Assessment

of the Pediatric Patient 1

Pediatrics Health History
*your assessment starts even before you meet the patient —medical history,
*Neonates: Birth – 28 days *Preschoolers: 3-6 years old etc
*Infants : Birth -12 Months *School Age: 6-12 years old *Physiologic Data—Family history and ROS(review of systems)
*Toddlers: 1-3 years old *Adolescents: 12- 20 years old *Developmental Status —Will guide assessment (are they
developmentally appropriate for their age)
*Not uncommon to see individuals pass 21 years of age being treated in *Psychosocial Data —Must be age appropriate
pediatric setting — Achondroplasia/Dwarfism (Developmental o Parents — Guns? Other Children?- (Tells you about their
level/smaller wgt) involvement )
o Adolescents —HEEADSSS Screening tool
(Home environment, Education and Employment, Activities,
Drugs (substance abuse ), Sexuality, Suicidal thoughts,
Safety/Savagery (exposure to violence )

Vital Signs – Normal Limits Blood Pressure

*Take into account child’s age &development—

Heart Rate/Pulse Respiratory Rate

*Under 2 years old *Under 6 years old

o Apical —Must obtain o Feel or observe the
unless contraindicated child’s belly
o Femoral *Over 6 years old
o Brachial o Feel or observe chest
*Over 2 years old rise
o Radial
o Femoral —preferred in *infant apnea is normal —
critical situations should not last more than 20
o Carotid secs

Temperature

*Infant to 2 years —Axillary or Rectal

*2 years to 5 years — Axillary, Tympanic, Oral, Temporal
*5 years and up — *Radial Artery—limb at heart level , Cuff above wrist , Auscultate radial
artery
Normal ranges *Dorsal Pedal Artery—Cuff above malleolus or mid calf , Auscultate
Rectal : 36.6°C — 38°C posterior tibial artery/dorsalis pedis artery *2nd desired
Tympanic : 35.8°C — 38°C *Brachial Artery—limb at heart level, Cuff on upper arm, Auscultate
Oral: 35.5°C — 37.5°C brachial artery *Desired
Axillary : 34.7°C to 37.3°C *Popliteal Artery—Cuff above knee, Auscultate the popliteal artery

*Elevated Axillary temperatures should ALWAYS be confirmed with

rectal temperature (unless contraindicated)
*3 months and younger w/temperature >38°C —medical emergency
*Avoid rectal temperatures —neutropenia precautions, NICU, *Cuff bladder length —-is ≥ 80 percent of the patient's arm
Immunocompromised circumference

*Vitals should be taken in least invasive way to most invasive— *Cuff bladder width —is ≥ 40 percent of the patient's arm
1. RR circumference
2. Pulse
3. Temperature * if you are unable to obtain the correct size, go one size up
4. Vital signs
*Document the patients behavior while obtaining vital signs—sleeping,
crying, yelling, etc.
 Assessment of the Pediatric Patient 2

Age Specific Assessment —less invasive to more invasive Age Specific Assessment
*Assess Fontanelles
*Newborn to Six Months *Six Months to One year *Toddlers *Preschool
• Do not resist • Stranger danger sets in • Do not like to stop • Preschoolers are like box of
examination—observe • Start exam w/play moving! chocolates….
before touching • Use parent to aid in • Use parents help • Allow child to guide the
• Encourage use of comfort examination during exams. sequence of the exam
items or routines • Best to start with • Start with extremities • Use parents help when
• Observe parent interaction extremities • Offer choices only necessary
w/infant • Go with the flow when applicable — • Use positive reinforcement
• Go with the flow never yes or no, ask
which blood pressure
cuff (blue or pink)?
*School age Children *Adolescents Health History Health History
• Cooperative with the • Privacy and modesty are *Data confirmation vs Data *Physiologic Data
exam key Collection -including family history and ROS
• Begin to show signs of • Perform the exam -What type of data can be *Psychosocial Data
modesty WITHOUT parents if researchers prior to patient -Must be appropriate to the patient
• Give thorough patient is comfortable interaction ? *Developmental Status
explanations and offer • Give opportunity for -This will guide the rest of the
choices patient to ask questions -What types of data must be assessment (Your assessment starts
• Educate • Psychosocial assessment freshly collected? BEFORE you greet the patient)
• Let them play with should be directed at
equipment patient *Communication is Key
• Avoid using pet names — -What are some strategies for
sweetly, honey, etc. good communication?
Infant Skull Hair Facial Symmetry Eyes
*Sutures *Inspect *Size, spacing, position and external
• Fibrous connections • Distribution, bald Ø Face should be structures
between the different spots(braids, sleeping on approximately *Colors of the eye
bones of the skull back, cradle cap), symmetrical *Pupillary response and eye moment
• Should be LITTLE cleanliness, color, Ø Deviation in symmetry *Pinpoint —drugs, anesthesia ,
separation and LITTLE variations …LICE can be due to cranial overdose
TO NO overlap *Palpate nerve damage, or an *Enlarge/fixated—one eye fixated
*Fontanelles • Check the scalp for lesions acute condition — (impending herniation) both eyes
• Posterior—closes at swelling from fixated (brain is herniated)
approximately 2-3 infection, trauma, Conditions:
months stroke *Hydrocephalus(sunset eyes)-
• Anterior—closes at inter-cranial pressure
approximately 18 *Eyelid ptosis —droopy eye (can be
months associated w/amblyopia
• Normal —-soft and flat *Strabismus (crossed eyed)
-can cause Or maybe due to amblyopia
-can be categorized by direction of
deviation of eye (esotropia-eyes turn
inward ), exotropia—eyes turn
outward, hypertropia—one eye higher
than other, Hypotropia—one eye lower
than other ) can be constant or
intermittent
*Amblyopia (lazy eye)—can have
other causes aside from strabismus
(Practice )
*must check red reflex in eyes of
infants w/light pen

