Physical Assessment Findings Flashcards
Nursing Considerations of Physical Assessment
- keep the room warm and well lit
- perform examinations in nonthreatening environments. keep medical equipment out of sight
- provide privacy. determine whether older school-age children and adolescents prefer a caregiver to remain during examination
- take time to play and develop rapport prior to beginning examinations
- observe for behaviors that demonstrate child’s readiness to cooperate, such as interacting with RN, making eye contact, permitting physical touch, and willingly sitting on the exam table.
- explain each step of the examination to the child. (use age appropriate language. demonstrate what will happen using dolls, puppets, or paper drawings. allow the child to manipulate and handle equipment. encourage the child to sue equipment on others)
- examine the child in a secure, comfortable position.
- . proceed to examine the child in an organized sequence when possible.
- if the child is uncooperative, assess reasons, be firm, and direct about expected behavior, complete the assessment quickly and use a calm voice.
- encourage the child and family to ask questions during physical exams. discuss findings with family after the exam.
Temperature for 3 month old
37.5 or 99.5
Temperature of 6 month old
37.7 or 99.9
Temperature of 1 year old
37.2 or 99.0
Temperature of a 3 year old
37.2 or 99.0
Temperature of a 5 year old
37.0 or 98.6
Temperature of a 7 year old
36.8 or 98.2
Temperature of a 9 and 11 year old
36.7 or 98.1
Temperature of a 13 year old
36.6 or 97.9
Pulse of a newborn
80-180 (depending on activity)
Pulse of 1 week old to 3 month old
80-220 (depending on activity)
Pulse of 3 month old to 2 year old
70-150 (depending on activity)
Pulse of 2-10 year old
60-110 (deepening on activity)
Pulse of 10 years and older
50-90 (depending on activity)
Respirations of newborn to 1 year old
30-60
Respirations of 1-2 year old
25-30
Respirations of 2-6 year old
21-25
Respirations of 6-12 year old
19-21
Respirations of 12 years and older
16-19
Blood Pressure
Readings should be compared with standard measurements.
Age, height, and gender all influence blood pressure readings.
Growth
Growth can be evaluated by using weight, length/height, BMI, and head circumference. Growth charts are tools that can be used to assess the overall health of the child.
It is recommended to use the WHO growth standards for infants and children ages 0-2 in the US and the CDC charts for children 2 and older.
General Appearance
appears undistressed, clean, well kept, and without body odors.
Muscle tone: Erect head posture is expected in infants after 4 months of age.
Makes eye contact when addressed (except infants).
Follows simple commands as age-appropriate.
Uses speech, language, and motor skills appropriately.
Skin
Variations in skin color are expected based on race and ethnicity.
Temperature should be warm or slightly cool to the touch.
Skin texture should be smooth and slightly dry, not oily.
Skin turgor exhibits brisk elasticity with adequate hydration.
Lesions are not expected.
Skin folds should be symmetric
Hair and Scalp
Hair should be evenly distributed, smooth, and strong.
Manifestations of nutritional deficiencies include hair that is stringy, dull, brittle, and dry.
Scalp should be clean and absent from any scaliness, infestations, or trauma.
Assess children approaching adolescents for presence of secondary hair growth.
Nails
Pink over the nail bed and white at the tips.
Smooth and firm (but slightly flexible in infants)
Lymph Nodes
Lymph nodes should be nonpalpable. Lymph noes that are small, palpable, contender, and mobile can be expected finding in children.
Head
The shape of the head should be symmetric.
Fontanels should be flat.
The posterior fontanel usually closes by 6-8 weeks of age.
The anterior fontanel usually closes between 12-18 months of age.
Face
Symmetric appearance and movement.
Proportional features.
Neck
Short in infants.
Nonpalpable masses.
Midline trachea.
Full range of motion present whether assessed actively or passively.
Eyebrows
should be symmetric and evenly distributed from the inner to the outer canthus
Eyelids
should close completely and open to allow the lower border and most of the upper portion of the iris to be seen.
Eyelashes
should curve outward and be evenly distributed with no inflammation around any of the hair follicles.
Conjunctiva
Palpebral is pink.
Bulbar is transparent.
Lacrimal Apparatus
is without excessive tearing, redness, or discharge.
Sclera
should be white
Corneas
should be clear
Pupils
should be round, equal in size, reactive to light, accommodating.
Irises
should be round with the permanent color manifesting around 6-12 months of age.
Visual Acuity
Can be difficult to assess in children younger than 3 years old.
Visual acuity in infants can be assessed by holding an object in front of the eyes and checking whether the infant is able to fix on the object and follow it.
Use the tumbling E or HOTV test to check visual acuity of children who are unable to read letters and numbers.
Older children should be tested using Snellen char or symbol chart.
Peripheral Fields
upward 50 degrees
downward 70 degrees
nasally 60 degrees
temporally 90 degrees
Extraocular Movements
Might not be symmetric in newborns.
Corneal light reflex should be symmetric.
Cover/Uncover test should demonstrate equal movements of the eyes.
Six cardinal fields of gaze should demonstrate no nystagmus.
Color Vision
Should be assessed using the Ishihara color test or the Hardy-Rand-Rittler test.
