Lesson (1) Pediatric History Taking and Physical Examination

Lesson (1): Pediatric History Taking and Physical Examination
Lesson (1): Pediatric History Taking and Physical

Examination
Objectives:
After successful completion of this lesson the students must be able to:
1. Define physical assessment.
2. Demonstrate assessment skills.
3. Taking history for infants and children.
4. Apply four skills for the chest, heart, and abdomen
5. Perform physical assessment for children at different ages.
Definition of physical assessment:

It is examination of the body from the head to the toes; it is a continuous process
that begins during the interview primarily by using inspection, percussion,
palpation, and auscultation.
Objectives of physical assessment:
1- To formulate nursing diagnosis.
2- To evaluate the effectiveness of intervention
3- To detect any abnormalities.
4- To detect growth parameters
Dr. Atyat Mohammed Hassan (NRSG-3302) Page 1

Principle for physical assessment:

 Introduce myself to parent and child
 Hand washing and explain procedure
 Perform examination in appropriated area and decorated with neural colors.
 Have room temperature comfortably warm
 Have some toys, doll and games.
 Provide privacy for school age children.
 Observe sign of child's readiness as talking to the nurse, making eye contact,
accepting the offered equipment and allowing physical touching.
Sequence of the assessment:
In adult: The physical examination proceeds in a head-to-toe direction and from
general inspection to detailed investigation.
In pediatrics: The age of the child frequently alters this sequence of performance to
accommodate the child's developmental needs.
Assessment skills:
1 – Inspection 2 – Palpation 3 – Percussion 4 - Auscultation
Outlines of physical assessment:

1- Growth measurement: - including length, weight, head circumference, chest
circumference and mid arm circumference.
2- Physiological measurements: - including temperature, pulse, respiration and
blood pressure.
3-General appearance 4- Skin
5- Accessory appendages. 6- Lymph nodes
7- Head 8- Neck
9- Eyes 10-Ears
11- Nose 12- mouth and throat
13- Chest 14- Lung
15- Heart 16- Abdomen

17- Genitalia 18- Anus
19- Back and extremities
20- Neurological assessment as mental status-motor function – sensory function –
reflexes and cranial nerves.
1 – General appearance
A- Facial expression
The faces may give clues to children who are in pain, have difficulty in
breathing, feel frightened, have mentally deficient or are acutely ill.
B- Posture, position and the types of body movement are important in the overall
assessment of physical appearance. E.g. The child with hearing or vision loss may
characteristically tilt his head in an awkward position to facilitate perception of
sound.
C- Hygiene
The appropriateness of dress for climatic conditions, unusual odor, the condition
of the hair, neck, nails, teeth and feet and the condition of the clothing, such
observations give excellent clues to possible instances of neglect, inadequate
financial resources, housing difficulties such as no running water or lack of
knowledge of children’s needs.
D- Nutrition
General appearance includes an overall impression of the child’s state of
nutrition.
E- Behavior
It includes the child’s personality, level of activity, reaction to stress, requests, or
frustration, interactions with others and response to stimuli, some mental questions
that serve as reminders for observing behavior include: What is the child’s overall
personality, calm, anxious, tense, aggressive, stable, talkative or restless, does he
have a long attention span or is he easily distracted.

F- Development
The nurse should record under general appearance an overall estimate of the
child’s speech development, motor skills, and degree of coordination and recent area
of achievement.
2- Skin
Skin is assessed for color, texture, temperature, moisture and turgor.
A- Color: - The nurse should examine the child in a room with neutral in color.
Colors such as pink, blue, yellow or orange, are abnormal. Other abnormal colors as
pallor and cyanosis, erythema, ecchymosis and petechiae or jaundice.
B- Temperature: - the nurse evaluates skin temperature by symmetrically feeling
each part of the body and comparing upper areas with lower ones. In cases of
coarctation of the aorta are warm upper extremities and cool lower ones.
C- Turgor: - tissue turgor refers to the amount of elasticity in the skin; it is best
determined by grasping the skin on the abdomen between the thumb and index
finger.
3- Accessory organs
Inspection of the accessory organs of the skin namely e.g. hair – nails and
dermatoglyphics
A–Hair: - inspected for color, texture, quality, distribution, and elasticity. Normally
children’s scalp hair is usually lustrous, silky, and elastic. Genetic factors affect the
appearance of hair. Abnormal finding in hair as alopecia, dandruff or pediculosis
capitis.
B- Nails: - The nails are inspected for color, shape, texture, and quality. Normally
the nails are pink, convex in shape, smooth and hard but flexible not brittle.
C- Dermatoglyphics:- Flexion creases appear on the palm of the hand and the sole
of the foot. They have a significant genetic component. The palm normally shows
three flexion creases as (fig A). Dermatoglyphic patterns may be used as diagnostic
tool for predicting the possibilities of development of mental retardation; in some
situations the two distal horizontal creases are fused to form a single horizontal
crease called (Simian) crease as (fig B) which is the most common pattern in cases
of chromosomal abnormality. Whereas the (Sydney) creases as (fig C) are the
second common variant palmar creases.
Fig A Fig B Fig C

