Video Library
Childhood And Family Assessment
Study Questions
Practice Question
Which statement indicates the best sequence for the nurse to conduct an assessment in a nonemergency situation?
Explanation
In a nonemergencypediatric assessment, the nurse should follow a sequence that builds rapport, identifies concerns, gathers relevant history, and then proceeds to the physical exam. This approach ensures the family feels heard and that the nurse has essential context before examining the child.
Rationale for correct answer:
A.Introducing yourselfestablishes trust. Asking about problems shows concern for immediate issues. Taking a history before the physical examprovides valuable background that can guide the assessment and focus attention on potential problem areas.
Rationale for incorrect answers:
B.Starting with the physical exambefore discussing problems may increase anxiety for the child and family and risks missing important background information.
C.Combining the physical exam with history-takingmay be efficient in some urgent situations but is less ideal for a relaxed, thorough nonemergency assessment.
D.While understanding health beliefsis important, taking an overly detailed family history before addressing immediate concerns or examining the child may delay care and rapport building.
Take home points
- In nonemergency pediatric care: build rapport → identify concerns → take history → perform physical exam.
- Sequencing the assessment properly improves cooperation and accuracy.
- Always tailor the approach to the child’s developmental stage and comfort level.
What approach by the nurse would most likely encourage a child to cooperate with an assessment of physical and developmental health?
Explanation
The most effective approach is to explain what is going to happen in words the child can understand. This builds trust, reduces fear, and fosters cooperation by ensuring the child knows what to expect in a way that matches their developmental level.
Rationale for correct answer:
B.Using age-appropriate languagehelps children feel respected, informed, and less anxious. It allows them to mentally prepare for the assessment and encourages active participation. This aligns with pediatric communication principles that emphasize honesty, clarity, and developmental sensitivity.
Rationale for incorrect answers:
A.Waiting to explain only when the child asks questionsis reactive and may leave the child uncertain or fearful. Proactive communication is more effective in reducing anxiety.
C.Forcing cooperationundermines trust, increases fear, and can cause long-term resistance to medical care. It should be avoided unless absolutely necessary for urgent safety reasons.
D.Offering a reward before startingmay create expectations of discomfort or coercion. While positive reinforcement is useful, it is most effective when given after the procedure as acknowledgment of cooperation.
Take home points
- Use clear, age-appropriate explanations before starting any assessment to build rapport and reduce anxiety.
- Establish trust by respecting the child’s developmental stage and involving them in the process where possible.
- Avoid coercive measures; instead, focus on communication, comfort, and post-procedure positive reinforcement.
A nurse in the pediatric clinic is examining a group of clients. These general approaches can be helpful when performing a physical examination. Select all that apply
Explanation
Therapeutic communicationduring pediatric physical exams involves adapting strategies based on developmental stages to minimize fear, encourage cooperation, and build trust. This includes using age-appropriate language, involving caregivers, and offering limited choicesto empower the child while maintaining control of the situation.
Rationale for correct answers:
A. Toddlers often resist examinations due to fear and lack of understanding. Gentle restraint, with parental support, helps keep the child safe while providing comfort. Involving parents reduces the toddler’s distress and strengthens the nurse–family alliance.
B. Preschoolers like to feel a sense of control. Offering limited choicessuch as, "Should I look in your ears or your mouth first?", encourages cooperation and helps reduce anxietywithout compromising the exam.
Rationale for incorrect answers:
C. School-age children, especially older ones may prefer privacy, particularly for sensitive topics or exams. Asking the child’s preference promotes respect and autonomy.
D. Adolescents benefit from clear explanationsand often want to understand what’s happening with their bodies. While they may be self-conscious, providing honest information builds trust and supports their need for autonomy.
E. Infant exams are typically foot to headto allow the nurse to assess the least invasive areas first, building trust before disturbing the infant with more uncomfortable procedures like inspecting the ears or mouth.
Take home points
- Involve parents in exams for infants and toddlers for comfort and safety.
- Respect privacy and decision-making in older children and adolescents.
- Modify your exam order and explanations based on the child’s developmental stage and comfort.
- The key to effective pediatric care is flexibility, respect, and developmentally appropriate communication.
A 4½-year-old child is being assessed after sustaining an injury. The child is reluctant to tell the nurse exactly how the injury occurred. Which of the following statements made to the child by the nurse would likely result in the child communicating with the nurse? Select all that apply
Explanation
Therapeutic communicationwith young children, especially after trauma, requires sensitivity to their developmental level. For preschool-age children (3–5 years), play, art, and indirect storytelling techniqueshelp them express thoughts and feelings when verbal expression may be limited or overwhelming.
