Physical assessment - Pediatric: Nursing

A comprehensive physical assessment allows the nurse to assess a child’s growth, development, and health status. As the nurse, you’ll assess the child’s general appearance, growth and physiologic measurements, and each body system.

Now, unlike assessing an adult where a head-to-toe sequence is generally followed, with children, the sequence can be individualized to their developmental level.

For instance, when examining infants, you’ll often need to auscultate lungs and heart when they are quiet and examine their oral cavity when they’re crying.

You’ll also consider the child’s developmental stage when choosing techniques to prepare them for the examination. For infants you could examine the child on their caregiver’s lap.

For toddlers, you could use a doll to demonstrate what to expect during the examination or tell a story like “I’m checking to see if your tummy is hungry.” Likewise, you can teach school-age children about body parts and their function as you examine them.

As you begin your assessment, observe the child’s general appearance including facial expression, activity level, speech, posture, and interactions with you and their caregivers.

Take note of certain observations that warrant further investigation, like if you notice the child is tilting their head to a specific side, it could mean they’re having trouble hearing or seeing; or if they have dirty clothes or an unusual body odor, this may indicate neglect or financial difficulties at home.

Next, you’ll assess the child’s physical growth by measuring their length or height, weight, and head circumference. Until the child is around 2 years old, you’ll typically measure length using a length board with the child in a supine position.

Once they’re older and can stand, height is measured in the upright position, usually against a wall chart. Once you’ve obtained the measurements, you’ll plot them on a growth curve, and compare them to the expected percentile for age and sex.

Serial measurements can help you identify abnormal patterns of growth, like decreased growth velocity, which is a failure to gain weight or length at the expected rate.

Then, you’ll perform physiologic measurements, also known as vital signs, including temperature, pulse, respirations, and blood pressure.

Once these measurements are taken, they're compared to the child’s previous measurements, as well as expected values for their age group.

Remember to consider the child’s age when measuring vital signs. So, for children older than 2 years of age, taking a radial pulse will provide an accurate measurement for their heart rate; but before 2 years of age, auscultating their apical pulse for a full minute will be more accurate since occasional irregularities in rhythm may occur.

Moving onto assessing body systems, begin with an overall inspection of the child’s skin. You should expect a smooth, slightly dry texture, without areas of discoloration or lesions.

Be sure to keep the child’s natural variations in mind when assessing skin color; for example, in children with light skin, rashes may appear pinkish-red, but in children with darker skin, you’ll look for areas of hyperpigmentation or a purplish tone.

Next, inspect and palpate their head to assess the general shape and symmetry. In children younger than 2 years old, be sure to palpate the skull fontanels, which should be soft to palpation, and without bulging or depression.

Remember that the posterior fontanel usually closes around 2 months old, and the anterior fontanel closes between 12 and 18 months old.

Then, evaluate range of motion by asking an older child to turn their head side-to-side and look up and down. With infants, you may need to manually turn their head.

Limited range of motion can indicate torticollis, which is an inability to turn the head due to stiffness in the neck muscles.

Then, using a penlight, assess the child’s pupils, which should be equal, round, reactive to light, and accommodation, also known as PERRLA.

After that, inspect their ears for positioning and alignment. Expect the top of the ears to be even with a line drawn from the outer canthus of the eye to the occiput, or the back of the skull.

Alright, next you’ll assess their chest, beginning with inspection of size, shape, symmetry, and movement. In infants, the chest usually has a circular shape with the anteroposterior, or front-to-back diameter, equaling the lateral, or side-to-side diameter.

As the child gets older, their chest will grow in the lateral direction, causing the antero-posterior diameter to decrease.

Take note of alterations in chest shape, including a depressed sternum, called pectus excavatum, or a protruding sternum, or pectus carinatum.

You’ll also observe the child’s breathing by examining chest expansion during inspiration and expiration, which should be symmetrical.

Observe the depth and rhythm of breathing and auscultate their breath sounds, making note of any adventitious sounds, like crackles or wheezes, or diminished breath sounds.

Then, auscultate the quality, intensity, and rhythm of their heart sounds moving in an APE-To-Man sequence, meaning the Aortic valve, Pulmonic valve, Erb’s Point, Tricuspid valve, and Mitral valve.

Moving on to the abdomen, inspect for symmetry, contour or pulsations while the child is laying supine. Auscultate bowel sounds in all four quadrants, making note of any hypoactive or hyperactive sounds.

Then, palpate each quadrant to detect areas of pain or tenderness. Finally, inspect the child’s extremities for symmetry, length, and size.

You may notice bowleg, called genu varum, which is often present in children under 2, or knock-knee, or genu valgum, which is typically present in children 2 to 7 years old.

These usually resolve on their own. Alright, as a quick recap....

A comprehensive physical assessment allows the nurse to assess a child’s growth and physical development and gather information on all body systems.

As the nurse, you’ll examine their general appearance, growth and physiologic