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Physical Assessment

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Physical Assessment Professor Debora Halloran Azusa Pacific University Pediatric Physical Assessment Neonate and Infant The Young Child School Age and Adolescent ... – PowerPoint PPT presentation

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Title: Physical Assessment


1
Physical Assessment
  • Professor Debora Halloran
  • Azusa Pacific University

2
Pediatric Physical Assessment
  • Neonate and Infant
  • The Young Child
  • School Age and Adolescent

3
Infant Health History
  • Developmental History
  • Home Safety
  • Immunizations
  • Review of Systems
  • This review will help you identify normal
    physiologic changes as well as alert you to
    abnormal

4
The Neonate and Infant
  • The 1 minute and 5 minute Apgar results will give
    you important data on the neonates immediate
    response to extrauterine life.
  • The following slides depicts a standard sequence
  • You may reorder sequence as the infants sleep
    and wakefulness state or physical condition
    warrants
  • The infant is supine on a warming table or
    examination table with an overhead heating
    element. The infant may be nude.

5
Neonate and Infant
  • Vital Signs
  • Note pulse, respirations and temperature
  • Measurement
  • Weight, length and head circumference are
    measured and plotted on growth curves for the
    infants age.

6
Neonate and Infant
  • ABNORMAL FINDINGS
  • Greater than normal head circumference -
    hydrocephalus
  • Smaller - microcephaly
  • Measurements deviating from normal may be caused
    by underlying disease or inadequate eating or
    nutritional pattern
  • Axillary tem range is 35.9 C - 36.7 C
  • Low temperature suggests hypothermia
  • High temperature can cause seizures

7
Neonate and Infant
  • GENERAL APPEARANCE
  • Body symmetry, spontaneous position, flexion of
    head and extremities and spontaneous movement
  • Skin color and characteristics, any obvious
    deformities
  • Symmetry and positioning of the facial features
  • Alert and responsive affect
  • Strong lusty cry

8
Neonate and Infant
  • ABNORMAL FINDINGS
  • Eczema
  • Cradle cap
  • Depressed fontanels associated with dehydration
  • Bulging fontanels associated with intracranial
    pressure
  • Persistent cyanosis in a warm infant is never
    normal and requires immediate referral

9
Neonate and Infant
  • CHEST AND HEART
  • Inspect the skin condition over the chest and
    abdomen, chest configuration, and nipples and
    breast tissue
  • Note movement of the abdomen with respirations
    and any chest retraction
  • Palpate apical impulse and note its location
    chest wall for thrills tactile fremitus if the
    infant is crying
  • Auscultate breath sounds, heart sounds in all
    locations, and bowel sounds in the abdomen and in
    the chest
  • HR RANGE 80 - 160
  • CAP REFILL lt 1 SECOND
  • PULSES PRESENT

10
Neonate and Infant
  • ABNORMAL FINDINGS
  • Abnormal HR range requires attention
  • Murmurs accompanied by cyanosis may indicate
    congenital heart disease
  • Cap refill times longer than 2 seconds may
    indicate dehydrate or hypovolemic shock
  • Evaluate newly discovered murmurs
  • Infant eating poorly may have cardiovascular

11
Neonate and Infant
  • ABNORMAL FINDINGS - RESPIRATORY
  • Stressful breathing with flaring nares and
    sighing with each breath are signs of respiratory
    distress and require immediate attention
  • Inspiratory stridor, expiratory grunts,
    retractions, paradoxical breathing (seesaw)
    asymmetrical or decreased breath sounds, wheezing
    and crackles are abnormal
  • Depressed sternum may affect normal respiration

12
Neonate and Infant
  • ABDOMEN
  • Inspect the shape of the abdomen and skin
    condition
  • Inspect the umbilicus, note condition of cord or
    stump, any hernia
  • Palpate skin turgor
  • Palpate lightly for muscle tone, liver, spleen
    tip, and bladder
  • Palpate deeply for kidneys, any mass
  • Palpate femoral pulses, inguinal lymph nodes
  • Percuss all quadrants

13
Neonate and Infant
  • ABNORMAL FINDINGS
  • Umbilical hernias gt 2 cm wide may require further
    evaluation
  • Abdominal pain may indicate childhood diseases
  • Enlarged liver or spleen may indicate disease

14
Neonate and Infant
  • HEAD AND FACE
  • Note any molding after delivery, any swelling on
    cranium, bulging of fontanel with crying or at
    rest
  • Palpate fontanels, suture lines and any swelling
  • Inspect positioning and symmetry of facial
    features at rest and while the infant is crying.