Rationale for correct answers:
A. Drawingallows young children to express themselves nonverbally. It's a safe, developmentally appropriate method to explore thoughts and events, especially after distressing experiences.
C. Puppet playencourages communication through projection. A child may feel more comfortable attributing their experience to the puppet, reducing fear of judgment or retribution.
D. This technique uses third-person storytelling, allowing the child to describe their experience in a hypothetical, less direct way. It reduces anxiety and encourages narrativewithout direct confrontation.
Rationale for incorrect answers:
B. Most 4½-year-olds have not yet developed sufficient writing skills for storytelling. This request is developmentally inappropriate and may cause frustration or withdrawal.
E. This direct request can feel pressuring or guilt-inducing. It may cause the child to shut down, especially if fear or trauma is involved. Preschoolers respond better to indirect, play-based communication.
Take home points
- Use developmentally appropriate techniques like drawing, puppets, and storytelling to help young children express difficult experiences.
- Avoid direct, confrontational questions that may increase anxiety or lead to withdrawal.
- Create a safe, nonjudgmental space for expression, particularly in cases involving injury or suspected trauma.
Practice Exercise 2
A sleeping 5-month-old girl is being held by the mother when the nurse comes in to do a physical examination. What assessment should be done initially?
Explanation
A physical examination in childrenis a systematic evaluation of a child’s body systems to assess their health, growth, and development. It’s tailored to the child’s age, developmental stage, and presenting concerns, and it plays a vital role in early detection of illness and developmental delays.
Rationale for correct answer:
B.For infants, heart rate assessmentshould be performed first when they are calm or asleep because crying or activity can significantly elevate the rate. Accurate baseline readings are important for clinical evaluation, and the apical pulse should be counted for a full minute.
Rationale for incorrect answers:
A.Listening to bowel soundscan be done at any time, as bowel activity is not greatly affected by the infant’s state of alertness. It is not as time-sensitive as heart rate.
C.Checking temperaturerequires handling the infant more actively, which could wake her and cause distress before important calm-state measurements are taken.
D.Looking in the earsoften requires restraint and is uncomfortable for the infant, likely waking and upsetting her, making it harder to obtain accurate vital signs afterward.
Take home points
- In infants, assess least disruptive measures first while they are calm or asleep—especially heart rate and respiratory rate.
- More stimulating or invasive assessments should be saved for last to maintain cooperation and accurate readings.
- Prioritizing exam order helps ensure accuracy and reduces infant distress.
Which assessment finding is considered normal in children?
Explanation
A physical examination in childrenis a systematic evaluation of a child’s body systems to assess their health, growth, and development. It’s tailored to the child’s age, developmental stage, and presenting concerns, and it plays a vital role in early detection of illness and developmental delays.
Rationale for correct answer:
B.Sinus arrhythmiaresults from normal vagal tone variation with respiration. The heart rate increases with inspiration and decreases with expiration. A split S2 occurs because the aortic and pulmonic valves close at slightly different times during inspiration, which is normal in healthy children.
Rationale for incorrect answers:
A.An irregular respiratory rate and rhythmoutside the newborn period may indicate respiratory or neurologic issues; while periodic breathing can be normal in infants, it is not considered typical in older children.
C.Crying generally increases, not decreases, the heart ratedue to sympathetic stimulation; bradycardia with crying is abnormal and requires further evaluation.
D.Genu varum (bowlegs)is normal in toddlers but usually resolves by age 2–3; persistence beyond age 5 suggests underlying pathology such as rickets or Blount disease.
Take home points
- Sinus arrhythmia and split S2 are normal physiologic findings in healthy children.
- Assessment findings must be interpreted in the context of the child’s age and developmental stage.
- Persistent abnormal findings beyond expected age ranges should prompt further evaluation.
A nurse is attempting to get a 5-year-old child’s cooperation when auscultating heart sounds. Which of the following comments is most likely to elicit the child’s cooperation?
Explanation
A physical examination in childrenis a systematic evaluation of a child’s body systems to assess their health, growth, and development. It’s tailored to the child’s age, developmental stage, and presenting concerns, and it plays a vital role in early detection of illness and developmental delays.
Rationale for correct answer:
C.Involving the child in the examinationturns the assessment into an interactive activity rather than a passive procedure. At age 5, children are naturally curious and enjoy hands-on participation, which can reduce anxiety and increase cooperation.
Rationale for incorrect answers:
A.While using playful language like “boom boom”may be friendly, it does not engage the child’s participation as effectively as offering them the chance to listen.
B.Providing information (“Did you know that your heart beats in your chest?”)may pique curiosity but is less likely to actively involve the child in the procedure.
D.Showing a pictureis educational but does not directly invite the child to engage in the examination.
Take home points
- Active participation and choice-giving help gain cooperation in preschool and school-age children.
