Chapter 29: The Complete Physical Assessment: Infant, Young Child, and Adolescent

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Welcome to this deep dive.

If you're listening to this right now, chances are you are a nursing student gearing up for clinicals.

Or staring down the barrel of a really major upcoming exam.

Exactly.

We know exactly where you're sitting right now and we are thrilled you're here.

Consider this your personalized one -on -one tutoring session.

Right.

And our mission today is simple but crucial.

We are going to help you completely master the physical assessment of the pediatric patient.

Yep.

To be very specific, we're pulling strictly from Chapter 29 of Physical Examination and Health Assessment, the 9th edition.

That's the one.

We're looking at the complete physical assessment of the infant, the young child, and the adolescent.

We are going to walk through the exact sequence of how these exams happen in the real world.

The clinical reasoning behind those sequences and the specific subjective and objective data you need to be collecting.

Okay, let's unpack this because if there's one overarching theme you need to take away from this material, it is that a pediatric assessment is absolutely not just a mini adult exam.

No.

Not at all.

You can't just take the adult head -to -toe sequence, shrink it down and expect it to work.

It really requires a completely different sequencing strategy, unique clinical reasoning,

and a massive amount of developmental awareness.

Right.

Because the foundational concepts of a child's development, they dictate exactly how and when we touch the patient.

Which is huge.

It is.

As we move through the different age groups today, you'll see how preserving this logical flow from the initial interview to the physical exam is what guarantees safe patient care.

And allows you to accurately interpret your findings.

So picture this.

You walk into the exam room and your patient is a neonate.

Tiny.

Tiny.

They're lying supine on a warming table with an overhead heating element.

They are completely nude except for a diaper.

Which we leave on for now.

Right.

We leave the diaper on.

Okay.

But keeping the rest of their clothes off initially is crucial so we can clearly observe their body position and overall symmetry.

And right at the beginning you are looking at their vital signs.

Pulse, respirations,

temperature.

Yeah.

As well as measurements like weight, length, and head circumference which you will plot on growth charts.

Keep in mind while the one and five minute APGAR results give you really important data on the neonate's immediate extradural response.

That doesn't replace your job.

Exactly.

It does not replace your job.

A thorough physical assessment is still required immediately after birth and with each well child appointment throughout infancy.

I always wonder about the order of operations here.

With an adult you follow a strict head to toe progression.

Right.

But with an infant you are working around their schedule.

Say you walk in and the baby is completely asleep.

Your first instinct might be to wake them up to say hi.

Do not wake them up.

I cannot stress that enough.

Let sleeping babies lie.

If the baby is sleeping or resting quietly seize that golden gift of silence.

The clinical reasoning you need to remember for infants is that you must reorder the sequence of this exam based on the infant's sleep and wakefulness state.

So you do the quiet stuff first.

Yes.

That quiet moment is when you want to auscultate the breath sounds, the heart sounds in all locations and the bowel sounds.

Because if they're crying.

You really want to avoid auscultation while the infant is crying because it becomes nearly impossible to hear subtle abnormalities.

Makes total sense.

So assuming we've gotten our quiet auscultation done.

We move to general appearance.

Right.

We're looking for body symmetry, spontaneous positioning,

inflection of the head and extremities.

You want to see that spontaneous movement.

Exactly.

You're noting skin color, looking for any obvious deformities, checking the symmetry of the facial features.

You also want to note if they have an alert,

responsive affect and a strong lusty cry.

And as you move down to inspect the chest, do not be alarmed if you notice the nipples and breast tissue are swollen.

Which can seem surprising.

It can, but this is a completely normal physiological response to maternal hormones in the newborn.

You're also noting the movement of the abdomen with respirations and checking for any chest retraction.

And palpation.

Palpate the apical impulse, noting its location.

Feel the chest wall for thrills or tactile fremitus, which is a vibration you can feel on the chest wall if the infant happens to be crying.

Moving to the abdomen, we inspect the shape and the skin condition.

Now, in a newborn, we actually need to inspect the umbilicus and count the umbilical vessels.

Very important step.

We're looking for two arteries and one vein.

We also note the condition of the cord, or stump, and check for any hernias.

Then you palpate.

Use light palpation to check skin trigger, muscle tone, the liver, spleen tip and bladder.

Then you palpate deeply for the kidneys or any masses.

Deeply for the kidneys.

Got it.

You'll also palpate the femoral pulses and inguinal lymph nodes before percussing all four quadrants.

Okay, so we've checked the torso.

