Outline of a Physical Assessment

A / Vital Signs (*use Badge tags for reference, know patient’s baseline!)
1 / Temperature
2 / Pulse
3 / Respiration
4 / Blood pressure
5 / Pain assessment
6 / Pulse oximetry as needed

B. Growth Measurements

1 / Length and height
3 / Weight
4 / Head circumference (up to 2 yo)
C / General appearance
D / Skin
E / Lymph nodes
G / Head
H / Neck
I / Eyes
J / Ears
K / Nose
L / Mouth and throat
M / Chest
N / Lungs
O / Heart
P / Abdomen
Q / Genitalia
1 / Male
2 / Female
R / Anus
S / Back and extremities
T / Neurologic assessment
1 / Mental status
2 / Motor functioning
3 / Sensory functioning
4 / Reflexes (deep tendons)
5 / Cranial nerves

Assessment of Reflexes

Reflexes / Expected Behavioral Responses
Eyes
Blinking or corneal reflex / Infant blinks at sudden appearance of a bright light or at approach of an object toward cornea; persists throughout life.
Pupillary / Pupil constricts when a bright light shines toward it; persists throughout life.
Doll's eye / As head is moved slowly to right or left, eyes lag behind and do not immediately adjust to new position of head; disappears as fixation develops; if persists, indicates neurologic damage.
Nose
Sneeze / Spontaneous response of nasal passages to irritation or obstruction; persists throughout life.
Glabellar / Tapping briskly on glabella (bridge of nose) causes eyes to close tightly.
Mouth and Throat
Sucking / Infant begins strong sucking movements of circumoral area in response to stimulation; persists throughout infancy, even without stimulation, such as during sleep.
Gag / Stimulation of posterior pharynx by food, suction, or passage of a tube causes infant to gag; persists throughout life.
Rooting / Touching or stroking the cheek along side of mouth causes infant to turn head toward that side and begin to suck; should disappear at about age 3-4 months but may persist for up to 12 months.
Extrusion / When tongue is touched or depressed, infant responds by forcing it outward; disappears by age 4 months.
Yawn / Spontaneous response to decreased oxygen by increasing amount of inspired air; persists throughout life.
Cough / Irritation of mucous membranes of larynx or tracheobronchial tree causes coughing; persists throughout life; usually present 1 day after birth.
Extremities
Grasp / Touching palms of hands or soles of feet near base of digits causes flexion of hands and toes; palmar grasp lessens after age 3 months, to be replaced by voluntary movement; plantar grasp lessens by 8 months of age.
Babinski / Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex; disappears after age 1 year.
Ankle clonus / Briskly dorsiflexing foot while supporting knee in partially flexed position results in one or two oscillating movements (“beats”); eventually no beats should be felt.
Mass (Body)
Moro* / Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers, with index finger and thumb forming a C shape, followed by flexion and adduction of extremities; legs may weakly flex; infant may cry; disappears after age 3-4 months, usually strongest during first 2 months.
Startle* / A sudden loud noise causes abduction of the arms with flexion of elbows; hands remain clenched; disappears by age 4 months.
Perez / While infant is prone on a firm surface, thumb is pressed along spine from sacrum to neck; infant responds by crying, flexing extremities, and elevating pelvis and head; lordosis of the spine, as well as defecation and urination, may occur; disappears by age 4-6 months.
Asymmetric tonic neck / When infant's head is turned to one side, arm and leg extend on that side, and opposite arm and leg flex; disappears by age 3-4 months, to be replaced by symmetric positioning of both sides of body.
Trunk incurvation (Galant) / Stroking infant's back alongside spine causes hips to move toward stimulated side; reflex disappears by age 4 weeks.
Dance or step / If infant is held so that sole of foot touches a hard surface, there is a reciprocal flexion and extension of the leg, simulating walking; disappears after age 3-4 weeks, to be replaced by deliberate movement.
Crawl / When placed on abdomen, infant makes crawling movements with arms and legs; disappears at about age 6 weeks.
Placing / When infant is held upright under arms and dorsal side of foot is briskly placed against hard object, such as table, leg lifts as if foot is stepping on table; age of disappearance varies.

