2. INTRODUCTION
Physical assessment is an important part of the
nursing process, because it provides the data for
which nurse can make a nursing diagnosis and plan,
implement and evaluate nursing care.
Measurement of physical growth in children is a key
element in evaluating their health status.
Physical assessment uses four skills; inspection or
observation , palpation, percussion and auscultation.
4. HEIGHT
Until the child can stand steadily , generally before the age of 5
years, the height is taken as length while the child is lying on a
firm table.
The length is obtained by placing the feet against a fixed upright
surface at the zero mark of the rule and measuring from that
point to the vertex ,against which a flat movable surface placed.
The child’s body is fully extended by flattening the knees and
maintaining the head in a midline position.
Assistance can be needed to obtain an accurate measurement.
If the child stands straights and tall and hold the head so that the
line of vision parallels the floor surface , a standing height can be
measured.
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6. WEIGHT
The infant is weighed on an
infant scale , the older child
on a upright platform scale.
Either type of scale is
balanced before the weight
is read.
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10. TEMPERATURE
Normal temperature runs around 99 degrees until > 36
months.
A variance of 1-2 degrees is OK.
A temperature <97 degrees in an infant and > 100.5
degrees is indicative of a problem and should be noted.
Temperatures are taken commonly either axillary or
tympanic.
Be sure to document how taken.
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12. PULSE RATE
Apical pulse rates are most
commonly taken in children;
especially in those under 2.
Assess based on limits for age
and norms for that child.
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15. RESPIRATORY RATE
Assess the rate, depth, and ease of respiration in the
child. Varies with age of child.
Respirations should be quiet and effortless
Infants are abdominal breathers / nose breathers 4 weeks
to 4 months.
By age 7 – costal breathers
19. SKIN AND LYMPHATICS
INSPECTION : SKIN
Describe any variation in colour, particularly in children with increased pigmentation ,birth marks
,bruises or unusual marks , scars , wounds or insect bites , to ascertain suspected jaundice, scaliness ,
vernix caeseosa , Mongolian sot , Malia etc.
PALPATION
Check the tension of the skin by pinching up a fold of skin, normal skin quickly falls back , but
dehydrated skin remains in pinched position .
Skin examined for texture , moisture , temperature , colour and lesions .
The skin of young child is usually smooth , slightly dry and uniform temperature.
Skin is oily; cradle cap or ezema present.
Skin is too dry; child may bathed too and deficiency in vitamins .
Clammy skin ; heart disease
If the arms are warm and legs are cooler : coartation of aorta
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21. The skin is observed for pallor and cyanosis ; increased
deoxygenated haemoglobin .
Erythema and jaundice
Ecchymosis –haemorrhage of blood into skin .
Petechia
Presence of simian crease ; down syndrome
Skin turgor
Poor skin turgor : dehydration and in oedema , sign of kidney
disease.
ACCESSORY STRUCTURES
HAIR
Hair is examined for colour, texture , elasticity , distribution ,
cleanliness and infestation .
22. Alopecia : tinea capitis ,pyoderma and seboric dermatitis or side effects of
radiation and certain drugs such as chemotherapeutic agents, protein
deprivation and celiac disease.
Hair is dull, dry , brittle and depigmented : malnourished
Hypertrichosis
Hair growth from midforehead and excessive : cretinism
Excessive hair over the spine : spina bifida
NAIL
Inspected for shape , texture , flexibility and colour.
Normal nails are usually convex , translucent, smooth and firm but flexible.
Colour abnormalities may include blueness ;cyanosis
Yellow tint :jaundice
Dark colouration indicates haemorrhage
23. White opacity of the nail; benign hereditary defect or trauma
Clubbing in the base of the nail and becomes swollen : tetralogy of Fallot.
Micronychia : trisomy 18 and foetal alcohol syndrome.
HEAD AND NECK
head control
Presence of wry neck or torticollis
Opisthotonas : meningeal irritation
Nuchal rigidity
Inspection and palpation of skull
Symmetry, size, and general appearance
Asymmetry of the skull : craniosynostosis ,infants remained in one position for long period
Posterior fontanelles anterior fontanelles
Late closure of fontanelles : rickets , cretinism
Bulging and depressed fontanelle.: raised intracranial tension
Prominent scalp veins and crack pot sign : hydrocephalus
24. EYE
Alignment and placement on the face.
The eyes are inspected for shape , size , colour , movement and symmetry.
Epicanthal folds : Caucasian children .
Ptosis or drooping of eyelids.
Edema of eyelids : kidney diseases.
Ambylopia
Exophthalmos : hyperthyroidism
Setting sun sign
EYE LASHES
Inspected for position ,presence or absence of eyelashes
Assess for blepharospasm , blepharitis , hordeolum and chalazion
LACRIMALAPPARATU
position and patency and possibility of infection
25. Epiphora or excessive tearing ,plugged lacrimal duct, alacrimia , corneal
ulceration and scarring.
ORBIT
Sunken eyes : dehydration
Macrothalmia : toxoplasmosis
CONJUNTIVA
Normally glossy and pink
Assess for conjunctivitis
Pale conjunctiva : anemia in child
SCLERA
Inspected for discolouration
PUPILS
Inspected for shape ,size ,movement and the ability to accommodate and react
to light.
anisocoria
26. OCCULAR MUSCLES
Strabismus and nystagmus
TESTING FOR VISUAL ACQUITY
Snellen's chart is used
Snellen alphabet
Snellen’ E’ charts
Denver eye screening test is used for children over 2 ½ years of age.
TESTING FOR VISUAL FIELD
Peripheral vision ; child look at the nurse at a distance of 3 feet.
