This document provides an outline for conducting a physical assessment of a child. It discusses taking a health history, including chief complaint, present illness, past medical history, family history, medications, allergies and immunizations. It also covers a review of systems, physical examination, vital signs, nutritional assessment and developmental milestones. The goal is to collect comprehensive health information to identify issues, establish relationships and gather data.

1. Physical assessment the of child
Prepared by
Raveen Isamel Abdullah
B.CS.in Nursing
Hawler medical university
College of nursing
2016-2017

2. OUTLINES
• Introduction
• History taking and physical examination
• Steps of history taking
• Analyzing symptoms
• Nutritional assessment

3. Introduction
• Physical assessment is taking an educated,
systematic look at all aspects of an individual’s
health status utilizing knowledge, skills and
tools of health history and physical exam.
1. To collect data- information about the client’s
health, including physiological, psychological,
sociocultural and spiritual aspects.
2. To establish actual and potential problems.
3. To establish the nurse-client relationship.

4. History taking
The format used for history taking may be:
(1) Direct, in which the nurse asks for information via direct
interview with the informant.
(2) Indirect, in which the informant supplies the information
by completing some type of questionnaire.
• The direct method is superior to the indirect approach or a
combination of both. However, because time is limited, the
direct approach is not always practical.
• If the nurse cannot use the direct approach, he or she
should review the parents 'written responses and question
them regarding any unusual answers.

5. Informant
One of the important elements of identifying
information is the informant, the person(s) who
furnishes the information.
Record
(1) who the person is (child, parent, or other),
(2) an impression of reliability and willingness to
communicate.
(3) any special circumstances such as the use of an
interpreter or conflicting answers by more than
one person.

6. Identifying information
1. Name
2. Address
3. Telephone
4. Birth date and place
5. Race or ethnic group
6. Sex
7. Religion
8. Date of interview
9. Informant

7. Chief Complaint
• To establish the major specific reason for the child’s
and parents’ seeking professional health attention
• Elicit the chief complaint by asking open-ended,
neutral questions such as: “What seems to be the
matter?”
“How may I help you?” or “Why did you come here
today?”
• Avoid labeling-type questions such as: “How are you
sick?” or “What is the problem?” It is possible that the
reason for the visit is not an illness or problem.

8. Present Illness
• To obtain all details related to the chief
complaint.
Its four major components are:
(1)The details of onset.
(2)A complete interval history.
(3)The present status.
(4)The reason for seeking help now.

9. Analyzing a Symptom
• Because pain is often the most characteristic
symptom denoting the onset of a physical
problem, it is used as an example for analysis
of a symptom.
• Assessment includes (1) type, (2) location, (3)
severity,(4) duration, and (5) influencing
factors

10. Analyzing the Symptom: Pain
Type
Be as specific as possible. With young children, asking the parents
how they know the child is in pain may help describe its type,
location, and severity.
For example/
• a parent may state, “My child must have a severe earache because
she pulls at her ears, rolls her head on the floor, and screams.
Nothing seems to help.”
• Help older children describe the “hurt” by asking them if it is sharp,
throbbing, dull, or stabbing.
• Record whatever words they use in quotes.

11. Analyzing the Symptom: Pain
Location
• Be specific. “Stomach pains” is too general a
description.
• Children can better localize the pain if they are asked to
“point with one finger to where it hurts”
• or to “point to where Mommy or Daddy would put a
Band-Aid.”
• Determine if the pain radiates by asking, “Does the
pain stay there or move? Show me
with your finger where the pain goes.”

12. Analyzing the Symptom: Pain
Severity
• Severity is best determined by finding out how it
affects the child’s usual behavior.
• Pain that prevents a child from playing,
interacting with others, sleeping, and eating is
most often severe.
• Assess pain intensity using a rating scale, such as
a numeric or FACES scale.

13. Analyzing the Symptom: Pain
Duration
• Include the duration, onset, and frequency.
• Describe these in terms of activity and
behavior, such as “pain reported to last all
night; child refused to sleep and cried
intermittently.”