(Normal creases) (Simian) (Sydney)
4- Lymph nodes
The nurse palpates for nodes by using the distal portion of the fingers, gently
but firmly pressing in a circular motion to assess size, mobility, temperature and
tenderness.

5- Head
The head is inspected for general shape and symmetry. Marked asymmetry is
usually abnormal and may indicate premature closure of the sutures (cranio-
stenosis). The scalp is examined for cleanliness, lesion, signs of trauma such an
ecchymosis, masses, or scares. The skull is palpated for fontanels, fractures and
swelling. The nurse also evaluates range of motion by asking the older child to look
in each direction or manually puts the younger child through each position.
6 - Neck
The neck is normally short with skin folds between the head and shoulders
during infancy, however it lengthens during the next 3 to 4 years. Abnormal
findings as edema. The nurse palpates for the thyroid gland, which is located at the
base of the neck.
7 - Eyes
Examination of the eyes involves inspection of all exterior structures and
interior surfaces. Inspection of all exterior structures (fig A) for size, symmetry
color and motility and inspection of the interior surfaces for examination of retinal
structure. If the nurse observes any possible abnormality of placement this findings
can be substantiated by measuring the inner canthal distance which average about 3
cm. Large spacing between the eyes is called hypertelorism this may suggest
mental retardation.
 The nurse inspects the lids for proper placement on the eye, for blinking
movement.
 The nurse should inspect sclera or white covering of the eyeball should be
clear.
 The cornea or covering of the iris and pupil should be clear. Any opacity is
recorded since they can be signs of scarring or ulceration, which can interfere
with vision.
 The pupils are compared for size, shape and movement, they should be round,
clear and equal. The nurse tests their reaction to light
 The iris is inspected for color, size and clarity, permanent eye color is usually
established by 6 to12 months of age.
 The lens is also examined. Normally the nurse should not see the lens while
looking into the pupil. White or gray spots usually indicated opacities or
cataract in the lens.
(Fig A)
8- Ears
Examination of the ears involves inspection of the external auditory structures
and visualization of the internal landmark using otoscope
1- Placement and alignment: - The entire external earlobe is called the pinna
and is located on each side of the head. The height alignment of the pinna is
measured by drawing an imaginary line from the outer canthus of the eye to the
occipital or most prominent protuberance of the skull. The pinna should meet or
cross this line. Low set ears are commonly associated with renal anomalies or
mental retardation.

2- The skin around the ear is inspected for small opening, extra tags of skin
or sinuses, if a sinus is found the nurse makes a special notation for this, it may
represent a fistula that drains into some areas of the neck or ear.
3- The ear is also inspected for general hygiene; the nurse also observes the
presence of any discharge, noting its color and odor.
Inspection of internal structures

This should be conducted by using otoscope.
9 - Nose
The nurse notes its location, any deviation to one side and asymmetry in overall
size and in diameter of the nares.
Nostrils are noted for any sign of flaring which indicative respiratory difficulty.
In inspection of the internal structure, the nurse notes the color of the mucosal
lining, any swelling, discharge, dryness or bleeding. Normally there should be no
discharge from the nose. However, if the child has been crying, a watery discharge
is normal. The sputum is also inspected; any deviation is noted as well as testing for
smell is part of the assessment of the cranial nerves.

