Physical Assessment of the Child: Interpretation of Observations

Julian L. Gallegos, MS, RN, FNP-BC

Physical Assessment of the Child

It is essential that nurses develop good assessment skills to ensure that the child is treated appropriately The physical assessment of a sick child is a multifactorial process that can initially appear complex but very quickly becomes second nature. This process covers areas such as the recording of basic physical readings (e.g. temperature, pulse, respirations, blood pressure) and full system assessments (e.g. neurological, respiratory assessments).

Physical Assessment of the Child

A good assessment is much more than just the recording of numbers; the best information is gained from well-developed observational and listening skills. The physical assessment is more to do with the analysis and interpretation of findings than with the act of obtaining the information.

Physical Assessment of the Child

General assessment encompasses all aspects and acts as an overview of the whole child. The majority of this assessment can be carried out from a distance or while obtaining a nursing history and weighing the child. This includes looking:
at the color of the child (is he or she pale, cyanosed, mottled, flushed, jaundiced?) for any obvious birthmarks, bruises or rashes at the general appearance of the child (is he or she clean and are there any dysmorphic features?).

Physical Assessment of the Child

Next it is important to look at the interaction of the child with parents, surroundings and strangers.
Is the child alert, lethargic, agitated or drowsy? How much stimulation is required to obtain a reaction and is the reaction appropriate for the age of the child? Is the child interested in playing or looking at pictures or is she or he disinterested and sleepy? Is the child holding her- or himself in a normal position or is she or he unusually floppy (hypotonic) or stiff (hypertonic)?

Physical Assessment of the Child

Temperature Many people perceive an increase in temperature to be dangerous to the child and an indication of the severity of illness . In reality the height of a fever does not necessarily bear any relation to the severity of the underlying condition, nor is it in itself dangerous to the child. Many common viral infections will give rise to very high fevers, when in contrast a child with meningitis may have only a slight rise in temperature. Temperature reading is a valuable asset within the assessment and can have an effect on other readings, such as pulse and respirations, which can be raised in the presence of a fever.

Physical Assessment of the Child

It is essential that an accurate measurement is taken using an appropriate method for the individual child, and that the method used is documented clearly. It is also important to note the environmental temperature and conditions, as these can have an effect on the child's temperature. Assessing the temperature of a child is not just a case of 'has the child got a fever?' but more an issue of what the temperature is and whether this fits with the other findings or there is too much of a variance.

Physical Assessment of the Child

Respiratory
The most common reason for parents to seek medical assistance for their child is an acute respiratory infection (Gill & O'Brien 2003). The assessment of the respiratory system involves assessing the rate of breathing, type of respirations, any noise on breathing, cough, chest movement, colour of the child, ability to feed or talk, oxygen saturation level, nasal flaring and position of the child. A large amount of the assessment of breathing can and should be done from a distance without even touching the child. Normal respiratory rates vary with the age of the child and the rate can be affected by various other factors, such as fever, pain, circulatory failure and fear; the rate therefore needs to be assessed along with the type of respirations to give a clearer picture.

Physical Assessment of the Child

Heart rate
The heart rate is affected by various external and internal factors, such as hypoxia. It is therefore very important to remember that on its own the heart rate will tell you very little about the condition of the child. Other factors that will initiate a normal rise in heart rate are fever, excitement, crying and fear. Heart rate can increase by 10 beats/min for each 1r rise in temperature (Gill & O'Brien 2003). When assessing the heart rate, it is important to think about not just the rate and whether it is within normal limits for the child but also if it is regular or irregular in pattern. Pulse volume is also important to note, especially in a sick child who may be displaying other signs, such as those of dehydration, sepsis or shock.

Physical Assessment of the Child

Capillary refill time
Cutaneous pressure is applied to a digit or the center of the distal phalange for 5 s. The pressure is then released and the number of seconds that it takes for the capillaries to refill and the skin color to return to normal is counted. This should be less than 2 s. A slower time indicates poor perfusion, which can be a sign of shock; however, a low ambient temperature can reduce the specificity of this test. Additionally, if the child has a fever that is in the rising stage the peripheral circulation may well be shut down and the refill time will be delayed. In this instance it is advisable to test on the centre of the sternum. This test should be undertaken alongside other assessment tools and the results interpreted accordingly (e.g. a prolonged capillary refill time and raised heart rate could indicate a fever, anxiety, hypoxia or hypovolemia).

Physical Assessment of the Child

Age (years) Respiration Heart rate (beats/min) rate (breaths/mi n) 30-40 110-160 25-35 110-150 25-30 95-140 20-25 80-120 15-20 60-100 Systolic blood pressure (mmHg) 70-90 80-95 80-100 90-110 100-120

<1 1-2 2-5 5-12 > 12

(From Mackway-Jones et al 2005)

Physical Assessment of the Child

Blood pressure
Blood pressure is a reading that is often overlooked in children, as it is considered difficult and usually normal. It is unusual to find abnormal blood pressure readings in children, as their bodies compensate for the disease processes very well. Although hypertension may be found following a severe head injury and in children with severe renal disease, hypotension in children is a preterminal sign and would therefore be found only in an extremely sick child. It is important to remember to check the blood pressure of any child, as this provides a baseline when normal and indicates a potentially serious condition when abnormal.