14. Analyzing the Symptom: Pain
Influencing Factors
• Include anything that causes a change in the type, location, severity,
or duration of the pain:
(1) Precipitating events
(those that cause or increase the pain)
(2) Relieving events
(those that lessen the pain, such as medications)
(3) Temporal events
(times when the pain is relieved or increased)
(4) Positional events
(standing, sitting, lying down)
(5) Associated events
(meals, stress, coughing).

15. History
• The history contains information relating to all
previous aspects of the child’s health status
and concentrates on several areas that are
ordinarily passed over in the history of an
adult.

16. Past History
To elicit a profile of the child’s previous illnesses,
injuries, or operations.
1. Birth history (pregnancy, labor and delivery, prenatal
history)
2. Previous illnesses, injuries, or operations
3. Allergies
4. Current medications
5. Immunizations
6. Growth and development
7. Habits

17. Birth History
The birth history includes all data concerning
(1) The mother’s health during pregnancy.
(2) The labor and delivery.
(3) The infant’s condition immediately after birth.
• Because prenatal influences have significant
effects on a child’s physical and emotional
development, a thorough investigation of the
birth history is essential.

18. Birth History Cont
• Because emotional factors also affect the
outcome of pregnancy and the subsequent
parent–child relationship, investigate:
(1) Crises during pregnancy.
(2) Prenatal attitudes toward the fetus.

19. Previous illnesses ,injuries, and
operations
• When inquiring about past illnesses, begin with a
general question such as “What other illnesses has
your child had?”
• Ask about injuries that required medical
intervention, operations, and any other reason for
hospitalization, including the dates of each incident.
• Focus on injuries such as accidental falls, poisoning,
choking, or burns.

20. Taking an Allergy History
Has your child ever taken any drugs or tablets that have
disagreed with him or her or caused an allergic reaction?
If yes,
• Can you remember the name(s) of these drugs?
• Can you describe the reaction?
• Was the drug taken by mouth (as a tablet or syrup), or
was it an injection?
• How soon after starting the drug did the reaction
happen?
• How long ago did this happen?
• Did anyone tell you it was an allergic reaction, or did
you decide for yourself?

21. Current Medications
• Inquire about current drug regimens,
including vitamins, antipyretics (especially
aspirin), antibiotics, antihistamines,
decongestants, and herbs and homeopathic
medications.
• List all medications, including their names,
doses, schedules, durations, and reasons for
administration.

22. Immunizations
• A record of all immunizations is essential. Because many parents are
unaware of the exact name and date of each immunization, the most
reliable source of information is a hospital, clinic, or private
practitioner’s record.
• All immunizations and “boosters” are listed, stating
(1) the name of the specific disease, (2) the number of injections,
(3) the dosage (sometimes lesser amounts are given if a reaction is
anticipated), (4) the ages when administered, and (5) the occurrence
of any reaction after the immunization.

23. Growth and Development
The most important previous growth patterns to record are:
• Approximate weight at 6 months, 1 year, 2 years, and 5 years of age
• Approximate length at ages 1 and 4 years
• Dentition, including age of onset, number of teeth, and symptoms
during teething
Developmental milestones include:
• Age of holding up head steadily
• Age of sitting alone without support
• Age of walking without assistance
• Age of saying first words with meaning
• Present grade in school
• Scholastic performance
• If the child has a best friend
• Interactions with other children, peers, and adults.

24. Habits
• Habits are an important area to explore.
Parents frequently express concerns during
this part of the history.
• Encourage their input by saying, “Please tell
me any concerns you have about your child’s
habits, activities, or development.”

25. Sexual history
• The sexual history is an essential component
of adolescents’ health assessment.
• The history uncovers areas of concern related
to sexual activity alerts the nurse to
circumstances that may indicate screening for
sexually transmitted infections or testing for
pregnancy or need for sexual counseling.

