HEALTH ASSESSMENT (Physical Examination

and History Taking) – LAB / RLE

STUDENT’S ACTIVITY SHEET BS NURSING / FIRST YEAR
Session # 28

LESSON TITLE: ASSESSING YOUNG AND SCHOOL- Materials:

AGED CHILDREN Book, pen and notebook, index card/class list, speaker and
LEARNING OUTCOMES: LCD projector

Upon completion of this lesson, the nursing student can:

References:
1. Gather a history on young and school-aged children Hogan-Quigley, B., Palm, M. L., & Bickley, L. S. (2017).
2. Perform a developmental assessment on young and school-aged
children.
Bates' nursing guide to physical examination and history
3. Utilize age appropriate techniques to perform a physical examination on taking. Philadelphia: Wolters Kluwer
young and school-aged children.
4. Analyse findings against age appropriate norms and standards.
5. Identify education topics for anticipatory guidance, health promotion and
risk reduction.
6. Apply the learnt theories and body of knowledge.

LESSON PREVIEW/REVIEW (5 minutes)

Recapitulate the previously learnt lessons: ASSESSING INFANTS
MAIN LESSON (75 minutes)
The instructor should discuss the following topics. Instruct the students to take down notes and read their book about this
lesson Chapter 24: Assessing Children: Infancy through Adolescence, please refer to page 809 – 922.

ASSESSING YOUNG AND SCHOOL-AGED CHILD

DEVELOPMENT

EARLY CHILDHOOD: 1 – 4 YEARS MIDDLE CHILDHOOD: 5 – 10 YEARS

Physical Development
 After infancy, the rate of physical growth slows by  Children grow steadily but more slowly.
approximately half. Nevertheless, strength and coordination improve
 After 2 years, toddlers gain about 2 to 3 kg (4.5– dramatically, with more participation in activities.
6.5 lbs) and grow 5 cm (2 in) per year. This is also when children with physical disabilities
 Physical changes are impressive. or chronic illnesses become more aware of their
 Chubby, clumsy toddlers transform into leaner, limitations.
more muscular preschoolers.
 Gross motor skills also develop quickly.
 Most children walk by 15 months, run well by 2
years, and pedal a tricycle and jump by 4 years.
 Fine motor skills develop through neurologic
maturation and environmental manipulation.
 The 18-month-old who scribbles becomes a 2-
year-old who draws lines and then a 4-year-old
who makes circles.
Cognitive and Language Development
 Toddlers move from sensorimotor learning  Children become “concrete operational”—
(through touching and looking) to symbolic capable of limited logic and more complex
thinking, solving simple problems, remembering learning.
songs, and engaging in imitative play.  They remain rooted in the present, with little ability
 Language develops with extraordinary speed. An to understand consequences or abstractions.
18-month-old with 10 to 20 words becomes a 2-  School, family, and environment greatly influence
year-old with three-word sentences, and then a learning. A major developmental task is self-

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 3year-old who converses well. efficacy, or the ability to thrive in different
 By 4 years, preschoolers form complex sentences. situations. Language becomes increasingly
They remain preoperational, however, without complex.
sustained logical thought processes.
Social and Emotional Development
 New intellectual pursuits are surpassed only by an  Children become progressively more
emerging drive for independence. Because independent, initiating activities and enjoying
toddlers are impulsive, temper tantrums are accomplishments.
common.  Achievements are critical for self-esteem and
developing a “fit” within major social structures—
family, school, and peer activity groups.
 Guilt and poor self-esteem also may emerge.
Family and environment contribute enormously to
the child’s self-image. Moral development remains
simple and concrete, with a clear sense of “right
and wrong.”

THE HEALTH HISTORY

 An important and unique aspect of examining children is that parents are usually watching and taking
part in the interaction, providing you the opportunity to observe the parent–child interaction.
 Note whether the child displays age-appropriate behaviors.
 Assess the “goodness of fit” between parents and child. Although some abnormal interactions may
result from the unnatural setting of the examination room, others may be a consequence of interactional
problems.
 Careful observation of the child’s interactions with parents and the child’s unstructured play in the
examination room can reveal abnormalities in physical, cognitive, and social development.
 The health history of the child is similar to the infant health history on pp. 815-816, updated for the
child’s developmental level. A complete history would be obtained if the child is a new patient.
Otherwise, the history is continuously updated at each visit.
 Normal toddlers are occasionally terrified or angry at the examiner. Often, they are completely
uncooperative. Most eventually warm up to you. If this behavior continues or is not developmentally
appropriate, there may be an underlying behavioral or developmental abnormality. Older, school-aged
children have more self-control and prior experience with nurses and are generally cooperative with the
examination. You can detect a surprising amount by using observation.
 Abnormalities detected while observing Play, please refer to page 858
 Some tips for examining young children (1-4 year-old), please refer to page 859