- Interactive strategies reduce fear and build trust during physical assessments.
- Tailoring communication to the child’s developmental stage fosters a positive healthcare experience.
The nurse enters the examination room of a mother and her 8-month-old. The baby is asleep in the mother’s arms. Which of the following actions would be best for the nurse to perform at this time?
Explanation
A physical examination in childrenis a systematic evaluation of a child’s body systems to assess their health, growth, and development. It’s tailored to the child’s age, developmental stage, and presenting concerns, and it plays a vital role in early detection of illness and developmental delays.
Rationale for correct answer:
B.Heart, lung, and bowel sounds are best assessed when the infant is quiet or asleepto minimize interference from crying or movement. Starting with the least invasive and least disturbing assessments preserves cooperation and accuracy.
Rationale for incorrect answers:
A.While obtaining an updated historyis important, it can be done after completing quiet-state assessments. The priority is to take advantage of the infant’s current calm state.
C.Beginning a full head-to-toe examwould require more handling and could wake the baby, making it difficult to get accurate auscultation findings afterward.
D.Waking the baby unnecessarilydisrupts the opportunity for a calm, accurate examination and may make the rest of the assessment more challenging.
Take home points
- For infants, assess least disruptive measurements first when they are calm or asleep—especially heart rate, respiratory rate, and auscultation of heart/lungs/bowel sounds.
- More stimulating or invasive assessments should be left for last.
- Planning exam order around the child’s state maximizes accuracy and minimizes distress.
While performing a chest assessment on an 11-month-old child, the nurse palpates for the cardiac point of maximum intensity (PMI). The nurse would expect the PMI to be felt at the:
Explanation
A cardiac examination in childrenis a focused assessment of the heart and circulatory system, adapted to the child’s age, developmental stage, and clinical presentation. It’s essential for detecting congenital heart defects, acquired heart diseases, and circulatory abnormalities.
Rationale for correct answer:
B.In children under 7 years old, the heart lies higher and more horizontally in the thorax compared to adults. The PMI is found at the 4th intercostal space, slightly lateral to the midclavicular line. After age 7, the PMI moves to the adult position at the 5th intercostal space at the midclavicular line.
Rationale for incorrect answers:
A.The 3rd intercostal spaceis too high for a normal PMI location in infants or adults.
C.The 5th intercostal space at the midclavicular lineis the adult PMI location, typical after age 7, not at 11 months.
D.The 6th intercostal space near the axillais far too lateral and low for the PMI in any age group and would suggest pathology if palpated there.
Take home points
- PMI location changes with age:
- <7 years: 4th intercostal space, lateral to MCL
- ≥7 years: 5th intercostal space, at MCL
- The higher, more lateral PMI in infants is due to the anatomical position of the heart in the developing thorax.
- Deviation from expected PMI location for age may indicate cardiac enlargement or other pathology.
When taking an infant’s blood pressure, which points are important for a nurse to remember? Select all that apply
Explanation
Blood pressure (BP) monitoring in childrenis a vital part of pediatric care, used to assess cardiovascular health and detect early signs of hypertension or other systemic conditions. When taking an infant’s blood pressure, it is essential to use the correct cuff size, proper placement, and appropriate devices for accuracy.
Rationale for correct answers:
A.An infant cuffis designed to fit the smaller arm circumference and ensures accurate readings; an incorrect cuff size can lead to false high or low results.
B.The cuff bladder lengthshould be approximately two-thirdsthe length of the upper arm to obtain an accurate reading.
C.A Doppler ultrasound devicecan be used for infants because it allows detection of blood flow sounds even in low-pressure situations, improving accuracy in small or restless children.
Rationale for incorrect answers:
D.In infants and children, thigh systolic blood pressure is normally 10–40 mmHg higherthan arm systolic pressure due to greater distance from the heart and larger artery size; the reverse suggests possible pathology.
E.In coarctation of the aorta, the arm reading is higher than the thigh reading; equal readings are not diagnostic and are not a typical sign of coarctation.
Take home points
- Use correct cuff size and proper measurement technique for accurate pediatric BP readings.
- In healthy children, thigh BP > arm BP; reversed or significantly lower leg BP suggests possible coarctation of the aorta.
- Doppler devices are especially useful for obtaining reliable BP in infants and very young children.
A 22-month-old toddler is walking into the examination room independently in front of the toddler’s mother. Which method should the nurse plan to use to weigh the child?
Explanation
Weight assessment in childrenis the process of measuring and interpreting a child’s body weight in relation to age, height, and sex to evaluate growth, nutritional status, and overall health. It’s a key part of pediatric care and helps identify undernutrition, overweight, or obesity early on.