15
Neonate and Infant
  • EYES
  • To open the neonates eyes, support the head and
    shoulders and gently lower the baby backward, or
    ask the parent to hold the baby over his or her
    shoulder while you stand behind parent
  • Inspect the lids(edematous in the neonate),
    palpebral slant, conjunctivae, any nystagmus and
    any discharge
  • Using a penlight elicit the pupillary reflex,
    blink reflex and corneal light reflex, assess
    tracking of moving light
  • Using an ophthalmoscope, elicit the red reflex

16
Neonate and Infant
  • ABNORMAL FINDINGS
  • Continued strabismus after 6 months is abnormal
  • Lack of tears after 2 months may be caused by
    clogged lacrimal ducts and requires medical
    attention
  • Fixed or dilated pupils indicate neurological
    problem

17
Neonate and Infant
  • EARS
  • Inspect size, shape, alignment of auricle,
    patency of auditory canals, any extra skin tags
    or pits
  • Note the startle reflex in response to a lound
    noise
  • Palpate flexible auricles
  • Defer otoscopic examination until the end of the
    complete examination

18
Neonate and Infant
  • ABNORMAL FINDINGS
  • Lack of response to noise may indicate hearing
    problem

19
Neonate and Infant
  • NOSE
  • Determine patency of nares
  • Note the nasal discharge, sneezing and any
    flaring with respirations

20
Neonate and Infant
  • ABNORMAL FINDINGS
  • Flaring of nares is sign of respiratory distress
  • Bloody discharge or large amount of nasal
    secretions may obstruct nares

21
Neonate and Infant
  • MOUTH AND THROAT
  • Inspect the lips and gums, high-arched intact
    palate, buccal mucosa, tongue size and frenulum
    of tongue note absent or minimal salivation in
    neonate
  • Note the rooting reflex
  • Insert a gloved little finger, note the sucking
    reflex and palpate palate
  • Note the nasal discharge, sneezing and any
    flaring with respirations

22
Neonate and Infant
  • ABNORMAL FINDINGS
  • Protruding tongue associated with congenital
    disorders such as Downs syndrome or
    hypothyroidism

23
Neonate and Infant
  • NECK
  • Lift the shoulders and let the head lag to
    inspect the neck note midline trachea, any skin
    folds and any lumps
  • Palpate the lymph nodes, the thyroid and any
    masses
  • While the infant is supine, elicit the tonic neck
    reflex note a supple neck with

24
Neonate and Infant
  • UPPER EXTREMITIES
  • Inspect and manipulate, noting ROM, muscle tone,
    and absence of scarf sign (elbows should not
    reach midline)
  • Count fingers, count palmar creases, and note
    color of of hands and nail beds
  • Place your thumbs in the infants palms to note
    the grasp reflex, then wrap your hand around
    infants hands to pull up and note the head lag

25
Neonate and Infant
  • ABNORMALFINDINGS
  • Inadequate range of motion may indicate
    congenital malformation or birth injury or may
    result from pulling or lifting infant

26
Neonate and Infant
  • LOWER EXTREMITIES
  • Inspect and manipulate the legs and feet, noting
    ROM, muscle tone and skin condition
  • Note alignment of feet and toes, look for flat
    soles and count toes note any syndactyly
  • Test Ortolanis sign for hip stability

27
Neonate and Infant
  • GENITALIA
  • Females Inspect labia and clitoris (edematous in
    the newborn), patent vagina
  • Males Inspect position of urethral meatus (do
    not retract foreskin), strength of urine stream
    if possible, and rugae on scrotum
  • Palpate the testes in the scrotum

28
Neonate and Infant
  • ABNORMAL FINDINGS
  • Ambiguous genitalia abnormal
  • Male
  • Phimosis - tight foreskin
  • Weak urine stream
  • Solid scrotal mass
  • Hernias present as scrotal mass
  • Undecended testicles
  • Swollen scrotum - hydrocele
  • Female
  • Vaginal discharge or labial redness or itching
    may be cuase by diaper or soap irritation or
    sexual abuse
  • Blood tinted fluid from vagina after first week
    abnormal

29
Neonate and Infant
  • NEUROMUSCULAR
  • Lift infant under the axillae and hold the
    infant facing you at eye level
  • Note shoulder muscle tone and the infants
    ability to stay in your hands without slipping
  • Rotate the neonate slowly side to side note the
    dolls eye reflex
  • Turn the infant around so his or her back it to
    you elicit the stepping reflex and the placing
    reflex against the edge of the examination table

