Pediatric Health Assessment and Physical Examination

You assess children constantly, on admission and at every visit. The job is to gather an accurate picture of history and current status, catch deviations from normal growth and development early, and intervene before small problems become big ones. Assessment runs from infancy through adolescence, and your technique has to shift with the child's age.

Collecting Subjective Data

Subjective data is whatever the child or family tells you. Record it verbatim. Most of it comes from interviewing the caregiver and the child.

Conducting the Client Interview

The interview does more than collect facts. It builds the relationship between you, the child, and the family, so listening and good communication technique matter as much as the questions. Introduce yourself to the child and caregiver and state why you are there. Keep a calm, reassuring manner, get everyone comfortably seated, and include the child in the process.

For infants and toddlers, the caregiver provides most of what you need. Rather than handing over a form, ask the questions yourself and write down the answers; that lets you watch how the child and caregiver react and interact. Stay nonjudgmental, and do not signal disapproval verbally or nonverbally.

Include preschool and older children in their own interviews. Use age-appropriate toys and questions, show genuine interest in what the child says, and answer their questions honestly, which builds trust. Listen attentively and make the child feel important.

Adolescents can speak for themselves. Interview them in private, which often gets you information they would not share in front of a caregiver.

Obtaining a Client History

Gather both the current condition and the medical background.

Collect biographical data: the child's name, address, and phone number, plus caregiver information. A questionnaire often captures the rest, including nickname, feeding habits, food likes and dislikes, allergies, sleep schedule, and toilet-training status. The chief complaint is the reason for the visit; get a complete explanation of what brought the child in. For the history of present concern, elicit the symptoms, when they began, how long they have lasted, their description, intensity, and frequency, and any treatment so far.

The health history includes the mother's pregnancy and prenatal course, common childhood and serious or chronic illnesses, immunizations and health maintenance, feeding and nutrition, and hospitalizations and injuries. Family health history, usually from the caregiver, drives your preventive teaching. Review each body system, and review the system tied to the chief complaint in detail.

Ask specifically about allergies, medications, and substance use. Document any allergic reactions to foods, medications, or anything else so the child is not given something that triggers a reaction, and record all medications, prescribed or over the counter, current or recent. In adolescents especially, assess tobacco, alcohol, and illegal drug use. Cover lifestyle too: school grade level, academic performance, and behavior; the home environment, parents' occupations, siblings, pets, religion, and economics; hygiene, sleep, and elimination patterns; and nutrition habits and preferences that may flag illness. Finally, assess developmental level by asking directly about growth and development milestones, because knowing normal patterns tells you when to look closer.

Collecting Objective Data

Objective data is what you observe and measure. Start with baseline height, weight, blood pressure, temperature, pulse, and respiration.

General Status

Use normal growth and development as your reference and note whether the child fits the stated age. Observe general appearance: the face should be symmetrical, and you assess nutritional status, hygiene, mental alertness, posture, and movement. Examine the skin for color, lesions, bruises, scars, and birthmarks, and note hair texture, thickness, and distribution. For psychological status and behavior, note what triggered a behavior and how often it repeats, and consider physical, emotional, and intellectual responses. Factor in the child's age and developmental level, the unfamiliar facility, and any prior hospitalization or separation from caregivers.

Measuring Height and Weight

Height and weight are key growth indicators. Measure and record them at every routine physical and at other visits. In the hospital, weigh the infant or child at the same time each day, on the same scale, in the same amount of clothing. Weigh an infant nude on an infant scale, or seated once big enough to sit. Measure a child who can stand at the same time. For a child who cannot stand steadily, usually under about age 2, lay the child flat on an exam table, hold the knees flat, straighten the body, and measure from the top of the head to the bottom of the foot.

Measuring Head Circumference

Measure head circumference routinely to age 2 or 3 years, and in any child with a neurologic concern. Place a paper or plastic tape around the largest part of the head, just above the eyebrows and around the most prominent part of the back of the head. Record the measurement and plot it on a growth chart to track head growth.

Vital Signs

Take temperature, pulse, respirations, and blood pressure at each visit and compare them with normal values for the child's age.

