Community Health Clinical Nursing Manual
GUIDELINE Physical Assessment 0-4 years
Scope (Staff): Community health staff Scope (Area): CAHS-CH, WACHS
Child Safe Organisation Statement of Commitment CAHS commits to being a child safe organisation by applying the National Principles for Child Safe Organisations. This is a commitment to a strong culture supported by robust policies and procedures to reduce the likelihood of harm to children and young people.
This document should be read in conjunction with this disclaimer
Aim To conduct comprehensive and systematic physical assessments that focus on identifying key risk and protective factors and implementing early interventions according to client need, to maximise optimal health and developmental outcomes. Risk Where there are delays in identifying health and developmental concerns, this negatively impacts on children developing to the best of their ability.1 Background There is compelling evidence that early childhood is a sensitive period for child development and functioning.2 Community health nurses conduct comprehensive cephalocaudal physical assessments as a component of a holistic assessment, using evidence informed knowledge and skills, and clinical judgement through: • Eliciting and responding to parental concerns • Gathering information about the child’s current abilities and functions • Identifying risk and protective factors • Using evidence informed assessment methods and tools that are age appropriate.3 4
Physical Assessment 0-4 Years
The Pediatric Physical Examination: An Illustrated Handbook and Mary Sheridan’s from birth to five years: Children’s developmental progress, have guided the content for specific body systems assessments for the following age parameters: • Appendix A: Neonate – Birth to four weeks • Appendix B: Infant – One month to twelve months • Appendix C: Children – Twelve months to four years Key points • Comprehensive physical assessments will be conducted at Universal contacts according to Universal Contact Guidelines and at other times, as required. • Commence parts of the physical assessment that require the child to be in a quiet and alert state, prior to undertaking a comprehensive assessment. • The child is the focus of care and their best interests are the primary consideration in all decisions. • Nurses think critically and use the best available evidence and relevant policy documents, in making decisions and providing care that is safe, appropriate and responsive. • Nurses will provide additional contacts for monitoring of deviations from normal and/or will refer to a General Practitioner or other appropriate medical service, for further management. • The Guidelines for Protecting Children 2020 publication will guide practice when nurses have concerns that a child is being, or has been, abused.5 Documentation • Nurses maintain accurate, comprehensive and contemporaneous documentation of assessments, planning, decision making and evaluations; in electronic and/or MR600 child health records.
References
1. Sharma A, Cockerill, H.,. From Birth to Five Years: Children's Developmental Progress. 4th ed. Abingdon, Oxon: Routledge; 2014. 2. Department of Health. National Action Plan for the Health of Children and Young People: 2020-2030. Perth: Government of Western Australian 2019. 3. Duderstadt K. Pediatric Physical Examination: An Illustrated Handbook. 3rd Edition ed: Elsevier Health Sciences; 2019. 4. Sharma A, Cockerill H. From Birth to Five Years: Practical Developmental Examination: Taylor & Francis; 2014. 5. Department of Health: Child and Adolescent Health Services. Guidelines for Protecting Children: 2020. Perth: Government of Western Australia; 2020.
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6. Dietitians of Canada, Canadian Paediatric Society, The College of Family Physicians of Canada, Community Health Nurses of Canada. Promoting optimal monitoring of child growth in Canada: Using the new World Health Organization growth charts – Executive Summary. Paediatrics & Child Health. 2010;15(2):77-9.
Related policies, procedures and guidelines
The following documents can be accessed in the Clinical Nursing Manual via the HealthPoint link, Internet link or for WACHS staff in the WACHS Policy link
Universal contact guidelines (0-14 days, 8 weeks, 4 months, 12 months, 2 years, SEHA)
Related CAHS-CH forms
The following forms can be accessed from the CAHS-Community Health Forms page on HealthPoint
Breastfeeding Assessment Guide form (CHS012)
Related CAHS-CH resources
The following resources can be accessed from the CAHS-Community Health Resources page on HealthPoint
Early Parenting Groups: Facilitator Guide
How children develop
Indicators of Need
Practice guide for Community Health Nurses
Related external resources
Advance Pediatric Assessment. 2019. Ellen M Chiocca.
Guidelines for Protecting Children 2020. Statewide Protection of Children Coordination Unit, Child and Adolescent Community Health.
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Nursing and Midwifery Board of Australia. Code of conduct for nurses and Code of conduct for midwives. 2018
Nursing and Midwifery Board of Australia. Registered Nurses Standards for Practice. 2016.
This document can be made available in alternative formats on request.
