Chapter 28 The Complete Physical Assessment Infant Child

Chapter 28 The Complete Physical Assessment: Infant, Child, and Adolescent Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.

Sequence: Neonate and Infant Review Chapter 8 for steps on preparation and positioning as well as developmental principles of the infant Apgar (1 and 5 minutes) will provide evidence of newborn’s immediate adaptation to extrauterine life Following sequence will expand these data Sequence may be reordered based on Infant’s sleep and wakefulness state Ø Physical condition Ø Infant is supine on warming table/exam table with overhead heating unit Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 2

Vital Signs and Measurement Note pulse, respirations, and temperature Weight, length, and head circumference are plotted against growth chart Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 3

General Appearance Body symmetry: spontaneous position, flexion of head and neck, and spontaneous movement Skin color and characteristics: note any obvious deformities Symmetry and positioning of facial features Alert, responsive effort Strong, lusty cry Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 4

Chest and Heart Inspection of skin condition, chest configuration, nipples, and breast tissue Note movement of abdomen with respirations and any chest retractions Palpate apical impulse and note location, chest wall for thrills, and tactile fremitus if the infant is crying Auscultate breath sounds, heart sounds in all locations, and bowel sounds in the abdomen and chest Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 5

Abdomen Inspect Shape of abdomen and skin condition Ø Umbilicus, count cord vessels, condition of cord or stump, detection of hernia Ø Skin turgor Ø Palpate Light palpation to note muscle tone, liver, spleen tip, and bladder Ø Deep palpation to note kidneys and potential masses Ø Femoral arteries and inguinal lymph nodes Ø Percuss all quadrants Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 6

Head and Face Note molding after delivery, any swelling on cranium, bulging of fontanel with crying or at rest Palpate fontanels, suture lines, and any swellings Inspect positioning and symmetry of facial features at rest and while the infant is crying To open neonate’s eyes Support head and shoulders Ø Gently lower baby backward, or ask the parents to hold the baby over his or her shoulder while you stand behind the parent Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 7

Eyes, Ears, and Nose Eyes Inspect the lids (edematous in the neonate), palpebral slant, conjunctivae, any nystagmus, and any discharge Ø Elicit pupillary reflex, blink reflex, and corneal light reflex using a penlight—assess movement and tracking of light Ø Elicit red reflex using an ophthalmoscope Ø Ears Inspect size, shape, alignment of auricles, patency of canals Ø Any extra skin tags or pits Ø Defer otoscopic exam until the end of the complete examination Ø Nose Determine patency of nares Ø Note any nasal discharge, sneezing, and flaring with respirations Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 8

Mouth, Throat, and Neck Inspect lips and gums, high-arched palate, buccal mucosa, tongue size, frenulum of tongue —note absent or minimal salivation in neonate Note rooting reflex Note sucking reflex and, using gloved finger, palpate the palate Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 9

Extremities Upper Lower Inspect and manipulate ROM, muscle tone, and absence of scarf sign Count fingers, palmar creases, and note color of hands and nail beds Place your thumbs in the infant’s palm to note grasp reflex Wrap your hands around infant’s hands to pull up, and note head lag Inspect and manipulate legs and feet, noting ROM, muscle tone, and skin condition Note alignment of feet and toes, look for flat soles, and count toes Perform Ortolani sign for hip stability Check plantar grasp reflex (present 8 to 10 months) Check Babinski reflex (fanning of toes until 24 months) Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 10

Genitalia Females: inspect labia and clitoris (edematous in newborn), vernix caseosa between labia, and patent vagina Males: inspect position of urethral meatus (do not retract foreskin), strength of urine stream if possible, rugae on scrotum, and palpate testes Position: lift the infant under the axillae & hold him or her facing you at eye level Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 11

Neuromuscular Note shoulder muscle tone Rotate the infant slowly from side to side—Note doll’s eye reflex Position Turn the infant around so that his or her back is to you; elicit stepping and placing reflex against the edge of the exam table Ø Turn the infant over and hold him or her prone in your hands, or place infant prone on the exam table Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 12

Spine and Rectum Inspect Length of spine, trunk incurvation reflex, and symmetry of gluteal folds Ø Intact skin, note any sinus openings, protrusions, or tufts of hair Ø Note patent anal opening Ø Check for passage of meconium during first 24 to 48 hours Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 13