If the child has a nasogastric, nasointestinal, or nasotracheal tube, inspect nares

for excoriation or inflammation.
10- Mouth and throat
Inspection of the lips for color, the nurse should note the presence of painful,
inflamed and dried cracks or fissures of the lips, habitual biting of the lips, mouth
breathing or dehydration.
Inspection of the internal structures
Inspection of the oral cavity, oropharynx and nasopharynx, the major structures
those are visible on examination of the oral cavity. Oropharynx are mucosal lining
of the lips and cheeks, gums, teeth, tongue, palate, uvula, tonsils and posterior
oropharynx. With a cooperative child, the entire examination can be done without
the use of a tongue blade. The nurse asks the child to open his mouth wide, requests
that he move his tongue in different directions and say ‘ Ahh’ in order to depress the
tongue for full view of the back of the mouth.
The nurse inspects all areas lined with mucous membranes noting its color, any
ulceration, bleeding, sensitivity and moisture. The teeth are inspected for number
and hygiene. The tongue is inspected and the nurse notes the size and mobility of
the tongue. The hard palate and soft palate are inspected carefully to be sure that
both palates are intact.
11- The chest and lungs:


Inspection:
A. Note the movement of the chest wall. It should: symmetric bilaterally and
coordinated with breathing. In children under 6-7 years of age respiratory movement
is principally abdominal. In older children, respiration is chiefly thoracic. In either
types, the chest and abdomen should raise and fall together. Any asymmetry of
movement should be referred for further investigation.
B. Observe the rate and depth of respiration. Normal respiration is regular in
depth and rhythm. An increase in the rate of respiration is called tachypnea, an
increase in depth is called hyperpnea.
C. Inspect accessory muscles of breathing: sternocleidomastoid, trapezius, and
abdominal muscles, noting effort to breathe .observe for retractions during
assessment of the thorax. Retractions are signs of respiratory distress and may
involve the intercostal, suprasternal, or supraclavicular muscles.
Palpation
Following inspection, palpate the thorax for breast tissue and tenderness,
masses, lesions, respiratory excursion and vocal fremitus.
1) Respiratory excursion
Respiratory excursion is an estimation of thoracic expansion and may reveal
significant information about the symmetry of breathing. Difference in expansion is
more readily detectable on the anterior thorax, where a fuller range of motion occurs
during respiration. The examiner's thumbs are placed along each costal margin,
below the xiphoid process, while the hand rest along the lateral rib cage. The patient
is instructed to inhale deeply while the examiner observes the movement of the
thumps during inspiration and expiration. This movement is normally symmetric.
A posterior assessment is done by placing the thumbs adjacent to the spinal
column at the level of the 10th ribs

Respiratory lag or impairment is often the result of pleurisy, fractured ribs or
trauma to the chest wall.
2) Tactile fremitus
It is a sound generated by the larynx that travels distally along the bronchial
tree to set the chest wall in a resonant motion. The capacity to fell sound on the
chest wall is called vocal or tactile fremitus. To elicit tactile fermitus, the examiner
instructs the child to repeat the word (ninety-nine) with each movement of the
examiner's hands. The vibrations are perceived by placing the palmer surfaces of the
fingers and hands on the thorax
Percussion:
The examination is usually initiated with percussion of posterior thorax. Ideally
the patient is in a sitting position with the head flexed forward and the arms crossed
on the lap. This position separates the scapulae widely and exposes more lung area
for assessment Percussion over the anterior chest is performed with patient in an
upright position with shoulders arched backward and arms at the side. The examiner
begins in the supraclavicular area and proceeds downward on the intercostal spaces.
Dullness noted to the left of the sternum between the third and the fifth
intercostal spaces is normal finding of the heart. Similarly, there is a normal span of
liver dullness in the right thorax from fifth intercostal space to the right costal
margin at the midclavicular line. The lateral walls are examined by having the
patient alternately raise an arm and rest of the hand on his head while the examiner
percusses from the axilla down to the costal margin. The anterior and lateral thorax
is examined with the patient in a supine position. If the patient is too ill or is unable
to sit up, percussion of the posterior thorax is done with the patient rolled on his
side.
Auscultation;
Auscultation is useful in assessing the flow of air through the bronchial tree and
in evaluating the presence of fluid or solid obstruction in the lung structure.

