By

Dr.Rasha Said
Lecturer of pediatric nursing
 HIGH RISK
PHYSICAL NEONATE
EXAMINATION

❑ The physical examination may be part of a well-child

assessment, as well as an ill child assessment
❑ The physical examination provides objective and subjective
information about the child, allows health care providers to
determine the child’s health status and make judgments about
children' needs for nursing care.
 PHYSICAL EXAMINATION

Physical examination

• It is the process of examining the child’s body to

determine the presence or absence of physical problems.

• SOAP stands for Subjective Objective Assessment Plan.

 PHYSICAL
HIGH RISK
EXAMINATION
NEONATE

Purpose

▪ To obtain valid information concerning the health of

the pediatric patient.

▪ To identify, analyze, and synthesize the accumulated

information into a comprehensive assessment.

▪ Aids in determining the correct diagnosis and devising

the treatment plan.
 PHYSICAL
HIGH RISK
EXAMINATION
NEONATE

Schedule of follow up:

❑ Each month during the first year
of life.
❑ Each 3 months during the 2nd
and 3rd years.
❑ Each 6 months during the 4th and
5th years.
❑ Yearly from the 6th year
throughout life
 PHYSICAL
HIGH RISK
EXAMINATION
NEONATE

Physical examination
equipment

❑ Stetoscope
❑ Penlight
❑ Otoscope
❑ Toung depressor
❑ Cotton ball
❑ Thermometer
❑ Scale
❑ Measuring tape
 HIGH RISK
PHYSICAL NEONATE
EXAMINATION

General guidelines for performing pediatric physical

examination:
❑ Perform an examination in appropriate, nonthreatening area.
❑ Have some toys, dolls, stuffed animals, and games available
for children.
❑ If possible, have room decorate and equipped for different
age children.
❑ Provide privacy, especially for school- age children and
adolescents.
❑ Observe behaviors that signal child's readiness to cooperate
through talking to the nurse, making eye contact, accepting
the offered equipment.
 PHYSICAL EXAMINATION

❑ If a child refuses to cooperate, use the following techniques

➢ Try to involve the child and parent in the process.
➢ Avoid prolonged explanation about examining procedure.
➢ Use firm, direct approach regarding expected behavior.
➢ Perform examination as quickly as possible.
❑ Minimize any disruptions or stimulation (limit number people
in the room use isolated room, use quiet, calm, confident
voice).
❑ If several children in the family be examined, begin with
cooperative children in the family to provide modeling of
desired behavior.
 PHYSICAL EXAMINATION

❑ Involve child in the examination process, provide choices

on the table or in parent's lap.
❑ Allow child to handle or hold equipment.
❑ Proceed to examine the body in an organized sequence
(usually head to toe), examine painful areas last).
❑ In an emergency, examine vital signs, circulation and
injured area first.
❑ Discuss findings with family at the end
❑ Praise child for cooperation during examination.
 PHYSICAL EXAMINATION

Preparation of the child to physical examination:

Developmental stage Proper considerations
1. Approach slowly
2. Conduct on parent's lap.
Infants 3. Distract attention
4. Graduate from noninvasive to invasive technique.
1. Distract attention
2. Allow for touching/ holding of equipment. Demonstrate on
Toddlers doll/ parent before exam on the child
3. Exam on parent's lap.
1. Inform what you are going to do and how they can help.
2. Role plays with equipment.
Preschool 3. Teach about body parts.
4. Praise for help and cooperation

School Age 1. Explain the use of equipment.

2. Answer questions with age-appropriate vocabulary

Adolescents 1. Ensure privacy.