Rationale for correct answer:
A.If a toddler can stand alone, a standing scaleprovides an accurate weight and is more comfortable for the child. At 22 months, many children have the stability to stand still briefly for weighing.
Rationale for incorrect answers:
B.Infant scalesare generally used for babies and younger toddlers who cannot stand unsupported; by this age and developmental stage, a standing scale is suitable.
C.While involving the mother in care decisionsis important, the method of weighing is based on developmental capability, not caregiver preference.
D.The “subtracting method”is less accurate and is typically used only when the child cannot stand and an infant scale is unavailable.
Take home points
- Choose the weighing method based on developmental ability, not strictly on age.
- Standing scales are appropriate for toddlers who can stand still without assistance.
- Accurate anthropometric measurements are key for growth monitoring and detecting developmental or nutritional concerns.
A pediatric nurse is to perform a head-to-toe assessment on a toddler who is admitted to a hospital for nausea and vomiting. Which is most important for the nurse to consider before beginning the examination?
Explanation
A physical examination in childrenis a systematic evaluation of a child’s body systems to assess their health, growth, and development. It’s tailored to the child’s age, developmental stage, and presenting concerns, and it plays a vital role in early detection of illness and developmental delays.
Rationale for correct answer:
D.Developmental ageguides how the nurse communicates, sequences the exam, and engages the child. For toddlers, this means using simple language, allowing parental presence, and starting with least invasive assessments first.
Rationale for incorrect answers:
A.While parental presencecan provide comfort and reduce anxiety, it is not the primary consideration; the developmental approach to the exam comes first.
B.A firm tonemay increase fear and resistance in toddlers; calm, gentle, and encouraging communication is more effective.
C.Waiting until the child is “ready”may not be practical in a hospital setting, and some cooperation can be gained through distraction and play without unnecessary delays.
Take home points
- Pediatric assessments should always be tailored to developmental age for accuracy and cooperation.
- Toddlers respond best to gentle communication, parental presence, and strategic sequencing of the exam.
- Understanding developmental milestones helps nurses choose the right techniques for assessment and interaction.
A clinic nurse assesses an infant diagnosed with thrush. Place an X on the photograph illustrating a thrush infection.
Explanation
Oral thrush, also called oral candidiasis, is a fungal infectionin the mouth caused by Candida albicans, a type of yeast that normally lives in the body but can overgrow under certain conditions. They appear as creamy white patches on the tongue, inner cheeks, gums, or roof of the mouth. Thepatches resemble cottage cheese and don’t wipe off easily.
Take home points
- White patches in the mouth that resemble cottage cheese and don’t wipe off easily are a hallmark sign of oral thrush.
- Feeding difficulties or fussiness may indicate discomfort caused by the infection, especially in infants.
A nurse in the pediatric unit is preparing to take the blood pressure readings of several clients. When assessing blood pressure in a child:
Explanation
Effective pediatric assessmentincludes not only age-appropriate interaction but also a solid understanding of developmental physiology. Therapeutic communication complements accurate assessment by helping nurses explain procedures and results in ways appropriate to the child’s age and developmental stage.
Rationale for correct answer:
A. Accurate interpretation of BPin pediatric patients requires an understanding of age-specific norms. Blood pressure gradually increases with age, so a reading of 95/58 mm Hg may be normal for a toddler but hypotensive for a school-age child. Using correct reference values ensures appropriate identification of hypotension or hypertension.
Rationale for incorrect answers:
B. While cuff size is crucial, it should be based on limb circumference, not length. The cuff bladder width should be approximately 40% of the arm circumference, and the length should cover 80–100% of the arm. Using the wrong size can yield inaccurate readings.
C. A child is normotensiveif their BP is below the 90th percentilefor age, sex, and height. Readings between the 90th and 95th percentiles are considered prehypertensive, while readings above the 95th percentile suggest hypertension.
D. In conditions like coarctation of the aorta, upper-extremity BP is higherthan lower-extremity BP. A lower BP in the legscompared to the arms is a classic sign of this condition, not the reverse.
Take home points
- Know age-specific BP norms to detect abnormalities in pediatric clients.
- Use the correct cuff size, measured by arm circumference, for accurate readings.
- Interpret BP percentiles properly: Normal is below the 90th percentile.
- Compare upper and lower extremity BPs in suspected cardiac conditions like coarctation of the aorta, not aortic stenosis.
Lessons
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Objectives
- Understand the critical components of a comprehensive childhood and family assessment.
- Master effective communication techniques for interviewing children and their parents.
- Learn how to conduct a thorough health history and physical examination tailored to a pediatric population.
- Identify key developmental milestones and nutritional considerations for children.
- Learn how to perform systematic head-to-toe physical examinations.
Introduction
- A comprehensive childhood and family assessment is the cornerstone of pediatric nursing.