Document Owner: Nurse Co-Director, Community Health Reviewer / Team: Clinical Nursing Policy Team Date First Issued: 2007 Last Reviewed: May 2021 Amendment Dates: Next Review May 2024 Date: Approved by: Community Health Clinical Nursing Policy Date: 23 April 2021 Governance Group Endorsed by: Executive Director of Nursing and Date: 10 May 2021 Executive Lead Community Health Standards Applicable: NSQHS Standards: Child Safe Standards: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 Printed or personally saved electronic copies of this document are considered uncontrolled
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Appendix A: Neonate - Birth to four weeks
Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies
General Appearance
• Facial expressions • Initial presentation of • Deviations from the • Genetic conditions Concerns will be the neonate is norm may be initially documented and • Posture • Pregnancy complications consistent with the identified through noted for additional • Hydration and situation (e.g. crying assessing the general • Birth trauma monitoring and/or nutritional health due to hunger) appearance of the referral to a medical • Congenital or non- neonate practitioner • Activity level • Neonate is healthy congenital conditions and developing • Recognise indicators • Temperament • Child abuse appropriately for child abuse, Refer to the • Responsiveness including but not Guidelines for limited to: injury, • Interaction with protecting children bruising, burns, retinal others 2020 publication for haemorrhages, bite • Proportion of body marks, fractured more information. parts bones, bleeding, pain or physical discomfort • Symmetry of body or poor standard of parts hygiene. • Movement and • Assess appearance of capacity child with • Skin integrity consideration of their age, level of mobility Observe appearance 1 prior to comprehensive and development. assessment
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Head (continued next page)
Visual inspection with • Rounded • Elongated • Birth trauma Parent education and the neonate resting support may include: • Symmetrical • Asymmetrical o Instrumental delivery supine, and head in • Postural exercises midline, noting: Head circumference • Misshapen • Genetic conditions and repositioning averages: o • General shape • Measurements outside Achondroplasia • Handling • males: 32-39.5cm of expected norm o Noonan syndrome • Size strategies • females: 31.5–39.cm6 o Microcephaly • Hydrocephalus • Circumference o Macrocephaly • Massage When in supine position, • Craniosynostosis • Symmetry • Positioning of toys head will comfortably sit • Lesions, nodules, • Uterine placement to non-favoured • Alignment in the midline masses, birth marks • Intrauterine growth side • Positional head conditions and exposure • Variable preference to tetragons positioning of head • Persistent head tilt • Plagiocephaly when put down to (lateral flexion) sleep
Visual inspection and • Anterior fontanelle • Bulging anterior • Birth trauma Monitor premature palpation of: should be open, soft, fontanelle o Caput succedaneum closure of sutures flat, an average of • Suture lines • Sunken anterior o Cephalohaematoma 2cm long by 2-3cm fontanelle • Scalp wide, but can be up to • Changes in intracranial 3 Overriding sutures pressure • Bony structures 5cm long • Bruising • Dehydration • Fontanelles • Posterior fontanelle • should be smaller, • Oedema • Genetic conditions triangular and 0.5 cm long by 1 cm wide 3 • Pitting o Alpert’s
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies o Crouzon • Suture lines can be • Premature closure of overlapping or sutures • Craniosynostosis protuberant
Neck (continued next page)
Visual inspection • A short neck, which is Movement deviations: • Intrauterine growth Parent education and through the following creased with skin conditions support may include: • Limited range of process: folds motion • Plagiocephaly • Postural exercises • Controlled pulling up • The neck rotates and repositioning • Head bobbing • Torticollis from the supine to freely as it cannot • Handling sitting position • Jerking • Genetic conditions support the weight of strategies the head • Observing supported • Tremors o Turner syndrome • Massage in sitting position o Noonan syndrome • The head briefly stays • Stiffness erect, then lags when • Positioning of toys • Placing in the ventral • Resistance to to non-favoured suspension pulled up from a supine to a sitting movement side • Extending the head position • Involuntary muscle • Variable in all directions • In the prone position, contractions or spasms positioning of head • Placing in prone when put down to the head can be • Webbed neck position raised slightly sleep Positional deviations: Noting: • The head will fall • Head held erect • Symmetry forward in the sitting position • Persistent head tilt • Shape • The head will drop • Range of movement below or in line with
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Head control the plane of the body • Positional head when in ventral preference suspension
Face
Through visual • Face is relaxed and • Low-set ears • Genetic conditions Encourage medical inspection observe symmetrical practitioner or • Low-set hairline o Trisomy 21/Down facial features and Breastfeeding • Features are Syndrome expressions, noting: • Epicanthal folds Support Services symmetrical during inconsistent with ethnic • Birth or other trauma review for any • Spacing episodes of crying origins • Neurological deficit concerns, in particular • Size • Nasolabial folds are feeding difficulties • Frontal bossing symmetrical • Milia • Symmetry of • Absent philtrum features • Preauricular sinus or tag • Deviated septum • Movement symmetry • Birthmarks • Cleft lip • Intrauterine conditions, • Unilateral flattening of including exposure to nasolabial fold teratogens • Micrognathia o Syphilis o Foetal alcohol • Lesions, nodules, spectrum disorder masses (FASD)
• Congenital hypothyroidism
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Philtrum
Visual inspection, • Philtrum is visible and • Short • Intrauterine conditions, noting: can be pronounced including exposure to • Smooth teratogens • Definition • Can form a teardrop • Limited definition to no like shape o FASD • Depression depression o Foetal valproate • Can be in straight • Length syndrome lines from septum to tubercule • Genetic conditions o Pallister Killain o Cornelia de Lange o Wolf-Hirschhorn
Eyes (continued next page)
Visual inspection, • Eyes may move • Discharge • Acquired head injury Parent education and noting: independently, support for eye • Reddened or yellow • Trauma appearing to watering may include: • Shape sclera intermittently squint • Birth trauma • Massage • Size • Eye watering, with or • The upper eyelids • Infection techniques without infection • Symmetry appear symmetrical • Immature tear ducts • Regular review at • Bruising • Spacing • When closed, eyelids universal contacts • Allergy completely cover • Inflammation • Position • Discussion of cornea and sclera • Genetic conditions • Oedema signs of infection • Colour o Stickler syndrome • Subconjunctival o Cri-du-chat Urgent referral to haemorrhages ophthalmologist
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies syndrome through medical • Epicanthal folds practitioner for (eyes), inconsistent o Prader-Willi opacities in the pupil with ethnic origin syndrome or corneal • Ptosis • Jaundice abnormalities • Myotonic Gaze