Adapted from Wong’s Clinical Manual of Pediatric Nursing, 8th Ed.

General Guidelines for Physical Examination

During Childhood

Perform examination in pleasant, nonthreatening area.
• / Have room well lit and decorated.
• / Have room temperature comfortably warm.
• / Place all strange and potentially frightening equipment out of sight.
• / Have some toys, dolls, stuffed animals, and games available for the child.
• / If possible, have rooms decorated and equipped for different-age children.
• / Provide privacy, especially for school-age children and adolescents.
• / Check that equipment and supplies are working properly and are accessible to avoid disruption.
Provide time for play and becoming acquainted.
• / Talking to the nurse
• / Making eye contact
• / Accepting the offered equipment
• / Allowing physical touching
• / Choosing to sit on examining table rather than parent's lap
If signs of readiness are not observed, use the following techniques:
• / Talk to the parent while essentially “ignoring” the child; gradually focus on the child or a favorite object, such as a doll.
• / Make complimentary remarks about the child, for instance, about his or her appearance, dress, or a favorite object.
If the child refuses to cooperate, use the following techniques:
• / Assess reason for uncooperative behavior; consider that a child who is unduly afraid of a male examiner may have had a previous traumatic experience, including sexual abuse.
• / Try to involve child and parent in process, or, if appropriate, ask parent to leave.
• / Avoid prolonged explanations about examining procedure.
• / Use a firm, direct approach regarding expected behavior.
• / Perform examination as quickly as possible.
• / Have parent gently restrain child.
• / Minimize any disruptions or stimulation:
○ / Limit number of people in room.
○ / Use isolated room.
○ / Use quiet, calm, confident voice.
Begin the examination in a nonthreatening manner for young children or children who are fearful (Atraumatic Care box).
Atraumatic Care
Reducing Young Children's Fears
Young children, especially preschoolers, fear intrusive procedures because of their poorly defined body boundaries. Therefore avoid invasive procedures, such as measuring rectal temperature, whenever possible. Also, avoid using the word “take” when measuring vital signs, because young children interpret words literally and may think that their temperature or other function will be taken away. Instead, say, “I want to know how warm you are.”
• / Use activities that can be presented as games, such as tests for cranial nerves (see p. 73) or parts of developmental testing (see p. 121).
• / Use approaches such as “Simon says” to encourage child to make a face, squeeze a hand, stand on one foot, and so on.
• / Use the paper-doll technique:
○ / Lay the child supine on an examining table or floor that is covered with a large sheet of paper.
○ / Trace outline around the child's body.
○ / Use the body outline to demonstrate what will be examined, such as drawing a heart and listening with the stethoscope before performing the activity on the child.
If several children in the family will be examined, begin with the most cooperative child.
Involve child in the examination process.
• / Provide choices, such as sitting either on the table or on the parent's lap.
• / Allow child to handle or hold equipment.
• / Encourage child to use equipment on a doll, family member, or examiner.
• / Explain each step of the procedure in simple language.
Examine child in a comfortable and secure position.
• / Sitting in parent's lap
• / Sitting upright if in respiratory distress
Proceed to examine the body in an organized sequence (usually head to toe) with the following exceptions:
• / Alter sequence to accommodate needs of different-age children (see p. 30).
• / Examine painful areas last.
• / In emergency situation, examine vital functions (airway, breathing, circulation) and injured area first.
Reassure child throughout examination, especially about bodily concerns that arise during puberty.
Discuss the findings with the family at the end of the examination.
Praise child for cooperation during examination; give reward such as an inexpensive toy or paper sticker.