- It's not just about a single physical exam but about creating a complete picture of the child's health within their family and environmental context.
- This includes evaluating their physical, emotional, social, and cognitive development.
- The assessment is a dynamic process that begins the moment you meet the child and family and continues throughout every interaction.
Key Differences Between Children and Adults
System / Characteristic
Pediatric Differences
Body Surface Area
Larger for weight → susceptible to hypothermia
Head Size
Proportionately larger → increased risk of head injury
Metabolism & Needs
Higher metabolic rate, oxygen needs, and caloric demands
Rib Cage
More cartilage → ribs more flexible and compliant
Respiratory
Faster rate, fewer/smaller alveoli, lower lung volume; primary breathing muscle is diaphragm (up to 4–5 years)
Acid-Base Balance
CO₂ not effectively expired when in distress → risk for metabolic acidosis
Skeletal System
Bones softer and more prone to bending/fracture
Muscular System
Less tone, power, coordination; muscles make up 25% of weight in infants vs. 40% in adults
Fontanelles
Anterior: palpable up to ~18 months; Posterior: closes between 2–3 months
Airway Anatomy
Tongue large relative to oral cavity; short, narrow trachea (↑ risk of obstruction)
Abdominal Organs
Liver and spleen poorly protected → vulnerable to trauma
Renal Function
Kidneys immature until ~12–18 months → limited urine concentration and electrolyte control
Water Balance
Larger proportion of total body weight is water (especially extracellular); rapid daily water exchange
Blood Volume
Weight dependent: ~80 mL/kg
Neurologic System
All brain cells present at birth; myelination continues during the first year
Cardiac Output
Rate-dependent (not stroke volume) until late school age/adolescence → HR crucial for perfusion
Communication And Interviewing A Child
- Effective communication is the most powerful tool a pediatric nurse has. It's essential to establish trust and rapport with both the child and their parents to obtain accurate information and ensure a positive healthcare experience.
Establishing a Setting for Communication
Create a safe, private, and comfortable environment. This might involve:
- Ensuring the room is quiet and free from distractions.
- Positioning yourself at the child's eye level.
- Using a warm, calm tone of voice.
- Having age-appropriate toys or books available.
Computer Privacy and Applications in Nursing
Nurses must adhere to strict privacy regulations (like HIPAA in the U.S.). This means:
- Never leaving a computer screen with patient information visible.
- Logging out of electronic health records (EHRs) when not in use.
- Using secure, encrypted systems for any electronic communication.
EHRs are invaluable for documenting assessments, tracking growth, and sharing information securely with other providers.
Telephone Triage and Counseling
When providing care over the phone, nurses must use a structured approach to:
- Assess the severity of the child's symptoms.
- Provide clear, concise instructions.
- Document every conversation meticulously.
- Recognize when a child needs immediate medical attention versus at-home care.
Communicating with Parents
Parents are the primary source of information and a crucial partner in care. The key is to:
- Listen actively and show empathy.
- Acknowledge their concerns and feelings.
- Use clear, simple language, avoiding medical jargon.
- Encourage them to ask questions and participate in decision-making.
Communicating with Children
Communication must be tailored to the child's developmental stage.
- Infants: Respond to touch, sound, and a calm tone. The assessment is often done with the parent holding the infant.
- Toddlers (1-3 years): Use simple words and short sentences. Give them choices when possible (e.g., "Do you want me to listen to your tummy first or your back?"). Fear of separation is common.
- Preschoolers (3-5 years): They have magical thinking. Explain procedures in a simple, non-threatening way (e.g., "I'm going to put a sticker on your finger to see how much air is in your blood.").
- School-age children (6-12 years): They can understand cause and effect. Give them more detailed explanations and allow them to participate in the exam.
- Adolescents (13-18 years): Treat them with respect. Ensure privacy and confidentiality. Address them directly and allow them to speak without interruption from parents.
Communication Techniques
- Therapeutic play: Use dolls, puppets, or drawings to explain procedures and assess the child's understanding and feelings.
- Clarification: "Can you tell me more about that?"
- Reflection: Repeating a word or phrase to encourage them to elaborate.
- Open-ended questions: "How have you been feeling?" vs. "Do you feel sick?"
History Taking
A comprehensive history provides context for the physical examination. Key components include:
- Demographics: Name, age, gender, ethnicity.
- Chief Complaint: The reason for the visit in the parent's and/or child's own words.
- History of Present Illness (HPI): Use the mnemonic "OLD CARTS" or "PQRST" to get a detailed description of the symptoms (Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, Timing, Severity).
- Past Medical History: Birth history, previous illnesses, hospitalizations, surgeries, injuries, and allergies.