Ears( low set —genetic/renal) Nose Mouth Neck

*External Structures—start *External features and patency *Lips—Color, moisture and *Inspection—Physical abnormalities,
*Inspect the tympanic *Smell test— (often skipped) shape swelling or lumps and neck strength in
membrane *Sinuses — *Teeth—Condition, number and infants
*Drainage/Discharge—DO NOT color *Palpation—Lymph nodes, Trachea
Flush *Gums and Mucosa—Color and and Thyroid
—Pull pinna back and up —over 3 moisture *Range of motion—Chin to chest
years old *Tongue and Palate—Size,
—Pull pinna back and down— shape, color and cranial nerve XII
under 3 years old *Throat—Color, presence of
*When administering drops as well swelling, symmetry
*Perform hearing assessment
—Rattle/Clap test for infants
 Assessment of the Pediatric Patient 3

—Whisper test for preschoolers o Ethmoid(present/air filled
—Rinne and Weber tests for older at birth),
children o maxillary(present at
birth, air filled until 3 years
old),
o sphenoid(NOT present at
birth, develops at 5 years
old )
o Frontal(NOT present at
birth, forms as 8, develops
by 13 years old )
*Internal Assessment
o Internal—penlight,
Palpation and Percussion
o Flatten bridge —common
in AA and Asians

Skin Inspection Skin Physical Assessment Chest

(Must be Thorough) *Temperature—use the back of
your hand *General —Inspect, Palpation, *Inspection
*Skin Breakdown—pressure *Moisture—Note areas of excessive Percussion, Auscultation -Landmarks—intercostal spaces,
spots, scrapes and cuts dryness or diaphoresis Sternum, Clavicle, Xiphoid process,
*Color variations —Hyper/hypo *Resilience—Skin should be taunt *Abdomen —Inspection, etc.
pigmentation, pallor and rebound quickly when pinched Auscultation, Percussion, -Shape, Symmetry, and Movement —
—Redness, mottling, ecchymosis *Texture—Smooth and Soft Palpation Pectus carinatum & Pectus
*Skin assessment should place *Capillary Refill —Always Check excavatum, Chest movement while
throughout the entire physical (perfusion status) *best to check for *When assessing the abdomen breathing
exam cyanosis Look , Then Listen *Palpation (feeling for crepitus,
*working in pediatrics comes with tactile fermitus)—while child is
an ethical obligation to report - <2 no rma l *in an emergency —Focus ‘breathing quietly and while they are
anything that may be an - 3-5 sec cap refill assessment only repeating a word, Point of Maximum
indication of potential child abuse (Concerning —BP too lo w, Intensity (PMI)
*Your job is not to decide whether dehydratio n, Hypovolemic *PMI <7 years old – 4th ICS medial to
or not abuse is present, your job is shock, Cardio genic sho ck, left midclavicular line
to decide whether or not a call Septics ) *PMI > 7 years old -5th ICS left
should be placed to child protective midclavicular line
services (cps) • Heave—sign of left
ventricle hyper trophy , is
palpable —feels like
abnormally large heart
beating (can be seen if
severe )
• Thrill —palpable
murmur(vibratory)
*Percussion
Chest and Lungs Chest and Heart Abdomen Genitalia

