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Course: Pediatric Nursing�Topic: Health Assessment in Children

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Module Goals

Learners will be able to:

Describe the process for obtaining a health history from child and parent or caregiver
Outline the health assessment utilizing approaches related to age and developmental stage of child
Explain appropriate sequence of the physical exam based on the child’s developmental stage

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Health History Taking with a Child: General Tips

Government of Canada, 2012

Technique

Children who can communicate verbally should be included as historians with additional details provided as necessary by parents or caregivers.
Interact (smile, ‘coo’) or play with children while taking history.
Frame questions, explanations at the level of child’s understanding.
Young children may be assisted in providing details of the history by having them role play or draw pictures.

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Health History Taking of an Adolescent

Government of Canada, 2012

Consideration for privacy and confidentiality:

Interview the adolescent alone.
Ask permission to include parents.
Discuss with parents or caregiver separately, with the adolescent’s permission.

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Components of a Health History

Government of Canada, 2012

Identify data
Chief complaint
History of present illness
History of past illnesses
Allergies
Medication history
Tobacco, alcohol and/or drug use
Family history
Personal and social history (family of origin, interests, lifestyle)
Review of systems

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Health History (continued)

Who is the primary caregiver (parent/guardian) and who is providing the history?
Pregnancy and perinatal history of the birth parent
Birth history (including Apgar score)
Immunization history
History for the first year of life, (vitamin supplements and fluoride use)
Dietary intake for other age groups, (including how much tea, carbonated beverages and juices are being consumed)

Government of Canada, 2012

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Health History (con.):

Government of Canada, 2012

Developmental history:

Physical
Cognitive
Language
Social and emotional

Physical environment at home (including presence of mold and poor heating/ insulation/water/safety)

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Health History: Presenting Complaints

Why are you bringing the child to the health care facility today?
When was the child last completely well?
What are the presenting complaints (symptoms)?
When and how did they start?
Are they getting worse?
Does anything make them better or worse?
Is any treatment being used?
Are there any other symptoms (what the child feels) or signs
Has the child been in contact with other children with similar complaints?

Better Health, n,d

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Health History: History of Past Illnesses

Problems during pregnancy, labor and delivery
Gestational age and birth weight
Problems during the first few days of life
Diet and feeding
Growth and development
Previous illness before the start of the problem
Previous or present medication
Surgeries or hospital admissions
Allergies
HIV status

Better Health, n.d

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Health History: Immunizations

Better Health, n.d

Review the child’s immunization record.

Children may present with an infectious disease if they have not been fully immunized against a disease.

An incomplete immunization schedule may indicate social problems.

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Health History: Social History

Children are influenced by their environment.
Many childhood problems are caused by problems at home (poverty, malnutrition, abuse, neglect, poor housing, unemployment) or at school (discipline, fear, bullying).
The presenting complaint may be a warning of social problems.
Poverty and poor maternal education contribute to many childhood problems.
Some mothers may bring their child to a clinic because they have a problem themselves.

Better Health, n,d

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Special Questions

Ask about each system e.g. respiratory, gastrointestinal
Use specific questions related to the body system involved in the present history.
For example:

If the presenting complaint is abdominal pain it would be important to ask about appetite, vomiting, diarrhea or constipation, worms, blood in the stool and weight loss
Asking the right questions is essential to determine the problem

Better Health,n. d

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Critical Thinking Question:

Interview techniques:

A mother brought a 7 year old child to the clinic with abdominal pain.

What questions would you ask the mother about the child’s pain?

What question would you ask the child about the pain?

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The Physical Examination of a Infant and Child

Government of Canada, 2012

General Appearance:

Observe a child initially without touching (if possible):
Level of consciousness, alertness, general behavior and appearance
Symmetry of body
Posture of limbs (flexed, extended)
Body movements (arms and legs, facial grimace)
State of nutrition and hydration
Color of sclera, skin, and nailbeds
Any sign of clinical distress (eg. respiratory distress includes dyspnea, pallor, cyanosis, irritability)

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Physical Assessment (continued)

Government of Canada, 2012

Gait
Breathing frequency and pattern
Responses to sound
Fine and gross motor skills as the child plays
Lesions (for example, petechiae, eczema, impetigo)
Responses to parental comforting measures
Ability to entertain themselves while the caregiver is talking
Quality of infant's cry or quality of child's voice

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Physical Assessment: Vital Signs

Government of Canada, 2012

Assess for:

Heart rate
Blood pressure
Respiratory rate
Temperature (if warranted)
Oxygen saturation (if warranted)

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Physical Assessment: Vital Signs (continued)

Recommended Temperature Measurement Methods

Less than 2 years:

Definitive Method: Rectal
Method to Screen Low risk children: Axillary

2–5 years:

Definitive Method: Rectal
Method to Screen Low risk children: Axillary and Tympanic

Older than 5 years:

Definitive Method:Oral
Method to Screen Low risk children:Axillary Tympanic

Government of Canada, 2012

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Physical Assessment: Growth Measurement

Government of Canada, 2012

Length and weight should be taken at each visit for infants under 1 year of age presenting for a well-child visit.