- Family History: Genetic conditions, chronic diseases, and mental health issues within the family.
- Social History: Home environment, school performance, peer relationships, and exposure to tobacco or other substances.
- Review of Systems (ROS): A head-to-toe questioning about each body system to uncover any missed symptoms.
Nutritional Assessment
Nutrition is vital for growth and development. A proper nutritional assessment includes:
Dietary Intake
- 24-hour dietary recall: Ask the parent or child to describe everything the child ate and drank in the past 24 hours.
- Food frequency questionnaire: Ask about how often the child consumes certain foods or food groups.
- Observation: Note the child's appetite, feeding behaviors, and any feeding difficulties.
- Breastfeeding/Formula: For infants, document the type, amount, and frequency of feeding.
Clinical Examination and Nutrition
- General appearance: Note if the child appears well-nourished, underweight, or overweight.
- Skin: Check for signs of vitamin deficiencies, such as dry, flaky skin or petechiae.
- Hair: Note if the hair is dry, brittle, or sparse (can indicate protein deficiency).
- Mouth: Check for cracked lips, swollen tongue, or bleeding gums.
Evaluation of Nutritional Assessment
- Growth charts: Plot the child's weight, height/length, and head circumference on growth charts to see if they are following a consistent growth curve.
- BMI: Calculate and plot BMI for children over 2 years of age to screen for overweight or obesity.
- Laboratory values: Check for anemia (iron deficiency), vitamin D levels, or other micronutrient deficiencies if indicated.
General Approaches Toward Examining The Child
The pediatric physical exam is not a rigid, head-to-toe procedure. It must be flexible and opportunistic.
Sequence of Examination
- "Least invasive to most invasive" is the golden rule.
- Observation: Start by simply observing the child's general appearance, activity level, and interactions with parents.
- Auscultation: Listen to the heart, lungs, and abdomen while the child is quiet. This is best done early.
- Palpation/Percussion: Perform these on the abdomen and chest.
- Otoscopic/Oropharyngeal Exam: Save this for last, as it's often the most invasive and can cause the child to cry, making the rest of the exam difficult.
Preparation of the Child
- Infants: Keep them warm and close to their parent.
- Toddlers: Let them sit on the parent's lap. Use a toy or distraction.
- Preschoolers: Use simple, concrete explanations and let them touch the equipment.
- School-age: Give them choices and explain what you're doing.
- Adolescents: Provide privacy and explain the purpose of each part of the exam.
Nursing Insight: A key difference between a pediatric and adult physical exam is the order. You must adapt the exam to the child's mood and developmental stage. Crying can significantly alter vital signs, especially heart rate and respiratory rate.
Age-Based Examination Approaches
A. Newborns and Infants Under 6 Months
- Easiest to examine: Less resistance and less stranger anxiety.
- Keep the parent present for comfort.
- Soothing techniques: Feeding, pacifier, rocking, diaper change.
- Begin with auscultation when infant is quiet or sleeping.
- Proceed head-to-toe, saving disturbing procedures (e.g., hips) for last.
- Observe activity level, mood, responsiveness.
B. Infants Over 6 Months
- Separation/stranger anxiety emerges.
- Examine while sitting on parent’s lap; some steps (e.g., ears) may require child held against parent's chest.
- Keep room warm and child comfortable.
- Use soothing voice, toys, pacifier, bottle to calm.
- Begin exam with hands and feet, saving more invasive steps for later.
C. Toddlers
- Strong stranger anxiety; prefer to stay on parent’s lap.
- Allow child to observe instruments.
- Avoid yes/no questions (expect "No"). Instead, state actions confidently.
- Offer choices when possible (e.g., “Which ear first?”).
- Assess neurologic/musculoskeletal system by observing play.
- Perform ear, eye, and mouth exams last.
D. Preschoolers
- May be examined on parent’s lap or alone depending on age.
- Most cooperate and are willing to undress; keep underpants until genital exam.
- Let them handle equipment; use distraction and simple explanations.
- Offer praise and encouragement throughout.
E. School-Age Children
- Willing to cooperate; modesty begins to develop.
- Offer a gown to preserve modesty.
- Let child decide on privacy (parent present or not).
- Use a head-to-toe sequence.
- Teach using opportunities (e.g., let child listen to heart sounds).
F. Adolescents
- Protect modesty: Provide privacy for dressing, gowning, and during exam.
- Use head-to-toe sequence.
- Unless requested, perform exam without parents; chaperone required for genital/breast exams.
Nursing insight: Professionalism in Practice/Using Chaperones
Use a same-gender chaperone (nurse or technician) for breast/genital/anorectal exams. Family members are not substitutes. Follow institutional policies for documentation.
Physical Assessment
A detailed physical exam provides objective data to confirm or refute findings from the history.