TESTING FOR COLOUR VISION
Colour blindness
Red green defect and blue yellow defects
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28. EAR
Inspection for alignment and placement on the head
Assess auricle or pinna ( helix, antihelix ,concha, tragus and lobule )
Assess for any anomalies
EAR CANAL : inspection is done with otoscope.
1. 2.5 cm
2. Pink in colour
3. Thin
4. Presence of ear cerumen
5. Inspected for discharge
TYMPANIC MEMBRANE
Transparent tissue of a grey coloured
Examined for loss of any bony land marks
Examine middle ear , inner ear and auditory or eustachian tube
29. Examination of mastoid area for any infection (mastoiditis)
TESTING FOR HEARING ACUITY
Crib-o-Gram is used to test the hearing of the new-born and infant.
Audiometer is an electric instrument that measure pure tone , frequencies and
loudness of voice.
NOSE
It is a framework of bone and cartilage covered with skin and lined with
mucus membrane.
Assess the external triangular structure of the nose.
Insect type and amount of watery , purulent and crusty discharge if any , are
noted.
Patency of nose
Observe for “Allergic salute” : rhinitis , rhinorrhoea or itching .
Assess for nasal cavities , mucus membrane and small hairs.
30. Assess for nasal septum deviation and perforated septum.
Assess olfactory areas , sinuses( palpate frontal sinus)
MOUTH
Assess for lips for shape, colour ,inflammation, fissuring and lesion.
Anaemia : pale lips
Cherry red lips : heart lesion
Cyanosis or grey colour : congenital heart lesion.
Cheilitis
Assess for oral or buccal cavity , gag reflex ,oral thrush.
Assess salivary glands , tonsils
31. THORAX AND CHEST
Palpate thorax area(rachitic rosary) , clavicle( fracture)
Assess deformities in the bones of chest
Harrisons groove , barrel chest
Assess inspiration and expiration and non symmetrical
movements of chest.
Auscultation of breath sounds.
Abnormal lung sounds: rales , rhonchi , wheezing etc
HEART
To inspect and palpate heart child lies flat on the back with chest
elevated at a 45 angle.
Both sides of anterior chest wall should be symmetric.
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33. Auscultation of heart sounds
ABDOMEN
Abdomen is inspected for skin abnormalities , contour , symmetry , size , muscle
tone , masses.
Examined Convexity and concavity.
Inspect Scaphoid abdomen ,distended abdomen protruding abdomen.
Auscultation is done to determine presence or absence of peristaltic waves.
Each quadrants is heard for 5 mins
Soft friction rubs ; peritoneal obstruction or inflamed spleen
Splashing noise ; presence of fluid in the stomach.
Palpate abdomen for degree of distention , edge of liver , spleen , femoral pulse
and skin turgor
Deep palpation to feel abdominal organs.
34. ANUS AND RECTUM
Observe anal sphincter , firmness of buttocks muscle.
Inspect for any signs of inflammation , redness , scars , marks , rashes and anal
fissures.
Observe pin worm around the anus.
Palpation ; determine the presence of fistulas , sinuses , strictures and abscess .
GENETALIA
Examination male genetalia
The scrotum is inspected and palpated for possible inguinal hernia , oedema ,
colour and masses .
If red and shiny skin – orchitis
Assess for hydrocele
Spermatic cords are traced and examined for swelling or masses
Both testes are examined for descended and undescended testes
Assess prostrate gland. Its position and shape
35. The shaft of penis is examined for its size .
Micropenis (2.5cm)
Balanitis and venereal warts
URETHRA
The meatus is examined for an ulceration
Assess for hypospadias's and epispadiasis
Observe for priapism
EXAMINATION OF FEMALE GENETALIA
Mons pubis is inspected for skin discolouration , pubic lice or crabs and palpated for
masses.
The skin of labia is inspected for abrasion and ulceration.
Assess vulvitis , gonorrhoea , labio inguinal hernia
Check for any adhesion
Assess for abnormally large clitoris to investigate virilization
36. URINARY MEATUS
Assess for prolapse of urethra , hematuria , dysuria ,urethritis
Examine vaginal opening and hymen , congenital absence of vagina
Assess for vulvoginitis , unpleasant odour , abnormal colour of discharge.
MUSCULOSKELETAL SYSTEM
Knock – kneed appearance
In Pre-schoolers ; assess eversion of extremities .
Assess range of motion , congenital dislocation , tenderness , heat , swelling over joints;
infection.
Inspect atrophy, hypertrophy , spasticity , flaccidity , tone, rigidity of muscles .
Examine vertebral column for spina bifida , abnormal curvatures , meningomyelocele, tenderness
or note areas of mass.
Upper extremities assessed for fractures any deformity , length and shape of fingers , extra digits.
Lower extremities ; assess fracture , joint pain , arthritis , equality of length , complete range of
motion at the hip , knees , ankles and toes , abnormal hip dislocation and tibial torsion or bowing
of tibia.
37. CENTRAL NERVOUS SYSTEM
It is done to note orientation , level of consciousness, intellectual ability
and behaviour .
Assess any disorientation , hyperactive problems , cerebral palsy ,
cerebral dysfunction any injury or trauma , tumor to the brain.
Assess for language ability , cry , senses.
Assessing the milestones.
Assessing the reflexes
Biceps tendon reflex
Triceps tendon reflex
Patellar deep tendon reflex
Achilles deep tendon reflex
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40. CONCLUSION
Physical examination of a child should be done
to rule out the distinguish between normal and
abnormality of body parts. It should be done in
the presence of his or her to parents to reduce
anxiety. It helps a nurse and a physician to know
that all the organs are functioning normally or
not.