2. Examine, without a parent.
3. Inform of each step of the examination.
4. Provide reassurance.
 PHYSICAL EXAMINATION

Techniques used in
physical examination:
 PHYSICAL EXAMINATION

Inspection:

Is examining a child or adolescent,

initially with your eyes for observing all body
parts& use the nose, to detect any odors that
may point to a health problem.
 PHYSICAL EXAMINATION

Palpation:
 Obtain information by using the hands and fingers to palpate.
PHYSICAL EXAMINATION
 PHYSICAL EXAMINATION
Types of palpation

Light • done to determine how soft or hard the

abdomen is
palpation

• done to feel for masses and identify any tenderness

Deep
palpation

• It is employed during the processes of liver, spleen, kidney

Bimanual or abdominal masses examination
palpation

Guidelines for Palpation:
• Warm hands.
• Use light palpation before
deep palpation.
• Use palms of hand to
assess vibrations.
• Use pads of fingers (most
sensitive part) to identify
texture, size, shape, or
movement (e.g., pulse).
PHYSICAL EXAMINATION
• Use dorsum of fingers for
temperature assessment.
• Gently pinch skin to
assess turgor.
• Use deep palpation
gently and briefly to
assess areas such as pelvis
and abdomen for body
organs and masses.
• Palpate painful areas last.
 PHYSICAL EXAMINATION
Percussion:
 Produces sound waves by using the fingers
as a hammer.
 Place the inter phalange joint of the
middle finger on the skin surface of the
non-dominant hand.
 Using the tip of the middle finger of the
dominant hand, and strike the placed
finger.
 It is used to determine whether the
underlines tissues are failed with air, fluid,
or solid material.
 Percussion is of little clinical benefit and
should be avoided, especially in low birth
weight or premature infants as it may
cause injury.
 PHYSICAL EXAMINATION

Auscultation
 Is listening to sounds that are either
discernible to the ear (wheezing or
heavy breathing) or as in most cases,
made louder by means of a stethoscope.

 Always listen four qualities of sound:

duration, frequency, intensity, and pitch
 PHYSICAL EXAMINATION

OLFACTION

Smelling

A method used to evaluate the relationship between

abnormal odor from the patient and disease

The odor is elicited from the exudates of skin, mucosa,

respiratory tract, GI, blood etc.

E.g. If the client‘s breath has a ―fruity‖ or ―acetone‖

odor, you would suspect ketoacidosis.
 PREMATURE
PHYSICAL NEONATE
EXAMINATION

Components of health
assessment for children:

❑History taking

❑System review
 PHYSICAL EXAMINATION

Personal data

Chief complaint

Present history
History taking
Past history

Family history
Psychosocial
history
 PHYSICAL EXAMINATION

Review of systems

A systemic review of the major anatomical and

psychological parts which begins from the head to the

toes.
 NEONTALEXAMINATION
PHYSICAL CONVULSION

Physical examination:
General Appearance
Physical examination begins with inspection of general
appearance to form a general impression of the child's health.
▪ The face: The facial expression, the face may give clues to
children who are in pain, have difficulty breathing, feel frightened
or happy.
▪ Posture/position, and type of body movement: The child in pain
may favor a body part.
▪ Child's hygiene: cleanliness, usual body odor, the condition of hair,
neck, nails, teeth, feet, and the condition of clothing.
 PHYSICAL EXAMINATION

▪ Nutrition: it includes an overall impression of the

child's state of nutrition. .
▪ Behavior: it includes the child's personality, level of
activity, reaction to stress, frustration, interaction
with others, degree of alertness, and response to
stimuli.
▪ Development: the child's speech development,
motor skills, and degree of coordination are
estimated.
 PHYSICAL EXAMINATION

skin
❑ Color, texture, turgor, and pigmentation (jaundice,

cyanosis, pale).

❑ Palpate: moisture and dryness.

❑ Temperature.

❑ Edema: especially in extremities.

❑ Lesions
 PHYSICAL EXAMINATION

LYMPH NODES

Note size, mobility, temperature, and

tenderness, as well as reports by parent

regarding any visible change of enlarged node.

PHYSICAL EXAMINATION
 PHYSICAL EXAMINATION

Head
❑ Fontanels for infants: shape
❑ Assess symmetry of both sides.
❑ Evaluate range of motion by asking the older child to
looking in each direction
❑ Sunken fontanel means dehydration.
❑ Bulging means increase ICP or there are cough, vomiting
and crying.
PHYSICAL EXAMINATION
 PHYSICAL EXAMINATION

Eye
➢ Inspect the lids for proper placement on the eye.
➢ The sclera, or white covering of the eyeball, should be clear.
➢ The cornea, or covering of the iris and pupil, should be clear and
transparent.
➢ Compare the pupils for size, shape, color, clarity, movement, and reaction
to light.
➢ Permanent eye color is usually established by 6 to 12 months of age.