Assess gaze behavior • Neonate attempts to • No mutual gaze • Trauma Parental education through facial engage with human attempts made and support to • Intraventricular insult expressions, faces, particularly promote bonding and movements and caregivers, through • Interrupted bonding and attachment attempts to attract mutual gaze attachment attention from others • Intrauterine exposure to teratogens
Vision Behaviours (continued next page)
Assess vision • Pupils should be • Leukokoria • Cataract Prompt referral to behaviours via round, clear, and medical practitioner, • Coloboma • Scleral icterus examining pupil and iris equal particularly for any: by shining a light into • Fixed pupils • Esotropia • Pupils react equally to • Constant visual the eyes, noting: light, movement, and • Cloudiness and • Exotropia impairment • Size patterns opacity of cornea • Hypertropia • Opacity • Equality of size • Eyes turn towards • Slow lateral • Hypotropia • Constant squint diffused light sources movements
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Colour • Eyes are turned away • Nystagmus • Clarity from bright light or • Sundowning neonate blinks in • Shape response to a flash of • Squint (intermittent or constant) • Movement light • Differing pupil size • Pupillary reaction • Increased alertness • Refusal to open eyes • Blinking after exposure to the • Following the light to light midline
Ears (continued next page)
Assess external ear • The superior portion • Discharge - pus/debris • Infection Sebaceous cyst Parent education and including mastoid of the auricle is equal support may include • Swelling • Genetic conditions process, auricles, tragus in height to the outer ear care in relation to and external auditory canthus of the eye • Inflammation o Trisomy 21/Down discharge and foreign meatus, noting: Syndrome objects Pinna is: • Foreign object o Goldenhar • Shape • Soft • Excessive wax o Wolf-Hirchhorn • Size • Pliable Dysmorphic deviations: o Di George • Symmetry o Trecher-Collins • Recoils readily when • Low-set-ears o Nagar • Patency folded and released • Skin tags o Usher • Position • Accessory tragi • Firmness of cartilage • Malformed auricles • Auricular sinus
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Preauricular sinus
Assess neonatal • Interested in sounds • Absence of startle • Congenital infections: Parent education and hearing through reflex support for age • Responds to calm o Cytomegalovirus observation of response appropriate auditory and familiar voices • Delay in response to o rubella to sounds stimulation voice stimulation o toxoplasmosis • Eyes will ‘corner’ N.B. Determine if o herpes reflexively to the side • Signs of distress from Newborn Hearing of the noise exposure to loud o syphilis Refer to hospital Screen has been noises o varicella of birth or aligned completed. • May startle at a loud medical professional noise beyond visual • Prematurity/low birth for Newborn Hearing field weight Screen follow up • Intrauterine exposure to teratogens or ototoxic drugs • Intrauterine conditions affecting audio processes • Trauma • Genetic conditions
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Nose
Visual and auditory • Small and narrow • Nasal secretions • Birth processes Parent education and inspection, noting: support may include: • Cartilage is soft and • Swelling • Facial trauma Patency: malleable • Feeding strategies • Frequent detachment, • Choanal atresia • Nasal cavity size • Septum is relatively or slow or difficult Discussion around • Polyps and shape straight and in the feeding use of saline drops to clear nasal passages • Obvious deviations midline of the nose • Deviated septum • Persistent snuffling where appropriate at bridge, columella • Obligatory nose • Intrauterine exposure to • Cyanosis when and tip breathers teratogens feeding Symmetry: • Nasal patency is o FASD Encourage medical • Upturned nose practitioner or • Alignment demonstrated if • Genetic conditions Breastfeeding neonate breathes • Flattening of bridge o Di George syndrome • Skin integrity easily with mouth Support Services o Achondroplasia closed review for any o Stickler syndrome concerns, in particular • Removes feeding difficulties obstructions by sneezing
Mouth (continued next page)
Visual inspection, and • Healthy gums are Cleft deviations: • Nerve damage Parent education and palpation where firm, moist, and pink support may include: • Cleft palate • Infection, including indicated, noting: The tongue surface Candidiasis • • Narrow cleft • Management of • General appearance appears rough but Epstein pearls precocious teeth • Cleft lip •
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies moist and pink to pale • Gums • Micrognathia • Nasal allergy • Feeding patterns pink and strategies • Integrity of hard and • Sub mucosal cleft • Dehydration where deviations • The lingual frenulum soft palates exist allows the tongue to Lip deviations: • Fever • Mucosa protrude over gums to • Thin lip • FASD Referral to • Pharynx meet lips and to the Breastfeeding roof of the palate • Loss of control of oral • Genetic conditions Support Services • Fremulum secretions regarding unresolved • Upper lip can be lifted o Wolf-Hirschorn feeding concerns • Maxillary labial and to touch the nose Gum deviations: o Beckwith- lingual • Oedema Wiedermann When blisters or • Tongue fills mouth to o Di George Lips: support effective calluses are present, • Lesions o Pierre Robin • Colour feeding conduct a • Erythema breastfeeding • Lips are pink at rest, • Symmetry • Friable assessment for possible • Integrity • Palate should appear • Hematomas dome shaped with breastfeeding • Moisture transverse firm ridges Tongue and teeth concerns Tongue: deviations: • Palate is not deeply • Colour indented and is whiter • Coated • Size than the buccal • Plaque mucosa and soft • Movement palate • Geographic tongue Assess feeding comfort • Macroglossia for mother and infant • Precocious teeth • Short or inflexible maxillary labial or
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies lingual frenulum impacting on function
Vocal Behaviour
Auditory observation, Cry is normally: • High pitch • Dehydration Discuss provision of and parent report, comfort measures • Strong • Continuous • Pain noting the following: with parents • Lusty • Hoarseness • Raised intracranial • Alertness Seek urgent pressure • Medium pitch • Excessive crying referral to medical • Cry • Gastro oesophageal practitioner for signs • Intermittent, in • Audible stridor of respiratory distress response to reflux or abnormal breathing discomfort or need • Intrauterine exposure to sounds teratogens including alcohol or drugs • Laryngeal trauma • Neurological condition • Laryngomalacia
Chest and Respiratory Function (continued next page)
Visual and auditory • The chest is Respiratory deviations: • Infection Parent education and assessment, with symmetrical and support may include: • Stridor • Laryngomalacia neonate supine, noting: compliant, and slightly barrel-shaped • Grunting • Trauma • Shape
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Size • Sternum often drawn • Crackles • Birth process • Range of expected • Symmetry slightly inward on • Rales • Pneumothorax normal mucosa inspiration secretions • Contour • Wheezing • Cystic fibrosis • Chest rises and falls • Normal breath • Movement symmetrically • Rhonchi • Intrauterine exposure to sounds teratogens including • Respiration • Cough • Chest circumference alcohol, drugs, tobacco • Expectations and functioning from nipple line is • Snoring management of • Hormonal influences • Breath sounds approximately 2-3cm engorged breast • Apnoea less than head • Genetic conditions tissue circumference • Nasal flaring • Acute bronchiolitis Circumference is very • • Head bobbing Seek urgent close in size to head • Acute epiglottitis referral to medical circumference at birth • Paradoxical breathing • Foreign body aspiration practitioner for signs • Tachypnoea • The xiphoid may be • Gastroesophageal reflux of respiratory distress prominent • Intercostal retractions or abnormal breath sounds • The regular breath • Use of accessory rate is 30-60 breaths muscles per minute • Chest deviations:
• Engorged breast tissue • Nipple secretions • Supernumerary nipples • Pectus carinatum or excavatum
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Musculoskeletal – General
Placing neonate in • Muscles are in a • Poor, increased or • Trauma Urgent referral to a supine, prone and flexed position, asymmetrical tone medical practitioner • Genetic conditions supported sitting normotonic and where muscle tone • Asymmetry position, observe for symmetrical • Hypotonia deviation is overall: • Flaccidity accompanied by • In the supine position, • Hypertonia other signs of illness • Symmetry arms and legs are in • Abnormal posture or • Infection • Flexibility a semi flexed position positioning of with the hips slightly extremities • Intrauterine exposure to • Resting position abducted teratogens • Reluctance to use or • Muscle tone move extremities • Motor activity • Evidence of pain on • Skin folds movement Observe range of movement, noting: • Flexion/extension • Adduction/abduction • Internal/external rotation Palpation and passive movement may be used where required to reinforce visual findings
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Reflexes
Assess alert neonate for • Primitive reflexes are • Absence • Genetic / congenital presence of primitive symmetrical and Conditions • Asymmetrical reflexes, including: indicative of central o Fragile X syndrome • Asymmetrical tonic nervous system • Poor or delayed o Stickler syndrome function expression neck o Cerebral palsy • Moro reflex o Trisomy21/Down Syndrome • Gallant’s reflex • Trauma • Placing reflex o Hemorrhage • Stepping reflex o Infection • Palmar grasp o Hypoxia o brachial injury • Plantar grasp / Babinski reflex • Prematurity – infant may have hypotonia lasting • Rooting reflex up to 12 months • Sucking reflex • Intrauterine exposure to teratogens including alcohol or drugs Back and Spine (continued next page)
Assess general • The infant has a C- • Sacral dimple and/or • Spina bifida Ensure medical appearance of the back, shaped spinal curve tufts of hair practitioner review • Intrauterine growth noting: and assessment of • The secondary • Curvature conditions pilonidal dimple • Symmetry cervical curve is
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Flexibility present around 3-4 • Asymmetry • Nutritional status months • Skin integrity • Masses o Vitamin D, calcium • spine is straight, and and protein in midline • Swelling • Abnormalities in spinous • Lesions processes • Genetic Conditions Upper Limbs (continued next page)
Palpate the clavicles, • In the prone position, • Oedema • Trauma and observe range of the arms are close to • Flaccidity o Fractures arm movement the chest and the o Brachial palsy including: elbows are fully • Asymmetrical posture, o Dislocations • Shoulders flexed positioning, tone or movement • Cerebral palsy • Elbows • In the supine position, the arms are kept • Polydactyly • Intrauterine exposure to • Wrists semi-flexed, whilst teratogens • Syndactyly the posture is • Hands • Amniotic Banding symmetrical • Digital clubbing Assess through Syndrome • Hands are relaxed • Webbing observation of: • Genetic conditions and commonly held in • Flexion/extension • Persistent thumbs in a loose fist with/out o Edwards syndrome fist • Adduction/abduction thumb flex over finger o Neonatal Marfan syndrome • Internal/external • Hands open o Rubinstein-Taybi rotation intermittently syndrome • Strength o Achondroplasia
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Flexibility • Full range of movement when extending the arms • Movements are equal in flexibility and strength
Hips
• Skin folds are • Hip instability (normal • Developmental Refer any hip Follow Hip Assessment symmetrical in first few weeks) Dysplasia of the Hip concerns to medical practitioner, or directly procedure to assess • Hips are stable and • Asymmetrical skin • Intrauterine growth to PCH Orthopaedic hips for stability, limb relaxed with thighs creases conditions Clinic if the infant is length and symmetry. easily adducted and • Limb length o Breech presentation less than 4 months of abducted discrepancy o Birthweight over 4kg age o Oligohydramnios • Fine clicking sounds (normal) • Genetic conditions • Clunking sounds • Trauma
Lower Limbs (continued next page)
With neonate in supine • Legs are equal in • Asymmetrical skin • Developmental position, assess range length, with knee and folds Dysplasia of the Hip of leg movement, • Fractures
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies including the knee and hip joints extended • Asymmetrical • Trauma ankle through and aligned movement or tone observation of: • Genetic conditions • Knees will naturally • Unequal length of legs o Edwards syndrome • Flexion/extension lie apart with soles of o Rubinstein-Taybi • Adduction/abduction the feet turned slightly inward syndrome • Internal/external o Achondroplasia rotation • Full range of movement in all • Intrauterine growth Assess symmetry of: directions conditions • Leg Length • Legs are equal in • Talipes • Muscle strength and tone, movement, tone strength and flexibility • Flexibility • Skin folds
Foot and heel: • Supple foot • Polydactyly • Intrauterine growth Parent education and conditions support may include: • Observe the position • Normal angle to tibia • Absent plantar crease and alignment of • Trauma • Use of passive • The plantar crease is • Webbing forefoot and heel stretching visible • Talipes • Assess the range of • Rigidity of heel or exercises for motion in the ankle limited range of • Developmental minor positional and plantar arch movement Dysplasia of the Hip deviations where feet can easily be • Adduction of the • Lower leg deviation returned to midline forefoot • Genetic conditions • Monitoring and review for resolution
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Referral to medical practitioner or allied health professional (Child Development Services) where an inflexible deviation exists
Abdomen
Visual inspection, and • Protuberant and • Tension • Malrotation of the bowel Urgent referral to palpation where round medical practitioner • Distension • Obstruction indicated, noting: for: • Symmetrical • Sunken or scaphoid • Diaphragmatic hernia • Size • Sustained • Moves with abdominal shape • Paralytic ileus vomiting • Shape respiration • Asymmetry • Intussusception • Projectile vomiting • Contours • Soft • Visible peristalsis • Pyloric stenosis (usually • Reduced bowel • Movement • Bowel sounds occur • Hyperactive or absent between 2-6 weeks of sounds every 10 to 20 • Symmetry bowel sounds age seconds • Bowel Sounds • Vomiting • Hirschsprung’s disease Umbilicus (continued next page)
Visual inspection, The umbilical cord is: • Delay in separation • Infection Cyst Parental education noting: and support may • Odourless • Cord moisture, • Umbilical polyp include: • Separation of cord discharge or • Dry • Granuloma • Healing process inflammation
