ASSESSMENT IN PREGNANCY MCDONALD’S RULE

FUNDAL HEIGHT = WEEK OF GESTATION +/ -

2-4 WEEKS
▪ Distance from fundus to symphysis in centimeters is equal to
the week of gestation between week 20 to 31.
▪ Measure from the notch of the symphysis pubis to over the top
of the fundus while in supine.
▪ NOTE: This becomes inaccurate in 3rd trimester because the
fetus is growing in weight than height.

GTPAL SYSTEM FOR OBSTETRIC HISTORY

G Gravida The number of times a woman has been
pregnant, regardless of pregnancy
outcomes
T Term The number of pregnancies delivered at
37 w 0 d gestation and beyond
P Preterm The number of pregnancies delivered
from 20 w 0 d gestation through 36 w 0 d • For the first 24 weeks, the fundal height is equivalent to fetal
gestation growth and development.
A Abortion The number of pregnancies ending before For example: If a woman is 24 weeks pregnant, the
20 w 0 d gestation; these may be fundal height should be approximately 23-29 cm.
spontaneous (miscarriage) or induced
abortions LEOPOLD’S MANUEVER
L Living The number of currently living child ▪ Named after the gynecologist Christian Gerhard Leopold.
▪ This technique helps determine the position and presentation
EDD/ EDC of the fetus inside the woman’s uterus.
• The estimated date of delivery, also known as expected date ▪ Can indicate whether the delivery is going to be complicated,
of confinement or whether a caesarian section is necessary.
• One of the most important factors in early pregnancy ✓ There are virtually no side effects or complications of the
assessment Leopold Methods.
• Normal pregnancies last between 37 and 42 weeks. ✓ A skilled nurse should execute the procedure and care should
be taken not to disturb the fetus in an excessive manner.
IMPORTANCE OF ACCURATE EDC ✓ The method can be painful for the expectant mother if the
ACCURATE DATING IS VIT AL FOR: nurse performing the
maneuvers does not take care to perform the procedure
✓ The timing of appropriate antenatal care
properly.
✓ Scheduling & interpretation of tests
✓ Performing the 4 STEPS of the Leopold Maneuvers requires
✓ Determining appropriate fetal growth skill and patience to locate the position of the mother’s fetus.
✓ Intervention purposes: The maneuvers should be performed in a manner that is
- prevention of preterm birth comfortable to the expectant mother.
- prevent postdates
- prevent comorbidities
FETAL PRESENTATION
✓ For research

LMP
• Last menstrual period
• This refers to the first day of the menstrual period (latest cycle)
• The use of LMP to detect the EDC is applicable for women
with regular menstrual cycle.

INACCURATE IN PATIENTS I N THE

FOLLOWING CIRCUMSTANCES
• Oligomenorrhea or polymenorrhagia (irregular cycles)
• Bleeding in the first trimester of pregnancy (implantation 1. FUNDAL GRIP
bleeding)
• Pregnancy following the use of oral contraceptives or IUD o Using both hands and facing the patient,
• Pregnancy in the postpartum period (lactational amenorrhea) palpate the upper abdomen.
o The nurse should use this method to
METHODS TO COMPUTE determine the shape, size, mobility, and
consistence of what he or she feels.
o The nurse should feel that the limbs and
NAEGELE’S RULE shoulders contain little bone processes that
• Most common method of pregnancy dating. move with the fetus’ trunk.
EDD = LMP – 3 + 7 o the head is firm, hard, round and moves
separately from the trunk; and the buttocks is symmetric and
feels soft.
2. UMBILICAL GRIP
o After identifying the form and
palpating the upper abdomen, the
location of the fetus’ back must be
identified.
o While still facing the patient, apply
deep pressure with the palm of hands to
palpate the abdomen gently. Perform
this maneuver by placing the right hand
on one side of the patient’s abdomen
while using the left hand to explore the
woman’s uterus on the right side. Repeat this step on the
opposite side using the opposite hand.
o Observe that the fetal back is smooth and firm. The
extremities of the fetus should feel like protrusions and small
irregularities. The back should connect with the form felt in the
lower (maternal inlet) and upper abdomen
3. PAWLICK’S GRIP
o During this step of the process, identify
the part of the fetus that is above the inlet.
Use your fingers and thumb on the right
hand to grasp the lower abdomen area
located above the pubic symphysis. The
findings should validate what is
determined in the first maneuver.
o The two- hand approach is an alternative
that is more comfortable for the patient.
Nurses can perform this approach by
positioning the fingers of both hands in a
lateral position on one side of the presented part.
4. PELVIC GRIP
o This step should be done while facing
the patient’s feet.
o The process involves locating the
fetus’ brow.
o Gently move the fingers on both
hands toward the pubis by sliding the
hands over the sides of the patient’s
uterus, and the side where the greatest
resistance to the descending fingers is
the location of the brow.
o A well-flexed fetal head is located on the opposite side of the
fetal back. If the head is extended, the back of the head is felt
on the side that the back is located.
FACTORS AFFECTING THE PERFORMANCE
OF THE MANEUVER:
● Difficult to perform in obese women
● Women with hydramios
● Women with full bladder
NURSING CONSIDERATIONS
● Instruct the patient to empty her bladder
● Position the patient in supine position with knees slightly
flexed.
● Drape properly to maintain privacy, expose abdomen.
● Explain the procedure
● Warm hands by rubbing together (cold hands stimulate
uterine contractions)
● Use the palm for palpation not the fingers
PREGNANCY SIGNS & SYMPTOMS
PRESUMPTIVE (SPECULATION)
P Period absent (Amenorrhea)
R Really tired
E Enlarged breasts
S Sore breasts
U Urinary frequency
M Movement perceived (quickening)
E Emesis & nausea
PROBABLE (LIKELY)
P Positive (+) PT (high level of the hormone hcg)
R Return of fetus when uterus is pushed (ballotement)
O Outline of fetus palpated
B Braxton hicks contractions
A A softened cervix (Goodell’s sign)
B Bluish color of the vulva, vagina or cervix (Chadwick’s sign)
L Lower uterine segment soft (Hegar’s sign)
E Enlarged uterus
POSITIVE SIGNS
F Fetal movement palpated by a doctor or nurse
E Electronic device detects heart tones
T The delivery of the baby
U Ultrasound
S See visible movements
HEAD TO TOE ASSESSMENT
HAIR AND NAILS
▪ Growth of hair and nails tends to increase during pregnancy.
▪ 6 WEEKS - Some women note excessive oiliness and dryness
of scalp and a softening and thinning of nails.
▪ 2nd & 3rd TRIMESTER – hirsutism of the face, abdomen and
back due to hormonal changes (androgen).
▪ 3-4 MONTH POSTPARTUM – transient hair loss is noticed
and resolves within 9 months to 1yr of delivery.
SKIN
• Striae gravidarum - reddish or purple lesions that develop due
to overstretching of the abdominal skin as the gravid
uterus expands (commonly referred to as stretch marks).
• Striae albicans - mature stretch marks which appear silver-like
in color and are less pronounced.
• Linea nigra – dark line extending from the umbilicus to the
mons pubis. Hyperpigmentation from hormonal influences.
• Chloasma – darkening of the skin on the face, known as the
facial “mask of pregnancy”.
• Spider nevi – tiny red angiomas on face, neck, chest, arms and
legs due to elevated estrogen levels.
• Darkening of the areola & nipples, axilla, umbilicus &
perineum.
• Palmar erythema – pinkish color on the palms of hands.
• Pruritic urticarial papules and plaques of pregnancy (PUPPP)
– skin disorder during the 3rd trimester of pregnancy
characterized by erythematous papules, plaques and urticarial
lesions.
• Acne vulgaris – unpredictable response during pregnancy.
May worsen or improve.
EARS & HEARING
• Decrease in hearing, fullness in the ears or earaches due to
increased vascularity of tympanic membrane and blockage of
the eustachian tube.
MOUTH, THROAT, NOSE AND SINUS
• Gingival bleeding when brushing teeth and hypertrophy
common.
• Epulis – small, irritating nodules of the gums that usually
resolves on their own. Occasionally excised if bleeding is
excessive.
• Vocal changes may be noted due to edema of the larynx.
• Nasal stuffiness and epistaxis also common due to estrogen-
induced edema and vascular congestion of the nasal mucosa and
sinuses.
THORAX AND LUNGS
• Respiratory pattern changes from abdominal to costal.
• Shortness of breath is a common complaint during the last
trimester.
• Oxygen requirement increases because of the additional
cellular growth of the body and the fetus.
MUSCULOSKELETAL
• Gradual Lordosis – uterine growth pulls the pelvis forward,
which causes the spine curve forward.
• Enlarging breasts cause shoulders to droop forward.
• Pregnant woman typically finds herself pulling her shoulders
back and straightening her head to accommodate for this
weight.
• Waddling gait – a way of walking wherein a person sway from
side to side and hip drops with each step.