PHYSICAL EXAMINATION

 General Survey and Vital signs (please refer to page 862 – 865)
Somatic Growth (page 862 – 863) Vital signs (page 863 – 865)
 Height  Blood pressure
 Weight  Pulse
 Head circumference  Respiratory rate
 Body Mass Index for Age  Temperature

 THE SKIN, THE HEAD and THE EYES (please refer to page 866)

 THE EYES (please refer to page 866 – 867)

The two most important components of the eye examination for young children are to determine whether
the gaze is conjugate or symmetric and to test visual acuity in each eye.
Conjugate Gaze Visual Acuity Visual Fields

Use the methods described in It may not be possible to measure The visual fields can be examined

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Chapter 11, the visual acuity of children in infants and young children with
younger than 3 years who cannot the child sitting on the parent’s lap.
The Eyes, for adults to assess
identify pictures on an eye chart. One eye should be tested at a time
conjugate gaze, or the position
For these children, the simplest with the other eye covered. Hold
and alignment of the eyes, and
examination is to assess for the child’s head in the midline while
the function of the extraocular
fixation preference by alternately bringing an object such as a toy
muscles.
covering one eye; the child with into the field of vision from behind
The corneal light reflex test and normal vision will not object, but a the child.
the cover–uncover test are child with poor vision in one eye
The overall method is the same as
particularly useful in young will object to having the good eye
that for adults, except that you will
children. covered.
have to make this into a game for
Perform the cover–uncover test as a In all tests of visual acuity, it is your patient.
game by having the young child watch important that both eyes show the
your nose or tell you if you are smiling same result.
or not while you cover one of the
child’s eyes.

 THE EARS, THE NOSE and SINUSES, THE MOUTH and PHARYNX, and THE NECK (please refer to
page 868 – 874)
THE EARS THE NOSE and THE MOUTH and THE NECK
SINUSES PHARYNX
 Tympanic Membranes Inspect the anterior For anxious or young Lymphadenopathy
Until approximately 3 years portion of the nose by children, perform this part of is unusual during
the external auditory canal is using a large speculum the examination toward the infancy but very
directed downward similar to on your otoscope. end, because it may require common during
infants and the auricle must Inspect the nasal parental assistance. The childhood. The child’s
be pulled downward and mucous membranes, young, cooperative child may lymphatic system
backward to afford the best noting their color and be more comfortable sitting reaches its zenith of
view. After about 3 years the condition. Look for in the parent’s lap. growth at 12 years,
ear canal assumes an adult nasal septal deviation The child who can say and cervical or
like slope and the auricle is and the presence of “ahhh” will usually offer a tonsillar lymph nodes
pulled upward and polyps. sufficient (albeit brief) view of reach their peak size
backward. Hold the child’s the posterior pharynx so that between 8 and 16
head with one hand (your left Maxillary sinuses are a tongue blade is years.
hand if you are right- noted on x-rays by age unnecessary. Healthy The vast majority of
handed), and with that same 4 years, sphenoid children are more likely to enlarged lymph
hand pull on the auricle. With sinuses by age 6, and cooperate with this nodes in children are
your other hand, position the frontal sinuses by age examination than sick due to infections
otoscope. 6 to 7. The sinuses of children, especially if the sick (mostly viral but also
 Formal Hearing Testing older children can be child sees the tongue blade bacterial) and not to
Although formal hearing palpated as in adults, or has had previous malignant disease,
testing is necessary for looking for tenderness. experience with throat even though the
accurate detection of hearing cultures. latter is a concern for
deficits in young children, If you need to use the tongue many parents. It is
you can grossly test for blade, push down and pull important to
hearing by using the slightly forward toward differentiate normal
whispered voice test. To do yourself while the child says lymph nodes from
this, stand behind the child “ahhh,” being careful not to abnormal ones or
(so that the child cannot read place the blade too far from congenital cysts
your lips), cover one of the posteriorly, eliciting a gag of the neck.
child’s ear canals, and rub reflex.  Check for neck
the tragus, using a circular Examine the teeth for the mobility.

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motion. Whisper letters, timing and sequence of  In children, the
numbers, or a word and eruption, number, character, presence of
have the child repeat it; then condition, and position. nuchal rigidity is a
test the other ear. This Abnormalities of the enamel more reliable
technique has relatively high may reflect local or general indicator of
sensitivity and specificity disease. meningeal
compared with formal irritation than the
testing. Brudzinski sign
or Kernig sign.

