Chapter 21: Health Assessment

Question 1

Approach to the Physical Assessment

Answer 1

-based on the child’s age, cognitive level, and degree of illness
-infants can be examined head to toe without difficulty; some are fearful of any examiner and are uncooperative; others seem to enjoy the experience as something new
-exam starts with LEAST invasive actions and concludes with the most distressful actions
>ex: easier to examine the posterior lung fields with the caregiver holding the child on her lap early in the exam while leaving the the examination of the ears and mouth for the end of the exam

Question 2

Anthropometric Measurements

Answer 2

-before the physical assessment, vital signs and anthropometric measurements (growth measurements of length, weight, and head circumference) are taken and recorded
>Length, Weight, BMI, Head Circumference, and Skinfold Thickness Measurements)

Question 3

Anthropometric Measurements: Length

Answer 3

-Infant: taken lying supine on a measuring tray or board; if measuring board not available, nurse holds the head midline while an assistant holds the hips and knees extended flat on a paper covered table
-points are marked at the top of the head and the heels of the feet; distance between markings is measured
>for older child, a stadiometer (device used to measure a standing height) is used; child removes his shoes and stands with his back to the stadiometer, with the back of the heels and shoulders touching the wall

Question 4

Anthropometric Measurements: Weight

Answer 4

-Infant: measured using an infant scale lined with a thin paper cover; after scale setting is balanced, the infant’s clothing is removed and the child is weighed in either a supine or sitting position; nurse protects the child from an accidental fall by placing a hand over the infant without direct contact
-older children: weighed on a standing scale
>same scales should be used to measure height and weight at each visit

Question 5

Anthropometric Measurements: BMI

Answer 5

once weight and height are assessed, body mass index (BMI) can be calculated
-BMI used to assess total body fat and nutritional status
-In children, BMI is represented as a percentile, allowing a comparison to other children of the same age and gender
>BMI assessed at least once a year at the annual well-child appointment
-A BMI-for-age plotted below the 5th percentile = underweight
-A BMI-for-age between the 5th and less than the 85th percentile = healthy weight
-A BMI-for-age between the 85th and 95th percentile =overweight
-A BMI-for-age greater than 95% = obese
>calculated by dividing the weight (in kg) by the meter height squared

Question 6

Anthropometric Measurements: Head Circumference

Answer 6

• for children ages 3 and under, head circumference measurements are done at routine well-child visits
• the head’s largest circumference is measured by placing the tape over the lower forehead, above the pinna of the ears, and over the occipital prominence
• recorded in cm and displayed as a percentile
• evidence of growth within the percentiles remains consistent overtime, with normal values according to age and gender reflecting normal development
• when there is deviation, either below or above the percentile from the previous visit, it may = a potential problem; nurse informs primary care provider of findings

Question 7

Anthropometric Measurements: Skinfold Thickness Measurements

Answer 7

• not used in routine assessment
• taken when child is obese
• denotes the degree of adipose tissue or body fat
• skinfold measurements can add to the objective assessment of obesity in children and adolescents who are at risk
• measure the degree of skinfold thickness in the triceps or abdominal areas
• the average of 2 consecutive readings is used as the skinfold thickness measurement

Question 8

Vital Signs: Temperature

Answer 8

-variety of digital and tympanic thermometers are available
-route used for assessing temperature depends on the age and developmental level of child
>Newborn Temp= axillary; rectal temp not routinely measured (if indicated, do not insert more than 1/2 inch)
>Older children= tympanic membrane or temporal temperature

Question 9

Vital Signs: Pulse

Answer 9

• HR variable and changes with illness
• apical pulse counted for 1 minute while infant/child is quiet
• uncooperative infant: femoral arteries are palpated in the inguinal area, or the brachial arteries in the antecubital fossa

