for size, shape, and deformity.deformity.

Consider male and female structures.Consider male and female structures. Palpate the male scrotom for …Palpate the male scrotom for …

Musculoskeletal systemMusculoskeletal system

Bone, joints-cartilages, ligaments and Bone, joints-cartilages, ligaments and muscles.muscles.

Inspect the joint for flexion and Inspect the joint for flexion and extension, abduction, adduction, extension, abduction, adduction, rotation.rotation.

Inspect the symmetry and observe Inspect the symmetry and observe the edema.the edema.

SpineSpine

Normally the back of the newborn is Normally the back of the newborn is round or C shape.round or C shape.

Older child develop to S shape.Older child develop to S shape.

ExtremitiesExtremities Assess symmetry of length and size.Assess symmetry of length and size. Observe shape of bones, temp, and color.Observe shape of bones, temp, and color. Observe for bowlegs. And space b/t the Observe for bowlegs. And space b/t the

knee more than 5 CM. should disappear knee more than 5 CM. should disappear after 2-3Y.after 2-3Y.

Inspect for knock-knee: from 2-7Y, and Inspect for knock-knee: from 2-7Y, and distance between two ankle should not distance between two ankle should not exceed 3 CM.exceed 3 CM.

Palpate for presence on edema.Palpate for presence on edema. Assess muscle strength.Assess muscle strength. Muscle tone estimation.Muscle tone estimation.

ReflexesReflexes

11 - -Moro Reflex Moro Reflex ((Startle ReflexStartle Reflex))

Infants will respond to sudden Infants will respond to sudden sounds or movements by throwing sounds or movements by throwing their arms and legs out, and throwing their arms and legs out, and throwing their heads back. Most infants will their heads back. Most infants will usually cry when startled and usually cry when startled and proceed to pull their limbs back into proceed to pull their limbs back into their bodies.their bodies.

Hold supine infant by arms a few Hold supine infant by arms a few inches above bed.inches above bed.

Gently drop infant back to elicit Gently drop infant back to elicit startle startle

Baby throws Arms out in extension Baby throws Arms out in extension and baby grimaces.and baby grimaces.

disappears by 3 months. disappears by 3 months.

22 - -HandHand--toto--Mouth Mouth ((BabkinBabkin) ) ReflexReflex

Stroke newborns cheek or put finger Stroke newborns cheek or put finger in babies palmin babies palm

Baby will bring his fist to mouth and Baby will bring his fist to mouth and suck a finger.suck a finger.

disappears by 2 years.disappears by 2 years.

33 - -Gripping Reflex (palmar grasp)Gripping Reflex (palmar grasp)

Babies will grasp anything that is placed Babies will grasp anything that is placed in their palm. The strength of this grip is in their palm. The strength of this grip is strong, and most babies can support strong, and most babies can support their entire weight in their grip.their entire weight in their grip.

When an object is placed in the infant's When an object is placed in the infant's hand and strokes their palm, the fingers hand and strokes their palm, the fingers will close and they will grasp it.will close and they will grasp it.

disappears at 3 to 4 months.disappears at 3 to 4 months.

http://en.wikipedia.org/wiki/Image:Greifreflex.JPG

44 - -Rooting ReflexRooting Reflex

The rooting reflex is most evident The rooting reflex is most evident when an infant's cheek is stroked. when an infant's cheek is stroked. The baby responds by turning his or The baby responds by turning his or her head in the direction of the touch her head in the direction of the touch and opening their mouth for feeding.and opening their mouth for feeding.

disappears at 3-4 months.disappears at 3-4 months.

55 - -Toe Curling Reflex (Plantar Toe Curling Reflex (Plantar reflex)reflex)

When the inner sole of a baby’s foot When the inner sole of a baby’s foot is stroked, the infant will respond by is stroked, the infant will respond by curling his or her toes. When the curling his or her toes. When the outer sole of a baby’s foot is stroked, outer sole of a baby’s foot is stroked, the infant will respond by spreading the infant will respond by spreading out their toes. out their toes.

disappears at 8 to 10 monthsdisappears at 8 to 10 months

66 - -Stepping ReflexStepping Reflex

When an infant is held upright with When an infant is held upright with his or her feet placed on a surface, his or her feet placed on a surface, he or she will lift their legs as if they he or she will lift their legs as if they are marching or stepping.are marching or stepping.

disappears by 2 months. disappears by 2 months.

77 - -Sucking ReflexSucking Reflex

The sucking reflex is initiated when The sucking reflex is initiated when something touches the roof of an something touches the roof of an infants mouth. Infants have a strong infants mouth. Infants have a strong sucking reflex which helps to ensure sucking reflex which helps to ensure they can latch onto a bottle or breast. they can latch onto a bottle or breast. The sucking reflex is very strong in The sucking reflex is very strong in some infants and they may need to some infants and they may need to suck on a pacifier for comfort.suck on a pacifier for comfort.

disappears at 10 to 12 months.disappears at 10 to 12 months.

Newborn reflexesNewborn reflexes

Tonic neck: disappears by 4 to 6 Tonic neck: disappears by 4 to 6 monthsmonths