For any infant or child who presents with vomiting, diarrhea, signs of shock, or in need of a medication where dosage is dependent on weight.

Height & weight at least annually for older children.

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Physical Assessment: Skin

Color:

Pallor, low hemoglobin or vasoconstriction (in shock)
Cyanosis (hypoxemia)
Plethora (polycythemia or vasodilation)
Cherry red face (carbon monoxide poisoning)
Jaundice (elevated bilirubin Lesions)

Lesions:

Stroke bite, Café au lait spots, Mongolian spots, Acne, bruises

Texture:

Turgor

Government of Canada, 2012

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Physical Assessment: Head and Neck

Head Neck and Face

Check for:

Palpate anterior and posterior fontanelles (size, consistency, bulging or sunken) and cranium
Bruising of head, behind the ears or periorbitally
Size and shape of the head
Facial symmetry at rest and while crying for the infant

Government of Canada, 2012

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Physical Assessment: Head and Neck (continued)

Eyes: (Inspection)

Cornea for cloudiness (sign of congenital cataracts)
Conjunctiva for erythema, exudate, orbital edema, subconjunctival hemorrhage, jaundice of sclera
Pupillary size, shape, equality and reactivity to light (PERRL: pupils equal, round, reactive to light), accommodation normal
Red reflex
Visual acuity in children over 3 years of age

Government of Canada, 2012

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Physical Assessment: Head and Neck (continued)

Ears:

Check for asymmetry, irregular shape
Setting of ear in relation to corner of eye (low-set ears may suggest as renal anomalies, fetal alcohol spectrum disorder or Down’s syndrome)
Look for fleshy appendages, lipomas or skin tags
Palpate and inspect auricles
Perform otoscopic examination:

Discharge, foreign bodies and colour, and tympanic membranes for colour, brightness, perforation, effusion, bony landmarks and light reflex

Government of Canada, 2012

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Physical Assessment: Head and Neck (continued)

Government of Canada, 2012

Nose: (Inspection)

Determine if nares are patent
Look for foreign body
Look for nasal flaring, which is a sign of increased respiratory effort
Look for hypertelorism or hypotelorism (increased or decreased space between eyes)
Note nasal discharge or sneezing
Look at the mucosa, septum and turbinates with otoscope

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Physical Assessment: Head and Neck (continued)

Government of Canada, 2012

Mouth:

Inspect lips, gums, palate, buccal mucosa, tongue, palate, tonsils.
Inspect tongue size and frenulum of tongue in infants.
Inspect teeth for number, character, condition, position and caries.
Palpate palate in young infants
Note if uvula is midline.

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Physical Assessment: Head and Neck (continued)

Government of Canada, 2012

Neck: (Visual Inspection):

Symmetry of shape, midline trachea
Alignment: torticollis is often secondary to positional plagiocephaly
Tracheal tug: can occur with dyspnea
Neck mass

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Physical Assessment: Head and Neck (continued)

Government of Canada, 2012

Neck: (Palpation)

Palpate any masses (may signify congenital cysts), trachea, lymph nodes and thyroid
Neck range of motion for nuchal rigidity:

May be present in meningitis; in older children (over 5) Kernig and Brudzinski reflex may be helpful in assessing for meningitis

Palpate clavicles

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Physical Assessment: Respiratory System

Inspection of Chest-Anterior and Posterior:

Cyanosis, (central or peripheral)
Respiratory effort, rate and pattern (periodic breathing, gasping, periods of true apnea)
Observe chest movement for symmetry and retractions
Note any movement of the abdomen with respirations
Note chest size, shape, configuration and anatomical abnormalities of chest (pectus excavatum)
Use of accessory muscles, tracheal tug, indrawing of intercostal or subcostal muscles
Note any nipple and breast development

Government of Canada, 2012

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Physical Assessment: Respiratory System (continued)

Government of Canada, 2012

Palpation:

Any abnormal masses (palpate gently)
Nipples and breast tissue – it may be slightly enlarged in newborns due to secondary presence of maternal hormones in infants

Auscultation:

Breath sounds
Rate and rhythm
Inspiratory to expiratory ratio
Adventitious sounds (stridor, crackles, wheezes, grunting)

Percussion as indicated

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Physical Assessment: Cardiovascular System

Visual Inspection:

Color: pallor, cyanosis, plethora
Pulsations on precordial area

Palpation:

Locate point of maximal impulse (PMI) by positioning one finger on the chest and note this location
Palpate chest wall for thrills
Capillary refill (< 2 seconds is normal)
Peripheral pulses in each extremity and femoral: note character of pulses (bounding or thready; equality)

Government of Canada, 2012

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Physical Assessment: Cardiovascular System

Government of Canada, 2012

Auscultation:

Note rate and rhythm
Note presence and quality of S1 and S2 heart sounds
Assess for S3 and S4: S3 may be a normal finding in infants and children
Note presence of murmurs (consider murmurs pathologic, as in congenital heart defects, until proven otherwise)

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Physical Assessment: Abdomen

Government of Canada, 2012

Inspection

Shape of abdomen: flat abdomen may signify decreased tone or abnormalities of the abdominal musculature
Periumbilical area
Contour: note any abdominal distension
Visible peristalsis