Question 10

Vital Signs: Respirations

Answer 10

• counted for 1 full minute
• when infant or child is not crying
• good time to count= when sleeping or resting quietly in parents arms
• wise to start the vital sign assessment with respiration
• great deal of variability in respiratory rate in children
• infants and young children are diaphragmatic breathers; can visually count respirations by observing the abdomen as child breathes

Question 11

Vital Signs: Blood Pressure

Answer 11

• measured during well-visits or routine physicals when child reaches 3 years old
• important in cardiac, pulmonary, or kidney disease, dehydration, or complaints of dizziness regardless of age
• selection of cuff size is important; width of the bladder is 40% and the length is 80% of circumference of the arm

Question 12

Average Range for Vital Signs: Infant

Answer 12

> HR: 80-150
RR: 25-55
BP Systolic: 65-100
BP Diastolic: 45-65

Question 13

Average Range for Vital Signs: Toddler

Answer 13

> HR: 70-110
RR: 20-30
BP Systolic: 90-105
BP Diastolic: 55-70

Question 14

Average Range for Vital Signs: Preschooler

Answer 14

> HR: 65-110
RR: 20-25
BP Systolic: 95-110
BP Diastolic: 60-75

Question 15

Average Range for Vital Signs: School-age

Answer 15

> HR: 60-95
RR: 14-22
BP Systolic: 100-120
BP Diastolic: 60-75

Question 16

Average Range for Vital Signs: Adolescence

Answer 16

> HR: 55-85
RR: 12-18
BP Systolic: 110-125
BP Diastolic: 65-85

Question 17

Physical Assessment: General Impression

Answer 17

as the nurse meets the child and the parents and engages in conversation with them, an impression begins to take form

• uniqueness of child is portrayed
• reflection of the child’s family life becomes evident
• note behaviors of the child as he interacts with parents
• how does the child react to questions
• what is the child’s speech like
• is the child quiet, pleasant, talkative, uninterested, or angry
• for the younger child, does the child listen to parents, interact in a meaningful way, or engage in age-appropriate behavior?
• hygiene and nutritional status; is the child clean and appropriately dressed for the season; body size, skin color, eyes, and the condition of hair are observed for evidence of good overall nutritional status

Question 18

Physical Assessment: Skin Assessment

Answer 18

-color, turgor, and lesions
-skin color reflects ethnicity, diet, disease and injury
-variations in tone are a result of genetic composition
-Carotenemia, a benign yellowing of the skin caused by excessive carotene in the blood, may be present in a child with a diet high in yellow and orange vegetables, or yellowing of the ski and sclerae may = dysfunction of the liver
-pallor = anemia
-cyanosis = a compromised cardiorespiratory state
-petechial lesions = an infectious process or a blood disorder
-ecchymotic lesions= blood disorder or be a tell-tale sign of past accidental or non-accidental injury
>skin examination concludes with the inspection of the texture of hair and the condition of the scalp, palms, and nails
-cradle cap is common
-child monitored for lice or ticks

Question 19

Carotenemia

Answer 19

a benign yellowing of the skin caused by excessive carotene in the blood
-may be present in a child with a diet high in yellow or orange vegetables

Question 20

Assessing Child’s Skin Turgor

Answer 20

-for evidence of dehydration
>grasping a small area of skin and pulling up; once released, the skin should quickly return to its normal position
-skin that remains in the “tenting” position for several seconds = absence of skin turgor or presence of skin turgor with inadequate hydration

Question 21

If Rash is present or Jaundice is suspected

Answer 21

-nurse determines if the skin blanches, or turns pale
-nurse applies pressure to the skin with the thumbs about 1 to 2 inches apart; this presses the normal pink and darker colors out
>in the presence of jaundice, there is a yellowish underlying color
>Petechial lesions do not blanch, which may indicate a serious bacterial infection in an ill child; notify primary health-care provider immediately