➢ Ocular Alignment. Normally, by the age of 3 to 4 months, children

achieve the ability to fixate on one visual field with both eyes
simultaneously (binocularity).
PHYSICAL EXAMINATION
 PHYSICAL EXAMINATION

Abnormalities during eyes' assessment

1. Puffy eyelids in case of renal edema (nephritic
syndrome) conjunctivitis and severe cough.

2. Squint.
3. Yellow sclera in case of jaundice.
4. Sunken eyes in case of dehydration or toxemia.
5. Sunset appearance in case of hydrocephalus.
 PHYSICAL EXAMINATION

EARS
➢ Inspect the skin surface around the ear.
➢ Looking into the external canal to note the presence of wax.
If any discharge is seen, its color and odor are noted.
 PHYSICAL EXAMINATION

Pinna line:
➢ To detect the correct placement of the external ears, draw an
imaginary line through the medial and lateral canthi of the eye
toward the ear. This line normally passes through the upper portion
of the pinna.
➢ The pinna is considered “low set” when the top lies completely
below the imaginary line. Low–set ears are often associated with
renal disorders and mental retardation
➢ Pinna is pulled down and back to straighten ear canal in children
less than 3 years during ear examination.
 PHYSICAL EXAMINATION

NOSE
▪ Note its location, any deviation to one
side and asymmetry in overall size
and in diameter of the nares.

▪ Observe the nostrils for any signs of

nasal flaring, which indicates
respiratory difficulty

▪ Inspect septum, which should divide

the vestibules equally.
 PHYSICAL EXAMINATION

Mouth and throat

❑ Lips: color, moisture, lesion.

❑ Teeth:
- Inspect the teeth for number in each dental arch, for
hygiene, and for occlusion or bite.
- Discoloration of tooth enamel with obvious plaque is a
sign of poor dental hygiene.
❑ Gum: color, inflammation or swelling.
❑ Tongue: color, shape, deformity, ulceration.
❑ Oropharynx: color.
❑ Tonsils: pink or inflammation.
quiz
General Examination covers:
A. Clinical anthropometry: weight, height, frame size, body mass
index
B. Non-vital signs: reading, repertory, declaratory, fracking.
C. Liveable: Chock, signs, rails, sails, snails.
D. Vital signs: temperature, pulse rate, respiratory rate, blood
pressure (both arms, two positions [lying and sitting])

•General Oberservation.
A. Pulse
B. Hygiene, manner of dress.
C. Vision
D. Hair, fingernails
E. Is patient dressed appropriately for the weather?
•What does a SOAP stand for?
A. Subject Oriented Assignment Plan
B. Subjective Objective Assesment Plan
C. Signs Outlook Assign placement
D. None of theis

•A bodily discomfort that a person feels is called

A.Symptom
B. Pain
C. Sign
D. None of the above
Which of the following is an example of objective data?
A. Alert and oriented
B. Dizziness
C. An earache
D. A sore throat

A nursing diagnosis is best described as:

A. a determination of the etiology of disease.
B. a pattern of coping.
C. an individual's perception of health.
D. a concise statement of actual or potential health concerns or
level of wellness.
 PHYSICAL EXAMINATION

CHEST and LUNGS

❑ Inspect the chest for size, shape, symmetry

❑ Measure chest circumference.
❑ Evaluate respiration for rate, rhythm,
depth and quality (effortless, automatic,
difficult or labored).
❑ Note the character of breath sounds,
such as noisy or grunting.
 PHYSICAL EXAMINATION

Abnormal chest shape:

➢ Pigeon chest (pectus carinatum): If the sternum
protrudes, increasing the anteroposterior diameter.
➢ Funnel chest (pectus excavatum): If the lower portion of
the sternum is depressed, decreasing the anteroposterior
diameter.
 PHYSICAL EXAMINATION

Various patterns of respiration:

1. Hypoventilation means decreased depth (shallow and irregular
rhythm).
2. Hyperventilation means increased rate and depth.
3. Kussmaul respiration means that the child has hyperventilation and
labored respiration, usually seen in diabetic coma or respiratory
acidosis.
4. Seesaw (paradoxic) respiration means that the chest falls on
inspiration and rises on expiration.
5. Cheyne - Stokes respiration means gradual increasing rate and depth
with periods of apnea.
 PHYSICAL EXAMINATION

Light palpation

Applying fingertip pressure to

depress the skin surface
approximately half inches and
then moving fingertips in
circular motion
 PHYSICAL EXAMINATION

Tactile fremitus
 PHYSICAL EXAMINATION

Auscultation

To determine the condition of

the lungs by assessing the flow
air through the bronchial tree
and evaluating the presence of
fluid or solid obstruction in
the lung structure.
 Auscultation

Breathing Sound
1- Bronchial breath sounds:

heard only over trachea near suprasternal

notch. Inspiratory phase is short, and
expiratory phase is long.
 Auscultation

Breathing Sound

2- Broncho vesicular breath sounds:

Heard on the second intercostal spaces

where trachea and bronchi bifurcate.
Inspiration is equal the expiration.
 Auscultation

Breathing Sound
3- Vesicular breath sounds:

Heard over entire surface of lungs, with exception of

upper intrascapular area and area beneath manubrium.

Inspiration is louder, longer and higher pitched than

expiration. Sound is soft, swishing noise.

 PHYSICAL EXAMINATION

HEART
The heart is situated in the thoracic cavity between the
lungs in the mediastinum and above the diaphragm.

 Inspection is best done with the child sitting in semi-

Fowler position. Look at the anterior chest wall from an
angel, comparing both sides of the rib cage with each
other. Normally they should be symmetric.
 PHYSICAL EXAMINATION

 Auscultation
✓ the heart sounds are produce by the opening and
closing of valves and the vibration of blood against
the wall of the heart and vessels.
✓ Normally two sound S1 and S2 are heard, which
correspond respectively to the familiar ''lub dub'. S1 is
caused by the closing of the tricuspid and mitral
valves (lub). S2 is the result of closer of pulmonic and
aortic valves (dub).
✓ Another important category of heart sound is murmurs,
sounds that are produced by vibrations within the heart
chambers,
PHYSICAL EXAMINATION
 PHYSICAL EXAMINATION

Abdomen

❑ Inspect the abdomen to assess the contour, symmetry,

characteristics of the umbilicus, skin, pulsation, and
movement.
❑ The umbilicus is inspected for size, hygiene, and evidence
of any abnormalities e.g., hernias.
❑ Listen for peristalsis or bowel sounds. Their frequency per
minute should be recorded e.g., five bowel sound /
minute.
 PHYSICAL EXAMINATION

▪ Absence of bowel sounds may

indicate peritonitis or a paralytic

ileus.

▪ Hyperactive bowel sounds may

indicate gastroenteritis or a

bowel obstruction.
 PHYSICAL EXAMINATION

GENITALIA
▪ In males assess for the location of the scrotum, the
size of the penis, glans and urethral meatus opening
and presence of anomalies (hypospadias).

▪ The female genitalia are examined for size and

location of the structure of the valva, clitoris, labia
majora, labia minora, urethral meatus and vaginal
orifices.
 PHYSICAL EXAMINATION

BACK AND EXTREMITIES

Inspect:
• Spine curvature: The general curvature of the spine is

noted.

• Normally, the back of a newborn is rounded or C-shaped

from the thoracic and pelvic curves.

• Gait: 1st or 2nd year, a wide-based gait is used in walking

 PHYSICAL EXAMINATION

Palpate:
o Spine, especially lumbosacral region for any deformity
o Hip: Examine hip for dislocation
o Extremities:
Each extremity is inspected for symmetry of length
and size.
Count the fingers and toes to be certain of the
normal number.
The arms and legs are inspected for color. The shape of
bones is assessed.
 PHYSICAL EXAMINATION