Auscultate breath sounds in the midaxillary areas of the thorax.
Listen to normal breathing sounds e.g.:

1-Vesicular breath sounds: it is heard over the entire surface of lung, with
exception of upper intrascapular area and area beneath manubrium. Inspiration
is louder, longer and higher in pitch than expiration.
2-Bronchovesicular breath sounds: it is heard on the second intercostal space on
the both sides and in upper intrascapular regions. Inspiration is equal
expiration.
3-Bronchial breath sounds: heard only over trachea near suprasternal notch.
Inspiration is shorter than expiration.
Assess for adventitious sounds:
The presence of an abnormal condition that affects the bronchial tree and alveoli
may produce additional or adventitious sounds. It is divided into two categories:
non-continuous sounds i.e. rails and continuous sounds i.e. crackles.
12- Heart

Inspection
1-Inspect heart size with the child in semi-Fowler’s position
2- Observe chest wall from front and an angle for symmetry, note obvious bulging.
Apical impulse sometimes appears in the thin child.
Palpation
Palpate anterior chest wall using finger tips for
1-Point of maximum impulse: lateral to the left midclavicular line and fourth
intercostal space in children younger than 7 years of age. At the left
midclavicular line and fifth intercostal space near left nipple in children 7 years
and more.
2-Point of maximum intensity: it is the area of most intense pulsation. It is usually at
the same site of apical pulse, but it can be palpated elsewhere.
3-Capillary filling time: Press the skin lightly on a central site, e.g., forehead or
peripheral site, e.g. top of the hand to produce a slight blanching. Calculate the
time it will take for the blanched area to return to its original color. (It is
normally 1 - 2 seconds)
Percussion
In normal patient, only the left border of the heart is located by percussion. It
extends from the sternum to the midclavicular line in the third to fourth intercostal
space. Enlargement of the heart to either the left or right can be noted.
Auscultation
The heart sounds are produced by the opening and closing of the valves and the
vibration of blood against the wall of the heart and vessels. "Normally, two sounds
Sl and S2 are heard, which correspond respectively to the familiar “lub dub” often
used to describe the sounds.
S1: Is caused by the closure of the tricuspid and mitral valves (sometimes called the
atrioventricular valves).
S2: Is the result of the closure of the pulmonic and aortic valves (sometimes called
semilunar valves)
The heart sounds are evaluated for:
 Quality; which should be clear and distant and not muffled or diffuse.
 Intensity: especially in relation to location or auscultatory site.
 Rate: which should be the same as the radial pulse.
 Rhythm: which should be regular and even.
13-
Abdomen
The child is positioned in supine position during examination with pillow under
the head and the knee flexed to enhance abdominal relaxation.
The abdomen is divided into four quadrants that correlate with underlying
anatomical structures. Examination of the abdomen involves inspection followed by
auscultation and then at last percussion and palpation because it may distort the
normal abdominal sounds.
Inspection

Inspect abdomen to assess the contour, symmetry, characteristics of the umbilicus,

skin, pulsation and movement. Normally, the abdomen of infant and child is quite
cylindrical and in the erect position, fairly prominent because of the physiologic
lordosis of the spine. In the supine position the abdomen appears flat.
N.B. tens and board like abdomen are a serious sign of paralytic illeus and intestinal
obstruction. Movement of the abdomen is observed. Normally chest and
abdomen movements are synchronous. In infant and thin child peristaltic
waves may visible through the abdominal wall. The umbilicus is inspected for
size, hygiene and evidence of any abnormalities as hernias (inguinal hernia,
femoral hernia and umbilical hernia).
Auscultation
Listen for peristalsis or bowel sounds. Their frequency per minute should be
recorded e.g. five bowel sound / minute. The examiner also listen in the epigastric
region and around the umbilicus for a venous hum-a soft, low pitched and
continuous sound.
Percussion
Percuss all four quadrants of the abdomen to determine the nature of the
underlying tissue, hollow organs will produce tympanic sounds e.g. Stomach and
solid or fluid filled tissue will produce a dull sounds e.g. Liver, Spleen and Kidney.
Palpation

Guidelines for promoting relaxation during palpation:

- Position the child comfortable with knee flexed.
- Warm the hands before touching the skin.
- Use distraction such as telling stories or talking to the child.
- Teach child to take deep breathing and to concentrate on an object.
- Give infant a bottle, pacifier or toy.
- Begin with light, superficial palpation and gradually progress to deeper palpation.
- Palpate painful areas last.
- Use non palpating hand to comfort the child, such as placing the free hand on the
child’s shoulder while palpating abdomen.
- To minimize sensation of tickling during palpation:
- Have the child “help” with palpation by placing his/her hand over the palpating
hand
14- Genitalia
Examination of genitalia follows assessment of the abdomen while the child is
still supine. In adolescents inspection of the genitalia may be left to the end of the
examination. In males assess for location of the scrotum, size of the penis, glans,
and urethral meatus. While palpating scrotum for descended testes block inguinal
canal with opposite hands. The female genitalia are examined for size and location
of the structures of the vulva, clitoris, labia majora, labia minora, urethral meatus
and vaginal orifice
15- Musculoskeletal system
It is composed of the bones, joints, cartilage, ligaments and muscles, joint
motions are defined as flexion, extension, abduction, adduction, internal rotation,
external rotation and circumduction. General inspection begins with visual scanning
of the body; comparing the two sides of the body for symmetry, contour, size and
involuntary movement. Inspecting the two sides for areas of swelling or edema and
ecchymosis or other discoloration.
a- Spine
The back of a newborn is rounded or C- shaped from the thoracic and the
pelvic curves. The development of the cervical and lumber curves approximates
development of various motor skills, such as a cervical curvature with head control,
and lumber curve gives the older child the typical double S- curve. Marked
curvature in posture is abnormal, scoliosis, internal curvature in the spine is a
problem especially in females.
b- Extremities
Each extremity is inspected for symmetry of length and size. The fingers and
toes are counted to be certain of normal manner. The arms and legs are inspected for
color. The shape of bones is assessed. Several variations of bone shape may be
observed in children; most of them require no treatment.
Bowlegs (Genu varum)
It is the lateral bowing of the tibia, it is clinically present when the child stands
with rounded prominence on either of
the ankle opposite each other and the
space between the knees is greater than
5cm. Toddlers are usually bowlegged
after beginning to walk until all their
lower back and leg are well developed.
Unilateral or symmetric bowlegs that
are present beyond the age of two to
three years may represent pathological
condition.
Knock-knee (Genu valgum):
It is normally present in children from 2-7 years of age. Knock- knee that is
excessive asymmetric, accompanied by shortened stature requires further
evaluation.

Feet
Feet are inspected. Infants’ and toddlers’ feet appear flat because the foot is
normally wide and arch is covered by a fat pad. Development of the arch occurs
naturally during the action of walking.
Edema: note any edema of lower extremities. Assess whether it is pitting or non-
pitting. Note the extent of involvement.
Joints
Joints are evaluated for range of motion, tenderness and swelling.
Muscles
To assess the strength of each muscle, ask the child to flex the muscle and then
resist, as opposing force is applied against flexion. Muscle tone should be firm on
palpation. Tone is estimated by grasping the muscle and feeling its firmness when it
is relaxed and contracted. A common site for testing tone is the “biceps muscle” by
clenching their first. Strength is estimated by having the child use an extremity to
push or pull against resistance (arm strength/ hand strength and leg strength).
16- Nervous system
Assess mental status
Observe the child’s behavior, mood, affect, general orientation to surrounding
and level of consciousness. Test the vision and hearing
Assess sensory intactness and discrimination
a- For sensory intactness, the examiner touch the child’s skin lightly with a pin, then
ask the child while he is closing his eyes to point to the stimulated area.
b- For sensory discrimination, the examiner touch the child’s skin with pin and
cotton and ask him/her to describe it as sharp or dull.
c- Touch the child’s skin with warm and cold object and ask him/her to differentiate
between temperatures.

Learning guide for physical assessment of children
Procedure
Getting ready:
1. Wash hands
2. Prepare the necessary equipment.
3. Verify the correct child by using two identifiers
4. Explain the procedure to the mother or the child.
History taking:
1. Biosocial data: Name, age, sex, address, religion, educational level, eating and
sleeping patterns.
2. Health History:
 Birth history
 Immunization
 Previous childhood illnesses, accidents or injuries
- Previous hospitalization, if yes: Obtain the following information:
- Reason for admission
- Place of admission
- Length of stay
- Surgical procedure
- Outcomes
 Presents of allergies:
3. Obtain history of current health status (Present Complaints): onset, duration,
medication taken
4. Family History: ask about hereditary diseases, present of chronic illness in the
family members
Assess Anthropometric Measurements
 Length/ height
 Weight
 Head circumference
 Chest circumference
 Mid arm circumference
Vital Signs
 Temperature
 Pulse
 Respiration
 Blood pressure
General Appearance
1. Posture, position: e.g. Child with hearing or vision loss.