Age-Specific Approaches to Physical Examination During Childhood

Position / Sequence / Preparation
Infant
Before sits alone: supine or prone, preferably in parent's lap; before 4-6 months: can place on examining table
After sits alone: sit in parent's lap whenever possible
If on table, place with parent in full view / If quiet, auscultate heart, lungs, abdomen.
Record heart and respiratory rates.
Palpate and percuss same areas.
Proceed in usual head-to-toe direction.
Perform traumatic procedures last (eyes, ears, mouth [while infant is crying]).
Elicit reflexes as body part examined.
Elicit Moro reflex last. / Completely undress infant if room temperature permits.
Leave diaper on male.
Gain cooperation with distraction, bright objects, rattles, talking.
Have older infants hold a small block in each hand; until voluntary release develops toward end of the first year, infants will be unable to grasp other objects (e.g., stethoscope, otoscope).
Smile at infant; use soft, gentle voice.
Pacify with bottle of sugar water or feeding.
Enlist parent's aid in restraining to examine ears, mouth.
Avoid abrupt, jerky movements.
Toddler
Sitting or standing on or by parent
Prone or supine in parent's lap / Inspect body area through play: count fingers, tickle toes.
Use minimal physical contact initially.
Introduce equipment slowly.
Auscultate, percuss, palpate whenever quiet.
Perform traumatic procedures last (same as for infant). / Have parent remove child's outer clothing.
Remove underwear as body part is examined.
Allow child to inspect equipment; demonstrating use of equipment is usually ineffective.
If uncooperative, perform procedures quickly.
Use restraint when appropriate; request parent's assistance.
Talk about examination if cooperative; use short phrases.
Praise for cooperative behavior.
Preschool Child
Prefers standing or sitting
Usually cooperative prone or supine
Prefers parent's closeness / If cooperative, proceed in head-to-toe direction.
If uncooperative, proceed as with toddler. / Request self-undressing.
Allow to wear underpants.
Offer equipment for inspection; briefly demonstrate use.
Make up story about procedure: “I'm seeing how strong your muscles are” (blood pressure).
Use paper-doll technique.
Give choices when possible.
Expect cooperation; use positive statements: “Open your mouth.”
School-Age Child
Prefers sitting
Cooperative in most positions
Younger child prefers parent's presence.
Older child may prefer privacy. / Proceed in head-to-toe direction.
May examine genitalia last in older child.
Respect need for privacy. / Request self-undressing.
Allow to wear underpants.
Give gown to wear.
Explain purpose of equipment and significance of procedure, such as otoscope to see eardrum, which is necessary for hearing.
Teach about body functioning and care.
Adolescent
Same as for school-age child
Offer option of parent's presence. / Same as for older school-age child / Allow to undress in private.
Give gown, Expose only area to be examined.
Respect need for privacy.
Explain findings during examination: “Your muscles are firm and strong.”
Matter-of-factly comment about sexual development: “Your breasts are developing as they should be.”
Emphasize normalcy of development.
Examine genitalia as any other body part; may leave for end.
Irregular Patterns of Respiration
Tachypnea—Increased rate
Bradypnea—Decreased rate
Dyspnea—Distress during breathing
Apnea—Cessation of breathing
Hyperpnea—Increased depth
Hypoventilation—Decreased depth (shallow) and irregular rhythm
Hyperventilation—Increased rate and depth
Kussmaul breathing—Hyperventilation, gasping, and labored respiration, usually seen in respiratory acidosis (e.g., diabetic coma)
Cheyne-Stokes respiration—Gradually increasing rate and depth with periods of apnea
Biot breathing—Periods of hyperpnea alternating (similar to Cheyne-Stokes except that the depth remains constant)
Seesaw (paradoxic) respirations—Chest falls on inspiration and rises on expiration
Agonal breathing—Last gasping breaths before death
Irregular patterns of heart Rate
Tachycardia—Increased rate
Bradycardia—Decreased rate
Pulsusalternans—Strong beat followed by weak beat
Pulsusbigeminus—Coupled rhythm in which beat is felt in pairs because of premature beat
Pulsusparadoxus—Intensity or force of pulse decreases with inspiration
Sinus arrhythmia—Rate increases with inspiration, decreases with expiration
Water-hammer or Corrigan's pulse—Especially forceful beat caused by a very wide pulse pressure (systolic blood pressure minus diastolic blood pressure)
Dicrotic pulse—Double radial pulse for every apical beat
Thready pulse—Rapid, weak pulse that seems to appear and disappear