Question 22

Cradle Cap

Answer 22

• common in newborns and infants

- thick, crusty scales over scalp

Question 23

Assessment of Nails

Answer 23

-normal = pink and convex, with white edges extending over the end of fingers
>in children with cardiac disease, nails examined for clubbing
>nail biting is a nervous habit that is e/b very short nails without the normal white edges

Question 24

Assessment of Palms

Answer 24

examined for normal flexion creases
-Normal = 3 creases
-in a small section of the population, the 2 horizontal creases fuse to form a single horizontal palmar crease; common finding in genetic disorders (Down Syndrome)
>if palmar crease is evident in only one hand, child may have no genetic disorders

Question 25

Melanin

Answer 25

pigment that gives color to skin and hair and protects against UV rays

Question 26

Head Assessment

Answer 26

-observed for symmetry and shape
-beyond the newborn period, head shape abnormalities in the infant may be caused by craniosynostosis (a premature fusing of one or more of the cranial sutures, or by gravitational influences caused by the infant’s head being kept in the same position for an extended period of time)
-an odd head shape can develop because of the malleability of the skull bones
-skull palpated to evaluate fontanelles, sutures, contusions, or other swellings
-face is examined for general appearance and the comparison of features to those of parents
>unusual features are noted, such as micrognathia (shortened chin), low-set ears, flattened nasal bridge, enlarged or protruding tongue, allergic shiners (dark, under-eye rings), or a wide and flattened philtrum (vertical groove from the bottom of the nose to the upper lip)

Question 27

Craniosynostosis

Answer 27

a premature fusing of one or more of the cranial sutures, or by gravitational influences caused by the infant’s head being kept in the same position for an extended period of time

Question 28

Supine Position for Sleep

Answer 28

• reduced the incidence of sudden infant death syndrome

- but, can be at increased risk for deformational posterior plagiocephaly, or flattened, of the occiput

Question 29

Micrognathia

Answer 29

shortened chin

Question 30

Allergic Shiners

Answer 30

dark, under-eye rings

Question 31

Philtrum

Answer 31

the vertical groove from the bottom of the nose to the upper lip

Question 32

Assessment of the Fontanelles

Answer 32

-Fontanelles are fibrous-membrane covered areas where two or more skull bones converge
-there are 6
-2 most commonly evaluated are posterior and anterior
>posterior fontanelle closes within 1 to 3 months after birth
>anterior fontanelle (diamond-shaped) remains open until 12 to 18 months of age
-anterior fontanelle is most significant for evaluation; a larger AF or one with a delayed closure may signify a infant with hypothyroidism, Down Syndrome, achondroplasia (congenital dwarfism), or increased intracranial pressure
>assess the fontanelles when the infant is held in a sitting position
-depression of AF can indicate dehydration
-fullness of the AF can indicate increased intracranial pressure

Question 33

Neck Assessment

Answer 33

-Lymph nodes palpated, starting at preauricular area, to postauricular area, and then to occipital nodes
-tonsillar nodes at the angle of the mandible are examined, followed by the submandibular and submental nodes under the chin, the cervical chain of lymph nodes, and the supraclavicular area
>size, shape, mobility, and tenderness documented
-common for young children to have palpable, painless, movable nodes up to 1 cm in diameter
-pain upon palpation may = upper airway infection
-trachea palpated for midline placement and masses; a lateral deviation may be caused by a mass or collapsed lung
-thyroid gland examined for enlargement, nodules, and goiters

Question 34

Eye Assessment

Answer 34

-assessment of symmetry, shape, and placement in relation to the nose
-assess for symmetry and size of the pupils and their response to light
-the conjunctiva and lids are observed for conjunctivitis, styes, or chalazions (small discrete swellings of the upper lid that develop when a Meibomian oil gland becomes blocked)
-sclerae inspected for color
-nurse notes erythema, swelling, or discharge from the eye
-documentation of the presence of discharge includes type (e.g. watery or purulent), color, amount, and associated symptoms
>treatment depends on the cause, which may be bacterial, viral, or an allergen