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Separates in 7-10 • Discharge from • Neonatal Omphalitis • Hygiene and days umbilicus, including • Diastasis rectus infection control in faeces • Umbilicus heals relation to cord • Urachal remnant within 2 to 3 weeks • Swelling, persistent or separation and from birth and should intermittent occurring • Omphalomesenteric duct healing be dry, intact and where abdominal remnant • Expectations for non- inflamed pressure is increased • Umbilical hernia umbilical (crying and defecation) herniation • Environmental factors • Lesions, Rashes, • Referral to medical Masses practitioner for: • Umbilical granuloma • Any purulent umbilical discharge Urgent referral to medical practitioner if omphalomesenteric duct remnant
Buttocks and Rectal Area (continued next page)
Visual inspection and • Anus is located Buttock deviations: • Genetic conditions Parent education and discussion with parent, behind the vagina in support may include: • Lesions or rashes • Mongolian spot or other noting: birthmarks
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies females and the • Anal patency • Sacral sinus, dimples • Spina bifida • Expected scrotum in males • Stool consistency, or tufts of hair • Allergy or atopy elimination • Sphincter muscles patterns colour and frequency • Discolouration normally maintain • Infection, of skin or • Strategies for • Skin integrity constriction of the Anus deviations: gastrointestinal tract management of anal orifice • Skin features • Inflammation • Normal adjustment to minor skin oral intake • Patency is • Bleeding irritations or demonstrated by the • Constipation alterations in passing of faeces • Small opening bowel actions • Trauma Neonate’s faeces are: • Evidence of pain or • Referral to medical discomfort • Rectal tears practitioner for: • Human milk fed – transitioning from Stool deviations: • Fissures • Sacral sinus meconium to yellow • Explosive • Anal stenosis • Bleeding (brown and dark green may be normal • Absence • Recto-urethral fistula • Recto-urethral in the absence of • Reduction in bowel fistula deviations) with movements Consider referral to texture from loose, specialist services granular to curdled • Frequent and/or very loose bowel actions where child protection • Infant formula fed - issues are suspected pale yellow to yellow, • Faecal matter in urine Refer to Guidelines brown, green or grey for Protecting with paste to semi- Children 2020 for formed texture further information, including information on mandatory reporting
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Urinary System
Assess urinary output • Normal neonatal • Decrease in volume • Dehydration Parental education through parental report, urine output is 2 and frequency and support may • Altered feeding patterns or visual inspection ml/kg/hour include: • Darker colour where possible, noting: • Infection • Neonates are less • Expected fluid • Weight loss • Volume able to concentrate • Jaundice input and output urine • Fever for age • Frequency • Congenital abnormalities • Colour of kidneys and urinary • Fluid requirements tract Genitourinary – Male (continued next page)
Visual inspection and Urinary orifice is: • Ambiguous genitals • Genetic conditions Parental support and palpation of external education may • Clear • Curvature of penis • Intrauterine exposure to genitalia, noting: include: teratogens • Uncovered by the • Microphallus • Urinary meatus – • Strategies for foreskin • Intrauterine growth position and patency • Non-central position of routine hygiene • On the tip of the glans conditions • Foreskin urethral meatus, and care penis including hypospadias • Hydrocele • Referral to medical • Scrotum and epispadias Foreskin: practitioner for: • Testicular descent • Does not retract • Phimosis o Hypospadias easily until 2- 3 years • Relative position of • Paraphimosis o epispadias scrotum to anus old, complete separation of the • Chordee N.B. Do not attempt foreskin and glans to forcibly retract the • Balanitis
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies foreskin penis is usually • Balanoposthitis complete by 6 years • Retractable testis Scrotum: • Testis absent or • Spontaneous palpable outside testicular descent scrotal sac usually occurs prior to birth and may retract • Masses during the first 6 • Swelling months of life Genitourinary – Female (continued next page)
Visual inspection of • Labia majora is • Discharge • Genetic conditions Parent support and external genitalia, enlarged and usually education may • Swelling • Maternal hormone noting: covers labia minora include: influence • Masses • Labia • Clitoris is often • Expected range of • Pseudo menstruation • Presence and size of disproportionately • Lesions normal enlarged • Infection: clitoris • Rashes • Strategies for • Labia minora is o commonly bacterial routine hygiene • Vaginal orifice • Ambiguous genitals thickened, enlarged or fungal and care • Location and and dull pink • Imperforate hymen • Intrauterine exposure to patency of urethral • Strategies for teratogens orifice • The clitoris and labia • Hydrocolpos management of minora may be more • Skin tags minor skin • Relative position of prominent in preterm irritations posterior fourchette infants • Polyps and anus • Hymen is a thickened • Hernia rim of tissue surrounding the
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Birth to 4 weeks - Area Within the Norm Common Deviations Possible Causes Specific Strategies vaginal orifice, which is pink-white with a range of shapes • Creamy white, mucoid/ blood - tinged vaginal discharge is normal in first 10 days
Inguinal Area
Visual inspection, and • Equal, strong femoral • Poor or unequal • Circulatory deviation, Prompt medical palpation of inguinal pulses can be felt femoral pulses including coarctation of review is indicated for area, noting: midpoint between the the aorta any inguinal swelling • Swelling iliac crest and that does not change • Shape • Inguinal herniation symphysis pubis • Masses – either firm size when the • Contours and reduced with neonate cries • A horizontal chain of pressure, or hard and • Symmetry inguinal nodes run immobile • Femoral pulses along the inferior groin • Enlarged nodes
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Appendix B: Infant - One month to twelve months
1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
General Appearance
• Facial expressions • Initial presentation of • Deviations from the • A range of congenital or Observation of the infant is norm may be initially non-congenital general appearance • Posture consistent with the identified through conditions should be completed • Hydration and situation (e.g. crying assessing the general prior to a more • Genetic conditions nutritional health due to hunger) appearance of the detailed assessment. infant • Environmental conditions • Activity level • Infant is healthy and Any areas of developing • Recognise indicators • Birth trauma concerns will be • Temperament appropriately for child abuse, documented and • Intrauterine conditions • Responsiveness noted for additional including but not limited to: injury, monitoring and/or • Interaction with bruising, burns, retinal referral to a medical others haemorrhages, bite practitioner • Proportion and marks, fractured Refer to the symmetry of body bones, bleeding, pain Guidelines for parts or physical discomfort or poor standard of protecting children • Movement hygiene. 2020 publication for • Skin integrity more information. • Assess appearance of Observe appearance child with prior to comprehensive consideration of their assessment age, level of mobility 1 and development.