 THE THORAX and LUNGS, THE HEART, and THE ABDOMEN (please refer to page 875 - 879)
THE THORAX and LUNGS THE HEART THE ABDOMEN

Auscultation usually is easiest The examination of the heart and Toddlers and young children
when a child barely notices (as vascular systems in infants and commonly have protuberant
when in a parent’s lap). Let a children is similar to that in adults, abdomens, most apparent when
toddler who seems fearful of the but recognition of their fear, their they are upright. The examination
stethoscope play with it before inability to cooperate, and in many can follow the same order as for
touching the child’s chest. instances, their desire to play will adults, except the child may need
to be distracted during the
make the examination easier and
examination.
more productive.
Most children are ticklish when a
Assess the relative proportion of hand is first placed on their
Use your knowledge of the
time spent on inspiration versus abdomens for palpation. This
developmental stage of each child.
expiration. The normal ratio is reaction tends to disappear,
A 2-year-old may be easiest to
about 1:1. Prolonged inspirations particularly if the child is distracted
examine while standing or sitting
or expirations are a clue to disease with conversation and the whole
on the mother’s lap, facing her hand is placed flush on the
location.
shoulder, or being held, as shown. abdominal surface for a few
Give young children something to moments without probing. For
hold in each hand. They cannot children who are particularly
Young children asked to “take figure out how to drop the object sensitive and who tighten their
deep breaths” often hold their and therefore have no hand free to abdominal muscles, start by
breath, further complicating push you away. Endless chatter to placing the child’s hand under
auscultation. It is easier to let small children will hold their yours. Eventually the child’s hand
preschoolers breathe normally. attention and they will forget you can be removed and the abdomen
Demonstrate to older children how are examining them. Let children freely palpated.
to take nice, quiet, deep breaths. move the stethoscope themselves, Also try flexing the knees and hips
Make it a game. To accomplish a going back to listen properly. Use to relax the child’s abdominal wall,
forced expiratory maneuver, ask your imagination to make the as shown. Palpate lightly in all
the child to blow out candles on an examination work! areas, then deeply, leaving the site
imaginary birthday cake. of potential pathology to the end.
Benign Murmurs
Preschool and school-aged
children often have benign For expected Liver span of
murmurs The most common (Still children by Percussion, please
murmur) is a rade I–II/VI, musical, refer to page 878.
vibratory, early and midsystolic
murmur with multiple overtones, One method to determine the lower
located over the mid- or lower left border of the liver involves the
sternal border, but also frequently scratch test. (Please refer to page
heard over the carotid arteries. 879)
Carotid artery compression will
The spleen, like the liver, is felt

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 usually cause the precordial easily in most children.
murmur to disappear. This murmur
Palpate the other abdominal
may be extremely variable and
structures.
may be accentuated when cardiac
output is increased, as occurs with Palpating for abdominal
fever or exercise. tenderness in an older child is the
same as for the adult; localization
For the location and
of tenderness may help you
characteristics of Benign heart
pinpoint the abdominal structures
murmurs in children, please
most likely to be causing the
refer to page 877
abdominal pain.(Please refer to
page 879)

 MALE and FEMALE GENITALIA (please refer to page 879 – 882)

MALE GENITALIA FEMALE GENITALIA
Inspect the penis. The size in prepubertal The genital examination can be anxiety provoking for the older
children has little significance unless it is child and adolescent (especially if you are of the opposite sex),
abnormally large. In obese boys, the fat for parents, and for you; however, if not performed, a significant
pad over the symphysis pubis may finding may be missed. Depending on the child’s developmental
obscure the penis. stage, explain what parts of the body you will check, and that this
There is an art to palpation of the young is part of the routine examination.
boy’s scrotum and testes because many After infancy, the labia majora and minora flatten out, and the
have an extremely active cremasteric hymenal membrane becomes thin, translucent, and vascular,
reflex that may cause the testis to retract with the edges easily identified.
upward into the inguinal canal and thereby Most children can be examined in the supine, frogleg position.
appear to be undescended. Examine the If the child seems reluctant, it may be helpful to have the parent
child when he is relaxed because anxiety sit on the examination table with the child; alternatively, the
stimulates the cremasteric reflex. With examination may be performed while the child sits in the parent’s
warm hands, palpate the lower abdomen, lap.
working your way downward toward the
scrotum along the inguinal canal. This will  Do not use stirrups, as these may frighten the child. The
minimize retraction of the testes into the following diagram demonstrates a 5-yearold child sitting on
canal. her parent’s lap with the parent holding her knees
A useful technique is to have the boy sit outstretched.
cross-legged on the examining table, as  Examine the genitalia in an efficient and systematic manner.
shown here. You can also give him a  Next, visualize the structures by separating the labia with
balloon to inflate or an object to lift to your fingers as shown below. Labial adhesions, or fusion of
increase intraabdominal pressure. If you the labia minora, may be noted in prepubertal children and
can detect the testis in the scrotum, it is can obscure the vaginal and urethral orifices.
descended even if it spends much time in  Avoid touching the hymenal edges because the hymen is
the inguinal canal. exquisitely tender without the protective effects of
The cremasteric reflex can be tested by hormones. Examine for discharge, labial adhesions, lesions,
scratching the medial aspect of the thigh. and hygiene.
The testis on the side being scratched will  The physical examination may reveal signs that suggest
move upward. sexual abuse, and the exam is particularly important if there
are suspicious clues in the history.