The child should be able to correctly identify shapes, symbols, or numbers
Internal Exam
Red relex should be present in infants.
Arteries, veins, optic discs, and maculae can be visualized in older children and adolescents.
Alignment of Ears
the top of the auricles should meet in an imaginary horizontal line that extends from the outer canthus of the eye.
External Ear
Should be free of lesions and contender.
Ear canal should be free of foreign bodies or discharge.
Cerumen is an expected finding.
Internal Ear
In infants and toddlers, pull the pinna down and back to visualize the tympanic membrane.
In children older than 3 years old, pul the pinna up and back to visualize.
The ear canal should be pink with fine hairs.
The tympanic embrace should be pearly pink or gray.
The light reflex should be visible
Umbo (tip of the malleolus) and manubrium (long process or handle) are the bony landmarks that should be visible.
Hearing
Newborns should have intact acoustic blink reflexes to sudden sounds.
Infants should turn towards sounds.
Older children can be screened by whispering a word from behind to see whether they can identify the word
Nose
The portion should be midline.
Patency should be present for each nostril without excessive flaring.
Smell can be assessed in older children.
Internal Structure of Nose
The septum is midline and intact.
The mucous is deep pink and moist without discharge.
Lips
Darker pigmentation than facial skin.
Smooth, soft, and symmetric.
Gums
Coral pink.
Tight against the teeth.
Mucous Membranes
Without lesions.
Moist, pink, smooth, and glistening.
Tongue
Infants can have white coating on their tongues from milk that can be easily removed. Oral candidiasis coating is not easily removed.
Children and adolescents should have pink, symmetric tongues that they are able to move beyond their lips.
Teeth
Infants should have 6-8 teeth by 1 year of age.
Children and adolescents should have teeth that are white and smooth, and begin replacing the 20 deciduous teeth with 32 permanent teeth.
Hard and Soft Palates
intact, firm, and concave
Uvula
Intact and moves with vocalization
Tonsils
Infants: might not be able to visualize
Children: barely visible to prominent, same color as surrounding mucosa
Speech
Infants: strong cry
Children and adolescents: clear and articulate.
Chest Shape
Infants: shape is almost circular with anteroposterior diameter equalling the transverse or lateral diameter.
Children: the transverse diameter to anteroposterior diameter changes to 2:1
Ribs and Sternum
more soft and flexible in infants; symmetric and smooth, with no protrusion or bulges
Movement of Chest
Symmetrical, no retractions.
Infants: irregular rhythms are common
Child: more abdominal movement is seen during respirations
Breath Sounds
Inspiration is longer and louder than expiration.
Vesicular, or soft, swishing sounds are head over most of the lungs.
Breasts
Newborns: Breasts can be enlarged during the first few days.
Children: nipples and areoles are darker pigmented and symmetric.
Females: breasts typically develop between 10-14 years of age. The shape should appear asymmetric, have no masses, and be palpable.
Males: can develop gynecomastia, which is unilateral or bilateral enlargement that occurs during puberty.
Circulatory system
A comprehensive assessment of the circulatory system includes assessment of pulses, capillary refill time, neck veins, clubbing of fingers, peripheral cyanosis, edema, BP, and RR.
Heart Sounds
Ascultation should be done in both a sitting and reclining position.
S1 and S2 heart sounds should be clear and crisp. S1 is louder at the apex of the heart. s2 is louder near the base of the heart. Physiologic splitting of the S2 and S1 hear sounds are expected findings in some children. Sinus arrhythmias that are associated with respirations are common
Pulses
Infants: Brachial, temporal, and femoral pulses should be palpable, full, and localized.
Children: pulse locations are expected findings are the same as those in adults.
Abdomen
Without tenderness, no guarding. Peristaltic waves can be visible in thinner children
Shape: symmetric and without protrusions around the umbilicus.
Infants and toddlers have rounded abdomen.
Children should have a flat abdomen.
Bowel sounds should be heart every 5-30 seconds.
Anus
surrounding skin should be intact with sphincter tightening noted if the anus is touched. Routine rectal exams are not done with the pediatric population.
Male Genitalia
hair distribution is diamond shaped after puberty in adolescent males. No pubic hair is noted in infants and small children.
Penis
Penis should appear straight.
Urethral meatus should be at the tip of the penis.
Foreskin might not be retractable in infants and small children.
Enlargement of the penis occurs during adolescence.
The penis can look abnormally small in males who are obese because of skin folds partially covering the base.
Scrotum
The scrotum hands separately from the penis.
The skin on the scrotum has a rugs appearance and is loose.
The left testicle hands slightly lower than the right.
The inguinal canal should be absent of swelling.
During puberty the testes and scrotum enlarge with darker scrotal skin.
Female Genitalia
Hair distribution over the mons pubs should be documented in terms of amount and location during puberty. Hair should appear in an inverted triangle. No pubic hair should be noted in infants or small children.
Labia
Symmetric, without lesions, moist on the inner aspects.
Clitoris
Small, without bruising or edema
Urethral meatus
slit like in appearance with no discharge.
