Physical examination

physical examination of children

1. PHYSICAL EXAMINATION PRESENTED BY: R.SIVABARATHY M.SC(N) 1 ST YEAR CON JIPMER

2. PHYSICAL ASSESSEMENT P hysical examination of a child involves a complete head to foot examination, including all the system with the special emphasis on the areas most probably affected, as per the history taken. It usually begin with an inspection of the general apperance of the child.

3. Purposes:

4. Principles: Gather as much data as possible by observation first. Position of child : P arent’s lap or exam table Stay at the child’s level as much as possible Order of examination: Least distressing to Most distressing Rapport with the child explain to the child’s level.

5. Cont... Distraction is valuable tool Examine painful area last, get general of overall attitude Be honest: If something is going to hurt, tell them that in a calm fashion, understand development stages impact on child’s response

6. Age specific approaches to physical examination during childhood:

7. POSITION SEQUENCE PREPARATION Infant: Befor able to sit supine or prone preferably in parent’s lap. Before 4 – 6 month: can place on examination table. after able to sit alone: Sitting in parent’s lap whenever possible if on table, place with parent in full view. If quiet, auscultate heart, lungs and abdomen. Record heart and RR. Proceed in usual head to toe direction. Perform traumatic procedure last. Elicit reflex as body part is examined. Elicit moro reflex last. Complete undress if room temperature permits. Leave diaper on male infant Gain co operation with distraction Enlist parent’s aid for restraining to examine ears, mouth Avoid abrupt, jerky movement

8. POSITION SEQUENCE PREPARATION Toddler: Sitting or standing on or by parent. Prone or supine in parent’s lap Inspect body area through play. Introduce equipment slowly. Auscultate, percuss, perform traumatic procedures at last. Have parent remove outer clothing Remove underwear as body part is examined Allow to inspect equipment Demonstrating use of equipment is usually ineffective. If uncooperative, perform procedure quickly with the use of restrain.

9. POSITION SEQUENCE PREPARATION Preschool Prefer standing or sitting. Usually co operative prone or supine. Prefer parent’s closeness If cooperative, procced in head to toe direction If uncooperative proceed as with toddler. Request self undressing Allow to wear innerwear. If shy offer equipment for inspection, brief demonstrate use, make up stony about procedure. Use paper- doll technique give choice when possible.

10. POSITION SEQUENCE PREPARATION School age children: Prefer sitting, cooperative in most position Younger child prefer parent’s presence. Older child may refer privacy Proceed in head to toe direction May examine genitalia last in older child Request self undressing: Allow to wear inner, give gown to wear Explain purpose of equipment and significance of procedures

11. POSTION SEQUENCE PREPARATION Adolescent: Same as for school children. Offer option of parent’s presence Same as older school age child May examine genitalia last Allow to undress in private Give gown Expose only the area to be examined Respect need for privacy.

12. General appearance: Consciousness Delirium Lethargy Obtundation Stupor Coma Stature Normal stature Short stature Tall stature

13. Facies: Mongoloid facies Cushingoid facies Haemolytic facies Doll like face Hepatic facies Cretinoid facies.

14. Facies: Haemolytic face Doll like face

15. Posture and position: Observe the posture, position and types of body moment. The child in pain may favor a body part, the child with low esteem or a feeling of rejection may assume a slumped, careless and apathetic pose. Hygiene: Note the child hygiene in term of cleanliness, unusal body odor, the condition of hair, nails, teeth, neck and feet and the condition of clothing possible instances of neglect, inadequate financial resources, housing difficulties or lack of knowledge concerning children’s need.

16. Behaviour and development: Behaviour include the child’s personality, activity level, reaction to stress, request, frustration, interaction with others. Degree of alertness and response to stimuli development can be assessed by carefully observing the child Record an overall estimate of the child’s speech development, motor skills, co ordination and recent area of achievement.