30
Neonate and Infant
  • ABNORMAL FINDINGS
  • Note shoulder muscle tone and the infants
    ability to stay in your hands without slipping
  • Delays in motor or sensory activity may indicate
    brain damage, mental retardation, illness,
    malnutrition or neglect
  • Asymmetrical posture or spastic movements need
    further evaluation
  • Maintenance of infant reflexes past usual age is

31
Neonate and Infant
  • SPINE AND RECTUM
  • Turn the infant over and hold him or her prone
    in your hands, or place the infant prone on the
    examination table
  • Inspect the length of the spine, trunk
    incurvation reflex and symmetry of gluteal folds
  • Inspect intact skin note any sinus openings,
    protrusions, or tufts of hair
  • Note patent anal opening. Check for passage of
    meconium stool during the first 24 - 48 hours

32
Neonate and Infant
  • ABNORMAL FINDINGS
  • Dimpling in spine may be associated with neural
    tube defects
  • Watery stools and explosive diarrhea indicate
    infection.
  • Constipation or hard stools indicate inadequate
    hydration

33
Neonate and Infant
  • FINAL PROCEDURES
  • With an otoscope, inspect the auditory canal and
    tympanic membrane
  • Elicit the Moro reflex by letting the infants
    head and trunk drop back a short way, by jarring
    crib sides or by making a loud noise.

34
Neonate and Infant
  • SUMMARY
  • Is a fundamental component in health promotion
    and disease prevention
  • Baby clinic visit may be the only access to the
    healthcare system for the family
  • BC infant health depends on family health,
    incorporating the total family is critical in
    your approach to health assessment
  • Encourage parents to keep all scheduled visits
    and take every opportunity to make necessary
    referrals for the family members

35
The Young Child
  • Review Developmental Considerations when
    preparing for examination of the toddler and
    young child
  • A young child during this time goes between
    independence and dependence on parent
  • Is aware and fearful of a new environment, has a
    fear of invasive procedures, dislikes being
    restrained, and may be attached to a security
    object
  • Focus on the parent as the child plays with a toy
  • Health History (bio data, current health status,
    past health history, family history, review of
    systems, psychosoical profile)
  • Collect the history, including developmental data
  • During the history, note data on general
    appearance

36
The Young Child
  • General Appearance
  • Note childs ability to amuse himself or herself
    while the parent speaks
  • Note parent/child interaction
  • Note gross motor and fine motor skills while
    child plays with toys
  • GRADUALLY FOCUS ON AND INVOLVE YOURSELF WITH THE
    CHILD AT FIRST IN A PLAY PERIOD
  • Evaluate developmental milestones by using a
    Denver II test gait, jumping, hopping, building
    a tower and throwing a ball
  • Evaluate posture while the child is sitting and
    standing. Evaluate alignment of the legs and feet
    while the child is walking
  • Evaluate speech acquisition
  • Evaluate vision, hearing ability
  • Evaluate social interaction

37
The Young Child
  • Neurological check
  • Test balance coordination and accuracy of
    movements.
  • Toddlers usually can walk alone by 12 - 13
    months.
  • Balance is unsteady with wide base of support
  • The preschoolers gait is more balanced, smaller
    base of support child walks, jumps and climbs by
    age 3
  • Strength increases during preschool years
  • Balance and coordination improve with refinement
    of fine motor skills

38
The Young Child
  • ASK THE PARENT TO UNDRESS THE CHILD TO THE
    DIAPER OR UNDERPANTS. POSITION THE OLDER INFANT
    AND YOUNG CHILD 6 MONTHS TO 2 OR 3 YEARS, IN THE
    PARENTS LAP.
  • A 4 OR 5 YEAR OLD USUALLY FEELS COMFORTABLE ON
    THE EXAMINATION TABLEFINAL PROCEDURES
  • Measurement
  • Height, Weight, head circumference ((may been to
    defer until later in the examination)

39
The Young Child
  • For your general inspection note toddler general
    appearance
  • Pot belly and wide base of support
  • Note delays or premature maturation
  • As you continually inspect the skin
  • Lesions such as tinea capis or ringworm need
    treatment
  • Pediculosis is common among preschoolers

40
The Young Child
  • CHEST AND HEART
  • Auscultate breath sounds and heart sounds in all
    locations, count respiratory rate, count heart
    rate, and auscultate bowel sounds
  • Inspect size, shape and configuration of chest
    cage. Assess respiratory movement
  • Inspect pulsations on the precordium. Note nipple
    and breast development
  • Palpate apical impulse and note location, chest
    wall for thrills, any tactile fremitus

