Assessment of the Infant, Child, and Adolescent

Assessment of the infant, child, and adolescent involves a variety of techniques depending on the patient’s age and development. As the nurse, you’ll collect subjective and objective data, while keeping in mind age-specific techniques and variations.

During your assessment, keep in mind the techniques you’ll use based on your patient’s age and developmental stage. Infants are typically examined on their caregiver’s lap during the quiet parts of the exam like cardiac and respiratory auscultation; then, you’ll complete the rest of the exam with the infant on the examination table. Remember that stranger anxiety begins around six to nine months of age, so you’ll need to build trust before starting your assessment by taking time to let the infant adjust to their new surroundings and by speaking to them softly before touching them.

When examining a toddler, you’ll want to keep them on their caregiver’s lap for the duration of the exam and encourage them to hold a security object like a stuffed toy or blanket during the exam. Also, remember that most toddlers and preschoolers are learning to gain independence, so offer them choices when possible, such as asking them which ear you should look at first. They also enjoy playing games and pretending, so you can use a doll to demonstrate what to expect during the exam.

When examining school-aged patients and adolescents, promote relaxation by asking about school or hobbies, and explaining how the body works as you examine each system. Adolescents are often ready to receive health teaching regarding how they can stay safe and healthy, so you can teach as you examine them.
Also, be sure to give your adolescent patient a choice to speak to you without their caregiver in the room to ensure confidentiality about specific problems like sexual activity, substance use, or mental health issues.

Begin your examination by collecting subjective data, or information your patient or their caregiver shares. For patients up to age 2, obtain a perinatal history from their caregiver, which includes health during pregnancy, the length of labor, type of delivery, and problems related to pregnancy or delivery. You’ll also collect information about your patient’s progress in reaching developmental milestones like walking, talking, or turning a page in a book.
In addition, collect data about their past medical history, including allergies, chronic disorders, and immunization status. Other subjective data includes sleeping and eating patterns, amount of screen time, and the use of safety measures, like car seats and helmets when biking, skateboarding, or using a scooter.

Next, gather objective data, or information you observe. During your examination, you’ll observe your patient’s general appearance, motor skills, and speech patterns, as well as their interactions with you and their caregiver.
As with an adult, you’ll complete a comprehensive assessment, but the pediatric assessment sequence is generally conducted from the least invasive to most invasive, instead of head-to-toe. For example, when assessing infants, toddlers, and preschoolers, you’ll typically examine their ears and mouth last, whereas in school-age patients and adolescents, the genitalia are assessed last.