17. Height/length:

18. Weight:

19. Head circumference:

20. Chest circumference:

21. Mid arm circumference:

22. AGE WEIGHT (KG) LENGTH (CM) HEAD CIRCUMFERENCE (CM) Birth 3 50 34 6 month 6 (double) 65 43 1 year 9 (triple) 75 46 2 year 12 (quadruple) 90 48 3 year 15 95 49 4 year 16 100 50

23. Skin fold thickness: It is used to measure the body fat and its measured with special calipers such as the lange calipers the most common site fro measuring skinfold thickness:

24. Physiological measurement: Temperature Pulse Respiration Blood pressure

25. Temperature: Temp is the measurement of the heat content within an individual body, the core temperature most closely reflects the temperature of the blood flow through the carotid arteries to the hypothalamus .

26. Pulse: A satisfactory pulse can be taken radially in children older than 2 years of age. In infants and young children, the apical pulse is heard. Count the pulse for 1 min in infant and young children because of possible irregularities in rhythm.

27. Grading of pulse: GRADE DESCRIPTION Not palpable +1 Difficult to palpate, thread, weak, easily obliterated with pressure +2 Difficult to palpate, may be obliterated with pressure ( normal) +3 Difficult to palpate, not easily obliterated with pressure ( normal) +4 Strong, bounding, not obliterated with pressure

28. Respiration:

29. Blood pressure: The oscillometric BP monitoring method is a reliable screening tool used in a variety of age groups. Use an appropriate size cuff 2/3 rd width of upper arm for upper arm pressure ( cuff bladder width should be approximately 40% of mid arm circumference)

30. AGE TEMPERATURE PULSE RESPIRATION BP Newborn 97.9 /36.5 C 100-180 35 65/41 6 month 99.5 / 37.5 C 80-150 30 95/58 1 years 99.7 /37.7 C 80-150 30 95/58 3 years 99 F/37.2 C 70-110 23 101/57 5 years 98.3 F/37 C 70-110 21 101/57 9 years 98.1 F/36.7 70-110 19 101/57 11 years 98 F/36.7 C 55-90 19 101/57

31. Skin: Skin is assessed for : Color Texture Temperature Moisture Turgor Normally the skin texture of young children is smooth, slightly dry and not oily or clammy. Note any difference in temperature b/w upper part and lower part. E rythema

32. P etechiae ecchymosis

33. Assess the edema: Edema scale: 0.5 cm = + 1 cm = ++ 1.5 cm = +++ 2 cm = ++++

34. Lymph node: Palpate nodes using the distal portion of the fingers and gently but firmly pressing in a circular motion along the region where the nodes are normally present. During assessment nodes in the head and neck , tilt the child’s head upward slightly. This facilitates palpation of the submental, submandibular, tonsillar and cervical nodes. Palpate the axillary nodes with the child’s arm relaxed at the side but slightly abduction. Inguinal node with the child in supine position .

35. Head: Inspect scalp and hair for dandruff, pediculosis and texture of the hair. Palpate fontanelle for size, shape, tension and closure Palpate skull for patent or overriding sutures, fractures or swellings. Evaluate range of motion by asking the older child to look in each direction or by manually putting the younger child through each position. Size shape

36. Eyes: Inspection of eye brows, alignment and lashes Spacing of the eyes refers to the distance between both eyes. Canthral index is derived from the ratio of the distance between inner and outer canthi of both eyes multiple by 100. Normal CI is 3 – 8. if CI is < less than 3cm then its called hypotelorism , if CI is more than 8 cm then its called hypertelorism .

37. Screen visual fields by confirmation. Corneal reflection shine Extra ocular movement Pupillary reaction (PERRLA) Visual acuity test with the use of snellen chart Inspection of internal structure

38. PERRLA: REACTION TO ACCOMDATION: Hold an object about 10 cm from the bridge of the client’s nose Ask the client to look first at the top of the object and then at a distant object behind the penlight. Observe the pupil responses. The pupils should constrict when looking at the near object and dilate when looking at the far object

39. The opthalmoscope permits visuvalized of the Interior of the eye ball with a system of lenses and a high intensity light. Look through the scope and shine the light into the Patient’s eye from about 2 feet away to see retina as a red reflex

40. Ears: Externally: Check the alignment Palpate the mastoid process for tenderness or deformity Inspect the skin surface around the ear for small openings, extra tags of skin, or sinuses. If the sinuses is found, note this because it may represent a fistula that drains into some area of the neck or ear. Assess the ear of hygiene, note the presence of cerumen. Discharges.