2. Facial expression: Pain, difficulty in breathing, frightened, happy, mentally

retarded
3. Hygiene: the appropriateness of dress for climatic condition, unusual odor, the
condition of hair, nails, teeth and feet.
4. Nutrition: Child's general state of nutrition
5. Behavior: Level of activity, interaction with others, response to stimuli, child
overall personality as calm, anxious, tense aggressive, stable, talkative, or
restless.
6. Development: Speech appropriately to his age, motor skills, degree of
coordination and recent area of achievement.
Skin
 Color: Abnormal colors as, cyanosis, yellow, presents of erythema, ecchymosis,
petechiae or jaundice
 Temperature: Comparing the temperature of the upper and the lower parts. In
case of coarctation of the aorta upper extremities are warm while lower ones
cool.
 Turgor: Amount of elasticity in the skin. It is determined by grasping the skin on
the abdomen between the thumb and index finger
Accessory Organs
- Hair: Inspect color, texture, distribution and elasticity. Normally children’s scalp
hair is lustrous, silky, and elastic. Abnormal findings of hair as alopecia, or
dandruff.
- Nails: Inspect: color, shape, texture, and quality. Normally the nails are pink,
convex in shape, smooth and hard but flexible
- Dermatoglyphics: Flexion creases appear on the palm of the hand. in some
situations, the two distal horizontal creases are fused forming a single horizontal
crease called simian line occurs in chromosomal abnormalities
Lymph Nodes
- Palpate for nodes by using the distal portion of the fingers, gently but firmly
pressing in circular motion to assess size, mobility, temperature and tenderness.
The common lymph nodes assessed are cervical, maxillary, and inguinal nodes.
Head
- Inspect: Shape and symmetry of the head, scalp for cleanliness, lesion,
ecchymosis, masses, or scare
- Evaluate the range of motion
Neck
Inspect: Cleanliness of the neck
Palpate: the thyroid gland
Face
Inspect: Symmetry of the facial feature, color
Palpate: for texture, warmth, mass, dryness and edema
Eyes
Inspect: Symmetricity,
 Lids for proper placement,
 Blinking movement
 Sclera
 Cornea,
 Iris and pupils
Ears
Inspect: Placement and alignment
 Skin around the ear for small opening
 Hygiene
 Internal structures using otoscope
Nose
Inspect: Location of the nose
 Symmetricity
 Internal structure for swelling of the mucosal lining, discharge, dryness, bleeding
Mouth and Throat
Inspect: lips for color, moisture, cracking, or lesions
 Teeth; number, cavities, occlusion
 Gums for color, swelling or ulcer
 Tongue for normal motion, ulcer,
 Hard and soft palate for color, shape, or deformity
 Oropharynx using tongue depressor
 Tonsils for color, inflammation
Chest
Inspect: movement of the chest wall
 Rate and depth of respiration
Palpate: for breast tissues
 Tenderness, masses, lesions
 Respiratory excursion: the examiner’s thumbs are placed along each costal
margin below the xiphoid process, while the hand rest along the lateral rib cage,
the patient is instructed to inhale deeply while the examiner observes the
movement of the thumps during inspiration and expiration. This movement is
normally symmetrical
 Tactile fremitus: the examiner instructs the child to repeat the word (ninety- nine)
with each movement of the examiner’s hands. The vibrations are perceived by
placing the palmer surfaces of fingers and hands on the thorax
Percussion: percuss the anterior and the posterior chest from side to side, top to
bottom, compare one side to the other looking for asymmetry
Auscultation; breath sound
 Vesicular breath sound: heard over the entire surface of lungs