BREASTS
• Tingling sensations and
tenderness
• Enlargement and
hyperpigmentation of breast,
areola and nipple.
• Enlargement of Montgomery
tubercles.
• Prominence of superficial
veins NEUROLOGIC
• Development of striae • Pain or tingling in the thigh caused by pressure on the lateral
• Expression of colostrum in the 2nd and 3rd trimesters. femoral cutaneous nerve.
• Carpal tunnel syndrome – pressure on median nerve below
HEART & PERIPHERAL VASCULATURE carpal ligament of the wrist.
• Increase cardiac output. Heart is required to pump much • Leg cramps caused by inadequate calcium intake.
harder, it actually increases in size. • Dizziness and lightheadedness.
• HR may increase by 1-15 beqts/min and systolic murmurs
may be heard.
• Pseudoanemia – physiologic anemia develops due to increase
in maternal blood volume.
• Dizziness and lightheadedness beginning 2nd trimester.
• Dependent edema and varicosities.
• Swelling usually noted at the end of the day after standing for
long periods.
• Pregnant women are also more prone to development of
thrombophlebitis due to hypercoagulable state of pregnancy.
Women on bedrest during pregnancy are at a very high risk.

ABDOMEN
• Abdominal muscles stretch as the uterus enlarges.
• Diastasis recti abdominis – rectus abdominis stretch to the
point that permanent separation occurs.
• Lower pelvic discomfort commonly results from stretching
the ligaments, especially the round ligaments.
• Kidney infection when the expanding uterus exerts pressure
on bladder, kidney, and ureters.
• Urinary frequency is a common complaint in the 1st and 3rd
trimesters.
• Linea nigra, striae gravidarum (discussed earlier)
• Constipation and acid reflux is common.
• Ptayalism – excessive salivation may occur in the 1st
trimester.

GENITALIA
• Goodell sign
• Chadwick sign
• Increase in whitish vaginal discharge, which is acidic.
• Amenorrhea - absence of menstruation.

ANUS AND RECTUM

• Hardening of stool (constipation) and decreased frequency of
bowel movements. Iron supplementation can contribute to
constipation.
• Hemorrhoids – varicose veins in the rectum due to pressure
on the venous structures from straining to have bowel
movement.
COMPREHENSIVE GERIATRIC DOMAINS OF COMPREHENSIVE GERIATRIC
ASSESSMENT ASSESSMENT
• Medical Assessment
WHAT IS GERIATRICS? • Cognitive Function
• Relating to old people, especially with regard to their • Affective Disorders
healthcare. • Visual Impairments
• From a chronological viewpoint, medical treatment of the • Hearing Impairment
elderly (geriatrics) starts from the age of 65 years old. • Dental Health
• Geriatrics, or geriatric medicine, is a specialty that focuses on • Functional Status
health care of elderly people. ... The term geriatrics comes from • Nutritional Status
the Greek “geron” meaning "old man", and “iatros” meaning • Gait and Balance Impairment
"healer“. • Social Support
• Sometimes called, “gerontology” • Environment
• Advance Directives Medical Assessment
DEFINITION
MEDICAL ASSESSMENT
• A multidisciplinary diagnostic process intended to determine
a frail older person’s medical, functional, and psychosocial • Interview of both patient and caregiver
status and limitations in order to develop a plan for treatment • Use of old medical records
and long-term follow-up. • Factors that contribute to time-consuming interview:
• The geriatric assessment is a multidimensional, • Communication problems (hearing, vision, slow
multidisciplinary assessment designed to evaluate an older processing and cognitive impairment)
person's functional ability, physical health, cognition and • Underreporting
mental health, and socioenvironmental circumstances. • Vague, nonspecific symptoms
• Atypical presentation
• Multiple comorbidity, etiologies
THE MULTIDISCIPLINARY TEAM • History of Present Illness
• Past Health History
• Physician • Family History
• Nurse • Pain History
• Nurse Practitioner or Physician Assistant • Psychological History
• Social Worker • Sleep pattern, behavioral history, cognitive function, affective
• Physical/Occupational /Speech/ Psychological Therapist disorder, psychiatric history
• Pharmacist
• Dietitian REVIEW OF SYSTEMS
• Dentist
• Respiratory
• Cardiovascular
GOALS
• Gastrointestinal
• Improve diagnostic accuracy • Genitourinary
• Guide selection of interventions to restore or preserve health • Musculoskeletal
• Recommend optimal living environment • Neurological
• Monitor clinical change over time • Psychological
• Predict outcomes
COMMON PHYSICAL FINDINGS AND THEIR
THREE-STEP PROCESS POTENTIAL SIGNIFICANCE IN GERIATRICS
1.Screening or targeting of appropriate patients.
2.Assessment and development of recommendations.
VITAL SIGNS
3.Implementation of recommendations (Physician and Patient
Adherence) • Blood pressure: hypertension (no end organ damage)
• Pulse: irregular pulse rate are caused by arrythmias. These are
WHO SHOULD BE EVALUATED? 3 relatively common in otherwise asymptomatic in elderly.
• Temperature: Extremes in temperature are highly sensitive in
CATEGORIES:
elderly
1. Healthy Elderly Persons • Tachypnea: baseline rate should be accurately recorded to help
2. Frail Elderly Persons assess future complaints (dyspnea) or conditions (such as
3. Institutionalized or Severely Impaired Elderly Persons pneumonia or heart failure)
• Pain: 5th vital sign
FRAIL / FRAILTY
• Frailty was measured as a sum of eight core frailty indicators: ULCERATIONS
weakness, fatigue, weight loss, low physical activity, poor • Lower extremity vascular and neuropathic ulcers common
balance, low gait speed, visual impairment and cognitive • Pressure ulcers common and easily overlooked in immobile
impairment. patients
PATIENTS WHO WOULD BENEFIT MOST
DIMINISHED TURGOR
• Frail because of age
• Muscle or tissue atrophy
• Decrease of functional status
• Dehydration
• Change in mental status – cognition/affect
• Multiple medical problems
• Multiple psychosocial problems BRUISING
• Multiple medications • Suspect “abuse”
• New onset urinary or fecal incontinence
• Involuntary weight loss
• Frequent falls
• One or more sensory impairments
• Disruptive behavior or personality changes
 HEAD-TO-TOE GERIATRIC ASSESSMENT THORAX AND LUNGS
• Variations of the respiratory system includes 4 broad areas:
SKIN, HAIR, AND NAILS • Anatomic changes
• Alveolar gas exchange
• The most visible signs of aging are manifested in the skin and • Regulation of ventilation
hair. • Lung defense mechanisms
• Wrinkles (diminished elasticity of skin)
• Sagging skin folds
ANATOMIC CHANGES
• Graying hair
• Hair loss • Degeneration of intervertebral discs
• Light-skinned individuals appear to manifest the changes of • Stiffening of ligaments and joints
aging more rapidly than do dark-skinned individuals. • Calcification of the costochondral cartilage
• Disruption in the body’s thermoregulation • Barrel chest
• Due to the diminished number of sweat and Barrel chest is a condition in which the
sebaceous glands chest appears to be partially inflated all the
• Loss of subcutaneous fat (in bony prominences, time, with the rib cage broadened as if in
increases the risk of skin breakdown) the middle of a deep breath. The person
• Diminished inflammatory response • Diminished perception may find it hard to breathe normally.
of pain
• Prolonged wound healing (due to thinning of epidermis)
• Senile pruritus (due to decrease in water content in skin,
decrease in number of sweat glands, and atrophy of the eccrine
glands)
• Generalized itching (associated with systemic diseases such
as diabetes, atherosclerosis, and liver disease)
• Number and thickness of hair diminish • Kyphosis
• Decrease melanin production
• Nails may thicken, split, and become more yellow and dull Kyphosis is an exaggerated,
forward rounding of the
back. It can occur at any age
HEAD, NECK, AND REGIONAL LYMPH NODES
but is most common in older
• Altered facial symmetry: affected due to presence of dentures women
or loss or teeth
• Neck veins are more prominent due to loss of fat
• Range of motion of the head may be limited or painful
• Dizziness accompanying movement of the head may create
safety problems