41. Internally The head of the otoscope permits visuvalized of the tymphanic membrane by use of a bright light, a magnifying glass, and a speculum Inspect the ear canal and middle ear structure noting any redness, drainage or deformity Normal colour of the ear drum Shiny translucent Pearly gray Abnormal findings: Erythema: otitis media, purulent discharge, serous otitis media with effusion. Conductive hearing loss is due to mechanical dysfunction of inner or middle ear. Audiometry and other hearing test can be done.

42. Nose and sinuses: Observe the location, symmentry in size and diameter of the nares. Observe ala nasi for sign of flaring. Inspect the nasal cavity Palapate the frontal sinuses below eyebrows and maxillary sinuses below zygomatic arch for any tenderness.

43. Mouth and throat: Size: normally the outer edge of the mouth lies on a perpendicular line drooped from the center of the either pupil, with the eyes looking straight. Floor – R anula is retention cyst of the sublingual glands. It is seen on either side of the frenulum. It is bluish and translucent in appearance. Perioral region:

44. stomatitis

45. Lips: chilosis Buccal mucosa: examine on both side of swelling and ulcers, koplik’s spot, apthous ulcers, oral thrush . Elicit the gag reflex

46. Examine the oropharynx and note the size and color of the tonsils. They are normally the same color as the surroundings mucosal glandular rather than smooth in appearance. Report any swelling , redness or white areas on the tonsils.

47. Grading system to size of tonsils: Grade 1: the tonsils are behind the tonsillar pillars. Grade 2: the tonsils are between the pillars and the uvula Grade 3: the tonsils touch the uvula Grade 4 : on or both tonsils extended to the midline of the oropharynx.

48. Teeth: Malocculsion is an improper dental alignment where the upper teeth do not align properly with lower teeth. Inspect the teeth for number in each dental arch, fro hygiene and for occlusion or bite. Brown spots in the grevices of the crown of the tooth or between the teeth may be caries. Chalky white to yellow or brown areas on the enamel may indicate fluorosis. Teeth may appear greenish black may be stained temporarily from ingestion of supplement iron,

49. Cont … Examine the gum (gingiva) surrounding the teeth. The color is normally coral pink and surface texture is stippled, similar to the appearance of a orange peel. Assess the gums for hypertrophy, swollen, red and spongy gums that bleed easily.

50. Tongue: Inspect the tongue for papillae, small projection that contain several taste buds and give the tongue its characteristics rough appearance. Note the size and mobility of the tongue the roof of the mouth consists of hard palate and soft palate and has a midline protrusion called uvula.

51. Neck: Inspect the symmentry , scars or other lesions. Palpate the neck to detect areas of tenderness, deformity, masses, distended neck veins, carotid artery pulsation and thyroid gland enlargement. ROM , nuchal rigidity and JVD . in

52. Respiratory system:

53. Chest: Inspection: Use of accessary muscle of respiration Shape RR Any scars { surgery scar}

54. Lungs: Inspection: Observe the rate, rhythm, depth and effort of breathing Note whether the expiratory phase is prolonged. Listen for obvious abnormal sounds with breathing Observe for retraction and use of accessory muscle.

55. Auscultation: Auscultate from side to side and top to bottom using the diaphragm of the stethoscope. Vesicular breath sounds are low pitched and normally heard over most lung fields. Tracheal breath sounds are heard over the trachea. Breath sounds are decrease when normal lung is displaced by air or fluid Breath sounds shift from vesicular to bronchial when there is fluid in the lung itself. Extra sounds that orginate in the lungs and airways are referred to as adventitious and are always abnormal.

56. Normal breath sounds: vesicular Soft intensity , low pitches due to air moving through smaller airway ( bronchi , bronchioles) Over peripheral lung ( best at the base of the lungs 5: 2) Broncho vesicular Moderate intensity and moderate pitched “ blowing sounds” due to air through longer airway Between scapula and lateral to the sternum at the first and 2 nd intercostal space 1 :1 Bronchial ( tubular) High pitched, loud sounds due to air moving through trachea. Anteriorly over the trachea, not normally heard over the lung tissues 1:2