41
The Young Child
  • ABNORMAL FINDINGS
  • Toddlers and preschoolers have a high incidence
    of respiratory infections
  • Children often have sinus arrhythmia and split
    second heart sound that both change with
    respiration This is a normal variation
  • Systolic innocent murmurs and venous hum are
    common findings
  • Note if you detect a murmur, refer patient for
    follow up and rule out pathology

42
The Young Child
  • THE CHILD SHOULD BE SITTING UP IN THE PARENTS
    LAP OR ON THE EXAMINATION TABLE, DIAPER OR
    UNDERPANTS IN PLACE
  • ABDOMEN
  • Inspect the shape of abdomen, skin condition and
    periumbilical area
  • Palpate skin turgor, musle tone, liver edge,
    spleen, kidneys and any masses
  • Palpate the femoral pulses. Compare strength with
    radial pulses
  • Palpate inguinal lymph nodes
  • NOTE Pot belly normal for toddler disappears as
    abdominal muscles strengthen.

43
The Young Child
  • GENITALIA
  • Inspect the external genitalia
  • On males, palpate the scrotum for testes. If
    masses are present, trans-illuminate

44
The Young Child
  • LOWER EXTREMITIES
  • Test Ortolanis sign for hip stability
  • Note alignment of legs and skin condition
  • Note alignment of feet. Inspect toes, and
    longitudinal arch
  • Palpate the dorsalis pedis pulse
  • Gain cooperation with reflex hammer. Elicit
    plantar, Achilles and patellar reflexes

45
The Young Child
  • UPPER EXTREMITIES
  • Inspect arms and hands for alignment, skin
    condition inspect fingers and note palmar
    creases
  • Palpate and count the radial pulse
  • Test biceps and triceps, reflexes with a hammer
    reflex
  • Measure blood pressure

46
The Young Child
  • HEAD AND NECK
  • Inspect the size and shape of the head and
    symmetry of facies
  • Palpate the fontanels and cranium. Palpate the
    cervical lymph nodes trachea, and thyroid gland.
  • Measure the head circumference
  • Note
  • Head size growth slows to 1 inch a year by end of
    age 2 then 1/2 inch a year until 5
  • Anterior fontanel closes by 18 months
  • Enlarged lymph nodes may indicate infection or
    lymphoma

47
The Young Child
  • EYES
  • Inspect the external structures. Note any
    palpebral slant
  • With a penlight, test the orneal light and
    pupillary light reflexes
  • Direct a moving penlight for cardinal positions
    of gaze
  • Inspect conjunctivae and sclerae
  • With ophthalmoscope, check the red reflex.
    Inspect the fundus as much as possible
  • Note visual acuity is normally 20/40 during
    toddler years. Begin vision screening between 3
    and 4

48
The Young Child
  • NOSE
  • Inspect the external nose and skin condition
  • With a penlight, inspect the nares for foreign
    body, mucosa, septum and turbinates
  • Abnormal finding
  • Boggy, bluish-purple or gray turbinates
  • Chronic rhinorrhea which can result from
    allergic rhinitis
  • Note when inspecting nares or external ear
    canal, be alert for foreign objects

49
The Young Child
  • MOUTH AND THROAT
  • With a penlight, inspect the mouth, buccal
    mucosa, teeth and gums, tongue, palate and uvula
    in midline. Use tongue blade as the last resort
  • Note Generally tonsils are large
  • Eruption of primary teeth is usually complete by
    2.5 years.
  • Note any baby caries.

50
The Young Child
  • EARS
  • Inspect and palpate the auricle. Note any
    discharge for the auditory meatus
  • Check for any foreign body
  • With an otoscope, inspect the ear canal and
    tympanic membrane. Gain cooperation throug the
    use of a puppet, encouraging the child to handle
    the equipment or to look in the parents ear as
    you hold the otoscope. You may need to have the
    parent help restrain the child
  • Note
  • Test hearing by age 3 or 4. Hearing deficits
    warrant follow up.
  • Toddlers and preschoolers have a high incidence
    of otitis media

51
The Young Child
  • SUMMARY
  • Toddlers and preschoolers have their own unique
    developmental and psychosocial issues
  • Understanding these issues and knowing how to
    communicate honestly and effectively with
    children and parents will help you conduct a
    thorough assessment and develop an effective plan
    of care
  • Inspect and palpate the auricle. Note any
    discharge for the auditory meatus

52
The School Age Child and the Adolescent
  • Sequence is the head to toe described in the
    adult format.
  • Be aware of developmental considerations
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