EYES ALVEOLAR GAS EXCHANGE

• Presbyopia (farsightedness) • Lung’s decreased elastic recoil (Causes closure of the airways)
• Cataract • Results to ventilation-perfusion mismatch of the apices and
• Pupils become smaller bases of the lungs
• Decreased peripheral vision • Loss of lung tissue
• Decreased corneal sensitivity and reflex • Alveolar capillaries and pulmonary wall thickening
• Thinning of the eyelid • Decrease in partial pressure oxygen
• Loss of pigment in the iris
REGULATION OF VENTILATION
EARS • The medulla is less sensitive to changes in carbon dioxide and
oxygen levels (Which normally trigger the respiratory drive)
• Presbycusis (Hearing Loss)
• Compromised acid-base balance
• Increased risk of balance and equilibrium deficits
• Neural output to respiratory muscles decrease
• Length and width of pinna increases
• Both peripheral and central chemoreceptors are affected
• Cerumen production decreases
LUNG DEFENSE MECHANISM
NOSE
• Increase susceptibility to infection
• Nasal hair are coarser and less efficient filtration occurs as a • Decreased cough reflex
person ages. (Can lead to sinus and respiratory problems) • Increased risk of aspiration
• A decline in the sense of smell (May result in decreased
appetite)
HEART