 THE RECTAL EXAMINATION (please refer to page 882)

The rectal examination is not routine. If intra-abdominal, pelvic, or perirectal disease is suspected, the child
should be referred to an advanced care provider.

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 THE MUSCULOSKELETAL SYSTEM (Please refer to page 882 – 883)
 In older children, abnormalities of the upper extremities are rare in the absence of injury.
 The normal young child has increased lumbar concavity and decreased thoracic convexity compared with the
adult, and often a protuberant abdomen.
 Observe the child standing and walking barefoot. You can also ask the child to touch the toes, rise from sitting,
run a short distance, and pick up objects. You will detect most abnormalities by watching carefully from both front
and behind. To indirectly assess the child’s gait pattern, you can also note the soles of the shoes to see which
side of the soles is worn down.
 Children may toe in when they begin to walk. This may increase up to 4 years of age and then gradually
disappear by about 10 years of age.
 Inspect any child who can stand for scoliosis.
 Also, have the child stand straight and place your hands horizontally over the iliac crests from behind.
 Test for severe hip disease, with its associated weakness of the gluteus medius muscle. Observe from behind as
the child shifts weight from one leg to the other. A pelvis that remains level when weight is borne on the
unaffected side is a negative Trendelenburg sign. With an abnormal positive sign in severe hip disease, the
pelvis tilts toward the unaffected hip during weight bearing on the affected side (positive Trendelenburg sign).
Please refer to the illustration in page 883.

 THE NERVOUS SYSTEM (Please refer to page 884 - 886)

Beyond infancy, the neurologic examination includes the components evaluated in adults. Again, you should combine the
neurologic and developmental assessment and will need to turn this into a game with the child to assess optimal
development and neurologic performance.
Perform the DENVER II, up to 6 years, as shown on page 818 - 820. Children usually enjoy this component, and you can
too. Remember that the DENVER II is better at detecting delays in motor skills than in language or cognitive milestones.
Many practitioners now use other standardized developmental instruments.
Sensation Gait, strength, and coordination Deep Tendon Reflexes
 The sensory  Observe the child’s gait while the child is walking and,  Deep tendon reflexes can be
examination can be optimally, running. Note any asymmetries, weakness, tested as in adults. First
performed by using undue tripping, or clumsiness. You can follow the demonstrate the use of the
a cotton ball or DENVER II examination milestones to test for appropriate reflex hammer on the child’s
cotton swab. This is maneuvers such as heel-to-toe walking (photo below), hand to assure the child that it
best performed with hopping, and jumping. Use a toy to test for coordination will not hurt. Children love to
the child’s eyes and strength of the upper extremities. feel their legs bounce when
closed. Do not use  If you are concerned about the child’s strength, have the their patellar reflexes are
pin pricks, which child lie on the floor and then stand up, and closely tested. The child must
may scare the child. observe the stages. Most normal children will first sit up, cooperate and keep the eyes
then flex the knees and extend the arms to the side to closed during some of this
push off from the floor and stand up. examination because tensing
 Hand preference is demonstrated in most children by age will disrupt the results. One
2. If a younger child has clear hand preference, check for trick is to ask the child to
weakness in the nonpreferred upper extremity. pretend the arms or legs “are
asleep.”
Development Cranial nerves Cerebellar function
 You can ask children Please refer to page 885 – 886.  The cerebellar examination
older than 3 years to CN I – ________________ can be tested using finger-to-
draw a picture, copy CN II – ________________ nose and rapid alternating
objects as is done in CN III – ________________ movements of the hands or
the DENVER II, and CN IV – ________________ fingers. Children enjoy this
then discuss their CN V – ________________ game. Children older than 5
pictures to test CN VI – ________________ years should be able to tell
simultaneously for CN VII – _______________ right from left, so you can
fine motor CN VIII – _______________ assign them right–left
coordination, CN IX – ________________ discrimination tasks, as is
cognition, and CN X – ________________ done in the adult patient.
language. CN XI – ________________
CN XII – _______________

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HEALTH PROMOTION AND COUNSELING (please refer to page 886 – 889)

CHECK FOR UNDERSTANDING (10 minutes)

The instructor will prepare 10-15 questions that can enhance critical thinking skills. Students will work by themselves to
answer these questions and write the rationale for each question.