Vaginal Orifice
The hymen can be absent or it can completely or partially cover the vaginal opening prior to sexual intercourse.
Musculoskeletal System
length, position, and size of extremities are symmetric
Joints
stable and symmetric with full ROM and no crepitus or redness.
Spine (Infants)
spines should be without dimples or tufts of hair. They should be midline with an overall C-shaped lateral curve
Spine (Toddlers)
appear squat with short legs and protuberant abdomens.
Spine (Preschoolers)
appear more erect than toddlers
Spine (Children)
should develop the cervical, thoracic, and lumbar curvatures like that of adults.
Spine (adolescents)
should remain midline (no scoliosis noted)
Gait (toddlers and young children)
a bowlegged or knock-knee appearance is common. Feet should face forward while walking.
Gait (Older children and adolescents)
a steady gait should be noted with even wear on the soles of shoes.
Deep Tendon Reflex
Should demonstrate the following:
Partial flexion of the lower arm at the bicep tendon.
Partial extension of the lower arm at the tricep tendon.
Partial extension of the lower leg at the patellar tendon.
Plantar flexion of the foot at the Achilles tendon.
Cerebellar Function
Finger to nose test: rapid coordinated movements.
Heel to shin test: able to run the heel of one foot down the shin of the other leg while standing.
Romberg Test: able to stand with slight swaying while eyes are closed.
Infant Blood Pressure
Systolic: 65-78
Diastolic: 41-52
1 year old Girl Blood Pressure
Systolic: 83-114
Diastolic: 38-67
3 year old girl blood pressure
systolic: 86-117
diastolic: 47-76
6 year old girl blood pressure
systolic: 91-122
diastolic: 54-83
10 year old girl blood pressure
systolic: 98-129
diastolic: 59-88
16 year old girl blood pressure
systolic: 108-138
diastolic: 64-93
1 year old boy blood pressure
systolic: 80-114
diastolic: 34-66
3 year old boy blood pressure
systolic: 86-120
diastolic: 44-75
6 year old boy blood pressure
systolic: 91-125
diastolic: 53-84
10 year old boy blood pressure
systolic: 97-130
diastolic: 58-90
16 year old boy blood pressure
systolic: 111-145
diastolic: 63-94
Sucking and Rooting Reflexes
Elicited by stroking an infants cheek or the edge of an infants mouth. The infant turns her head toward the side that is touched and starts to suck.
Expected age: birth-4 months
Palmar Grasp
Elicited by placing an object in an infants palm. The infant grasps the object.
Expected age: birth -3 months
Plantar Grasp
Elicited by touching the sole of an infants foot. The infants toes curl downwards.
Expected age: birth -8 months
Moro Reflex
Elicited by allowing the head and trunk of an infant in a semi-sitting position to fall backward to an angle of at least 30 degrees. The infants arms and legs symmetrically extend, then abduct while fingers to form a C shape.
Expected age: birth- 4 months
Startle Reflex
Elicited by clapping hands or by a loud noise. The newborn abducts arms at the elbows, and the hands remain clinched.
Expected age: birth- 4 months.
Tonic Neck Reflex (Fencer Positon)
Elicited by turning an infants head to one side. The infant extends the arm and leg on that side and flexes the arm and leg on the opposite side.
Expected Age: birth to 3 to 4 months
Babinski Reflex
Elicited by stroking the outer edge of the sole of an infants foot up toward the toes. The infants toes fan upward and out.
Expected age: birth - 1 year
Stepping
Elicited by holding an infant upright with his feet touching a flat surface. The infant makes stepping movements.
Expected age: birth- 4 weeks.
CN 1
Olfactory
Infants: difficult to test.
Children: identifies smell through each nostril individually.
CN 2
Optic
Infants: looks at face and tracks with eyes.
Children: had intact visual acuity, peripheral vision, and color vision.
CN 3
Oculomotor
Infants: blinds in response to light. Has pupils that are reactive to light.
Children: has no nystagmus and PERRLA is intact
CN 4
Trochlear
infants: looks at face and tracks with eyes
children: has the ability to look down and in with eyes.
CN 5
trigeminal
infants: has rooting and sucking reflexes
children: is able to clench teeth together. detects touch on face with eyes closed.
CN 6
abducens
infants: loos at face and tracks with eyes.
children: is able to see laterally with eyes.
CN 7
facial
infants: has symmetric facial movements
children: has the ability to differentiate between salty and sweet on tongue. Has symmetric eye movements.
CN 8
acoustic
infants: tracks a sound. blinds in response to a loud noise.
children: does not experience vertigo. Has intact hearing.
CN 9
glossopharyngeal
infants: has an intact gag reflex
children: has an intact gag reflex. is able to take sour sensations on the back of the tongue.
CN 10
vagus
infants: has no difficulties swallowing.
children: speech is clear, no difficulties swallowing. uvula is midline.
CN 11
spinal accessory
infants: moves shoulder symmetrically
children: has equal strength of shoulder shrug against examiners hands.
CN 12
hypoglossal
infants: has no difficulties swallowing. Opens mouth when nares are occluded.
children: has a tongue that is midline. is able to move tongue in all directions with equal strength against tongue blade resistance.