MOUTH AND THROAT • Size of the cardiac muscle decreases

• Cardiac output can fall by as much as 35% at rest after age 70
• Decreased saliva production • Skeletal changes such as osteoporosis, kyphosis or collapsed
• Neglect of oral care vertebrae can alter the position of the heart within the thoracic
• Tooth/teeth loss cavity
• Swallowing problems • Obesity in the elderly leads to increased abdominal girth and
• Decreased number of taste buds diaphragm elevation
• Difficulty in discriminating the tastes of sweet, sour, salt, and • Cardiac valves may develop calcifications or fibrosis (Which
bitter results in heart rhythm changes)
• Development of abnormal heart sounds (an S4 heart sound can
BREAST AND REGIONAL LYMPH NODES be auscultated)
• Changes in the conduction system (Resulting from electrolyte
• Adipose tissue of the breast atrophies with age
imbalance, pharmacotherapy, debilitating states, or thickening
• The glandular tissue of the breast gradually decreases, causing
myocardial fibers leading to dysrhythmias)
the breasts to feel glandular instead of lobular
• Reduced beta adrenergic response.
• Breast tissue mass decreases and becomes wrinkled
• Nipples become smaller and flatter
• Increased risk of breast cancer (starts at the age of 50 years)
 PERIPHERAL VASCULATURE MALE GENITALIA
• Blood vessels become fibrotic • Testicular degeneration
• Presence of atherosclerosis in the blood vessel • Decreased sperm output
• Decrease in vascular flow (Due to smoking that leads to • Altered penile erection
vascular spasm) • Decline in testosterone levels Male Genitalia
• Absence or marked reduction of ejaculatory fluid emission
ABDOMEN • Onset of impotence
• Erectile dysfunction
• Abdominal musculature diminishes in mass and tone.
• Fat content of the body increases, leading to increased fat
ANUS, RECTUM, AND PROSTATE
deposition in the abdominal area.
• Alterations in digestion and absorption (Due to changes in • Loss of muscle elasticity in the rectum
gastric motility and decreased elasticity of the abdominal • Rectal prolapse
mucosa) • Decline in large bowel transit and fecal water excretion
• Decreased esophageal motility and lower esophageal • Enlargement of prostate
sphincter pressure (Can lead to GERD symptoms).
• Decreased secretion of hydrochloric acid SPECIAL ASSESSMENTS
• Decrease in intestinal motility • Developmental Assessment
• Weakened intestinal walls • Cultural Assessment
• Pancreatic, enzymatic, and hormonal secretions decrease • Spiritual Assessment
• Nutritional Assessment
MUSCULOSKELETAL • Sleep Assessment
• Decreased bone density • Falls Assessment
• Decreased cortical and trabecular mass • Pain Assessment
• Increase risk of loss of balance and falls • Self-Determination Assessment
• Muscle atrophy accompanied by a reduction of muscle mass • Functional Assessment
Reduction of height • Cognitive Assessment
• Muscle atrophy (Loss of muscle strength and muscle mass)
• Decrease in water content of the cartilages DEVELOPMENTAL ASSESSMENT
• Growing old is a time of individual growth
MENTAL STATUS AND NEUROLOGIC SYSTEM • Coping with losses
• Adjusting to altered living arrangements
• Myelin sheath begins to degenerate (Decreases impulse
• Retiring
transmission and nerve conduction rates).
• Adjusting to sexual and physical functions
• Decreased reaction time
• The axons of the neurons become smaller
• Amount of neurotransmitter produced in the neuron is TOOLS FOR GERIATRIC ASSESSMENT
diminished (changes in neurotransmitter are known to affect • Mini-Cog
sleep, temperature, control, and mood). Mental Status and • CAM (Confusion Assessment Model)
Neurologic System • Katz Index of Independence in Activities of Daily Living
• Total brain weight, number of synapses, and number of (ADL)
neurons diminish • Lawton Instrumental Activities of Daily Living (IADL)
• Brain atrophy • Mini-Nutritional Assessment (MNA)
• Ventricles increase in size • Pittsburgh Sleep Quality Index (PSQI)
• Cerebrospinal fluid increases to fill in the spaces Mental • Modified Caregiver Strain Index (CSI) Confusion Assessment
Status and Neurologic System Method (CAM)
• Cognitive changes • Sleep Assessment
• Decrease in short-term memory • Sleep is part of the rhythm of life and necessary for
• Signs of dementia, delirium, or acute mental confusion may function, but older adults are at higher risk of having
develop sleep disturbances.
• Sleep disorders may be present
URINARY SYSTEM • Reports of feeling tired all the time or having no
energy
RENAL • Falls Assessment
• The kidney shrinks • Higher risk for falls (But not a consequence of aging)
• Glomerular degeneration • Falls are viewed as geriatric syndrome that has
• Decrease renal blood flow multiple complex causes
• Decrease in GFR by 60-70% • Falls are the leading cause of accidental injury and
• Impaired sodium regulation Urinary System the leading cause of traumatic death in older adults
• Fall intrinsic risk factors: cognition, vision, gait,
BLADDER balance impairment, side effects of medications
• Fall extrinsic risk factors: environmental factors such
• Bladder becomes less elastic (Due to reduced muscle tone)
as non-sturdy furniture or equipment, poor lighting,
• Delayed perception of voiding signals
and uneven or slippery surfaces
• Urinary incontinence
• Pain Assessment
• Decreased bladder detrusor muscle instability
• Always ask older adults about the pain they are
• Weakened urinary sphincter • Increased nocturnal production
feeling because they view it as an inevitable part of
of urine
aging.
• Assessment of pain (Be guided using the 10
FEMALE GENITALIA characteristics of a chief complaint
• Menopause (starts at 45-55) • Cognitive Assessment
• Generalized atrophy of the external and internal female • Problems with:
reproductive organs • Perception
• Ovaries and fallopian tubes decrease in size • Memory
• Uterine atrophy • Thinking
• Pelvic muscle atrophy • The major cognitive entities fall into 3 diagnoses:
• Decrease in normal vaginal flora • Dementia
• Delayed production of vaginal secretions • Delirium
• Depression
PEDIATRIC HEALTH ASSSESSMENT
The clinical assessment of infants and children differs in many
ways from that for adults. Because children are growing and
developing both physically and mentally, values for parameters
such as dietary requirements and prevalence of disease,
expected normal laboratory values and responses to drug
therapy will be different from those observed in adults.
HEALTH MAINTENANCE REQUIREMENTS
Healthy children should have regular health maintenance visits,
often done at well-baby clinics. Such visits customarily occur
at 1 and 2 weeks of age, at 1, 2, 4, 6, 9, 12 and 18 months of
age, and subsequently at 1- or 2-year intervals.
At each visit, the child should undergo an appropriate history,
physical examination and developmental assessment.
Immunizations should also be given according to provincial
guidelines. Anticipatory guidance should be provided about the
following topics:
– Appropriate nutrition
– Safety measures
– Expected developmental and behavioral events
In addition, an assessment should be made of the quality of
physical care, nurturing and stimulation that the child is
receiving.
The most important components that should be assessed at
each health maintenance visit are shown in Table 1
PEDIATRIC HISTORY
TIPS & TECHNIQUES
CHILDREN
Children who can communicate verbally should be included as
historians, with additional details provided as necessary by
parents or caregivers. Health care professionals should interact
(for example, smile, coo) or play with children so as to not scare
them or make them cry.
Questions, explanations and discussions occurring with
children present should take into account their level of
understanding. Young children may be assisted in providing
details of the history by such techniques as having them play
roles or draw pictures. The interviewer should gain an
understanding of the child’s terminology for various body parts.
ADOLESCENTS
Adolescents should be granted privacy and confidentiality.
– Interview the adolescent alone
– Discuss with parents or caregiver separately, with
the adolescent’s permission
COMPONENTS OF PEDIATRIC HISTORY
The pediatric history includes many of the same components as
the adult history, including:
– Identifying data
– Chief complaint
– History of present illness
– History of past illnesses
– Allergies
– Medication history
– Tobacco, alcohol and/or drug use
– Family history
– Personal and social history (including grade level,
family of origin, interests, lifestyle)
– Review of systems
In addition, the pediatric history should include the following
information:
– Who the primary caregiver is
– Who is providing the history
– Pregnancy and perinatal history
– Birth history, including Apgar score
– Immunization history
– Detailed dietary history for the first year of life,
including history of vitamin supplements and fluoride
use. Also include dietary intake for other age groups,
including how much tea, carbonated beverages and
juice are being consumed
– Developmental history (including physical,
cognitive, language, social and emotional)
– Social history, including questions about how many
people live in the home, recent separations, deaths,
family crises, friends, peer relationships, daycare
arrangements, progress in school, smoking in the
home and secure food access for child and family
– Physical environment at home, including presence
of mold and poor heating or insulation
PHYSICAL EXAMINATION OF THE NEWBORN
Observe the entire infant at the beginning of the examination,
before the assessment of specific organ systems. It is important
that the infant be completely undressed and in a warm
environment with adequate illumination.
GENERAL APPEARANCE
Assess the following:
– Level of consciousness, alertness, general
behaviour and appearance (how well the baby looks)
– Symmetry of body proportions
– Posture of limbs (flexed, extended)
– Body movements (for example, arms and legs,
facial grimace)
– State of nutrition and hydration
– Colour
– Any sign of clinical distress (for example,
respiratory distress includes dyspnea, pallor,
cyanosis, irritability)
VITAL SIGNS
Average values of vital signs for newborns:
– Temperature 36.5°C to 37.5°C
– Heart rate 120–160 beats/minute
– Respiratory rate 30–60/minute, up to 80/minute if
infant is crying or stimulated
– Systolic blood pressure 50–70 mm Hg
GROWTH MEASUREMENTS
Measure and record length, weight and head circumference. If
the infant appears premature or is unusually large or small,
assess gestational age
– Average length at birth 50–52 cm
– Average weight at birth 3500–4400 g
– Average head circumference at birth 33–35 cm (this
is done only at well-child visits unless hydrocephalus
is suspected)
These parameters should be recorded on gender-appropriate
growth curves, which should form part of the child’s health
record. Printable electronic versions of the growth charts are
available at:
– Growth charts for boys: Birth to 36 months, and 2 to
20 years
SKIN
COLOR
– Pallor associated with low hemoglobin or vasoconstriction
(for example, in shock)
– Cyanosis associated with hypoxemia
– Plethora associated with polycythemia or vasodilation
– Cherry red face associated with carbon monoxide poisoning
– Jaundice associated with elevated bilirubin
LESIONS
– Milia: Pinpoint white papules of keratogenous material,
usually on nose, cheeks and forehead, which last several weeks
and then spontaneously resolve
– Miliaria: Obstructed eccrine (sweat) ducts appearing as
pinpoint vesicles on forehead, scalp and skin folds; usually
clear within 1 week
– Transient neonatal pustular melanosis: Small vesicopustules,
generally present at birth, containing white blood cells (WBCs)
and no organisms; intact vesicle ruptures to reveal a pigmented
macule surrounded by a thin skin ring; spontaneously resolves
by 3 months of age
– Erythema toxicum: Most common newborn rash, consisting
of variable, irregular macular patches and lasting a few days
– Stork bite: Pink and flat nevus simplex, usually on face or
back of the neck; those on face usually disappear by 18
months4
– Café au lait spots: Irregular brown, flat macules. Suspect
neurofibromatosis if there are many (more than 5 or 6) large
spots
