Physical examination

Jays george
Msc Nursing

1. PHYSICAL EXAMINATION PRESENTED TO ; MRS. NISHA MANE ASSISTANT PROFESSOR D.Y.P.S.O.N

2. INTRODUCTION Physical assessment is an important part of the nursing process, because it provides the data for which nurse can make a nursing diagnosis and plan, implement and evaluate nursing care. Measurement of physical growth in children is a key element in evaluating their health status. Physical assessment uses four skills; inspection or observation , palpation, percussion and auscultation.

3. ARTICLES

4. HEIGHT Until the child can stand steadily , generally before the age of 5 years, the height is taken as length while the child is lying on a firm table. The length is obtained by placing the feet against a fixed upright surface at the zero mark of the rule and measuring from that point to the vertex ,against which a flat movable surface placed. The child’s body is fully extended by flattening the knees and maintaining the head in a midline position. Assistance can be needed to obtain an accurate measurement. If the child stands straights and tall and hold the head so that the line of vision parallels the floor surface , a standing height can be measured.

5. WEIGHT The infant is weighed on an infant scale , the older child on a upright platform scale. Either type of scale is balanced before the weight is read.

6. TEMPERATURE Normal temperature runs around 99 degrees until > 36 months. A variance of 1-2 degrees is OK. A temperature <97 degrees in an infant and > 100.5 degrees is indicative of a problem and should be noted. Temperatures are taken commonly either axillary or tympanic. Be sure to document how taken.

7. PULSE RATE Apical pulse rates are most commonly taken in children; especially in those under 2. Assess based on limits for age and norms for that child.

8. RESPIRATORY RATE Assess the rate, depth, and ease of respiration in the child. Varies with age of child. Respirations should be quiet and effortless Infants are abdominal breathers / nose breathers 4 weeks to 4 months. By age 7 – costal breathers

9. BLOOD PRESSURE

10. SKIN AND LYMPHATICS INSPECTION : SKIN Describe any variation in colour, particularly in children with increased pigmentation ,birth marks ,bruises or unusual marks , scars , wounds or insect bites , to ascertain suspected jaundice, scaliness , vernix caeseosa , Mongolian sot , Malia etc. PALPATION Check the tension of the skin by pinching up a fold of skin, normal skin quickly falls back , but dehydrated skin remains in pinched position . Skin examined for texture , moisture , temperature , colour and lesions . The skin of young child is usually smooth , slightly dry and uniform temperature. Skin is oily; cradle cap or ezema present. Skin is too dry; child may bathed too and deficiency in vitamins . Clammy skin ; heart disease If the arms are warm and legs are cooler : coartation of aorta

11. The skin is observed for pallor and cyanosis ; increased deoxygenated haemoglobin . Erythema and jaundice Ecchymosis –haemorrhage of blood into skin . Petechia Presence of simian crease ; down syndrome Skin turgor Poor skin turgor : dehydration and in oedema , sign of kidney disease. ACCESSORY STRUCTURES HAIR Hair is examined for colour, texture , elasticity , distribution , cleanliness and infestation .

12. Alopecia : tinea capitis ,pyoderma and seboric dermatitis or side effects of radiation and certain drugs such as chemotherapeutic agents, protein deprivation and celiac disease. Hair is dull, dry , brittle and depigmented : malnourished Hypertrichosis Hair growth from midforehead and excessive : cretinism Excessive hair over the spine : spina bifida NAIL Inspected for shape , texture , flexibility and colour. Normal nails are usually convex , translucent, smooth and firm but flexible. Colour abnormalities may include blueness ;cyanosis Yellow tint :jaundice Dark colouration indicates haemorrhage

13. White opacity of the nail; benign hereditary defect or trauma Clubbing in the base of the nail and becomes swollen : tetralogy of Fallot. Micronychia : trisomy 18 and foetal alcohol syndrome. HEAD AND NECK head control Presence of wry neck or torticollis Opisthotonas : meningeal irritation Nuchal rigidity Inspection and palpation of skull Symmetry, size, and general appearance Asymmetry of the skull : craniosynostosis ,infants remained in one position for long period Posterior fontanelles anterior fontanelles Late closure of fontanelles : rickets , cretinism Bulging and depressed fontanelle.: raised intracranial tension Prominent scalp veins and crack pot sign : hydrocephalus

14. EYE Alignment and placement on the face. The eyes are inspected for shape , size , colour , movement and symmetry. Epicanthal folds : Caucasian children . Ptosis or drooping of eyelids. Edema of eyelids : kidney diseases. Ambylopia Exophthalmos : hyperthyroidism Setting sun sign EYE LASHES Inspected for position ,presence or absence of eyelashes Assess for blepharospasm , blepharitis , hordeolum and chalazion LACRIMAL APPARATU position and patency and possibility of infection

15. Epiphora or excessive tearing ,plugged lacrimal duct, alacrimia , corneal ulceration and scarring. ORBIT Sunken eyes : dehydration Macrothalmia : toxoplasmosis CONJUNTIVA Normally glossy and pink Assess for conjunctivitis Pale conjunctiva : anemia in child SCLERA Inspected for discolouration PUPILS Inspected for shape ,size ,movement and the ability to accommodate and react to light. anisocoria

16. OCCULAR MUSCLES Strabismus and nystagmus TESTING FOR VISUAL ACQUITY Snellen's chart is used Snellen alphabet Snellen’ E’ charts Denver eye screening test is used for children over 2 ½ years of age. TESTING FOR VISUAL FIELD Peripheral vision ; child look at the nurse at a distance of 3 feet. TESTING FOR COLOUR VISION Colour blindness Red green defect and blue yellow defects