When we move back up to the head, I know we're checking the fontanels, those side spots on the baby's skull.

But how do we distinguish between a fontanel that's bulging, because the baby is just upset, versus one that's signaling a real neurological issue?

That is a great clinical distinction.

You're palpating the fontanels and the suture lines, looking for any molding from delivery.

A bulging fontanel when the baby is crying can just be a normal physiological response to the increased pressure from crying itself.

But if they're quiet.

If that fontanel is bulging while the baby is completely at rest, that requires further investigation.

It could indicate increased intracranial pressure.

Here's where it gets really interesting.

Examining a neonate's eyes.

You can't exactly ask a newborn to open their eyes for you.

No, you cannot.

But there's a brilliant little trick of the trade for this.

You support the baby's head and shoulders,

and gently lower them backward.

Yes, or you can ask the parent to hold the baby over their shoulder while you stand behind them.

Right, this gentle shifting movement naturally prompts the baby to open their eyes.

Once the eyes are open, you inspect the lids, which might be edematous or swollen in a neonate.

You're checking the palpebral slant, which is the upward or downward angle of the eyes.

Looking at the conjunctivet.

Exactly, noting any nystagmus, that involuntary darting eye movement, or any discharge.

Using your penlight, you elicit the pupillary reflex, the blink reflex, and the corneal light reflex, assessing how they track a moving light.

And the red reflex.

Yes, finally, using an ophthalmoscope, you must elicit the red reflex to ensure the lens is clear.

For the nose, we check the patency of the nares, and note any discharge, sneezing, or flaring with respirations.

Then for the mouth and throat, we inspect the lips, gums, buccal mucosa, tongue size, and the frenulum.

We're looking for a high -arched, intact palate.

And keep in mind, salivation is actually absent or very minimal in a neonate.

This is also where we check some specific developmental reflexes.

Note the rooting reflex when you touch their cheek.

Then, using a gloved little finger, gently insert it into the mouth to check the sucking reflex.

And you check the palate at the same time, right?

Exactly.

While your finger is in there, palpate the roof of the mouth to ensure the palate is fully intact.

Very efficient.

Moving to the neck, lift the shoulders, and let the head lag.

You're looking for a midline trachea, any skin folds or lumps.

Palpate the lymph nodes, thyroid, and any masses.

While the infant is supine, you will elicit the tonic neck reflex, noting a supple neck with movement.

Then we assess the extremities.

For the upper extremities, inspect and manipulate their range of motion and muscle tone.

We're looking for the absence of the scarf sign.

Meaning the infant's elbow should not easily reach all the way across their midline.

Right.

You'll count the fingers and palmar creases, note the color of the hands and nail beds, and check the grasp reflex.

Wrap your hands around the infant's hands to pull them up and note the head lag.

For the lower extremities, again, inspect and manipulate for range of motion, muscle tone, and skin condition.

Look at the alignment of the feet and toes.

Look for flat soles, count the toes, and note any syndactyly, which is the medical term for webbing of the digits.

And the hips.

To make sure those hips are stable and properly seated, you will perform the Ortolani maneuver gently abducting the thighs.

The reflexes here have very specific timelines, right?

They do, and it is vital to know them for your exams.

The plantar grasp reflex is normally present until 8 to 10 months of age.

Okay.

And the Babinski reflex, which is the fanning of the toes when the sole of the foot is stroked, is actually a normal finding in an infant until 24 months of age.

That is a huge point to remember.

Babinski is normal until 2 years old.

Yes.

Next, we examine the genitalia.

For females, inspect the labia and clitoris, which may be ademinous in the newborn.

Look for vernix casiosa, that thick, white protective coating between the labia.

And ensure a patent vagina.

And for males.

Inspect the position of the urethrometis, the strength of the urine stream if possible, and the rugae or wrinkling on the scrotum.

Palpate the testes in the scrotum.

And there is a critical safety rule for males.

Do not retract the foreskin.

You now retract it.

That is an absolute safety priority.

Retracting it can cause severe tissue damage.

Okay, understood.

To finish the neuromuscular and spine check, lift the infant under the axillary, holding them facing you at eye level.

Note their shoulder muscle tone and their ability to stay in your hands without slipping through.

Rotate them slowly side to side to note the doll's eye reflex.

Then turn them around?

Turn them around to face away from you, to elicit the stepping and placing reflexes against the edge of the exam table.

Then turn them over and hold them prone to inspect the length of the spine, the trunk incubation reflex, and the symmetry of the gluteal folds.

Cracking that the skin is intact.