– Mongolian spots: dark bluish/purplish patches present at
birth, usually on back and buttocks but may be on limbs;
common in First Nation’s and Inuit children; usually fade
away in first year of life
HEAD AND NECK
HEAD
Check for:
– Overriding sutures
– Anterior and posterior fontanelles (size, consistency, bulging
or sunken)
– Abnormal shape of head (for example, caput succedaneum,
molding, cephalohematomas, encephaloceles, microcephaly)
– Bruising of head, behind the ears or periorbitally Measure
head circumference.
EYES: INSPECTION
– Check cornea for cloudiness (sign of congenital cataracts)
– Check conjunctiva for erythema, exudate, orbital edema,
subconjunctival hemorrhage, jaundice of sclera
– Check for pupillary size, shape, equality and reactivity to light
(PERRL: pupils equal, round, reactive to light),
accommodation normal
– Red reflex: hold ophthalmoscope 15–20 cm (6–8 inches) from
the eye and use the +10 diopter lens. If normal, the newborn’s
eye transmits a clear red colour back; black dots may represent
cataracts; a whitish colour may suggest retinoblastoma
EARS: INSPECTION
– Check for asymmetry, irregular shape, setting of ear in
relation to corner of eye (low-set ears may suggest underlying
congenital problems such as renal anomalies, fetal alcohol
spectrum disorder or Down’s sydrome)
– Look for fleshy appendages, lipomas or skin tags
– Dimples may suggest a brachial cyst
– Perform otoscopic examination; check canals for discharge
and colour, and tympanic membranes for colour, brightness,
perforation, effusion, bony landmarks and light reflex
NOSE: INSPECTION
– Look for nasal flaring, which is a sign of increased respiratory
effort
– Look for hypertelorism or hypotelorism (increased or
decreased space between eyes)
– Check for choanal atresia (posterior nasal passage blockage
uni- or bilaterally), as manifested by respiratory distress.
Neonates are obligate nose breathers, so first check to
determine if air is coming from nostrils; if not and choanal
atresia is suspected, a soft nasogastric tube can be passed
through each nostril to check patency
PALATE: INSPECTION AND PALPATION
– Check for defects, such as cleft lip (some may have a
membrane covering the cleft so it may not be obvious) and
palate or a high arched palate
MOUTH: INSPECTION
– Observe size and shape of mouth
– Microstomia (small mouth): seen in trisomy 18 and 21
– Macrostomia: seen in mucopolysaccharidosis
– “Fish mouth”: seen in fetal alcohol syndrome
– Epstein pearls: small white cysts containing keratin,
frequently found on either side of the median line of the palate
(benign)
TONGUE: INSPECTION
– Macroglossia: indicates hypothyroidism or
mucopolysaccharidosis Teeth: Inspection
– Natal teeth (usually lower incisors) may be present – Risk of
aspiration if these are attached loosely
CHIN: INSPECTION
– Micrognathia (abnormally small lower jaw) may occur with
Pierre Robin syndrome, Treacher Collins syndrome and
Hallerman-Streiff syndrome
NECK:
INSPECTION
– Symmetry of shape
- Alignment: torticollis is usually secondary to
sternocleidomastoid hematoma
– Tracheal tug: can occur with dyspnea
– Neck mass (cystic hygroma is the most common type)
PALPATION
– Palpate all muscles for lumps and the clavicles for possible
fracture
– Neck range of motion for nuchal rigidity: decreased
movement may be present in meningitis
– Lymph nodes cannot usually be palpated at birth; their
presence usually indicates congenital
RESPIRATORY SYSTEM
VITAL SIGNS
– Respiratory rate
INSPECTION
– Cyanosis, central or peripheral (transient bluish colour may
be seen in extremities if infant is cooling off during the
examination)
– Respiratory effort, rate and pattern (for example, periodic
breathing, gasping, periods of true apnea)
– Observe chest movement for symmetry and retractions
– Anatomical abnormalities of chest (for example, pectus
excavatum)
– Use of accessory muscles, tracheal tug, indrawing of
intercostal or subcostal muscles
PALPATION
– Any abnormal masses (palpate gently)
– Breasts may be slightly enlarged secondary to presence of
maternal hormones
AUSCULTATION
– Breath sounds
– Inspiratory to expiratory ratio
– Adventitious sounds (for example, stridor, crackles, wheezes,
grunting)
Percussion is of little clinical benefit and should be avoided,
especially in low-birth-weight or preterm infants, as it may
cause injury (for example, bruising, contusions)
CARDIOVASCULAR SYSTEM
VITAL SIGNS
– Heart rate
– Blood pressure in upper and lower extremities
INSPECTION
– Colour: pallor, cyanosis, plethora
PALPATION
– Locate usual point of maximal impulse (PMI) by positioning
one finger on the chest, in the fourth intercostal space medial to
the midclavicular line
– Abnormal location of PMI can be a clue to pneumothorax,
diaphragmatic hernia, situs inversus viscerum, congenital heart
disease or other thoracic problem
– Capillary refill (< 2 seconds is normal)
– Peripheral pulses: note character of pulses (bounding or
thready; equality); any decrease in femoral pulses or radial-
femoral delay may be a sign of coarctation of the aorta
AUSCULTATION
– Note rate and rhythm
– Note presence and quality of S1 and S2 heart sounds
– Assess for S3 and S4: S3 may be a normal finding in infants
and children3
– Note presence of murmurs (consider murmurs pathologic, as
in congenital heart defects, until proven otherwise)
ABDOMEN
INSPECTION
– Shape of abdomen: flat abdomen may signify decreased tone,
presence of abdominal contents in chest or abnormalities of the
abdominal musculature
– Contour: note any abdominal distension
– Masses
– Visible peristalsis
– Diastasis recti
– Obvious malformations (for example, bowel contents outside
of abdominal cavity [omphalocele]; this abnormality has a
membranous covering [unless it has been ruptured during
delivery], whereas gastroschisis does not)
– Umbilical cord: count the vessels (there should be one vein
(large and thin-walled) and two arteries (small and thick-
walled); note colour, any discharge
AUSCULTATION
– Bowel sounds
PALPATION
– Check for any abnormal masses
– Liver and spleen: it may be normal for the liver to be located
about 2 cm below the right costal margin; spleen is not usually
palpable; if it can be felt, be alert for congenital infection or
extramedullary hematopoiesis
– Kidneys: should be about 4.5–5 cm vertical length in the full-
term newborn
– Techniques for kidney palpation: place one hand with four
fingers under the baby’s back, then palpate by rolling the thumb
over the kidneys; or place the right hand under the left lumbar
region and palpate the abdomen with the left hand to palpate the
left kidney (do the reverse for the right kidney)
– Check for hernias: umbilical or inguinal
Percussion usually omitted unless a problem such as abdominal
distension is noted.
Inspect the anal area for patency and for presence of fistulas or
skin tags.
GENITALIA
The genitalia should be carefully assessed, with particular
attention to any malformation, abnormalities or sexual
ambiguity.
MALE GENITALIA
INSPECTION
– Glans: colour, edema, discharge, bleeding
– Urethral opening: should be located centrally on the glans (in
hypospadias, the opening is found on the undersurface of the
penis)
– Foreskin (prepuce): never force retraction of the foreskin
– Scrotum: in full-term infant, scrotum should have brownish
pigmentation and should be fully rugated
– Palpation
– Testes: ensure that both testicles are descended into scrotum.
Palpate inguinal area. If one or both are not descended, consult
a physician
FEMALE GENITALIA
INSPECTION
– Check labia, clitoris, urethral opening and external vaginal
vault
– Whitish discharge is often present; this is normal, as is a small
amount of bleeding, which usually occurs a few days after birth
and is secondary to maternal hormone withdrawal
– Hymenal tags, if they occur, are normal
MUSCULOSKELETAL SYSTEM
INSPECTION AND PALPATION
SPINE
– Check for scoliosis, kyphosis, lordosis, spinal defects, a patch
of hair along the spine, meningomyelocele
UPPER EXTREMITIES
– Assess the shoulder girdle for injury and the clavicles for
fracture (especially if the delivery was traumatic and in large
infants with a history of shoulder dystocia)
– Assess mobility of the shoulder and extension of the elbow
– Inspect palmar creases for assessment of gestational age: they
may appear different in some hereditary syndromes
– Count the fingers
LOWER EXTREMITIES
– Assess the feet and ankles for deformity and mobility
– Count the toes
– Examine foot creases for assessment of gestational age
– Examine the hips for neonatal hip instability using Ortolani
and Barlow maneuvers. These tests may be somewhat
unreliable depending on the examiner’s experience, so further
assessment may be needed
ORTOLANI MANEUVER
– Flex the knee and hip
– Place middle fingers over greater trochanters
– Position thumbs on medial sides of knees
– Abduct the hip to 90° by applying lateral pressure with thumb
– Push forward with the middle fingers that are over greater
trochanters
– If there is a “clunk,” the hip may be dislocated
BARLOW MANEUVER
– Flex the knee and hip
– Place thumbs on knees
– Place middle fingers over greater trochanters
– Adduct the hip medially and push backward on the knee with
thumbs
– If there is a “clunk” or telescoping sensation, the hip may be
dislocatable
CENTRAL NERVOUS SYSTEM
– Assess state of alertness
– Check for lethargy or irritability
– Posture: For term infant, normal position is one with hips
abducted and partially flexed and with knees flexed; arms are
adducted and flexed at the elbow; the fists are often clenched,
with fingers covering the thumb
– Assess tone: for example, support the infant with one hand
under the chest; the neck extensors should be able to hold the
head in line for 3 seconds. There should not be more than 10%
head lag when the infant is moved from a supine to a sitting
position
REFLEXES
Reflexes are involuntary movements or actions that help to
identify normal brain and nerve activity and development.
Some are present at birth and serve a variety of purposes, others
develop later. Abnormal reflexes – ones that persist after an age
they should disappear, or are absent at birth when they should
be present – can help identify neurological or motor disease
early.
DEEP TENDON REFLEXES
These are not normally examined in the child under 5 years.
APGAR SCORE
Apgar scoring is done at 1 and 5 minutes after birth. If
necessary, it is repeated at 10 minutes after birth. Interpretation
At 1 Minute
< 7: depression of nervous system
< 4: severe depression of nervous system
At 5 Minutes
> 8: no asphyxia
< 7: high risk for subsequent dysfunction of central
nervous system
5–7: mild asphyxia
3–4: moderate asphyxia
0–2: severe asphyxia
ASSESSMENT OF GESTATIONAL
Age Gestational age can be assessed on the basis of the
newborn’s external characteristics.
SCREENING TESTS
PHENYLKETONURIA
– All newborns should be screened for phenylketonuria (PKU)
by means of a capillary blood sample before discharge from the
hospital.
– For any newborn who undergoes this type of screening at less
than 24 hours of age, the screening test must be repeated
between 2 and 7 days of age.
CONGENITAL HYPOTHYROIDISM
– All newborns should be screened by taking a thyroid-
stimulating hormone (TSH) or thyroxine (T4) level by means
of a dried capillary blood sample in the first week of life
– If a child was born in hospital, verify that this type of
screening was done before discharge
PHYSICAL EXAMINATION OF THE INFANT
AND CHILD
Clinicians should be aware of the different sizes of body parts
in children relative to adults: the head is relatively larger, limbs
relatively smaller and, in small children, the ratio of surface area
to weight is relatively larger.
TECHNIQUE
Much information can be obtained by observing the child’s
spontaneous activities while the history is being conducted,
without touching the child. For this purpose it is useful to have
an age-appropriate toy available. Approach infants and young
children slowly and start by playing with them to gain their
trust.
For a young child, do as much of the physical examination as
possible with the child either being held by the parent or
caregiver or supported on that person’s lap.
Generally, the least stressful parts of the exam should come