Question 35

Testing for Ocular Alignment

Answer 35

• Hirschberg corneal light reflex test; light is shone directly into the child’s eyes and note is taken of the position of the corneal light reflection in both eyes; reflection should fall in the same location on the cornea of each eye; displacement in one eye is indicative of strabismus
• Cover-uncover test; child is asked to focus on a distant object across the room; nurse covers the first eye while watching the second eye for any movement, the cover is then removed from the first eye, which is observed for any movement; if movement is detected, ocular alignment is intact; exam repeated on opposite eye
• Red Reflex; viewing the pupil through an ophthalmoscope from a distance of 10 inches; if pupil is red= normal; a white retinal reflex may = cataracts, retinoblastoma, or chorioretinitis

Question 36

Testing for Color Blindness

Answer 36

• should be screened once during the school-aged years for the ability to discriminate between red, yellow, and green
• use of Ishihara pseudochromatic charts; each chart consists of a field of colored dots, each with a number in the center of the color field: inability to identify these numbers = color blindness

Question 37

Ear Assessment

Answer 37

-external ears examined for size, shape, placement, pain, and presence of drainage from ear canal
-low-set ears may = a congenital anomaly such as Down Syndrome
-to assess for pain, the nurse moves the pinna of the ear up and down
-if complains of pain when pressure is applied to the tragus, the canal is examined for evidence of otitis externa
-Cerumen (ear wax) may be seen on the external ear or in the external canal with an otoscope
-purulent drainage may = a foreign body in the external ear canal or a ruptured tympanic membrane
>any clear drainage from the ear, particularly after head trauma or with cranial infections, should be reported as this fluid may indicate a cerebrospinal fluid leak
-tympanic membrane is examined for presence of normal anatomical landmarks; visual loss of landmarks may be b/c of erythema, fullness behind the tympanic membrane, inflammation, purulent exudate, or fluid
>because of the anatomical structure of their ears, infants and young children are prone to developing otitis media
>eustachian tubes are shorter and more horizontally positioned, enabling viruses and bacteria to travel to the middle ear; infants who are breastfed, do not attend day care, and are fed in an upright position have decreased rates of otitis media

Question 38

Use of a Small Cotton Swab to clean the ear

Answer 38

-small cotton swab should be used to clean only the external ear, not the ear canal
-when small cotton swab is sued in the ear canal, the cerumen is pushed back into the canal where it cannot be moved out by the mechanical action of the tiny ear hairs
>cerumen tends to dry, harden, and become difficult to remove over time; impacted cerumen in the ear canal may lead to hearing deficits

Question 39

When using an Otoscope

Answer 39

• canal should be positioned for the optimal viewing of the tympanic membrane and canal
• the pinna is pulled down and back for children younger than 3 years
• the pinna is pulled up and back for older children
• child positioned to prevent injury and discomfort
• can take place with the child sitting on parent’s lap or in supine position
• holding the otoscope upside down allows the nurse the use of one hand to help hold the child’s head and the other to position the stem of the otoscope against the child’s head for more stability

Question 40

Hearing Screening

Answer 40

-in older cooperative child: tuning fork is used to assess bone and air conduction of sound
>Weber Test: involves striking the tines of the tuning fork and immediately placing the handle of the tuning fork midline on top of the child’s head; nurse asks which ear he hears the sound best; if normal= sound heard equally in both ears; sound heard in one ear better than other = conductive hearing loss
>Rinne Test= assesses air and bone conduction of sound; bone conduction tested by placing the handle of the vibrating tuning fork on the mastoid process behind the ear; child informs the nurse when he no longer can hear the sound of the tuning fork and the nurse moves the tines forward to within 1 to 2 inches of the auditory meatus; child should hear the air-conducted sound of the vibrating tines twice as long as he heard the bone-conducted sound
>Tympanometry= assesses the status of the middle ear; nurse places a probe into the ear canal; amount of sound that is reflected by the tympanic membrane is measured along with the pressure in the canal; the tympanogram delineates the movement of the eardrum as stiffness, floppiness, or normal eardrum movement
>early detection of hearing loss is important to prevent delayed hearing, speech, and language development
>hearing loss may affect both academic success and psychosocial development of the child