Growth Measurements
- Head Circumference: Measured at the widest part of the head, from the supraorbital ridges to the occipital prominence. Monitored until age 2 to screen for microcephaly or macrocephaly.
- Length or Height: Length is measured while the child is lying down until age 2. Height is measured standing.
- Weight: Measured on a pediatric scale.
- Weight for Length: Used for infants and toddlers up to 24 months to assess for failure to thrive or obesity.
- Body Mass Index (BMI): Calculated for children 2 years and older as weight (kg)/height (m²). Plotted on a growth chart to assess for overweight or underweight.
Physiologic Measurements
- Temperature: Can be rectal (most accurate for infants), axillary, or tympanic depending on the age and situation.
- Pulse: Apical pulse is taken for 1 full minute in infants and young children. Radial pulse is used in older children.
- Respiratory Rate: Count for 1 full minute, noting any signs of respiratory distress.
- Oxygen Saturation: Measured with a pulse oximeter.
- Blood Pressure: Use an appropriate-sized cuff. The bladder should cover 80% of the arm's circumference.
General Appearance
- Appearance: Grooming, hygiene, and clothing appropriate for the weather.
- Posture and Position: Note any abnormal posturing or limp.
- Behavior: Note alertness, mood, and activity level.
- Nutrition: Note if the child appears well-nourished.
- Facial Expressions: Note for symmetry and any signs of pain or distress.
Skin
- Color: Note pallor, cyanosis, jaundice, or erythema.
- Temperature and Texture: Assess for warmth, dryness, or diaphoresis.
- Turgor: Assesses hydration by gently pinching the skin on the abdomen.
- Lesions: Document any rashes, bruises, or birthmarks.
Hyperpigmented patches (Mongolian spots)—bluish patches on sacral/buttock area in dark-skinned infants. Normal; fade by puberty.
- Nursing Insight: Bruises in non-mobile infants or in uncommon locations (e.g., trunk) may indicate abuse.
Lymph Nodes
- Palpate for enlarged nodes in the cervical, occipital, and axillary areas. Normal nodes are small, non-tender, and mobile.
Head and Neck, Eyes, Ears, and Nose
Head: Skull and Facial Features
|
Assessment Focus |
Normal Findings |
Abnormal Findings |
|
Skull shape & size |
Symmetrical, rounded; fontanels soft and flat in infants |
Bulging fontanel (↑ ICP), sunken fontanel (dehydration), asymmetry (craniosynostosis) |
|
Sutures |
Palpable in newborns, gradually fuse with age |
Wide sutures (↑ ICP), early closure |
|
Facial features |
Symmetrical, appropriate for age |
Dysmorphic features (e.g., low-set ears, slanted eyes, wide-spaced eyes—may indicate syndromes) |
Nursing Insight: The anterior fontanelle typically closes between 12 and 18 months of age, while the posterior fontanelle closes much earlier, usually by 2 to 3 months. A bulging fontanelle can indicate increased intracranial pressure, and a sunken fontanelle can indicate dehydration.
Eyes: Structures, Function, and Vision
|
Assessment Focus |
Normal Findings |
Abnormal Findings |
|
Eyelids, sclera, conjunctiva |
Symmetrical, white sclera, pink conjunctiva |
Redness, discharge, ptosis, jaundice |
|
Pupils (PERRLA) |
Equal, round, reactive to light and accommodation |
Unequal size, sluggish or non-reactive pupils |
|
Extraocular movements |
Eyes move together in 6 directions |
Strabismus, nystagmus |
|
Vision screening |
Age-appropriate acuity (Snellen chart from age 3–4) |
Inattention, squinting, poor school performance |
Ears: Structure and Hearing
|
Assessment Focus |
Normal Findings |
Abnormal Findings |
|
External ear |
Aligned with outer canthus of eye |
Low-set ears (may indicate genetic conditions) |
|
Ear canal & tympanic membrane |
Clear canal, pearly-gray TM with light reflex |
Redness, bulging TM (otitis media), discharge |
|
Hearing (age-appropriate) |
Startle to loud sound (infants), responds to name |
Lack of response, inattentiveness |
Hearing tests:
- Newborns: Otoacoustic emissions (OAE)
- Older infants/children: Response to sound, audiometry
Nursing Insight: When performing an otoscopic exam on a child under 3, pull the pinna down and back. For a child over 3, pull the pinna up and back, just like in adults.