first, with more intrusive or distressing parts later (for example,
examination of the pharynx and/ or ears with the child
restrained). Allowing the child to play with the equipment can
often decrease anxiety about certain parts of the exam.
One must choose the quietest moment to do the respiratory and
cardiac exam. This is usually at the beginning of the exam. The
order of the examination must be varied to suit the situation.
Care should be taken to select appropriate-sized equipment
when examining a child (for example, blood pressure cuff width
should be greater than two-thirds of the length of the upper
arm).
GENERAL APPEARANCE
Without touching the child, observe (if applicable):
– Level of consciousness, alertness, general behaviour and
appearance (how well the infant/ child looks)
– Symmetry of body
– Posture of limbs (flexed, extended)
– Body movements (for example, arms and legs, facial grimace)
– State of nutrition and hydration
– Colour
– Any sign of clinical distress (for example, respiratory distress
includes dyspnea, pallor, cyanosis, irritability)
– Gait
– Breathing frequency and pattern
– Responses to sound
– Fine and gross motor skills as the child plays
– Lesions (for example, petechiae, eczema, impetigo)
– Responses to parental comforting measures
– Ability to entertain themself while the caregiver is talking
– Quality of infant’s cry or quality of child’s voice
– Interaction pattern, speech and nature of child’s responses to
parent(s) and health care staff
VITAL SIGNS
Assess for:
– Heart rate
– Blood pressure
– Respiratory rate
– Temperature (if warranted)
– Oxygen saturation (if warranted)
Blood pressure measurements are influenced by sex, age and
height. Therefore blood pressure charts should be used to
interpret the values. Blood pressure should be recorded once in
the healthy child under 2 years and then annually after that.
Temperature Measurement in Children Proper temperature
measurement is essential for clinical decision making in the
pediatric population. Children should be unbundled for at least
15 minutes prior to taking their temperature. One needs to be
aware of the normal temperature ranges for each measurement
method and use recommended temperature measurement
methods in children.
Tympanic temperature measurement is contraindicated in
newborns due to the shape of the ear canal and the potential
for vernix or amniotic fluid in the canal.
GROWTH MEASUREMENTS
Weight should be done at each visit for any infant under 1, those
presenting for a well-child visit, at least annually for older
children, and for any infant or child who presents with
vomiting, diarrhea, signs of shock, or in need of a medication
where dosage is dependent on weight.
Measurements of recumbent length (until 24 months old) or
height, weight and head circumference (until 24 months old)
should be part of every health maintenance visit. These
parameters should be recorded on gender-appropriate growth
curves, which should form part of the child’s health record.
SKIN
Note colour, condition and lesions on all aspects of the body.
COLOUR
– Pallor associated with low hemoglobin or vasoconstriction
(for example, in shock)
– Cyanosis associated with hypoxemia
– Plethora associated with polycythemia or vasodilation
– Cherry red face associated with carbon monoxide poisoning
– Jaundice associated with elevated bilirubin
LESIONS
– Stork bite: Pink and flat nevus simplex; usually on face or
back of the neck; those on face usually disappear by 18 months
– Café au lait spots: Irregular brown, flat macules. Suspect
neurofibromatosis if there are many (more than 5 or 6) large
spots
– Mongolian spots: dark bluish/purplish patches present at
birth, usually on back and buttocks but may be on limbs;
common in First Nation’s and Inuit children; usually fade away
in first year of life
– Acne: blackheads, whiteheads; more severe forms have
papules, pustles and nodules; usually on face and sometimes on
back, chest and shoulders; most common in adolescence
HEAD AND NECK
HEAD AND FACE
– Palpate anterior and posterior fontanelles (size, consistency,
bulging or sunken) and cranium
– Bruising of head, behind the ears or periorbitally
– Size and shape of the head
– Facial symmetry at rest and while crying for the infant
EYES
Inspection To open the infant’s eyes, support their head and
shoulders and gently lower the infant backward.
– Check cornea for cloudiness (sign of congenital cataracts)
– Check the lids and external structures; note palpebral slant
– Assess for nystagmus
– Check conjunctiva for erythema, exudate, orbital edema,
subconjunctival hemorrhage, jaundice of sclera
– Check for position and alignment of the eyes using cover-
uncover test
– Check for corneal light reflex and ability to track movement
for cardinal fields of gaze
– Check for pupillary size, shape, equality and reactivity to light
(PERRL: pupils equal, round, reactive to light),
accommodation normal
– Red reflex: hold ophthalmoscope 15–20 cm (6–8 inches) from
the eye and use the +10 diopter lens; if normal, the newborn’s
eye transmits a clear red colour back; black dots may represent
cataracts; a whitish colour may suggest retinoblastoma
– Inspect fundus, if possible
– Check visual acuity in children over 3 years of age.
EARS
– Check for asymmetry, irregular shape, setting of ear in
relation to corner of eye (low-set ears may suggest underlying
congenital problems such as renal anomalies, fetal alcohol
spectrum disorder or Down’s sydrome)
– Look for fleshy appendages, lipomas or skin tags
– Palpate and inspect auricles
– Perform otoscopic examination; check canals for discharge,
foreign bodies and colour, and tympanic membranes for colour,
brightness, perforation, effusion, bony landmarks and light
reflex
NOSE: INSPECTION
– Determine if nares are patent. Look for foreign body
– Look for nasal flaring, which is a sign of increased respiratory
effort
– Look for hypertelorism or hypotelorism (increased or
decreased space between eyes)
– Note nasal discharge or sneezing
– Look at the mucosa, septum and turbinates with otoscope
MOUTH
– Inspect lips, gums, palate, buccal mucosa, tongue, palate,
tonsils
– Inspect tongue size and frenulum of tongue in infants
– Inspect teeth for number, character, condition, position and
caries
– Palpate palate in young infants
– Note if uvula is midline
NECK
INSPECTION
– Symmetry of shape, midline trachea
– Alignment: torticollis is often secondary to positional
plagiocephaly
– Tracheal tug: can occur with dyspnea
– Neck mass
PALPATION
– Palpate any masses (may signify congenital cysts), trachea,
lymph nodes and thyroid
– Neck range of motion for nuchal rigidity: may be present in
meningitis; in older children (over 5) Kernig and Brudzinski
reflex may be helpful in assessing for meningitis
– Palpate clavicles
RESPIRATORY SYSTEM
INSPECTION
– Cyanosis, central or peripheral (transient bluish colour may
be seen in extremities if infant is cooling off during the
examination)
– Respiratory effort, rate and pattern (for example, periodic
breathing, gasping, periods of true apnea)
– Observe chest movement for symmetry and retractions
– Note any movement of the abdomen with respirations
– Note chest size, shape, configuration and anatomical
abnormalities of chest (for example, pectus excavatum)
– Use of accessory muscles, tracheal tug, indrawing of
intercostal or subcostal muscles
– Note any nipple and breast development
PALPATION GENITALIA
– Any abnormal masses (palpate gently) Inspect the external genitalia and note stage of sexual maturity.
– Nipples and breast tissue
– it may be slightly enlarged secondary to presence of maternal
MALE GENITALIA
hormones in infants
INSPECTION
AUSCULTATION – Glans: colour, edema, discharge, bleeding
– Breath sounds – Urethral opening: should be located centrally on the glans (in
– Rate and rhythm hypospadias, the opening is found on the undersurface of the
– Inspiratory to expiratory ratio penis)
– Adventitious sounds (for example, stridor, crackles, wheezes, – Foreskin (prepuce): never force retraction of the foreskin
grunting) – Testes: ensure that both testicles are descended into scrotum
in infants. Palpate inguinal area. If one or both are not
Percussion as indicated. descended, consult a physician
– If masses are present, transilluminate the scrotum
CARDIOVASCULAR SYSTEM
FEMALE GENITALIA
INSPECTION INSPECTION
– Colour: pallor, cyanosis, plethora – Check labia, clitoris, urethral opening and external vaginal
– Pulsations on precordial area vault
– Hymenal tags, if they occur, are normal
PALPATION
– Locate point of maximal impulse (PMI) by positioning one MUSCULOSKELETAL SYSTEM
finger on the chest and note this location. Abnormal location of
PMI can be a clue to pneumothorax, diaphragmatic hernia or
other thoracic problems INSPECTION AND PALPATION
– Palpate chest wall for thrills
– Capillary refill (< 2 seconds is normal) SPINE
– Peripheral pulses in each extremity and femoral: note – Check for scoliosis, kyphosis, lordosis, spinal defects, a patch
character of pulses (bounding or thready; equality); compare of hair along the spine, meningomyelocele
strength of femoral pulses with radial pulses
UPPER EXTREMITIES
AUSCULTATION – Inspect and note ROM and muscle tone of the shoulder, wrist
– Note rate and rhythm and elbow
– Note presence and quality of S1 and S2 heart sounds – Note alignment of arms and hands
– Assess for S3 and S4: S3 may be a normal finding in infants – Inspect fingers and palmar creases
and children3
– Note presence of murmurs (consider murmurs pathologic, as LOWER EXTREMITIES
in congenital heart defects, until proven otherwise) – Inspect and note ROM and muscle tone of the toes, knees, and
ankles
ABDOMEN – Note alignment of legs, feet and toes
– Note arch of foot
INSPECTION – In infants, examine the hips for hip instability using Ortolani
– Shape of abdomen: flat abdomen may signify decreased tone and Barlow maneuvers. These tests may be somewhat
or abnormalities of the abdominal musculature unreliable depending on the examiner’s experience, so further
– Periumbilical area assessment may be needed.
– Contour: note any abdominal distension
– Masses ORTOLANI MANEUVER
– Visible peristalsis
– Flex the knee and hip
– Diastasis recti
– Place middle fingers over greater trochanters
– Anal area for presence of fistulas, excoriation or fecal soiling
– Position thumbs on medial sides of knees
– Abduct the hip to 90° by applying lateral pressure with thumb
AUSCULTATION – Push forward with the middle fingers that are over greater
– Bowel sounds trochanters
– If there is a “clunk,” the hip may be dislocated
PERCUSSION
– All quadrants BARLOW MANEUVER
– Flex the knee and hip
PALPATION – Place thumbs on knees
– Note muscle tone, skin turgor and underlying organs – Place middle fingers over greater trochanters
– Check for any abnormal masses – Adduct the hip medially and push backward on the knee with
– Check for enlarged organs thumbs
– Techniques for kidney palpation with infants: place one hand – If there is a “clunk” or telescoping sensation, the hip may be
with four fingers under the infant’s back, then palpate by rolling dislocatable
the thumb over the kidneys; or place the right hand under the
left lumbar region and palpate the abdomen with the left hand CENTRAL NERVOUS SYSTEM
to palpate the left kidney (do the reverse for the right kidney) – Assess state of alertness
– Check for hernias: umbilical or inguinal – Check for lethargy or irritability
– Check for inguinal lymph nodes – Posture
– Assess muscle tone (for example, support the infant with one
hand under the chest; the neck extensors should be able to hold
the head in line for 3 seconds; there should not be more than
10% head lag when the infant is moved from a supine to a
sitting position)
 REFLEXES
Reflexes are involuntary movements or actions that help to
identify normal brain and nerve activity and development.
Some are present at birth and serve a variety of purposes, others
develop later. Abnormal reflexes – ones that persist after an age
they should disappear, or are absent at birth when they should
be present – can help identify neurological or motor disease
early. The following are some of the reflexes that should be
tested in newborns and infants up to 2 years of age.