Question 41

Nose/Sinus Assessment

Answer 41

-nasal mucosa inspected for color and inflammation
-pale, boggy mucosa is a typical finding in a child with allergic rhinitis; nasal mucosa appears erythematous with upper respiratory infections
-note bleeding of mucosal lining, may = injury
-purulent drainage may = viral or bacterial condition
-purulent discharge occurring in one nostril is suggestive of a foreign object in the other nostril
-septum inspected for midline position
-maxillary sinuses are detected via x-ray by age 4, with other sinuses radiologically evident by age 6
>areas palpated for tenderness, using the thumbs of both hands and holding the child’s head

Question 42

Throat/Mouth Assessment

Answer 42

• saved for last in younger, less cooperative children
• nurse may ask the child to see “all of the tongue”
• eliciting the sound “eeehh” flattens the tongue better than “aaahh”, and visualization of the posterior pharynx is possible without use of a tongue blade
• the palate, uvula, tonsils, and mucous membranes are observed and assessed for color, exudate, and odor
• lips observed for shape, symmetry, color, dryness, fissures at the corners of the mouth indicative of vitamin B2 (riboflavin) deficiency, and clefts
• teeth are inspected for number present, condition, color, alignment, and caries
• tooth eruptions occur at varying rates; expect one tooth per month after 6 months of age until 20 are in place
• gingival tissue is inspected for color and condition; same color as surrounding mucous membranes and should not be hypertrophied or show evidence of bleeding

Question 43

Chest Assessment

Answer 43

• inspects for size, shape, symmetry, respiratory effort, and breast development
• a chest that is larger on the left than on the right may = an enlarged heart or collapsed right lung
• pectus carinatum (protrusion of chest) and pectus excavatum (abnormal depression of the lower portion of the sternum) are abnormal chest shapes caused by sternal deviations
• normal breast development begins in girls between 10 and 14 years of age
• boys undergo breast changes, and many show evidence of breast development

Question 44

Lung Assessment

Answer 44

-best auscultated sitting
-take slow deep breaths through an open mouth
-auscultates the five lobes of the lungs, anteriorly and posteriorly, beginning with the apices and then moving side to side to compare bilateral lung sounds
>best done early in the examination of an infant when they are quiet
-direct observation can help determine inadequate oxygenation status; a child with tachypnea (respiratory rate 80 to 120), shallow breathing, and use of accessory muscles = respiratory distress
-quiet breath sounds with an increased work of breathing means that air is not entering into the lung fields
-alteration in depth, hyperpnea (too deep) is associated with fever
-hypopnea (too shallow) associated with central nervous system depression
-child in respiratory distress sits in a tripod position sitting upright, leaning forward on outstretched arms with the jaw thrust forward

Question 45

Breath Sounds

Answer 45

-normal= bronchial, bronchovesicular, or vesicular
-adventitious= crackles, wheezes, and rhonchi
-Bronchial: loud, high-pitched, and heard over trachea; inspiratory and expiratory sounds equal in length
-Bronchovesicular: intermediate intensity and pitch, equal inspiratory and expiratory phases; best heard between the scapulae and over mainstem bronchi
-Vesicular: heard throughout lung fields; soft, low-pitched; longer inspiratory phase than expiratory
>decreased or absent breath sounds indicate a serious condition such as asthma, atelectasis, emphysema, pneumothorax, or acute respiratory distress syndrome (ARDS)