26. Family Medical History
• To identify genetic traits or diseases that have
familial tendencies and to assess exposure to
a communicable disease in a family member
and family habits that may affect the child’s
health, such as smoking and chemical use.

27. Family Structure
• Family assessment is the collection of data
about the composition of the family and the
relationships among its members.

28. Ask
(1) family composition
(2) home and community environment
(3) occupation and education of family members
(4) cultural and religious traditions
Family compostition

29. NUTRITIONAL ASSESSMENT
• To elicit information on the adequacy of the
child’s nutritional intake and needs
1. Dietary intake
2. Clinical examination

30. • Anthropometry, an essential parameter of
nutritional status, is the measurement of height,
weight, head circumference, proportions, skin
fold thickness, and arm circumference in young
children.
• Height and head circumference reflect past
nutrition, and weight, skin fold thickness, and
arm circumference reflect present nutritional
status
Growth and Development

31. NUTRITIONAL ASSESSMENT
• Dietary Reference Intakes (DRIs) are a set of
four nutrient basedreference values that
provide quantitative estimates of nutrient
intake for use in assessing and planning
dietary intake (AmericanAcademy of
Pediatrics, 2009).

32. The specific DRIs are:
Estimated Average Requirement (EAR)—Nutrient intake estimated
to meet the requirement of half the healthy individuals (50%) for
a specific age and gender group
Recommended Dietary Allowance (RDA)—Average daily dietary
intake sufficient to meet the nutrient requirement of nearly
all (97%–98%) healthy individuals for a specific age and gender
group
Adequate Intake (AI)—Recommended intake level based on estimates
of nutrient intake by healthy groups of individuals
Tolerable Upper Intake Level (UL)—Highest average daily nutrient
intake level likely to pose no risk of adverse health effects; as intake
increases above the UL, risk of adverse effects increases.
NUTRITIONAL ASSESSMENT

33. Review of Systems
• The review of systems is a specific review of each
body system following an order similar to that of
the physical examination.
• Begin the review of a specific system with a broad
statement such as “How has your child’s general
health been?” or “Has your child had any
problems with his eyes?” If the parent states that
the child has had problems with some body
function.
“Tell me more about that.”

34. General
• Overall state of health, fatigue, recent or
unexplained weight gain or loss (period of
time for either), contributing factors (change
of diet, illness,altered appetite),
• Exercise tolerance, fevers (time of day), chills,
night sweats(unrelated to climatic conditions),
frequent infections, general ability to carry
out activities of daily living.

35. Integument
• Pruritus, pigment or other color changes,
acne, eruptions, rashes(location), tendency
for bruising, petechiae, excessive dryness,
general texture.
• disorders or deformities of nails, hair growth
or loss, hair color change (for adolescents, use
of hair dyes or other potentially toxic
substances,such as hair straighteners)

36. Head and eye
• Head—Headaches, dizziness, injury and size.
• Eyes—Visual problems (behaviors indicative of
blurred vision, such as bumping into objects,
sitting close to television, holding a book close to
face, writing with head near desk, squinting,
rubbing the eyes, bending head in an awkward
position), cross eyes (strabismus), eye infections,
edema of the eyelids, excessive tearing, use of
glasses or contact lenses, date of last optic
examination.

37. Ears, Nose and Mouth
• Ears—Earaches, discharge, evidence of hearing loss (ask
about behaviors, such as the need to repeat requests, loud
speech, inattentive behavior), results of any previous
auditory testing.
• Nose—Nosebleeds (epistaxis), constant or frequent runny
or stuffy nose, nasal obstruction (difficulty breathing),
alteration or loss of sense of smell
• Mouth—Mouth breathing, gum bleeding, toothaches,
tooth brushing, use of fluoride, difficulty with teething
(symptoms), last visit to dentist (especially if temporary
dentition is complete), response to dentist.