DEEP TENDON REFLEXES

Deep tendon reflexes are not usually tested in children under 5
years of age. In older children, deep tendon reflexes may be
tested. Reflexes must be symmetric. The child must be relaxed
and comfortable. The reflexes include the biceps,
brachioradialis, triceps, patellar and achilles.

CRANIAL NERVE ASSESSMENT

After 2 years of age, cranial nerves can be tested with some
modifications according to the developmental stage of the chil

SCREENING
DEVELOPMENTAL MILESTONES
Assessment of developmental progress should be part of each
complete health assessment (well-child visit) and take place at
all visits for children who do not present regularly for well-child
care. Developmental assessment is done by making inquiries of
the parents or caregiver and by clinical observation of the
child’s achievement of major age-appropriate milestones.
These are in areas of gross and fine motor, speech and language,
and personal and social development.

Developmental milestones are achieved at different ages in

different children.
CONTINUING ASSESSMENT BEHAVIORAL RESPONSE TO PAIN
• Verbal responses
PAIN : THE 5TH VITAL SIGN • Non-verbal responses
• Pain is a complex experience consisting of a physiological and • Vocal behaviors
a psychological response to a noxious stimulus. "Pain is • Verbal statements
whatever the person says it is" • Facial expression
• Altered response environment
• PAIN is an unpleasant sensory or emotional experience
associated with actual or potential tissue damage, or described
in terms of such damage. - World Health Organization, n.d. SOURCES OF PAIN
• NOCICEPTIVE PAIN
PHYSIOLOGY OF PAIN Injury or inflammation → Stimulation of nociceptors
of the PNS → Nociceptors communicate injury
• Nociceptive System
information to the brain → Sensation of pain
The system involved in the transmission and
HYPERALGESIA
perception of pain
• NEUROPATHIC PAIN
• Nociceptor
Injury or inflammation → Damage to nerve fibers in
Peripheral nerve endings which transmit the
the periphery or to the CNS → Nociceptors
sensations to the CNS
communicate injury information to the brain →
• Nociception
Sensation of pain ALLODYNIA
Term used to describe how noxious stimuli are
typically perceived as pain; pain perception
PAIN CLASSIFICATION
PHYSIOLOGIC PROCESS OF NOCICEPTION
TRANSDUCTION CAUSE
Noxious stimuli causes cell damage with the release of • Nociceptive
sensitizing chemicals. These substances activate nociceptors • Neuropathic
and lead to generation of action potential.
• Inflammatory
⁃ Dolor
TRANSMISSION ⁃ Calor
Action potential continues from site of injury to spinal cord,
spinal cord to brainstem and thalamus to cortex for processing. ⁃ Rubor
⁃ Tumor
⁃ Function Laesa
PERCEPTION
Indicates the conscious experience of pain.
DURATION/ETIOLOGY
MODULATION • Acute
Neurons from the brainstem release neurotransmitters that • Chronic non-malignant pain
blocks pain impulse, producing an analgesic effect. • Cancer pain
• Intractable pain
PHYSIOLOGIC RESPONSE TO PAIN
• Noticeable upon the onset of acute pain ACUTE
• May differ from patient to patient
• sudden and recent onset
• Best used when patient is unconscious
• Must not be used to validate verbal report pain • associated with a specific injury
• varies in intensity
• lasts for a brief period
• can be treated easily
• heals spontaneously
• protective mechanism

• Anxiety, fear, hopelessness, sleeplessness, suicidal thoughts CHRONIC

• focus on pain, reports of pain, cries and moans, frowns, and • constant / intermittent pain that persists over a period of
facial grimaces time.
•decrease in cognitive function, mental confusion, altered • cause is not clear
temperament, high somatization and dilated pupils • difficult to treat
• ↑HR, peripheral, systemic and coronary vascular resistance, • can stem from prolonged disease or dysfunction
↑BP • can be associated with a mental disorder
• ↑RR and sputum retention, resulting in infection and • typically generalized
atelectasis • strongly influenced by emotions & environment
• ↓gastric and intestinal motility
• ↓UO, resulting in urinary retention, fluid overload, depression LOCATION
of all immune responses antidiuretic hormone, epinephrine,
norepinephrine, aldosterone, glucagons, testosterone • Cutaneous pain
• hyperglycemia, glucose intolerance, insulin resistance, • Visceral pain
protein catabolism • Deep somatic pain
• muscle spasm, resulting in impaired muscle function and
immobility, perspiration. PERCEPTION
- radiating
- referred
 SEVEN DIMENSIONS OF PAIN CHARACTERISITICS OF PAIN NSET OF PAIN
1. PHYSICAL DIMENSION - body's reaction to stimulus O Onset of the event : What were you doing when the pain
2. SENSORY DIMENSION - perception of pain's location, begin/started? Did it happen suddenly or had it been coming on
intensity, and quality. for a while?
3. BEHAVIORAL DIMENSION - patient's verbal and P Provocation/Palliation : What makes the pain worse?
non-verbal response. What makes it better?
4. SOCIOCULTURAL DIMENSION - influences of
patient's social context & cultural background on pain Q Quality of the pain: Can you describe the pain for
experience. me? Is it dull? Stabbing? Burning sharp? Tingling?
5. COGNITIVE DIMENSION - management part of pain R Region & Radiation : What area of the body is the
exp. pain occurring? Is it radiating to anywhere else? It is
6. AFFECTIVE DIMENSION - feelings, sentiments & spreading to another area? Foot to the leg? From
emotions
7. SPIRITUAL DIMENSION - meaning and purpose of shoulders to the back?
the person S Severity : On a scale of 1-10, with 10 being the worst pain
imaginable, Where is your pain level right now?
T Time and History: What were you doing when the pain
AGE & PAIN
started? Has it happened before? Is there anything different
• Infant from the time it started.
- Responds to stimuli with increased
sensitivity WHERE DOES IT HURT?
• Toddler and preschooler • LOCALIZED PAIN - felt only at its origin
- Considers pain as punishment • PROJECTED PAIN - travels along the nerve pathways
• School age • RADIATING PAIN - extends in several directions from the
- Tries to be brave in facing pain point of origin
• Adolescent • REFERRED PAIN - occurs in places remote from the site of
- Want to be brave due to peer pressure, origin
increased sensitivity to pain
• Adult INSTRUMENTS FOR ASSESSING PAIN
- Perceives pain as a sign of weakness & PERCEPTION
ignores it • ASSESSING PAIN PERCEPTION
• Elderly
- Perceives pain as part of aging process,
decreased sensations & perceptions of pain

CULTURE & PAIN

• Pain is a universal human experience but how people respond
varies with the meaning placed on pain and the response to pain • NUMERIC PAIN RATING SCALE
that is affected in the culture in which the person is raised.
• Pain can have several meanings bet. different cultures that
lead to different response patterns.
• Respond to patient’s pain perception and not the response.
AVOID STEREOTYPING!
• WORD GRAPHIC PAIN RATING SCALE
• Recognize your own response to pain.