*Auscultation—most important *Auscultation—Assess both rate *Inspection— Symmetry, shape *Use judgement when determining
part of the chest examine and rhythm, Use both sides of the and presence of abnormalities whether or not genitals need
—Evaluate: stethoscope *Auscultation— How long do assessment
o Respiratory Rate • Diaphragm for higher you need to listen before
o Rhythm pitched sounds (S1 and S2) concluding bowel sounds are — Which patients should have
o Depth • Bell for lower pitched absent?— Full 5 minutes a genital exam?—diaper
o Breath Sounds sounds/light pressure (S3 *Percussion— Dullness vs wearing
*perform when the child is calm and S4) Tympany — Which patients do not need
and quiet *Palpation— Light palpation vs an exam? —patient being
*Perform again when the child is Deep palpation seen for something
crying—fremitus and vocal —start examination in lower unrelated to genitalia
resonance quadrant
—-ask patient to bend knees - *Assess appropriate development and
makes abdomen less ridge growth based upon patient’s age

*Infants/toddlers —round belly

*Tanners stages
*Children/adolescence - flat belly

*Umbilicus—hernia common (be

sure you can push it in)
 Assessment of the Pediatric Patient 4

*Infants -rounded chest (anterior + *use landmarks to approximate best
posterior =lateral diameter) location for auscultation gardens
potential murmurs
*> 2 years – Lateral diameter
greater than anterior
*Older preschool -Oval shaped
chest

*Barrel chest is abnormal —

agnostic cystic fibrosis

*Infants nose breather until 3

months old , after 3 months uses
diaphragm to breath until 6 years
old Stage 1: <10 years old -no hair/flat
*Signs of respiratory distress— chest
grunting, retracting , seesaw *Aortic Area- 2nd right intercostal Stage 2: 10 -11 years old -small
breathing(obstruction) space(1) amount/downy hair /chest buds
*Pulmonic Area- 2nd left intercostal Stage 3: 11-13 years old —
*If infant seemingly in respiratory space (2) coarse/curly scant terminal hair /
distress (nasal flaring, muscle *Erb’s point- 3rd left intercostal chest slightly bigger
retraction ) and cold suspected — space/left stern alone border (3) Stage4: 13-14 years old —adult like
suction nose , clear nasal passage *Tricuspid area- 4th intercostal but not on thighs / noticeable breast
and re-assess space (left lower sternal border Stage 5: > 14 years old —extends to
*Mitral area/Apex- 5th left medial thigh/breast continues to grow
*Fine crackles—Soft, high intercostal space (midclavicular line)
pitched, brief
*Coarse crackles—Louder, low *S1 (Apex-Mitral/Tricuspid)
pitch, longer than fine crackles *S2 (Base-Aortic/Pulmonic)
*Wheezes— Bronchiospasm—
musical, continuous, rapid
movement of air through narrow
passages
*Rhonchi— continuous low pitch
snoring
*Stridor —inspiratory wheeze/
upper airway ( louder at
neck(trachea) vs chest)
Extremities Newborn feet variation Extremities—Normal vs Back and spine
*Movement *Metatarsus adductus—most Abnormal
*Range of motion—no limitation common (genetic /fetal position) *Genu Varum (Bow Legs) *Appearance—assess for any spinal
—Active (child moves) dimples
—Passive (you moves) —check hip
flexion (developmental hip
dysplasia )
*Gait
*Muscle Movement —have
patient stand on one foot, then the
other, iliac crest should stay
leveled —if opposite, possible hip
dislocation -inward turning of forefoot at instep
—Should have the same number of —passive range of motion
skin folds on each leg , if uneven ,
hip dislocation /difference in leg -Under developed abdominal and
length *Talipes Equinovarus (Club foot) leg muscles
—Refer to orthopedics( serial -Normal until 2-3 years old , after
*Syndactyly — 3 Blount disease (growth disorder -most are benign —X-ray
of the tibia suspected )
-Sacral dimples w/ hair, skin tags,
discoloration may/may not be normal
(evaluate because can be indicative of
spinal bifida —neural tube defect
where portion of underdeveloped tubes
fail to close properly causing defects in
spinal chord
casting)
*Posture—Observe from the front ,
both sides and back
 Assessment of the Pediatric Patient 5

*Polydactyly—extra digit *Genu Valgum (knock-knees) *Spinal alignment—have child been
over