Final Procedures: Neonate and Infant Using an otoscope, inspect auditory canals and tympanic membranes Elicit Moro reflex Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 14

Sequence: The Young Child Review developmental considerations in Chapter 8 Preschool child displays developing initiative and takes on tasks independently Child is cooperative and easy to involve Ø Fearful of body injury Ø May recoil from invasive procedures Ø Young school child is developing industry Ø Cooperative and interested in learning about the body Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 15

The Health History Collect history, including developmental data During the history, note data on general appearance Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 16

General Appearance and Measurement Note Child’s ability to amuse while parent speaks Ø Parent and child interaction Ø Gross and fine motor skills as child plays with toys Ø Gradually focus on and involve yourself with child, at first in a “play“ period Ø Evaluate Ø Ø Ø Ø Developmental milestones— Denver II Posture while child is sitting and standing Alignment of legs and feet while walking Speech acquisition Vision and hearing ability Social interaction Use age-appropriate techniques to engage child in exam Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 17

Upper Extremities and Head, Face and Neck Inspect arms and hands for alignment, skin condition, fingers, and note palmar creases Palpate and note radial pulse Test biceps and triceps reflexes with reflex hammer Inspect size and shape of the head and symmetry of facies Palpate the cervical lymph nodes, trachea, and thyroid gland Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 18

Eyes Inspect external structures. Note any palpebral slant Elicit corneal light and pupillary light reflexes with penlight Observe cardinal gaze using penlight If indicated, perform cover test, covering the eye with your thumb in a young child or an index card Inspect conjunctivae and sclera Observe red reflex, and inspect fundus using ophthalmoscope Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 19

Nose, Mouth, and Throat Nose Inspect external nose, noting skin condition Ø Inspect nares, mucosa, septum, and turbinates using penlight Ø Mouth and throat Ø Inspect mouth, buccal mucosa, teeth and gums, tongue, palate, and uvula with penlight (tongue blade as last resort) Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 20

Ears Inspect and palpate auricles Note any discharge from auditory meatus Check foreign body Inspect ear canal and tympanic membranes using otoscope Inspect tympanic membrane for color, position, landmarks, and integrity Gain child’s cooperation by letting child handle equipment or to look in the parent’s ear using the otoscope Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 21

Thorax and Breath Sounds Inspect posterior chest: configuration, skin characteristics, symmetry of shoulders, and muscles Palpate for lumps or tenderness over length of spinous processes Percuss over lung fields Auscultate breath sounds, perform bilateral comparison in upper and lower lung fields Note any adventitious sounds Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 22

Chest and Heart Inspect size, shape, and configuration of chest wall Assess respiratory movement Inspect pulsations on the precordium—Note nipple and breast development Palpate apical pulse and note location, chest wall for thrills and for tactile fremitus Auscultate breath and heart sounds in all locations, count respiratory, and heart rate Auscultate S 1 and S 2 across the precordium—Note presence of murmurs Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 23

Abdomen and Genitalia Abdomen Ø Ø Ø Inspect shape, skin condition, and periumbilical area Auscultate bowel sounds Palpate skin turgor, muscle tone, liver edge, spleen, kidneys, and note presence of any masses Palpate femoral pulses and compare strength with radial pulses Palpate inguinal lymph nodes Genitalia Inspect external genitalia Ø On males: palpate the scrotum for testes—If masses are present, then transilluminate Ø Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 24

Lower Extremities Perform Ortolani test to determine hip stability Note alignment of legs and skin condition and feet Inspect toes and longitudinal arch Check ROM of hips, knees, and ankles Palpate dorsalis pedis pulse bilaterally Elicit plantar, Achilles, and patellar reflex using reflex hammer Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 25

The Adolescent Perform the sequence noted in the head-to-toe format described in the aging adult section Major task of adolescence is identity Adolescent is increasingly self-conscious and introspective Allow adolescent to keep street clothes on for a well-person examination, and work around them Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 26

Position Sitting Up Supine Proceed with head, eyes, ears, neck, and thoracic examination Sit upright at edge of examination table Conduct cardiac, abdominal, and lower extremity examination next Place drape over lower abdomen when examining inguinal area Ask adolescent to unzip and lower clothes under drape Pant legs can be pulled up to examine lower legs and feet Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 27

Question Which approach to a complete physical assessment should be used for an adolescent? 1. 2. 3. 4. Head-to-toe approach Focused approach Systems approach divided into two or three visits Problem-centered approach Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 28