Nose and Sinuses
|
Assessment Focus |
Normal Findings |
Abnormal Findings |
|
Patency |
Bilateral air movement |
Nasal flaring (respiratory distress), obstruction |
|
Nasal mucosa |
Moist, pink |
Pale (allergies), red/swollen (infection) |
|
Discharge |
None or clear |
Purulent (infection), unilateral foul odor (foreign body) |
|
Sinus palpation |
Nontender (older children) |
Tenderness (sinusitis) |
Mouth and Throat
|
Assessment Focus |
Normal Findings |
Abnormal Findings |
|
Lips/mucosa/tongue |
Pink, moist, intact |
Dry/cracked (dehydration), lesions, thrush |
|
Teeth |
Appropriate for age, no caries |
Cavities, delayed eruption |
|
Tonsils |
Small to moderate size, pink |
Enlarged, exudate (pharyngitis, tonsillitis) |
|
Uvula |
Midline, rises with phonation |
Deviation (cranial nerve palsy) |
Primary and Secondary Tooth Eruption
Chest and Lungs
|
Assessment Focus |
Normal Findings |
Abnormal Findings |
|
Chest shape |
Symmetrical, rounded in infants; more adult-like with age |
Pectus excavatum/carinatum, barrel chest (asthma) |
|
Respiratory effort |
Quiet, even, no retractions |
Nasal flaring, retractions, grunting, tachypnea |
|
Breath sounds |
Clear bilaterally |
Crackles (pneumonia), wheezes (asthma), absent sounds |
9.9. Heart
|
Assessment Focus |
Normal Findings |
Abnormal Findings |
|
Heart sounds |
S1 & S2 distinct, regular rhythm |
Murmurs, gallops, irregular rhythms |
|
Apical pulse |
Counted for 1 full minute |
Tachycardia or bradycardia for age |
|
Capillary refill |
< 2 seconds |
Delayed refill (poor perfusion) |
|
Pulses (central/peripheral) |
Equal bilaterally |
Bounding or weak pulses (cardiac issues) |
Abdomen
- Inspection: Note contour, symmetry, and visible pulsations.
- Auscultation: Listen for bowel sounds.
- Palpation: Palpate for tenderness, masses, or organomegaly (e.g., enlarged liver or spleen).
|
Assessment Focus |
Normal Findings |
Abnormal Findings |
|
Contour |
Round in infants, flat in older children |
Distension, visible peristalsis |
|
Bowel sounds |
Present in all quadrants |
Absent (ileus), hyperactive (diarrhea) |
|
Palpation |
Soft, non-tender, organs not enlarged |
Masses, guarding, tenderness |
|
Liver & spleen |
May be palpable in young children |
Enlargement (hepatosplenomegaly) |
Genitalia
|
Assessment Focus |
Normal Findings |
Abnormal Findings |
|
External genitalia (male/female) |
Normal anatomy, no lesions or swelling |
Hypospadias, labial fusion, masses, discharge |
|
Testes (males) |
Descended, no masses |
Undescended testes, hydrocele, hernia |
|
Hygiene |
Clean, no odor or rash |
Signs of infection or abuse |
Anus
- Inspection: Check for rashes, fissures, or hemorrhoids.
Musculoskeletal System
|
Assessment Focus |
Normal Findings |
Abnormal Findings |
|
Posture & gait |
Symmetrical, age-appropriate |
Limping, scoliosis, toe-walking |
|
Joints |
Full range of motion, no swelling |
Limited movement, swelling, redness |
|
Muscle strength |
Equal bilaterally |
Weakness, asymmetry |
|
Spine |
Straight alignment |
Scoliosis (screen from age 10 onward) |
Neurologic Assessment
|
Assessment Focus |
Normal Findings |
Abnormal Findings |
|
Behavior & alertness |
Alert, appropriate for age |
Lethargy, irritability, altered LOC |
|
Cranial nerves |
Intact (e.g., suck/swallow, facial expression) |
Facial asymmetry, drooling, ptosis |
|
Motor coordination |
Smooth, purposeful movements |
Tremors, clumsiness, abnormal reflexes |
|
Reflexes |
Age-appropriate (e.g., Moro in infants) |
Persistence of primitive reflexes |
|
Sensory |
Responsive to touch/pain |
Absent or exaggerated responses |
Developmental Assessment
- Use standardized screening tools (e.g., Denver II) to assess gross motor, fine motor, language, and personal-social skills.
- Compare the child's skills to expected milestones for their age.
Pubertal Development and Sexual Maturation
Use Tanner Staging to assess:
|
Stage |
Girls (Breasts/Pubic Hair) |
Boys (Genitalia/Pubic Hair) |
|
I |
Prepubertal |
Prepubertal |
|
II |
Breast budding, sparse hair |
Testes enlarge, sparse hair |
|
III |
Enlargement, dark curlier hair |
Penis enlarges, darker hair |
|
IV |
Areola forms mound, coarse hair |
Scrotum darkens, coarse hair |
|
V |
Adult maturity |
Adult maturity |