17. EAR Inspection for alignment and placement on the head Assess auricle or pinna ( helix, antihelix ,concha, tragus and lobule ) Assess for any anomalies EAR CANAL : inspection is done with otoscope. 2.5 cm Pink in colour Thin Presence of ear cerumen Inspected for discharge TYMPANIC MEMBRANE Transparent tissue of a grey coloured Examined for loss of any bony land marks Examine middle ear , inner ear and auditory or eustachian tube

18. Examination of mastoid area for any infection (mastoiditis) TESTING FOR HEARING ACUITY Crib-o-Gram is used to test the hearing of the new-born and infant. Audiometer is an electric instrument that measure pure tone , frequencies and loudness of voice. NOSE It is a framework of bone and cartilage covered with skin and lined with mucus membrane. Assess the external triangular structure of the nose. Insect type and amount of watery , purulent and crusty discharge if any , are noted. Patency of nose Observe for “Allergic salute” : rhinitis , rhinorrhoea or itching . Assess for nasal cavities , mucus membrane and small hairs.

19. Assess for nasal septum deviation and perforated septum. Assess olfactory areas , sinuses( palpate frontal sinus) MOUTH Assess for lips for shape, colour ,inflammation, fissuring and lesion. Anaemia : pale lips Cherry red lips : heart lesion Cyanosis or grey colour : congenital heart lesion. Cheilitis Assess for oral or buccal cavity , gag reflex ,oral thrush. Assess salivary glands , tonsils

20. THORAX AND CHEST Palpate thorax area(rachitic rosary) , clavicle( fracture) Assess deformities in the bones of chest Harrisons groove , barrel chest Assess inspiration and expiration and non symmetrical movements of chest. Auscultation of breath sounds. Abnormal lung sounds: rales , rhonchi , wheezing etc HEART To inspect and palpate heart child lies flat on the back with chest elevated at a 45 angle. Both sides of anterior chest wall should be symmetric.

21. Auscultation of heart sounds ABDOMEN Abdomen is inspected for skin abnormalities , contour , symmetry , size , muscle tone , masses. Examined Convexity and concavity. Inspect Scaphoid abdomen ,distended abdomen protruding abdomen. Auscultation is done to determine presence or absence of peristaltic waves. Each quadrants is heard for 5 mins Soft friction rubs ; peritoneal obstruction or inflamed spleen Splashing noise ; presence of fluid in the stomach. Palpate abdomen for degree of distention , edge of liver , spleen , femoral pulse and skin turgor Deep palpation to feel abdominal organs.

22. ANUS AND RECTUM Observe anal sphincter , firmness of buttocks muscle. Inspect for any signs of inflammation , redness , scars , marks , rashes and anal fissures. Observe pin worm around the anus. Palpation ; determine the presence of fistulas , sinuses , strictures and abscess . GENETALIA Examination male genetalia The scrotum is inspected and palpated for possible inguinal hernia , oedema , colour and masses . If red and shiny skin – orchitis Assess for hydrocele Spermatic cords are traced and examined for swelling or masses Both testes are examined for descended and undescended testes Assess prostrate gland. Its position and shape

23. The shaft of penis is examined for its size . Micropenis (2.5cm) Balanitis and venereal warts URETHRA The meatus is examined for an ulceration Assess for hypospadias's and epispadiasis Observe for priapism EXAMINATION OF FEMALE GENETALIA Mons pubis is inspected for skin discolouration , pubic lice or crabs and palpated for masses. The skin of labia is inspected for abrasion and ulceration. Assess vulvitis , gonorrhoea , labio inguinal hernia Check for any adhesion Assess for abnormally large clitoris to investigate virilization

24. URINARY MEATUS Assess for prolapse of urethra , hematuria , dysuria ,urethritis Examine vaginal opening and hymen , congenital absence of vagina Assess for vulvoginitis , unpleasant odour , abnormal colour of discharge. MUSCULOSKELETAL SYSTEM Knock – kneed appearance In Pre-schoolers ; assess eversion of extremities . Assess range of motion , congenital dislocation , tenderness , heat , swelling over joints; infection. Inspect atrophy, hypertrophy , spasticity , flaccidity , tone, rigidity of muscles . Examine vertebral column for spina bifida , abnormal curvatures , meningomyelocele, tenderness or note areas of mass. Upper extremities assessed for fractures any deformity , length and shape of fingers , extra digits. Lower extremities ; assess fracture , joint pain , arthritis , equality of length , complete range of motion at the hip , knees , ankles and toes , abnormal hip dislocation and tibial torsion or bowing of tibia.

25. CENTRAL NERVOUS SYSTEM It is done to note orientation , level of consciousness, intellectual ability and behaviour . Assess any disorientation , hyperactive problems , cerebral palsy , cerebral dysfunction any injury or trauma , tumor to the brain. Assess for language ability , cry , senses. Assessing the milestones. Assessing the reflexes Biceps tendon reflex Triceps tendon reflex Patellar deep tendon reflex Achilles deep tendon reflex

26. CONCLUSION Physical examination of a child should be done to rule out the distinguish between normal and abnormality of body parts. It should be done in the presence of his or her to parents to reduce anxiety. It helps a nurse and a physician to know that all the organs are functioning normally or not.