Assessment of the Child

Basic Principles

Know norms; child vs. adult

A & P variations are farthest from adult norms at birth

Most of these variations mature quickly in the first year

By 5-7 years of age, body is that of a Small adult; however, a child is not a miniature adult and should not be treated as such.

As a child normally develops somewhat predictably in growth and physical development, he also matures emotionally, intellectually, and spiritually along certain paths.

Try to see the childs world and body through his/her mind. If you do this, you will connect with the child.

Approach to examination

Always think of where the child is developmentally.

Approach must be individualized

Usually the child will be frightened and anxious. May lack verbal skills to express fear or ask for information.

Use both hands on child when possible comforting touch.

Place left hand on shoulder while auscultating the heart.

Move unhesitatingly, firmly, and gracefully.

Talk pleasantly and reassuringly.

Instructions to the child:

Use a directive voice

Have specific instructions

Do not ask, but instead tell a child

. Example: Say Roll over on your belly rather than Will you roll over on your belly?

Physical Examination

Can take place almost anywhere

On parents lap

On the floor

Examiners lap

Conducting the examination

Perform the least distressing procedures first and the most distressing last.

Heart and lungs; have the child lie down.

Abdomen, throat, and ears (throat and ears are the worst)

Genitalia and rectum

Physical exam technique

Inspection

Observe before you touch

Auscultation

Use diaphragm of stethoscope for high pitched sounds (bowel sounds)

Use bell of stethoscope to help localize sounds for infant

Palpation

Use pads of fingers to determine tenderness and pulsations

Use palmar surface of fingers to determine masses and organ enlargement

Observe reaction to palpation rather than to ask if it hurts (dont suggest that it does)

Percussion

A more advanced technique usually done by physicians and advanced practice nurses.

The general survey

Vital signs

General appearance

Mental status

Body measurements

Vital signs

Temperature

Body temperature in infants is less constant than in adults

Use ax/tympanic for children less than 4 years of age

Values are the same as in adults

Axillary: hold childs arm firmly

Tympanic:

Less than 3 years of age

. Insert gently into ear

. Pull down on ear

Over 3 years of age

. Pull up on ear

Rectal temperature

Most hospitals are done only with doctors order, or there is a standing order.

Lubricate tip well

Insert 1 inch

Pulse

Apical is best

May use femoral arteries, brachial arteries

Radials only in older children (at least 2 years old)

Respirations

The younger the child, the more abdominal breathing

Observe the abdomen instead of the chest in infants and small children

May need to auscultate the chest or put the stethoscope in front of the mouth and nose.

Oxygen saturations

Blood pressure

Wide enough to over 75% of the upper arm

Narrow cuff elevates reading, wide cuff lowers reading

In infants less than 1 year:

. Thigh BP = arm BP

Older than 1 year:

. Systolic in thigh is 10-40 mm Hg higher than in arm

. Diastolic is same in thigh and arm

If BP in thigh is less than in arm:

. Cardiac anomaly or decreased circulation to extremities

. Be sure to use correct size cuff

. Use the same extremities, the same size cuff, and same position whenever possible when trending values for an individual patient.

Diastolic BP

. Diastolic pressure reaches about 55 mm Hg at one year of age

Gradually increases to 70 throughout childhood

The most common cause of hypertension in children are:

. Anxiety (increases BP in children)

. Renal disease (78%)

. Coarctation of the aorta (2%)

General appearance

To form a general impression of childs health and well-being

To pin-point specific areas that may require more detailed assessment

Initial observations

Degree of illness or wellness

Mood

State of nutrition

Speech, cry, facial expression, posture

Apparent chronological and emotional age

Respiratory pattern

Parent and child interaction

Parent and child interaction

Amount of separation tolerated

Displays of affection

Response to discipline

Look for signs of:

Anxious parents

Disengaged parents

Stressed families

Possible abusive parents (no separation anxiety when removed from parent, or over-affectionate)

Child cries or clings to parent

Ignore the child temporarily

Engage the parents in conversation, then place a small game, toy, or your stethoscope within reach of the child while continuing your discussion

Mental status

Is the child alert?

Able to respond to questions easily?

Assess appropriateness of behavior

Assess memory

Assessing Growth/Body measurements

Height, weight, head circumferenceimportant indicators of growth

Measured and plotted on standard growth charts

These charts are used to determine if the baby/childs growth is falling within the accepted percentile for age

Length

Birth to 36 months

Fully extend the body by:

. Holding the head midline

. Grasping the knees together gently

. Push down on the knees until the legs are fully extended and flat against the table.

Hold pencil at right angle to the table and mark the head and toes (which are pointed toward the ceiling)

Height

Childs back is to the wall, with heels, buttocks, and back of the shoulders touching the wall and the medial melleoli touching if possible.

Check for bending of the knees, slumping of the shoulders, or raising the heels of the feet

Weight

Birth to 36 months, weigh nude

Older children with panties and light gown

Balance (or zero) scale prior to weighing

Head circumference

Measure at greatest circumference

Slightly above the eyebrows and pinna of the ears

Around the occipital prominence at the back of the skull

Compare to 36 months

Denver Developmental

The standard for measuring the attainment of developmental milestones throughout infancy and childhood.

Designed for birth to 6 years

Includes screening for:

Personal social skills

Fine motor adaptive

Language

Gross motor

Denver screening for articulation and eyes

Example of DDST for One year of age:

Personal/Social

Drink from a cup, imitate activities, play ball with examiner, indicate wants, play pat-a-cake

Fine motor/adaptive

Scribbles, puts block in cup

Language

Dada/Mama specific, one word

Gross motor

Stands alone

More on DDST:

Only a measure of developmental attainmentnot a measure of intelligence

Not a highly specific test

Most normal children score as normal

Not very sensitive

Many children with mild developmental delays also score normal

Only a screening test

Other more sophisticated tests are available if delay is suspected even when DDST is normal.

Heart Murmurs

50% of all children develop an innocent heart murmur at some point during childhood. It is usually not something to be overly concerned bout unless there are other symptoms. Must be determines if murmur is normal; therefore always report when one is heard.

Abdomen

Protuberant abdomen is typical in most children until adolescence.

If child is ticklish on palpation, hold his/her hand over yours to reduce apprehension and increase relaxation of the abdominal musculature.

Neuromuscular

If possible, watch the child standing upright. Have them walk, stoop, and touch their toes

Checking for scoliosis.

More tidbits:

Always think of childs development when assessing

Know the BP and pulse variations

When there is an abnormal finding ALWAYS gather more data

Weight is a huge concern for children. Many medications are weight dependent.

The Denver Developmental is not very precise; its more of a screening tool

As it says, the Denver Developmental is only developmentalnot a cognitive or an IQ test.

For breath sounds:

Encourage the child to blow out your light, in your pen light or flashlight. This will almost always produce full inspiration.