Multiple Choice
(For 1-10 items, please refer to the questions in the Rationalization Activity)

1. What does laxity of the soft-tissue structures of the foot cause in young children?
a. Pronation
b. Pes planus
c. Metatarsus adductus
d. Talipes calcaneovalgus
ANSWER: ________
RATIONALE:______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

2. After the age of 2 years, how much do toddlers grow per year?
a. About 5 cm
b. About 6 cm
c. About 7 cm
d. About 8 cm
ANSWER: ________
RATIONALE:______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

3. You are examining a 3-year-old female patient who becomes very distressed during the examination. What
should you tell the parents?
a. “This behavior shows a lack of discipline.”
b. “This behavior shows inability to adjust.”
c. “This behavior is developmentally appropriate.”
d. “This behavior is socially inappropriate.”
ANSWER: ________
RATIONALE:______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

4. You are speaking to a local PTO about childhood obesity. What would you cite as the consequences of
childhood obesity?
a. Hepatic disease
b. Hypertension
c. Metabolic syndrome
d. Poor self-esteem
e. Pulmonary disease
ANSWER: ________
RATIONALE:______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

5. When examining visual acuity on a 30-month-old child, you should assess for what?
a. Fixation preference
b. “Lazy eye”
c. Hyperopia
d. Myopia
ANSWER: ________

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RATIONALE:______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

6. Ritalin is a medication that is use for attention deficit hyperactivity disorder (ADHD)and may cause:
a. Chronic hypertension
b. Transient hypertension
c. Uncontrolled hypertension
d. Sustained hypertension
ANSWER: ________
RATIONALE:______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7. Pneumonia in young children generally is manifested by the following. Mark all that apply.
a. Fever
b. Tachypnea
c. Bradypnea
d. Increased work of breathing
e. Retractions
f. Dyspnea
ANSWER: ________
RATIONALE:______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. Children in respiratory distress may assume what position?

a. Supination
b. Pronation
c. Sim’s position
d. Tripod position
ANSWER: ________
RATIONALE:______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. Precocious puberty may include the following symptoms. Mark all that apply.
a. Enlarged testicles and penis
b. Breast growth
c. Presence of lymphadenopathy
d. Pubic or underarm hair
e. Rapid growth
ANSWER: ________
RATIONALE:______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

10. An abnormal sign of sever hip disease in which the pelvis tilts toward the unaffected hip during weight
bearing on the affected side.
a. Positive modified Trendelenburg sign
b. Positive Trendelenburg sign
c. Negative modified Trendelenburg sign
d. Negative Trendelenburg sign
ANSWER: ________
RATIONALE:______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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RATIONALIZATION ACTIVITY (DURING THE FACE TO FACE INTERACTION WITH THE STUDENTS)
The instructor will now rationalize the answers to the students and will encourage them to ask questions and to discuss
among their classmates.

1. ANSWER: ________
RATIONALE:___________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________________________________________________________

2. ANSWER: ________
RATIONALE:___________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________________________________________________________

3. ANSWER: ________
RATIONALE:___________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________________________________________________________
4. ANSWER: ________
RATIONALE:___________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________________________________

5. ANSWER: ________
RATIONALE:___________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________________________________________________________

6. ANSWER: ________
RATIONALE:___________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________________________________
7. ANSWER: ________
RATIONALE:___________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________________________________

8. ANSWER: ________
RATIONALE:___________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________________________________________________________

9. ANSWER: ________
RATIONALE:___________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________________________________

10. ANSWER: ________

RATIONALE:___________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

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LESSON WRAP-UP (5 minutes)
Teacher directs the student to mark (encircle) their place in the work tracker which is simply a visual to help students track
how much work they have accomplished and how much work there is left to do. This tracker will be part of the student
activity sheet.

You are done with the session! Let’s track your progress.

MICRO – LECTURE

Please reflect back on the past discussions and see what you can get out of it for yourself.
I learned ______________________________________________________________________________________
I was surprised _________________________________________________________________________________
I am beginning to wonder _________________________________________________________________________
I rediscovered __________________________________________________________________________________
I feel __________________________________________________________________________________________
I promise ______________________________________________________________________________________

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