Assess bone shape: while the

child standing.
o Bowleg or genu varum:
It is a lateral bowing of the
tibia. It is clinically present when
the child stands with the medical
malleoli (rounded prominence on
either side of the ankle) opposite
each other and the space between
the knee is greater than 5 cm.
 PHYSICAL EXAMINATION

o Knock-knee:
✓ is normally present in children from about
2 to 7 years of age. It is a lateral bowing of
the tibia, in which the distance between
the two ankles is more than 2.5 cm when
knees are together.
✓ Knock-knee that is cause immediate pain or
difficult walking, excessive, asymmetric,
accompanied by shortened stature requires
further evaluation.
✓ Next, the feet are inspected. Infants' and
toddlers' feet appear flat because the foot is
normally wide, and arch is covered by fat pad.
 PHYSICAL EXAMINATION

Check joints& muscles for

range of motion:

Full motion

Flexible

No pain

No stiffnes
 PHYSICAL EXAMINATION

NERVOUS SYSTEM
▪ Assess mental status:
- Orientation - Level of consciousness
- Mood Affect - Behavior

▪ Motor functioning
-Muscle strength - Voluntary/ involuntary movements
-Coordination
▪ Sensory functioning
 Test vision and hearing
 Sensory intactness: touch skin lightly with a pin, ask the child to
point to stimulated area while closing the eyes
 PHYSICAL EXAMINATION

▪ Assess sensory discrimination:

1) Touch skin with cotton and pin: ask the child to describe it (dull
or sharp)
2) Touch skin with warm to cold object differentiates between
temperature
3) Touch skin with 2 pins simultaneously or with one only: ask the
child to discriminate when one or two pins are used
 PHYSICAL EXAMINATION

▪ Newborn and infant reflexes

Definition: Are involuntary movements or actions. Some movements are

spontaneous and occur as part of the baby's normal activity. Others are
responses to certain actions.

Purpose for assessing reflexes:

- To determine if the brain and nervous system are working well.

- Some reflexes occur only in specific periods of development.

 PHYSICAL EXAMINATION

1)Rooting reflex:
❑ When the corner of the baby's mouth is stroked or touched, the
baby will turn his or her head and open his or her mouth to follow
and root in the direction of the stroking.

❑ This helps the baby find the breast or bottle to start feeding.
 PHYSICAL EXAMINATION
2) Sucking reflex:
❑ Rooting helps the baby get ready to suck. When the roof of the baby's
mouth is touched, the baby will start to suck.

❑ This reflex doesn't start until about the 32nd week of pregnancy and is
not fully developed until about 36 weeks.

❑ Premature babies may have a weak or immature sucking ability because

of this.
 PHYSICAL EXAMINATION
3) Moro Reflex
❑ The Moro reflex is often called a

startle reflex. That’s because it

usually occurs when a baby is
startled by a loud sound or
movement.
❑ In response to the sound, the baby
throws back his or her head,
extends out his or her arms and
legs, cries, then pulls the arms and
legs back in.
 PHYSICAL EXAMINATION

4) Tonic neck reflex

❑When a baby's head is turned to
one side, the arm on that side
stretches out and the opposite arm
bends up at the elbow.

❑This is often called the fencing

position because of the position of
the hands.
 PHYSICAL EXAMINATION

5) Grasp reflex
❑ Stroking the palm of a baby's hand causes the baby to close
his or her fingers in a grasp (Palmer Grasp).

❑ A similar reflex in the toes lasts until 9 to 12 months

(Plantar Grasp).
 PHYSICAL EXAMINATION

6) Stepping reflex
❑ This reflex is also called the
walking or dance reflex
because a baby appears to
take steps or dance when held
upright with his or her feet
touching a solid surface.
 PHYSICAL EXAMINATION

7) Gag Reflex .
❑ The 'gag reflex' is triggered when a baby swallows too
much milk.
❑ In this case the baby closes off his throat and causes his
tongue to push the excess milk out of their mouth.
❑ When your baby starts on solids and finger food (usually
around 5-6 months) they tend to gag a lot as they try to
become accustomed to food.
❑ The gag reflex is important for survival and is closely
associated with the swallow, cough and sneeze reflexes.
 PHYSICAL EXAMINATION

8) Swimming
❑If you were to put a baby under six months of age in
water, they would move their arms and legs while
holding their breath.
❑This is why some families believe in swim training for
very little babies.
❑It is not recommended for you to test this reflex at
home for obvious safety reasons .
PHYSICAL EXAMINATION