Physical Assessment of the Child

Level of Hydration The normal circulating blood volume in children varies with age and is approximately 100 mL/kg at birth and 80 mL/kg at 1 year. The total amount of water in the body also decreases with age, with a level of 800 mL/kg in the neonate and 600 mL/kg at 1 year, two-thirds of which is intracellular and one-third extracellular (Mackway-Jones et al 2005). Under normal circumstances the child's kidneys can maintain normal hydration even in the presence of a poor fluid intake.

Physical Assessment of the Child

Dehydration occurs when the fluid loss is at a greater rate than the kidneys can cope with. Very young children and infants are more at risk of developing dehydration due to their greater surface area: mass ratio and therefore higher insensible losses (Gill & O'Brien 2003). Their high basal metabolic rate and increased febrile response to infection also increases the amount of fluid loss (Gill & O'Brien 2003).

Physical Assessment of the Child

There are three forms of dehydration: 1. Isotonic dehydration, when there is an equal loss of sodium and water 2. Hypotonic or hypernatremic dehydration, when the loss of water is greater than the loss of sodium 3. Hypertonic or hyponatremic dehydration, when the loss of sodium is greater than the loss of water.

Physical Assessment of the Child

There are many signs and symptoms that enable the detection and assessment of severity of dehydration. The most obvious ones, which reflect a loss of interstitial fluid and can be detected with a 3% loss of fluid upwards, are: 1. sunken anterior fontanelle (3%) 2. dull, sunken eyes (3%) 3. decreased skin turgor (8%) As the dehydration progresses fluid is lost from the intravascular volume and is reflected in: 1. diminished urinary output 2. reduced capillary refill time 3. reduced blood pressure (a very late sign)

Physical Assessment of the Child

Clinical sign Mucous membranes Eyes Skin turgor Peripheral circulation Mild (3%) Dry Sunken Instant recoil Normal peripheries Capillary refill in 1-2 s Normal Normal Moderate (8%) Dry Sunken 1-2 s Severe (> 8%) Dry Sunken >2s

Normal Decreased perfusion peripheries Capillary refill > 2 s Capillary refill in 12s Drowsy and irritable Deep acidotic breathing Increasingly drowsy and irritable Increasingly deep, rapid and acidotic

Neurological status Respirations

Physical Assessment of the Child

Oxygen Saturation
This is the non-invasive peripheral monitoring of the oxygen saturation of hemoglobin in arterial blood and has been widely used since 1988 (Robertson 1993). Unless the child is receiving oxygen therapy the SaO2 reading is a good indication of the efficacy of breathing (Mackway-Jones et al 2005); however, it is possible to have an SaO2 reading of nearly 100% and still be close to death if receiving high-flow oxygen (Stroobant & Field 2002).
Oxygen saturation monitors have a level of error of 2% in the 70100% range (Robertson 1993) but are less accurate at readings of < 70%, in the presence of carbon monoxide and in a shocked child with poor perfusion (Mackway-Jones et al 2005).

Physical Assessment of the Child

The accuracy of the reading can be affected by various factors, including:
hemoglobin level in the blood temperature of digit or limb used arterial flow to area percentage of inspired oxygen amount of ambient light seen by the sensor venous return at the probe site patient's oxygenation ability (Mackway-Jones et al 2005, Schutz 2001). movement of sensor probe nail varnish and/or dirt under the sensor It is essential that the correct sensor probe is used, as the wrong size could allow ambient light to distort the readings. In cases of carbon monoxide poisoning, when the carbon monoxide binds heavily to hemoglobin, the oxygen saturation reading is falsely high and cannot be relied on (Hampson 1998).

Physical Assessment of the Child

Height, weight, head circumference
The most rapid changes in weight occur during the first year of life. An average birth weight of 3.5 kg would have increased to 10.3 kg by the age of 1 year (Campbell & McIntosh 1998). It is important to determine a child's weight as soon as possible, as most drugs and fluids are given as the dose per kilogram of body weight.

Physical Assessment of the Child

Height, weight, head circumference
The most accurate method for measuring weight is to weigh the child on scales; however, in an emergency this may be impracticable. In this situation the child's weight may be estimated by one of a number of methods. The Broselow tape uses the height (or length) of the child to estimate weight. The tape is laid alongside the child and the estimated weight read from the calibration on the tape. This is a quick, easy and relatively accurate method. If a child's age is known and it is between 1 and 10 years, the following formula may be useful: weight (kg) = 2 (age in years + 4).

Physical Assessment of the Child

Height, weight, head circumference
Growth within expected limits is probably the best indicator of health during infancy and childhood (Bickley 2000). Any opportunity to measure the height and weight of a child should be taken so that any failure to thrive or over-nutrition can be identified early. Look for measurements above the 97th and below the 3rd centiles or any indication that a child's weight or height has crossed the centiles. Any large variation between height and weight should be examined.

Height, weight, head circumference

Ensure that the scales used are suitable for the age of the child (e.g. basin scales for infants or children who are unable to sit unsupported) and that they have been calibrated regularly. Children less than 3 years old should be weighed naked and the reading should be taken when the child is still. Check weight against expected weights for a child of that age and with previous weights recorded for the child. All weights and heights should be plotted in kilograms on a centile chart and any spurious readings reported.

Height, weight, head circumference

Head circumference should be measured at every examination within first 2 years of life and plotted on a percentile chart It is an indicator of brain growth (Gill & O'Brien 2003) and as such any crossing of the percentiles is abnormal. The infant should be laid supine and then, using a non-stretchable cloth or soft plastic or paper tape, stretch the tape over the occipital, parietal and frontal prominences; note the reading at the greatest measurement.