 Bronchovesicular breath sounds heard on the second intercostals space

 Bronchial breath sounds: heard over the trachea
Heart
Inspect: size and observe chest wall for symmetricity
Palpate:
point of maximum impulse, lateral to the left mid clavicular line and fourth
intercostal space in children younger than 7 years and at the left midclavicular
line and fifth intercostal space in children 7 years and above
 Point of maximum intensity, at the same site of apical pulse
 Capillary filling time, press top of the hand to produce a slight blanching,
calculate the time it will take for the blanched area to return to its original color
- Percussion of the heart: The left border of the heart is located by percussion. It
extends from the sternum to the left midclavicular line in the third to fourth
intercostal space
- Auscultation of the heart: listening for the heart sounds with stethoscope, two
sounds S1 and S2 are heard (lub dub). Assess rate, rhythm, and intensity
Abdomen
- Inspection: assess counter, symmetricity, characteristics of the umbilicus, and
skin
- Auscultation: listen for peristalsis movements and recorded per minute
- Percussion: hollow organs produce tympanic sounds and fluid filled tissue
produce a dull sound
- Palpation: begin in the lower quadrants and proceed upward to avoid missing,
the edge of an enlarged liver or spleen. If the liver is 3cm below costal margin, it
is considered enlarged
Genitalia
Male: Inspect
Location of scrotum
 Size of the penis
 Glans and urethral meatus
Palpate: scrotum for descended tests
 Female: Inspect
Valva
 Clitoris
 Labia majora
 Labia minora
 Urethral meatus
 Vaginal orifice
 Anus: Inspect: opening
Skin condition
Back And Extremities

Back: Inspect
Curvature of the spine (normal or present of scoliosis)
 Color and symmetricity of the back
Palpate back for: lesions
 Extremities: Inspect
Symmetrciy of length and size
 Color of arms
 Color of legs
 Shape of leg bones (present of bowlegs- knock knee)
 Count fingers
 Count toes
 Palpate: Pulse, Edema
- Evaluate joints, for range of motion
Tenderness, Swelling
Muscles:
 Assess muscle tone: grasp the muscle and feel its firmness when it is relaxed and
contracted
 Assess strength of the muscles: having the child use an extremity to push or pull
against resistance ( assess arms, hands and legs)
Neuromuscular System
Sensory discrimination:
 Touch the child’s skin with pin and cotton and ask him/her to describe it :sharp
or dull
 Touch the child’s skin with warm and cold object and ask him/her to differentiate
between temperature
After the Procedure
1. Record the findings &report for any abnormality.
2. Clean the equipments and return it to their place
3. Wash hands
Normal nail shape Clubbing nail shape

Palm (hand) creases (A: Normal- B: Abnormal)
Normal Palm creases Simian creases Sydney line
Normal inner canthus distance Hypertelorism

(abnormal inner canthus distance
Abnormal facial feature Low set ear (abnormal)

Sites of lymph Nodes
• Respiratory excursion anterior • Respiratory excursion posterior
Bowleg Knock-knee

• Chest percussion anterior • Chest percussion posterior

Lesson (1) Pediatric History Taking and Physical Examination

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Lesson (1) Pediatric History Taking and Physical Examination

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Lesson (1): Pediatric History Taking and Physical Examination

Lesson (1): Pediatric History Taking and Physical

Definition of physical assessment:

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 1

Principle for physical assessment:

Outlines of physical assessment:

15- Heart 16- Abdomen

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 3

Fig A Fig B Fig C

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 5

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 7

Inspection of internal structures

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 8

If the child has a nasogastric, nasointestinal, or nasotracheal tube, inspect nares

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 9

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 10

column at the level of the 10th ribs

in evaluating the presence of fluid or solid obstruction in the lung structure.

Listen to normal breathing sounds e.g.:

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 13

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 15

Inspect abdomen to assess the contour, symmetry, characteristics of the umbilicus,

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 16

Guidelines for promoting relaxation during palpation:

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 18

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 19

Learning guide for physical assessment of children

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 20

2. Facial expression: Pain, difficulty in breathing, frightened, happy, mentally

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 22

 Bronchovesicular breath sounds heard on the second intercostals space

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 23

Normal nail shape Clubbing nail shape

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 24

Palm (hand) creases (A: Normal- B: Abnormal)

Normal Palm creases Simian creases Sydney line

Normal inner canthus distance Hypertelorism

Abnormal facial feature Low set ear (abnormal)

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 25

Sites of lymph Nodes

• Respiratory excursion anterior • Respiratory excursion posterior

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 26

• Chest percussion anterior • Chest percussion posterior

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 27

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