BOX 1-6

Types of Foot and Ankle Deformities
Pesplanus (flatfoot)—Normal finding in infancy; may be result of muscular weakness in older child
Pesvalgus—Eversion (turning outward) of entire foot, but sole rests on ground
Pesvarus—Inversion (turning inward) of entire foot, but sole rests on ground
Metatarsus valgus—Eversion of forefoot while heel remains straight; also called toeing out or duck walk
Talipesvalgus—Eversion of foot so that only inner side of foot rests on ground
Talipesvarus—Inversion of foot so that only outer sole of foot rests on ground
Talipesequinus—Extension or plantar flexion of foot so that only ball and toes rest on ground; commonly combined with talipesvarus (most common of clubfoot deformities)
Talipescalcaneus—Dorsal flexion of foot so that only heel rests on ground

Adapted from Wong’s Clinical Manual of Pediatric Nursing, 8th Ed.

Signs and Symptoms Associated with Respiratory Infections in
Infants and Small Children
Fever
May be absent in newborn infants
Greatest at ages 6 months to 3 years
• / Temperature may reach 39.5° to 40.5° C (103° to 105° F), even with mild infections
Often appears as first sign of infection
Child may be listless and irritable, or somewhat euphoric and more active than normal temporarily; some children talk with unaccustomed rapidity
Tendency to develop high temperatures with infection in certain families
• / May precipitate febrile seizures
• / Febrile seizures uncommon after 3 or 4 years of age
Meningismus
Meningeal signs without infection of the meninges
Occurs with abrupt onset of fever
Accompanied by:
• / Headache
• / Pain and stiffness in the back and neck
• / Presence of Kernig and Brudzinski signs
Subsides as temperature drops
Anorexia
Common with most childhood illnesses
Frequently the initial evidence of illness
Almost invariably accompanies acute infections in small children
Persists to a greater or lesser degree throughout febrile stage of illness; often extends into convalescence
Vomiting
Small children vomit readily with illness
A clue to the onset of infection
May precede other signs by several hours
Usually short-lived but may persist during the illness
Diarrhea
Usually mild, transient diarrhea but may become severe
Often accompanies viral respiratory infections
Is frequent cause of dehydration
Abdominal Pain
Common complaint
Sometimes indistinguishable from pain of appendicitis
Mesenteric lymphadenitis may be a cause
Muscle spasms from vomiting may be a factor, especially in nervous, tense children
Nasal Blockage
Small nasal passages of infants easily blocked by mucosal swelling and exudation
Can interfere with respiration and feeding in infants
May contribute to the development of otitis media and sinusitis
Nasal Discharge
Frequent occurrence
May be thin and watery (rhinorrhea) or thick and purulent, depending on the type and/or stage of infection
Associated with itching
May irritate upper lip and skin surrounding the nose
Cough
Common feature
May be evident only during the acute phase
May persist several months after a disease
Respiratory Sounds
Sounds associated with respiratory disease
• / Cough
• / Hoarseness
• / Grunting
• / Stridor
• / Wheezing
Auscultation
• / Wheezing
• / Crackles
• / Absence of sound
Sore Throat
Frequent complaint of older children
Younger children (unable to describe symptoms) may not complain, even when throat highly inflamed
• / Often child will refuse to take oral fluids or solids

Adapted from Wong’s Clinical Manual of Pediatric Nursing, 8th Ed.

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