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Head (continued next page)
Visual inspection, • Rounded • Elongated • Trauma Parental education noting: and support may • Symmetrical • Asymmetrical • Plagiocephaly • General shape include: Head circumference • Misshapen • Vision defect • Postural exercises • Size averages: • Circumference outside • Hearing defect • Handling • Circumference • males: 35–48.5 cm expected trajectory • Intrauterine growth strategies • Symmetry • females: 34.5- • Microcephaly conditions • Massage 47.5 cm6 • Alignment • Macrocephaly • Intrauterine exposure to • Positioning of toys By 2 months, head is teratogens • Range of movement • Positional head to non-favoured held in midline o Alcohol (FASD), • Abnormal hair preference side Syphilis, Herpes, pattern By 4 months head • Variable control is achieved, and Cytomegalovirus Head alignment is positioning of head when held sitting, head is evaluated when infant is • Hydrocephalus in particular for firmly erect sleep in supine and resting • Craniosynostosis position • Hypotonia Refer to • Genetic conditions physiotherapist for o Fragile X assessment of any o Noonan syndrome positional or o Trisomy 21/Down symmetry deviations Syndrome that do not resolve o Achondroplasia
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Visual inspection and • Suture lines can be • Bulging or sunken • Raised intracranial Ensure medical palpation of: overlapping or anterior fontanelle pressure practitioner review is protuberant up to 2 in place for suture • Suture lines • Overlapping sutures • Dehydration months concerns, including present after 2 months • Scalp • Genetic conditions palpable suture lines • Suture lines may be • Closure of sutures after 6 months of age • Bony structures palpable until 6 o Crouzon before 6 months • Fontanelles months of age o Apert’s • Palpable suture lines o Trisomy 21/Down • Anterior fontanelle is Urgent referral to Inspect and palpate after 6 months Syndrome anterior fontanelle, flat with slight medical practitioner noting: pulsation, and tension • Separation of sagittal • Craniosynostosis where a sunken or bulging when infant sutures fontanelle is • Size • Birthmarks cries, flattening when accompanied by other • Caput succedaneum • Tension infant is calm • Intrauterine conditions signs of dehydration, • Cephalhematoma or illness such as • Pulsation • Anterior fontanelle fever, rashes, or begins to reduce in • Subgaleal N.B. Nutritional gastrointestinal size by 9 months with Hemmorrhage assessment may symptoms full closure by 18 provide relevant • Bruising additional months • Swelling information where • Posterior fontanelle there are closes by 4 months of • Pitting dehydration age concerns • Lesions
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Neck
Visual inspection and • Neck is shortened, Movement deviation: • Intrauterine growth Parent education and palpation, noting the and musculature is conditions support may include: • Persistent head lag following: gradually developed after 3-4 months • Hypotonia • Postural exercises • Symmetry • Until 3-4 months, and positioning • Limited range of • Vision defect head lag is normal • Shape motion • Handling • Hearing defect when pulled to sitting strategies • Range of movement position • Resistance to • Plagiocephaly movement • Massage • Musculature • When in ventral • Torticollis • Extraneous tissue or suspension, the head • Head bobbing • Positioning of toys • Pain to non-favoured masses is held well above the • Jerking line of the body side • Meningismus or Head control: • Tremors meningitis • Variable • For infants under 3 • When prone, infant is able to lift head and • Stiffness positioning of months head is • Genetic conditions head, particularly moved passively chest well up in • Involuntary muscle o Turner syndrome for sleep or for whilst infant is in midline by 4 months contractions or spasms o Noonan syndrome regular holding supine position • Flexion of lower positions • For infants over 3 extremities
months observe the • Webbed neck developing ability to follow light or an Positional deviations: object • Head held erect • Persistent head tilt • Positional head preference
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Face
Through visual • Face is relaxed and • Disproportionate • Genetic conditions Parent education and inspection observe symmetrical features o Russell-Silver support may include: facial features and • Age appropriate • Bossing or prominence syndrome • Feeding support expressions, noting: where development of a of forehead • Intrauterine conditions • Symmetry range of facial micrognathia • Epicanthal folds including exposure to expressions and exists • Spacing and size inconsistent with ethnic teratogens movements which are • Movement origins o Fetal Alcohol • Features and spontaneous and management of • Micrognathia Spectrum Disorder • Emotional responsive to birthmarks situation (FASD) expression • Lesions Refer to medical • Facial expressions • Trauma • Lumps, particularly on practitioner for facial and movement are or around ears • Milia birthmarks, symmetrical particularly around • Emotional expression • Birthmarks lips, eyes, nose or inconsistent with • Neurological condition scalp expectations for age Philtrum
Visual inspection, • Philtrum is visible and • Short or long • FASD noting: can be pronounced • Smooth • Genetic or Congenital • Definition • Tear drop shaped conditions • Limited definition • Depression • Can be in straight through to no o Foetal valproate • Length lines from septum to depression syndrome tubercule o Pallister-Killian o Cornelia de Lange
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies o Wolf-Hirschhorn o Achondroplasia Eyes (continued next page)
Visual inspection, • Eyes are • Discharge, watery or • Acquired head injury Parent education may noting: symmetrical, purulent include: • Trauma horizontal and in line • Shape • Reddened sclera • Eye toilet and • Infection with top of pinna hygiene • Size • Bruising or bleeding Eye spacing narrow • Subconjunctival • • Techniques for • Symmetry • Oedema haemorrhage or wider than blocked tear ducts expected • Spacing • Epicanthal folds, • Immature blocked tear including massage • Position • The upper eyelids are inconsistent with ethnic ducts Review eye watering symmetrical origin • Colour • Allergy regularly at universal • When closed, eyelid • Strabismus contacts (may take up • Intrauterine conditions Examine pupil and iris completely covers to 12 months to • Ptosis by shining a light into cornea and sclera • Environmental conditions resolve) the eyes, noting: • Leukokoria • Retinoblastoma • Size • Pupils are round, clear, and equal • Coloboma (commonly linked with • Equality/symmetry of Leukokoria) • Fixed pupils size • Pupils react equally to light, movement, and • Cataract • Cloudiness and • Colour patterns opacity of cornea • Scleral icterus • Clarity • Eye colour is • Nystagmus • Photophobia • Shape established by around 6 months • Sundowning • Genetic conditions • Pupillary constriction • Sclera visible above • Sensitivity to light o Stickler syndrome and below the cornea o Cri-du-chat