Temperature

Measure by oral, rectal, axillary, or tympanic route, and record in Celsius or Fahrenheit per facility policy. A normal oral range is 36.4 degrees Celsius to 37.4 degrees Celsius (97.6 degrees Fahrenheit to 99.3 degrees Fahrenheit). A rectal temperature usually runs 0.5 to 1.0 degrees higher than oral; an axillary temperature usually runs 0.5 to 1.0 degrees lower.

Pulse

Count the apical pulse before disturbing the child for anything else, with the stethoscope between the left nipple and the sternum. A radial pulse works for an older child. Count any pulse that is unusual in quality, rate, or rhythm for a full minute, and compare it on the opposite side. Rates vary with age, from 100 to 180 beats per minute in a neonate to 50 to 95 beats per minute in the 14- to 18-year-old adolescent.

Respirations

Observe the child lying or sitting quietly. Infants are abdominal breathers, so watch abdominal movement to count; observe the chest in an older child as you would an adult. Count an infant's respirations for a full minute because of normal irregularity. Note retractions as substernal, subcostal, intercostal, suprasternal, or supraclavicular.

Blood Pressure

For children 3 years of age and older, blood pressure is part of routine, ongoing data collection. Demonstrating on a stuffed animal or doll shows the child the procedure is nothing to fear. The common sites are the upper arm, lower arm or forearm, thigh, and calf or ankle, measured by auscultation, palpation, or Doppler or electronic method.

Physical Examination

Collect data by examining each body system.

Head and Neck

Note symmetry in the face and head. Assess range of motion: have the older child move the head in all directions, and gently move an infant's head to check for neck stiffness. Feel the skull to determine whether the fontanels are open or closed and to check for swelling or depression. Assess the eyes for symmetry and position relative to the nose, note redness, rubbing, or drainage, and have the older child (or an infant) follow a light to check focus; check pupils for equality, roundness, and reaction to light. For the ears, draw an imaginary line from the outer corner of the eye to the prominent part of the skull; the pinna should cross that line. Note hearing during normal conversation, since a child who speaks loudly, responds inappropriately, or speaks unclearly may have a hearing problem worth exploring. Assess the nose, mouth, and throat: the nose sits midline and both sides should be symmetrical, so observe for swelling, drainage, or bleeding. Have the older child open wide and move the tongue side to side; use a tongue blade for an infant or toddler. Observe the mucous membranes for color, moisture, and patchy areas suggesting infection, and note the number and condition of the teeth.

Chest and Lungs

Measure the chest in infants and children to gauge growth rate, taking the measurement at nipple level with a tape. Observe chest size, shape, movement with breathing, and any retractions. In the older school-age child or adolescent, note breast development. Evaluate respiratory rate, rhythm, and depth, and report noisy or grunting respirations. With a stethoscope, listen to breath sounds in each lobe, anterior and posterior, through inhalation and exhalation; describe, document, and report absent or diminished sounds and any crackling or wheezing.

Heart

In some children a chest pulsation marks the heartbeat, called the point of maximum impulse. Listen for rhythm and count the rate for 1 full minute. Abnormal or unusual heart sounds may signal a murmur, heart condition, or other abnormality and should be reported. To judge how well the heart is working, assess pulses in various parts of the body.

Abdomen

The abdomen may protrude slightly in infants and small children. Divide it into four quadrants for description: left upper (LUQ), left lower (LLQ), right lower (RLQ), and right upper (RUQ). With a stethoscope, listen for bowel sounds or peristalsis in each section and record what you hear.

Genitalia and Rectum

Respect the child's privacy and account for age and developmental stage. Wearing gloves, inspect the genitalia and rectum for sores or lesions, swelling, or discharge. In males the testes descend at varying times through childhood; if you cannot palpate them, report it.

Back and Extremities

Observe the back for symmetry and spinal curvature. In infants the spine is rounded and flexible, and it develops further as the child gains motor skills. Note gait and posture as the child enters or walks in the room. The extremities should be warm, well-colored, and symmetrical; watching the child move during the exam tells you range of motion, joint movement, and muscle strength.

Neurologic

The neurologic exam is the most complex part of the assessment. The practitioner does a complete exam, including detailed reflex responses and the function of each cranial nerve. Use a standard neurologic tool such as the Glasgow Coma Scale, which lets you compare results across times and across examiners while you monitor the child's neurologic function.