Physical Assessment of
Children
Depending of Age
Physical Assessment of
Infant








Assessment is NOT in the head-to-toe manner
When quiet, auscultate heart, lungs, abdomen
Assess heart & respiratory rates before temperature
Palpate and percuss same areas
Perform traumatic procedures last
Elicit reflexes as body part examined
Elicit Moro reflex last
Encourage caretaker to hold infant during exam
Distract with soft voice, offer pacifier, music or toy
Physical Assessment of
Toddler
 Inspect body areas through play – “count fingers and






toes”
Allow toddler to handle equipment during assessment
and distract with toys and bubbles
Use minimal physical contact initially
Perform traumatic procedures last
Introduce equipment slowly
Auscultate, percuss, palpate when quiet
Give choices whenever possible
Photo Source: Del Mar Image Library; Used with
permission
Physical Assessment of
Preschooler








If cooperative, proceed with head-to-toe
If uncooperative, proceed as with toddler
Request self undressing and allow to wear underpants
Allow child to handle equipment used in assessment
Don’t forget “magical thinking”
Make up “story” about steps of the procedure
Give choices when possible
If proceed as game, will gain cooperation
Photo Source: Del Mar Image Library; Used with
permission
Physical Assessment of
School-Age Child
 Proceed in head-to-toe
 May examine genitalia last in older children
 Respect need for privacy – remember modesty!
 Explain purpose of equipment and significance
 Teach about body function and care of body
Physical Assessment of
the Adolescent
 Ask adolescent if he/she would like parent/caretaker





present during interview/assessment
Provide privacy
Head-to-toe assessment appropriate
Incorporate questions/assessment related to
genitals/sexuality in middle of exam
Answer questions in a straightforward, noncondescending manner
Include the adolescent in planning their care
Pain Assessment
Pain
• “Pain is whatever the experiencing
person says it is, existing whenever
the person says it does.”
– McCaffery and Pasero, 1999
• This includes VERBAL and
NONVERBAL expressions of pain
Pain Facts and Fallacies
• FACT: Children are under treated for
pain
• FACT: Analgesia is withheld for fear
of the child becoming addicted
• FALLACY: Analgesia should be
withheld because it may cause
respiratory depression in children
• FALLACY: Infants do not feel pain
Principles of Pain Assessment in
Children: QUESTT
• Question the child
• Use a pain rating scale
• Evaluate behavioral and physiologic
changes
• Secure parent’s involvement
• Take the cause of pain into account
• Take action and evaluate results
Pain Rating Scales
• Not all pain rating scales are reliable
or appropriate for children
• Should be age appropriate
• Consistent use of same scale by all
staff
• Familiarize child with scale
Pain Scales
• FACES pain rating scale
• Numeric scale
• FLACC scale
– Facial expression
– Legs (normal relaxed, tense, kicking,
drawn up)
– Activity (quiet, squirming, arched,
jerking, etc)
– Cry (none, moaning, whimpering,
scream, sob)
– Consolability (content, easy or difficult to
console)
Nonpharmacologic
Interventions
•
•
•
•
•
Based on age
Swaddling, pacifier, holding, rocking
Distraction
Relaxation, guided imagery
Cutaneous stimulation
Anesthetics: Topical and
Local
• Major advancement for atraumatic
care
• EMLA
• NUMBY stuff
• Intradermal local anesthetics
• Importance of timing
Analgesics
•
•
•
•
Opioids
NSAIDs
“Potentiators”
Lytic cocktail (DPT)—Demerol,
Phenergan, and Thorazine
• Co-analgesics, amnesics, sedatives,
etc.
• Role of placebos
Dosage of Analgesia
•
•
•
•
•
Based on body weight up to 50 kg
Concept of “titration”
Ceiling effect of non-opioids
First pass effect
PCA
Fears of Bodily Injury
and Pain
• Common fears among children
• May persist into adulthood and result
in avoidance of needed care
Pain Assessment: Infants
Assessment of pain includes the use of
pain scales that usually evaluate indicators
of pain such as cry, breathing patterns,
facial expressions, position of extremities,
and state of alertness
Examples: FLACC scale,
NIPS scale
Young Infant’s Response
to Pain
• Generalized response of rigidity,
thrashing
• Loud crying
• Facial expressions of pain (grimace)
• No understanding of relationship
between stimuli and subsequent pain
Older Infant’s Response
to Pain
•
•
•
•
Withdrawal from painful stimuli
Loud crying
Facial grimace
Physical resistance
Pain Assessment:
Toddlers
Toddlers may have a word that is
used for pain (“owie,” “booboo,” “ouch” or “no”); be sure
to use term that toddler is
familiar with when assessing.
Can also use FLACC scale, or
Oucher scale (for older toddlers)
Young Child’s Response to
Pain
• Loud crying, screaming
• Verbalizations: “Ow”, “Ouch”, “It
hurts”
• Thrashing of limbs
• Attempts to push away stimulus
Pain Assessment:
Preschoolers
Think pain will magically go
away
May deny pain to avoid
medicine/injections
Able to describe location
and intensity of pain
FACES scale, poker chips
and Oucher scale may be
used
Photo Source: Del Mar Image Library; Used with
permission
School-Age Child’s
Response
to Pain
• Stalling behavior (“wait a minute”)
• Muscle rigidity
• May use all behaviors of young child
Pain Assessment:
Older Children
Older children can describe pain
with location and intensity
Nonverbal cues important, may
become quiet or withdrawn
Can use scales like Wong’s
FACES scale, poker chips, visual
analog scales, and numeric rating
scales
Adolescent
• Less vocal protest, less motor
activity
• Increased muscle tension and body
control
• More verbalizations (“it hurts”,
“you’re hurting me”)
Let’s Review
The nurse begins a full assessment on a 10 yearold patient. To ensure full cooperation from this
patient it is most important for the nurse to:
A. Approach the assessment as a game to play.
B. Provide privacy for the patient.
C. Encourage the friend visiting to stay at the
bedside to observe.
D. Instruct the child to assist the nurse in the
assessment.
Let’s Review
During a routine health care visit a parent asks the
nurse why her 10 month-old infant is not walking as
her older child did at the same age. Which response
by the nurse best demonstrates an understanding of
child development?
A. “Babies progress at different rates. Your infant’s
development is within normal limits.”
B. “If she is pulling up, you can help her by holding her
hand.”
C. “She’s a little behind in her physical milestones.”
D. “You can strengthen her leg muscles with special
exercises to make her stronger.”
Let’s Review
When assessing a toddler identify the order in
which you would complete the assessment:
1.
2.
3.
4.
Ear exam with otoscope
Vital signs
Lung assessment
Abdominal assessment
Let’s Review
When assessing pain in an infant it would be
inappropriate to assess for:
A.
B.
C.
D.
Facial expressions
Localization of pain
Crying
Extremity movement