Bowel sounds
Percussion – All quadrants

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Physical Assessment: Abdomen (continued)

Palpation:

Note muscle tone, skin turgor and underlying organs
Check for any abnormal masses
Check for enlarged organs
Techniques for kidney palpation with infants:

Place one hand with four fingers under the infant’s back, then palpate by rolling the thumb over the kidneys

Check for hernias: umbilical and inguinal
Check for inguinal lymph nodes

Government of Canada, 2012

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Physical Assessment: Genitalia & Rectal Area

Inspect the external genitalia and note stage of sexual maturity
Diastasis recti
Anal area for presence of fistulas, excoriation or fecal soiling
Male Genitalia (Inspection):

Glans: color, edema, discharge, bleeding
Urethral opening: should be located centrally on the glans (in hypospadias, the opening is found on the undersurface of the penis)
Foreskin (prepuce): never force retraction of the foreskin
Testes: ensure that both testicles are descended into scrotum in infants

Government of Canada, 2012

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Physical Assessment: Genitalia (continued)

Palpate inguinal area:

If one or both testes are not descended, consult a physician
If masses are present, transilluminate the scrotum

Female Genitalia (Inspection):

Check labia, clitoris, urethral opening and external vaginal vault
Hymenal tags, if they occur, are normal

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Physical Assessment: Musculoskeletal System

Visual Inspection and Palpation of Spine:

Check for scoliosis, kyphosis, lordosis, spinal defects, a patch of hair along the spine, meningomyelocele

Upper Extremities:

Inspect ROM and muscle tone of the shoulder, wrist and elbow
Note alignment of arms and hands
Inspect fingers and palmar creases

Lower Extremities:

Note ROM and muscle tone of the toes, knees, and ankles
Note alignment of legs, feet and toes
Note arch of foot

Government of Canada, 2012

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Physical Assessment: Musculoskeletal System

(continued)

Ortolani Maneuver:

Flex the knee and hip
Place middle fingers over greater trochanters
Position thumbs on medial sides of knees
Abduct the hip to 90° by applying lateral pressure with thumb
Push forward with the middle fingers that are over greater trochanters
If there is a “clunk,” the hip may be dislocated

Government of Canada, 2012

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Physical Assessment: Musculoskeletal System

(continued)

Barlow Maneuver:

Flex the knee and hip
Place thumbs on knees
Place middle fingers over greater trochanters
Adduct the hip medially and push backward on the knee with thumbs
If there is a “clunk” or telescoping sensation, the hip may be dislocatable

Government of Canada, 2012

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Physical Assessment: Central Nervous System

Assess state of alertness
Check for lethargy or irritability
Posture
Assess muscle tone:

Example: support the infant with one hand under the chest; the neck extensors should be able to hold the head in line for 3 seconds; there should not be more than 10% head lag when the infant is moved from a supine to a sitting position)

Government of Canada, 2012

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Physical Assessment: Nervous System (Reflexes)

Some are present at birth and others develop later
Abnormal reflexes
Observe for reflexes that persist after the age they should disappear, or are absent at birth when they should be present
May help identify neurological or motor disease early
The following are some of the reflexes that should be tested in newborns and infants up to 2 years of age (See next slide)

Government of Canada, 2012

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Physical Assessment: Nervous System

(Deep Tendon Reflexes)

Not usually tested in children under 5 years of age
In older children, deep tendon reflexes may be tested

Reflexes must be symmetric
The child must be relaxed and comfortable
The reflexes include:

the biceps,
brachioradialis,
triceps, patellar and
achilles

Government of Canada, 2012

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Physical Assessment: Cranial Nerve Assessment

After 2 years of age, cranial nerves can be tested with some modifications according to the developmental stage of the child
For the detail: See table 8: Cranial Nerve Assessment of Children.https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/fniah-spnia/alt_formats/pdf/services/nurs-infirm/clini/pediat/asses-eval-eng.pdf
For screening of developmental milestone:

See table 9 in the link above
Read this Developmental assessment checklist

Government of Canada, 2012

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Critical Thinking Question

See the clinical checklist for health assessment on a child and practice it on a doll. Have a peer provide feedback.

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Red Flags

Child behaves very withdrawn, fearful of caregiver, bruises in various stages of healing (signs of abuse)
Depressed level of consciousness.
Convulsion
Some parents bring their child to a clinic because they have a problem themselves

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur
Health customs: In some cultures family members play a large role in health care decision-making
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations

AHRQ, 2020

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References

Better Care (n.d ). The History and Physical Examination. https://bettercare.co.za/learn/child-healthcare/text/01.html#the-history

Government of Canada. (2012). Clinical Practice Guidelines for for Nurses in Primary Care- Pediatric and Adolescents Care. https://www.canada.ca/en/indigenous-services-canada/services/first-nations-inuit-health/health-care-se rvices/nursing/clinical-practice-guidelines-nurses-primary-care/pediatric-adolescent-care.html

Stanford Children’s Health. (2022). Neurological Exam for Children. https://www.stanfordchildrens.org/en/topic/default?id=neurological-exam-for-children-90-P02613

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