With no sinus openings, protrusions, or tufts of hair.

Finally, note a patent anal opening and verify the passage of meconium stool within the first 24 to 48 hours after birth.

We say the most invasive or upsetting steps for the very end.

This is when you use the otoscope to inspect the auditory canals and tympanic membranes.

You can absolutely have the caregiver hold the infant for this.

Yes, definitely use the caregiver.

And the absolute last thing you do is elicit the moro, or startle, reflex.

You do this by letting the infant's head and trunk drop back a short way, jarring the crib size, or making a loud noise.

By doing this last, you capture accurate objective data without a crying baby interrupting your flow.

What's fascinating here is how the approach entirely shifts as the patient grows.

We've navigated the completely passive, flexible world of the infant, but fast forward a couple of years, now you have a toddler or a preschooler in the room.

A whole different ballgame.

Totally.

The transition is from passive observation to active engagement, and the health history and the physical exam actually blend together through play.

Let's look at the developmental psychology at play here.

For preschoolers, their major developmental task is developing initiative.

They want to take on tasks independently, and they're usually cooperative.

But they have a major overriding fear of bodily injury.

A simple piece of plastic can look terrifying to them.

Oh, absolutely.

The young schoolchild, on the other hand, is developing industry.

They're cooperative, logical, and actually quite curious about how their bodies work.

So your approach shifts based on that.

Yes.

As you're collecting the history from the caregiver, you are simultaneously evaluating the child's gross and fine motor skills.

You evaluate developmental milestones like gait, jumping, hopping, standing on one foot, building a tower with blocks, or throwing a ball, all as a play period before you formally start examining them.

It's assessment in disguise.

Exactly.

You're also evaluating their posture, speech acquisition,

vision, hearing, and social interaction.

When it's time for the physical exam, preschoolers and young schoolchildren are generally willing to undress.

But you should leave their shorts and underpants on until the very end for the genital examination.

Modesty starts early.

Right.

And if you want to keep a child on your side, communication and games are your best tools.

Talk to them, explain the steps, make it fun.

A fantastic clinical example of this is having the child blow on a pinwheel while you listen to their lung sounds.

I love that trick.

It naturally encourages them to take deep breaths without making it feel like a medical test.

And then you let the pinwheel go home with them as a present.

So smart.

For the curious school -aged child, talk to them about school, family, friends, music, or sports.

Demonstrate how your equipment works on yourself or their parent first.

If they're uncomfortable on the exam table, allow them to sit on their caregiver's lap.

The sequence for the young child starts with measurements.

Height, weight, temperature, blood pressure.

Then you move to the upper extremities.

Inspect the arms and hands for alignment and skin condition, count the radial pulse, and test the biceps and triceps reflexes.

You can introduce the reflex hammer here as a fun tapping game.

Exactly.

Then you move to the head, face, and neck, inspecting symmetry and palpating the cervical lymph nodes, trachea, and thyroid gland.

Next are the eyes.

Inspect the external structures and note any palpebral slant.

Use your pen light to test the corneal light and pupillary light reflexes.

Ask the child to follow your finger or a moving pen light to check the cardinal positions of gaze.

And the cover test.

If indicated, perform the cover test using an index card to check for muscle weakness.

Inspect the conjunctivae and sclerae and use the ophthalmoscope to check the red reflex and inspect the fundus.

For the nose, inspect the external skin condition and use a light source to check the narrows for foreign bodies, which are surprisingly common in this age group.

Extremely common.

As well as the mucosa condition, the septum, and turbinates.

When you reach the mouth and throat, use a light source to inspect the buccal mucosa, teeth, gums, tongue, palate, and uvula.

But remember that preschooler's fear of body injury we talked about.

Yes, the tongue blade.

Treat that wooden tongue blade like an absolute last resort.

The minute they see it, their fear kicks in and you have likely lost their cooperation for the rest of the exam.

Good tip.

For the ears, inspect and palpate the auricles and look for any discharge or foreign bodies in the mias.

To gain their cooperation for the autostope exam, encourage the child to touch and handle the equipment first.

Let them play doctor for a second.

Right.

Let them look in their parent's ear while you hold the otoscope.

Demystifying the tool reduces their anxiety.

Then inspect the canal and the tympanic membrane.

Moving to the thorax, inspect the posterior chest configuration and symmetry,

palpate for lumps or tenderness, percuss the lung fields, and auscultate breath sounds, noting any adventitious or abnormal sounds.

For the anterior thorax and heart, assess respiratory movement and inspect the percordium, the area of the chest, directly over the heart for pulsations.