-Normal until 2-7 years old , after

7 close observation
Nervous System Measurements Infant Skull Fontanelles
*Circumference *Sutures *Sunken
*Cognition function, Head Circumference (6 month – 1 • Fibrous connections Fontanelle
*Cerebellar function,*Cranial year) between the different -Dehydration—
nerve/ Sensory function— does -Birth – 1 year (head circumference bones of the skull assess feeding,
not need to be a separate larger than chest) • Should be little to no wet diapers,
assessment -1 years old ( head circumference and overlap bowel
*Reflexes—Consider chest equal) *Fontanelles movements,etc.
incorporating a separate -1 years and older (Chest larger than • Normal: Soft and flat
assessment head • Poseterior Fontanelles *Raise
Abdominal circumference — —closes at 2-3 months Fontanelle
neonates in NICU (immature GI • Anterior Fontanelles -Intracranial hemorrhaging
System) —closes at 18 months -Encephalitis
*Length • Fully closed before (brain
*Height —standing scale after 2-3 time —limited brain infection)
years old growth/genetic -Meningitis
*Weight —nude/empty diaper deficits—notify (inflammation
provider of the brain and
Spinal cord
resulting in
Viral/bacteria
infection
-Hypoxic
(ischemic encephalopathy)
-Tumor
-increased intercranial pressure

Patterns of Accidental Bruising Patterns of Brusing Report to CPS Do not Report to CPS

*Common in bony prominences *Common in soft tissue —-use be

a pattern

*if abuse suspected—follow

chain of command (nurse
supervisor, social worker, etc)
 Assessment of the Pediatric Patient 6

Pain Scales
*NIPS—Neonatal Infant Pain Scale (Birth to 6 weeks) *FLACC (Face, Legs, Activity , Cry, Consolability— Non-verbal patients (6 weeks and up)
0 1 2
NPS Point Points Points
Face Relaxed Contracted ——
Expression

Cry Absent Mumbling Vigorous

Breathing Relaxed Different than —-

basal ;

Arms Relaxed Flexed/Stretched —-

Alertness Sleeping/Calm Uncomfortable —-

Maximal score of 7 points, considering pain >4

*Faces ( 3 and up). *Numerical ( 5 and up)

Pain scale examples *12 year old male admitted for cellulitis —-Numerical *4 week old NICU patient —-NIPS
*17 year old non-verbal pt w/developmental delay —-FLACC. *4 year old girl admitted after a T&A—Faces

Physiologic Indicators *Heart Rate(increase) *Temperature (increase) *Blood Pressure( increase/decreased)

of Pain *Respirations (increased/decreased) * Pupil dilation *Diaphoresis
Pharmacologic Pain *Non-Pharmacologic Pain *Pharmacologic Pain Management *Medications that Compliment
Management Management pain Management
*Comfort—hugs, rocking, skin to skin, ● Non-opioids *Gabapentin (Neurontin) – anti-
swaddling ○ For mild to moderate pain convulsant—Used to treat nerve pain
*Distractions—Have parents distract ○ Acetaminophen
child while procedures are being ○ Non-steroidal anti-inflammatory *Diazepam (Valium)-
performed drugs (NSAIDs) benzodiazepine—Used to treat
*Relaxation—Breathing techniques ○Acetylsalicylic acid (aspirin) is anxiety
and muscle contraction/relaxation NEVER given to pediatric patients
*Hot and Cold Packs—Never directly for pain *Ondansetron (Zofran) –
on skin ● Opioids antiemetic—Used to treat nausea ○
*Sweet-Ease!— For infants under 1 ○ Morphine, Hydromorphone,
years old (check with parents, order Methadone, Fentanyl, *Dexmedetomidine (Precedex) –
and hospital policies) Oxycodone alpha-2 agonist—Mimics the natural
● Combination (opioid/non-opioid) sleep pathway
therapy
● Patient Controlled Analgesia
(PCA)
● Regional or local anesthetic
 Assessment of the Pediatric Patient 7

*Parents can give oral and
Gastrointestinal medication w/
close observation —No IV, PCA
Infant reflexes *Stepping (Birth- 4 weeks)—infant steps forward when held upright

*Palmar grasp (Birth -3 months )—infant grasp s objects when placed in hand

*Tonic neck reflex(fencer position) (Birth- 3/4 months)—When i nfa nts head is to one side, infant extend s arm and leg on
that side and fl exes arm and leg on op posi te site

*Sucking & rooting (Birth- 4 months)—infant turns head to stro ked side a nd begins sucking

*Moro reflex (Birth-4 months)—head and trunk of i nfant (in semi-si tting position) allo w to fa ll back up to 30 degrees —
infants arms and legs symmetrically extend, then abduct while finger s spread to fo rm c shape

*Startle reflex (Birth- 4 months)—infant abducts arms at elbo ws and hands remain clenched to clap ping hands or loud noise

*Plantar grasp (Birth- 8 months)—infant toes curl do wnward when sol e of foot is stimulated

*Babinski reflex (Birth- 1 year)—infant toes curl upward when outer edge of sole is stimulated