HOW TO BE A CULTURALLY COMPETENT

NURSE?
• Be aware of your own cultural and family values.
• Be aware of your personal biases and assumptions about • VISUAL ANALOGUE SCALES
people with different values than yours.
• Be aware and accept cultural differences bet. yourself and
individual patients.
• Be capable of understanding the dynamics of the difference.
• Be able to adapt to diversity.

HOW TO ASSESS PAIN PERCEPTION

• FLACC PAIN ASSESSMENT OF CHILDREN
C Characteristics of pain
O Onset of pain
L Location of pain
D Duration of pain
S Severity
P Pattern
A Alleviating/Aggravating factors
• NEONATAL POST-OPERATIVE PAIN MEASUREMENT
SCALE
 NURSING MANAGEMENT FEVER A.K.A PYREXIA
• Maintain a quiet, comfortable and calm environment. • Body temperature above normal range without any
• Maintain privacy and ensure confidentiality. physiological cause
• Ask questions in an open-ended format. • 38 deg. celcius and above
• Listen carefully to the client's verbal descriptions and • A symptom of underlying disease
document the exact words/phrase used. process/protective function
• Note for the client's facial expressions and grimaces during • Reduces the content of iron in blood plasma
the interview. • Suppress the growth of bacteria
•DO NOT put words in the client's mouth (apply therapeutic • Enhances immune system
communication)
• Stimulation of WBC production
• Explore client's past experiences with pain.
• Fights against viral infection by stimulation
• Believe the client's expression of pain.
interferon
BODY TEMPERATURE • HYPERTHERMIA - body temp. above normal range.
• Reflects the balance between the heat produced and the heat • HYPERPYREXIA - body temp. of 41 deg.
lost from the body (heat balance) • FEBRILE - has fever.
• Measured in heat unit called "degrees" • AFEBRILE - no fever.

CORE TEMP. SURFACE TEMP. THE CAUSES OF FEVER

• Deep tissues • Superficial organs • Infection
• Body cavity • Skin, subcutaneous tissue, fat • Clots
• Relatively constant • Changes in response to • Cancer
environment • Autoimmune Disease
• Others (heat stroke, medications. brain lesions & thyroid
storm)
BODY TEMPERATURE REGULATION

TYPES OF FEVER
INTERMITTEN FEVER
• present only for some hours of the day and becomes normal
for remaining hours

REMITTENT FEVER
• temperature remains above normal throughout the day and
fluctuates more than 2 deg. in 24 hours

RELAPSING FEVER
• brief febrile episodes followed by one or more days of
normal temp

CONSTANT FEVER
METHODS OF BODY HEAT LOSS • body temp. fluctuates minimally but always remain above
RADIATION normal.
• Heat is loss from a warm object such as the body to the
cooler air surrounding the warm object (person loses heat in a CLINICAL MANIFESTATIONS OF FEVER
cold room)
ONSET (COLD/CHILL PHASE)
• ↑ HR
EVAPORATION • ↑ RR and depth
• When liquid becomes gas. (during exercise, sweat on the • shivering
surface of the skin evaporates and cools the body). • pallid, cold skin feeling
• cold cyanotic nail beds
CONDUCTION • "gooseflesh" skin appearance
• Loss of heat from a warm body to a cooler object in contact to • cessation of sweating
the warm body. (person becomes cold when sitting in a block
of ice) COURSE (PLATEAU PHASE)
•absence of chills
CONVECTION • skin feels warm
• Loss of heat by air currents moving over the surface of the • photosensitivity
skin. (an electric fan constantly removing layers of heated air • glassy-eyed appearance
next to the body) • ↑ HR & RR
• ↑ thirst (mild to severe dehydration)
FACTORS AFFECTING BODY TEMPERATURE • altered sensorium
• herpetic lesions of the mouth
• Age • loss of appetite
• Stress • body malaise, aching muscles
• Exercise
• Circadian rhythm
• Hormonal level DEFERVESCENCE (FLUSH PHASE)
• flushed and warm skin
• sweating
• decreased shivering
• possible dehydration
 ASSESSING BODY TEMPERATURE FEVER IN ELDERLY BOOK
ORAL • In the elderly, even slight elevations in temperature may
• Most convenient and accurate route. The sublingual area indicate serious infection or disease.
responds rapidly to changes in body temp. • Elderly often have a lower baseline temperature.
• Normal body temperature and the circadian pattern of
temperature variation often are altered in the elderly.
TYMPANIC MEMBRANE
• The absence of fever may delay diagnosis.
• Non-invasive and highly reliable. Uses infrared placed inside
• Unexplained changes in functional capacity, worsening of
the ear.
mental status, weakness and fatigue, and weight loss are signs
of infection in the elderly.
RECTAL • Confusion and delirium may follow moderate elevations in
• The most reliable but used only when other routes are not temperature.
avail.

SKIN/TEMPORAL ARTERY
• Safe and non-invasive. Infrared emissions in the temporal
artery. May deliver altered result due to sweaty skin.

AXILLARY
• Non-invasive but must be placed properly to gather accurate
result.

ASSESSMENT
✓ General Fever Related
• duration
• timing
• character
• associated factors (pain, night sweats, weight loss
etc)
✓ Review of Systems
• systemic approach
• identify possible focus of infection
• head to toe relevant questions to identify
accompanying symptoms to other body organs.
✓ It is good clinical practice to avoid unnecessary assessment
to patients.
COMMON ADDITIONAL EXAMS:
• CBC
• Liver Function test
• Urine Routine examination
• Chest X-Ray
• Cultures (urine, sputum, blood or pus for bacterial
infection)
✓ Narrow down focus during history taking and examinations
by thinking of probable diseases and exclude the unlikely
causes.

🚩RED FLAG:
1. neck stiffness
2. severe chest pain
3. rapid weight loss
4. toxic look
5. respiratory distress
6. surgery
7. immunocompromised
8. high risk behavior
9. history of travel
10. pyrexia of unknown origin

FEVER IN CHILDREN
• The most common causes of fever in children are minor or
more serious infections of the respiratory system, urinary
system, gastrointestinal tract, or central nervous system.
• Occult bacteremia and meningitis also occur in this age group
and should be excluded as diagnoses.
• The mechanisms for controlling temperature are not well
developed in the infant.
• In infants younger than 3 months, a mild elevation in
temperature (i.e., rectal temperature of 38°C) can indicate
serious infection.
• Some children ages 6 months to 5 years may experience
FEBRILE SEIZURES. (reassure parents that this does not
damage the brain and mostly harmless)
• Both minor and life-threatening infections are common in the
infant to 3-year age group.
 VISION
The Ateneo de Davao University is a Catholic, Jesuit, and Filipino University.
As a university it is a community engaged in excellent instruction and formation, robust research, and vibrant
community service.
As Catholic, it proceeds ex corde ecclesiae, from the heart of the Church.
As Jesuit, it appropriates the mission of the Society of Jesus and the spirituality of St. Ignatius of Loyola.
As Filipino, it contributes to and serves Mindanao.

MISSION
It participates in the reconciliation by the Father
of humanity with Himself
of human beings with one another,
of humanity with the environment.
It strengthens faith. It promotes humane humanity.
It engages in intercultural, interreligious,
and inter-ideological dialogue especially in Mindanao.
It responds to the needs of the Bangsamoro, the Bangsamoro Autonomous Region in Muslim Mindanao,
as well as the needs of Lumad communities.
It promotes the creation of wealth and its equitable distribution.
It strengthens its science and technology instruction, research, and technopreneurship in Mindanao.
It promotes cultural understanding and friendship with its Asian neighbors.
It promotes lifelong learning and the dialogue between academe and the world of work.
It protects and promotes the environment as “our common home.”
It develops ADDU sui generis leaders who appropriate this mission for life.
It treasures and works with its alumni.