Telpid the apical impulse.

Yes, auscultate breath and heart sounds and listen for S1 and S2 across the percordium, noting any murmurs.

Next is the abdomen.

Inspect the shape and skin condition, auscultate bowel sounds, then palpate skin turgor, muscle tone, the liver edge, spleen, and kidneys.

You'll palpate the femoral pulses in the groin and specifically compare their strength with the radial pulses in the wrist to check for any cardiovascular anomalies.

Don't forget the inguinal lymph nodes.

Right.

Finally, we check the lower extremities.

Note the alignment of the legs, feet, and toes, checking the longitudinal arches in their feet.

Check the range of motion of the hips, knees, and ankles.

Palpate the dorsalis pedus pulse on the top of the foot.

You can bring back that reflex hammer game here to elicit the plantar, Achilles, and patellar reflexes.

Lastly, you inspect the external genitalia, and for males, palpate the scrotum for testes, trans -illuminating if any masses are present.

So we've successfully navigated the playful chaos of the toddler and school -age years.

But as that child grows into an adolescent,

the game changes completely.

The major developmental task for this age group is developing a self -identity.

They are increasingly self -conscious and deeply introspective.

Suddenly, it is less about blowing on pinwheels and more about privacy.

How does this shift alter our clinical approach?

If we connect this to the bigger picture of clinical reasoning, their intense need for self -identity and self -consciousness means your approach must prioritize respect and modesty.

For a well -personed exam, you want to keep the adolescent in their street clothes and work around their clothing as much as possible.

And if they have to undress?

If they must undress, be highly cognizant of their privacy, and explicitly explain the exact medical reason why undressing is necessary.

At this stage, the sequence of the exam finally mirrors the adult head -to -toe format.

You actually break the physical exam into two main positions.

First, with the adolescent sitting upright at the edge of the exam table, you proceed with the head, eyes, ears, neck, and thoracic exam.

Then you have them lay supine to conduct the cardiac, abdomen, and lower extremity examinations.

There is a very specific gripping technique used here to protect their modesty when examining the inguinal area.

How does that work?

You place a drape over the lower abdomen and ask the adolescent to unzip and lower their jeans themselves, underneath the drape.

Pant legs can just be pulled up to examine the lower legs and feet.

It gives them control over their own exposure.

It makes a lot of sense.

With adolescents, the psychosocial aspect of the exam becomes just as critical as the physical data.

You aren't just checking reflexes, you're assessing their life.

Throughout the exam, you should be engaging them in conversation about their friends, family, and relationships.

You're assessing their habits, diet, exercise, screen time, potential substance use, and actively providing information on health and wellness.

You are acting as a resource, treating them as an equal partner in their own health journey.

And regarding communication, there is a crucial clinical safety guideline here.

You must ensure confidentiality is appropriate to build trust.

Teenagers need to know they can talk to you safely.

However, you must never make promises you cannot keep.

Meaning safety issues.

Yes.

If they disclose something concerning their safety or the safety of others, you have a duty to report it.

You have to establish those boundaries clearly but compassionately.

Let's do a quick recap.

We have gone on quite a journey today.

We started with the neonate and infant, where the assessment is highly flexible, observation heavy, and sequenced around their sleep and wake cycles, saving the startle reflex for the very end.

Then we moved to the young child, where the exam blends seamlessly with play, using pinwheels and reflex hammer games to gain the cooperation of preschoolers fearing injury and school children exploring their industry.

Finally, we covered the adolescent, where the sequence mirrors the adult head -to -toe But the approach is heavily focused on privacy, self -identity, and acting as an educational wellness resource.

The reason you, as a future nurse, need to care deeply about these distinctions is that mastering these specific stages guarantees two things.

First, it ensures you collect accurate, objective clinical data without causing unnecessary distress.

Second, it ensures you're providing safe, developmentally appropriate patient care.

It's not just checking boxes.

Right.

Doing this correctly doesn't just check a box on a chart.

It builds a foundation of lifelong trust between that pediatric patient and the healthcare system.

Which is what it's all about.

This raises an important question for you to mull over as you study.

How does the physical progression of the exam, from doing everything to a completely passive newborn to negotiating and playing with a toddler to treating an adolescent as an equal partner in their health, perfectly mirror the cognitive and emotional journey of a human being gaining independence?

That is a perfect thought to end on.

Thank you so much for joining us for this deep dive.

On behalf of the Last Minute Lecture Team, happy studying and you are going to do great on that exam.