Question 46

Important Respiratory Signals

Answer 46

• noisy breathing or snoring (air passing through a narrowed upper airway) may = nasal polyps, foreign body obstruction, choanal obstruction, hypertrophied adenoid tissue, or obesity
• grunting is caused by the glottis closing at the end of expiration and may = respiratory distress of pneumonia
• nasal flaring happens on inspiration and is a form of accessory muscle use
• coughing is a normal process that clears the throat but can indicate infection, asthma, lung disease, or sinusitis
• Stridor (a high-pitched, harsh sound occurring during inspiration) results from air moving through a narrowed trachea and larynx and can indicate croup
• wheezing (musical noise) results from air moving through mucus or fluids in a narrowed lower airway that is associated with asthma
• hoarseness is a rough quality in the child’s voice and can mean that airway is inflamed
• crackles is a fine, high-pitched sound heard on inspiration or expiration produced by air passing over retained airway secretions or the sudden opening of collapsed airways found in several respiratory conditions
• rhonchi are a low-pitched wheezing, snoring, or squeaking sound indicating a partial airway obstruction. Mucus or other secretions in the airway, bronchial hyperactivity, or tumors that occlude respiratory passages can cause airway obstruction
• color changes in the skin (e.g. pallor, mottling, and cyanosis) indicate cardiac involvement
• chest pain is caused by alteration in chest structures, non-pulmonary involvement, or variety of respiratory conditions
• clubbing (excessive growth of the soft tissues at the ends of the fingers or toes) is associated with hypoxia and pulmonary disease

Question 47

Cardiac Assessment

Answer 47

-chest inspected for symmetry and pulsations, and all peripheral pulses are palpated
-in slim children, pulsations from heart may be visible
-begins palpation with the carotid pulse, making note of any distended neck veins, and continues with brachial and radial pulses
-capillary refill assessed
-assess any changes in fingernails (e.g. clubbing)
-peripheral edema and cyanosis are assessed during palpation of the femoral, popliteal, posterior tibial, and dorsalis pedis pulses
-continued palpation of the chest can identify the presence of thrills, which are a consequence of blood flowing rapidly from high pressure to low pressure; the rough vibrating sensations are felt by placing the palm of the hand over the chest
>some ventricular septal defects result in thrills at the lower left sternal border
>pulmonary stenosis may cause a thrill at the upper left sternal border
>aortic stenosis is palpable in the suprasternal notch

Question 48

Auscultation of Heart Sounds

Answer 48

• S1= “lub”, reflects closure of mitral and tricuspid valve
• S2= “dub” reflects closure of the pulmonary and aortic valves and signifies the beginning of atrial contraction or diastole

Question 49

Abdominal Assessment

Answer 49

-lie quietly in a supine position
-begins with inspection of the abdomen and its contour, which may be flat, round, protuberant, or scaphoid (shaped like a boat)
-visible peristalsis may be noted in a thin child and should be documented and reported
-the umbilicus and inguinal areas are inspected for bulging, and a note is made of any scars, rashes, lesions, or piercings
-abdomen divided into 4 quadrants: RUQ, LUQ, RLQ, and LL
-after inspection, abdomen is auscultated in all 4 quadrants to assess for bowel motility; high-pitched sounds occur every 5 to 10 seconds; absence of bowel sounds or high-pitched tinkles in the presence of abdominal distention and/or peritoneal signs suggest an acute abdominal condition
>a child who is experiencing signs of bowel obstruction has absent bowel sounds below the obstruction; nurse must listen for up to 1 minute before determining the absence of bowel sounds in any one quadrant
-palpation of the abdomen occurs last so as not to disrupt bowel sounds; divided into light palpation and deep palpation; light= assists in identifying tenderness, deep= useful when assessing for the liver, kidneys, spleen, inguinal lymph nodes, and abnormal masses; if a mass is encountered, it is reported, noting its location, size, shape, consistency, and tenderness
-throughout assessment, nurse observes for changes in facial expression, guarding, and tensing of the abdominal muscles