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Refusal to open syndrome eyes after exposure o Prader-Willi to light syndrome • Congenital glaucoma • Congenital Cataract • Dacryocystitis • Sundowning Gaze
Assess gaze behaviour • Will move head to • No mutual gaze • Trauma Parent education and through observation of deliberately gaze attempts made support may include • Interrupted bonding and facial expressions, attentively around strategies to promote • Infant does not show attachment movements and bonding and • Watches movement an interest in their attempts to attract • Biochemical factors attachment of people, animals or surroundings attention from others motor vehicles • Recognises and enjoys the sight of familiar people approaching from a distance Vision Behaviours (continued next page)
Assess vision • Eyes may move in • Slow lateral • Esotropia Prompt referral behaviours, noting: unison until 3 months movements to medical • Exotropia of age practitioner for • Eye movements • Strabismus- constant constant visual
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Blinking • Coordination of extra- • Strabismus - • Hypertropia impairment or ocular muscles is intermittent (deviation evident squint over • Increased alertness • Hypotropia usually achieved by 6 from normal after 3 3 months of age and attention to weeks and should months of age) • Trauma surroundings occur by 3 months • Refractive error Urgent referral to • Infants can ophthalmologist Assess also through • Strabismus distinguish colour through medical presentation of an from 3 to 5 months of • Haemorrhage practitioner for object or light source age • Hyphema opacities in the pupil for infant to fixate and • Will follow an object or corneal follow. at 15-30 cm distance abnormalities through an arc of 30 degrees from midline at 6-8 weeks, increasing to 90 degrees by 4 months
Ears (continued next page)
Assess external ear • Pinna is soft, pliable, • Pus/debris • Congenital Infection Parental education including mastoid and recoils readily and support for ear • Sebaceous cyst o Rubella process, auricles, tragus when folded and o cytomegalovirus care in particular to: and external auditory released • Inflammation o toxoplasmosis • Discharge meatus, noting: The superior portion • Excessive wax • o syphilis • Foreign objects • Shape of the auricle should formation • Foreign objects • Size be equal in height to • Excessive wax
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Symmetry the outer canthus of • Evidence of fluid in • Trauma related to child Refer to medical the eye middle ear abuse practitioner for any • Patency suspected infection • Auricles are vertical • Tympanic membrane • Genetic conditions • Position with no more than a deviations o Trisomy 21/Down • Colour 10-degree tilt • Bruising around ear Syndrome Child Abuse - • Firmness of ear • Auricles are similar to o Goldenhar syndrome consider indicators Dysmorphic deviations: cartilage facial skin colour o Wolf-Hischhorn outside of what may be expected given the • Outer ear canal is • Low-set ears syndrome • Obstruction/foreign child’s age and covered with fine hair o Di George syndrome bodies • Skin tags development Refer o Treacher Collins • Cerumen is a normal • Accessory tragi to the Guidelines for protective secretion, syndrome protecting children ranging from grey, dry • Malformed auricles o Nagar Syndrome 2020 publication for and flaky to honey- • Auricular sinus • Intrauterine exposure to more information coloured to dark • Preauricular sinus teratogens or ototoxic brown and wet drugs • Tympanic membrane • Myringitis is pearl-grey, sometimes pink or red tinged, translucent, intact, and in neutral position
Assess infant hearing • Attentive to everyday • Startle reflex persistent • Intrauterine conditions Parent education and as a component of ear sounds, in particular after 3 months of age affecting audiometric support may include health assessment, will turn eyes and/or processes strategies to promote through discussion with
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies parent, and observation head towards voices • Delay in response to • Trauma appropriate auditory of the following: by 3 months voice stimulation stimulation • Congenital Syndromes • Vocalisation • Develops recognition • Language delay • Alport, Trisomy 21/Down • Response to and response to own • Decrease in age- Syndrome, Jervell, auditory stimuli name around 6-10 months appropriate response Treacher Collins, Lange- to range of sounds Nielson, Usher • Vocalisations are appropriate for age • Congenital Infection o Rubella • Age-appropriate response to sounds o cytomegalovirus o toxoplasmosis o syphilis o herpes • Environmental conditions • Prematurity/low birth weight
Nose (continued next page)
Visual and auditory • Nose is flattened and • Mucous and other • Facial trauma Parent education and inspection, of nasal malleable nasal secretions support may include: • Intrauterine exposure to bridge, nares, columella • Prone to increased • Epistaxis teratogens • Strategies to clear and septum, noting: airway resistance nasal passages • Narrowing of the nares o FASD • Symmetry because of small where patency is • Shape passages • Infection interfering with feeding
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Size • Infant removes • Infant frequently • Polyps • Management of obstructions by detaching during feeding difficulties • Integrity • Inflammation sneezing feeding associated with • Patency of nares • Environmental factors nasal deviations • Septum is relatively • Nasal flaring • Alignment straight and in the • Genetic conditions • Oedema midline of the nose • Skin integrity o Di George syndrome • Lesions o Achondroplasia • Infant nose breathes during feeding • Upturned nose o Stickler syndrome o Choanal atresia • Discolouration • Deviated septum
Mouth (continued next page)