57. Adventitious breath sounds: Crackles: fine, short, interepted crackling sound high pitched due to the air passing through fluid/ mucous in the air passage. Gurgles: continuous, low pitched, coarse, gurgling, harsh , louder sounds due to the air passing through narrowed air passages by tumor, secretion, swelling. Friction : crackling sounds during the inspiration and expiration due to the rubbing together of inflamed pleura. Wheeze: continuous, high pitched, squeaky musical sounds best heard on expiration due to air passage through constricted bronchi

58. Cardiovascular system:

59. Inspection: Are there the features of down syndrome, turner’s syndrome or marfan’s syndrome. Cynosis,hands,edema .

60. Palpation :

61. Auscultation: Auscultate heart sounds for quality, rate, rhythm and intensity. Position the patient supine with the head of the table slightly elevated. Always examine from the patient’s right side. A quite room is essential.

62. Auscultate for blowing, swishing sound. Some are innocent murmur, but most are indicative of disease. grade 1 and 2 functional systolic murmurs are common in young children and resolve with the age.

63. Gastrointestinal system:

64. Inspection:

65. Auscultation:

66. Percussion:

67. Palpation:

68. Genitourinary system:

69. Examination of the genital conveniently follows assessment of the abdomen while the child is still supine. In adolescents inspection of the genitalia may be left to the end of the examination. Respect the privacy by covering the lower abdomen with the gown.

70. Male genitalia:

71. Female genitalia:

72. Musculoskeletal SYSYTEM:

73. BACK:

74. EXTREMITIES: Inspect each extremities for symmentry , color, syndactyly, polydactyly and abnormalities like bow leg, knock knee or club foot. Joints: Examine each major joint for any areas of tenderness, swelling or heat. Evaluate joints for ROM. Muscles: Examine muscle tone and muscle strength.

75. Neurological examination: Mental status : Assess the level of consciousness facial expression and body language, speech, cognition and functioning. Cranial nerves: observe for ptosis III, facial droop or asymmetry VII, hoarse voice X, articulation of work (V,VII,X,XII), abnormal eye position (III,IV,VI), abnormal or asymmetrical pupils (II,III).

76. Assessment of motor response: Muscle tone – ask the patient to relax. Flex and extend the patient’s fingers, wrist and elbow Flex and extend patient’s ankle and knee, there is normally a small, continuous resistance to passive movement Observe for decrease/flaccid or increase tone ( rigid/spastic)

77. Muscle strength: test strength by having the patients move against your resistance. GRADE DESCRIPTION No muscle movement 1 Visual muscle movement, but no movement at joint 2 Movement at joint, but not against gravity 3 Movement against gravity, but not against added resist 4 Movement against resistance, but less than normal 5 Normal strength

78. Coordination and gait: Point to point movement: ask the patient to touch the index finger and their nose alternatively several times. Romberg test: ask the patient to stand with the feet together and eyes closed for 5 – 10 sec without support. Gait – ask the patient to walk across the room , turn and come back, walk heel to toe in a straight line and walk on their toes in a straight line.

79. Reflexes:

80. Biceps: patient should be partially flexed at the elbow with the palm down and place the thumb or finger firmly on the biceps tendon. Strike the finger with the reflex hammer. Triceps: support the upper arm and let the patient’s forearm hang free and strike the triceps tendon above the elbow with the broad side of the hammer Brachioradialis : have the patient rest the forearm on the abdomen or lap, strike the radius about 1.2 inches above the wrist and watch for flexion and supination of the forearm

81. Grading the reflexes: 0 = no response +1 = minimal activity ( hypoactive) +2 = normal response

82. Theory application: Here I applied VIRGINIA HENDERSON’S THEORY. Nurse need to assess the needs of human being based on the 14 component of basic nursing care.

83. Journal reference: Title: P hysical examination findings among children and adolescence with obesity, an evidence based review .

84. Bibliography: Marlow R, Redding A. Marlow’s textbook of pediatric nursing. Elseiver south Asia edition. 6 th 2013. Datta p.A textbook of pediatric nursing, jaypee brothers medical publishers ltd.2013. Hockenberry J. Wilson P, Wong’s essential of pediatric nursing elseiver south asia ed. 8 th .2012. Gupta P. textbook of paediatrics . CSP publishers. New Delhi. 2013. Pancahli P. textbook paediatric nursing. New delhi . Paras Medical Publication. 2016.