Question 50

Nursing Insight: Palpation of the Abdomen

Answer 50

to minimize the sensation of tickling during palpation of the abdomen, the nurse may palpate through a layer of light clothing or place the child’s hand on top of the nurse’s hand while palpating

• to relax the abdominal muscles, bend the child’s knees until feet are flat on the exam table
• palpate any tender or painful areas last
• the suprapubic area may feel tender if the child’s bladder is full; consider child empty bladder

Question 51

Assessment: Female Genitalia

Answer 51

-femoral nodes should be palpated; enlarged= presence of STI’s or something as simple as an inflamed hair follicle after shaving
-external genitalia (the labia minor, labia majora, clitoris, vaginal opening, and urinary meatus) are examined for the presence of lesions, discharge, and irritation
>a malodorous vaginal discharge may indicate the presence of a foreign body, or infection
>first gynecological visit between ages 13 and 15 and first pelvic exam at 21 years of age or sooner if sexually active

Question 52

Assessment: Male Genitalia

Answer 52

-penis expected for size, presence of foreskin, placement of urinary meatus, and signs of inflammation and infections
-penis should be straight, the glans clean and smooth, and the slit-shaped urinary meatus near the end of the glans
-palpate penis for masses and nodules
-inspect scrotum for size, shape, symmetry, and presence of testicles
-enlarged scrotum should be transilluminated to see for hydrocele (accumulation of serous fluid in the scrotum) versus a possible hernia
-nurse places a penlight under the scrotum; scrotum will exhibit a red glow with a hydrocele but not with a hernia
-testicles palpated for size and shape; are roughly the same size and smooth in contour
-a testicle that is hard or in which a nodule is palpated must be reported to rule out a tumor
-also report if one or both testicles have not descended
>testicular self-examination by age 14

Question 53

Assessment: Anal Examination

Answer 53

not routinely examined unless indicated by abdominal, bowel rectal, or stool abnormalities

• side-lying position with knees flexed
• examined for anal placement, lesions, trauma, irritation, fissures, bleeding, leakage of stool, hemorrhoids, and general cleanliness
• tone can be observed by lightly touching the anus and observing for the reflex

Question 54

Musculoskeletal Assessment

Answer 54

-can be done while observing the child enter and move about the exam room
-observed for range of motion, symmetry of movement, general alignment, and any deformities
-each joint palpated for range of motion and presence of any erythema or swelling
-muscles assessed for strength of movement
>for upper extremity strength, child is asked to hold both arms out to the sides and then out to the front; child ask to hold these positions as the nurse applies downward pressure to both arms
-symmetry of strength in both hands can be assessed by having the child squeeze the nurse’s index fingers
-strength of the legs can be tested by asking the child who is lying supine to raise his legs while nurse applies downward pressure
-screening for scoliosis is done between 9 and 15 years of age; scoliometer can be used; or noting if the back appears straight and the hips are even

Question 55

Neurological Assessment

Answer 55

-mental status assessed by observing the infant interact with the parent, or by asking the older child to answer questions and listening for clear speech in the responses
-assessed in the course of a normal interview
-assessment of motor functioning is done during skeletal exam
-child can be asked to hop, skip, or jump to assess symmetry of movement
-sensory testing is done if there is question regarding sensory functioning
-cerebellar function is checked by observing the child’s posture and gait or by using the finger-to-nose test; the young children perceive this test as a game and readily cooperate
-Romberg test assesses cerebellar functioning: child is assessed for the ability to stand without swaying while standing with eyes closed and arms outstretched
-assessed for persistence of primitive reflexes, which normally disappear during infancy; Babinski, Moro, palmar, plantar, and tonic neck are seen in neonate but disappear over time
>persistence of these reflexes may indicate cerebral dysfunction
-Deep-tendon reflexes (DTRs) are elicited using the reflex hammer
-cranial nerve assessment is an integral part of exam and may be completed throughout the exam or as a separate part