38. Throat, Neck and chest
Throat—Sore throats, difficulty swallowing,
choking (especially when chewing food; may be
from poor chewing habits), hoarseness or other
voice irregularities.
Neck—Pain, limitation of movement, stiffness,
difficulty holding head straight (torticollis),
thyroid enlargement, enlarged nodes or other
masses.
Chest—Breast enlargement, discharge, masses,
enlarged axillary nodes (for adolescent girls, ask
about breast self-examination).

39. Respiratory
• Chronic cough, frequent colds (number per
year), wheezing, shortness of breath at rest or
on exertion, difficulty breathing, sputum
production, infections (pneumonia,
tuberculosis),
• Date of last chest x-ray examination, skin
reaction from tuberculin testing.

40. Cardiovascular and Gastrointestinal
• Cardiovascular—Cyanosis or fatigue on exertion, history of
heart murmur or rheumatic fever, anemia, date of last
blood count, blood type, recent transfusion.
• Gastrointestinal (questions in regard to appetite, food
tolerance, and elimination habits are asked elsewhere)—
Nausea, vomiting (not associated with eating; may be
indicative of brain tumor or increased intracranial
pressure),jaundice or yellowing skin or sclera, belching,
flatulence, recent change in bowel habits (blood in stools,
change of color, diarrhea or constipation)

41. Genitourinary
• Genitourinary—Pain on urination, frequency,
hesitancy, urgency, hematuria,nocturia,
polyuria, unpleasant odor to urine, force of
stream, discharge , change in size of scrotum.
• date of last urinalysis (for adolescents,
sexually transmitted infection, type of
treatment; for male adolescents, ask about
testicular self-examination).

42. Gynecologic
• Menarche, date of last menstrual period,
regularity or problems with menstruation,
vaginal discharge, pruritus(ITCHING).
• Date and result of last Papanicolaou(Pap)test
• If sexually active, type of contraception.
• sexually transmitted infection and type of
treatment.

43. • Musculoskeletal—Weakness, clumsiness, lack of
coordination, unusual movements, back or joint
stiffness, muscle pains or cramps, abnormal
gait,deformity, fractures, serious sprains, activity level.
• Neurologic—Seizures, tremors, dizziness, loss of
memory, general affect,fears, nightmares, speech
problems, any unusual habits.
• Endocrine—Intolerance to weather changes,
excessive thirst or urination,excessive sweating, salty
taste to skin, signs of early puberty.

44. Physiologic Measurements
• Physiologic measurements, key elements in
evaluating physical status of vital functions,
include temperature, pulse, respiration, and
BP.
• Compare each physiologic recording with
normal values for that age group

45. Temparature
• Temperature is the measure of heat content
within an individual's body.
• The core temperature most closely reflects the
temperature of the blood flow through the
carotid arteries to the hypothalamus.
• Sites:
Oral,axillary ,ear based(Aural),rectal, Temporal
Artery(An infrared sensor probe scans across
forehead, capturing heat from arterial blood
flow).

46. Pulse
Pulse
A satisfactory pulse can be taken radially in children older
than 2 years of age.
• However, in infants and young children, the apical
impulse(heard through a stethoscope held to the chest at
the apex of the heart)is more reliable.
• Count the pulse for 1 full minute in infants and young
children because of possible irregularities in rhythm.
However, when frequent apical rates are necessary,
use shorter counting times (e.g., 15- or 30-second
intervals).

47. Respiration
Respiration
• Count the respiratory rate in children in the
same manner as for adult patients.
• However, in infants, observe abdominal
movements because respirations are primarily
diaphragmatic.
• Because the movements are irregular, count
them for 1 full minute for accuracy.

48. Blood Pressure
Blood Pressure
• Blood pressure measurement by noninvasive
methods is part of a routine vital sign
determination.
• Measure BP annually in children3 years of
age through adolescence and in children with
symptoms of hypertension, children in
emergency departments and intensive care
units, and high-risk infants

49. References
• Marilyn J.Hockenberry,David Wilson
,2009,Essentials of Pediatric
Nursing,(8)Edition.PP95-143.