Visually inspect: • Gums are firm, moist Cleft deviations: • Neurological deficit Parent education and and pink support may include • Gums • Cleft palate • Infection management of • The tongue surface • Hard and soft • Narrow cleft • Genetic conditions deviations such as: palates appears slightly rough, but moist, and • Sub mucosal cleft o Wolf-Hirschhorn • Precocious teeth • Mucosa syndrome pink to pale pink Lip deviations: o Beckwith- • Teething • Lips processes • The lingual frenulum • Cleft lip Wiedermann allows the tongue to • Tongue syndrome • Drooling protrude over gums to • Thin upper lip o Di George syndrome • Teeth meet lips and to • Minor lesions • Swelling o Pierre Robin Note the following: reach the roof of the • Dryness syndrome Refer to • Tooth eruption palate Breastfeeding
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies Support Services or • Odour • Tongue fills mouth to • Lesions • Intrauterine conditions other relevant health support effective Lips and mucosa: • Loss in control of oral • Environmental factors professional for feeding • Colour secretions and unresolved feeding • Dehydration • Hard Palate appears drooling concerns • Symmetry dome shaped, but not • Fever • Excessive upper lip • Integrity deeply indented, with frenulum • Hematoma transverse firm ridges • Moisture Gum deviations: • Trauma Tongue: • Hard Palate is lighter in colour than the soft • Swelling • Tooth eruption • Colour palate and buccal • Lesions • Allergy • Size mucosa • Reddening • Movement • Deciduous teeth erupt from 6 – 24 months • Friable • Symmetry • Anterior permanent • Hematomas Assessment of feeding teeth begin to calcify Tongue and teeth patterns and feeding at 3 to 12 months deviations: comfort may be relevant where oral deviations • Drooling increases as • Coated exist. objects are taken into mouth • Plaque • Infant develops • Unusual odour capacity to hold, bite • Geographic tongue and chew a small piece of food by 9 • Macroglossia months • Ankyloglossia
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Deciduous teeth are • Ulceration or other smooth and glossy alteration in skin with a whitish hue integrity • The biting surface of • Excessive lingual the molar teeth is frenulum grooved and pitted • Precocious teeth • Lesions, including white, yellow or brown spots • Tooth cavities Vocal Behaviour (continued next page)
Auditory observation, • Strong, lusty and of • High pitch • Dehydration Parent education and and parent report, medium pitch support may include: • Continuous • Pain noting the following: • Will develop • Discussion of • Hoarseness • Raised intracranial • Alertness deliberate comfort measures pressure vocalisation as a • Monotonous • Cry • Expected vocal vocalisation or • Gastro oesophageal means of development for • Pitch of sounds inconsistency with reflux interpersonal age communication developmental • Language • Laryngeal trauma expectations acquisition • Screams in • Neurological condition annoyance • Excessive crying • Croup • Laughs, chuckles or • Audible stridor squeals during play
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Gradual development • Infant of narcotic, or of a range of vocal other substance- sounds dependent mother • Hearing impairment Chest and Respiratory Function (continued next page)
Visual and auditory • The chest is • Oral/nasal mucosal • Infection, including; Parent education and assessment, with infant symmetrical and secretions bronchiolitis and support may include: supported in upright slightly barrel-shaped epiglottitis • Stridor • The range of position, noting: • Chest circumference • Laryngomalacia normal mucosal • Grunting • Chest shape is close in size to secretions • Trauma head circumference • Crackles • Movement • Strategies for up to 2 years of age • Foreign body aspiration • Rales management of • Respiratory rate • Chest then gradually • Asthma specific deviations • Wheezing • Respiratory effort develops adult shape • Croup • Signs to alert • Rhonchi • Breathing pattern • Rhythm of breaths is parent to need for • Gastroesophageal reflux • Cough further review • Breathing sounds regular including symmetrical rise and • Pneumothorax • Snoring Seek urgent • Assessment of sleep fall of chest • Genetic or congenital medical review for any patterns through • Apnoea conditions signs of respiratory parent report may • The regular breath • Nasal flaring distress including offer additional rate is 24-55 breaths o Cystic fibrosis per minute (between stridor, grunting, information related • Head bobbing o Joubert syndrome apnoea episodes, to respiratory tract, birth and 12 months • Paradoxical breathing nasal flaring and allergy or infection with higher rates for younger infants) intercostal retraction or • Tachypnoea
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Infant may use oral • Intercostal retraction other altered airway spontaneously breathing sounds • Use of accessory or in response to muscles nasal occlusion • Cyanosis central or extremities Musculoskeletal – General (continued next page)
Through placing infant • Muscles are in a • Asymmetry in tone • Trauma Parent education and in prone, sitting and flexed position, support may include: • Flaccidity • Infection standing position if child normotonic and • Safety is walking, observe for symmetrical • Abnormal posture or • Genetic or congenital overall: positioning of conditions • Avoidance of • In the supine position, • Symmetry extremities o Trisomy 21/Down common injuries arms and legs are in related to a semi flexed position • Movement limitation or Syndrome • Flexibility developmental reluctance to use limbs o Cerebral Palsy with the hips slightly milestones • Resting position abducted • Unbalanced gait • Hypotonia • Strategies to • Muscle tone • Infant will start to • Evidence of pain or • Hypertonia improve muscle transition from a ‘bear • Motor activity tenderness on tone and strength walk’ crawl to pulling movement • Skin folds up to standing Assess range of position • Swelling movement through • When hands are held, • Masses observation of age- will purposefully step • Inflammation appropriate activity, on alternating feet noting: and may start to walk • Flexion/extension alone
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Adduction/abduction • Internal/external rotation Palpation and/or passive movement may be used to reinforce visual findings Assess crawling, standing or walking, noting: • Balance and pivots • Agility • Gait
Reflexes (continued next page)
Assess alert infant for • Primitive reflexes are • Asymmetrical • Genetic conditions Refer to medical presence and gradual symmetrical and o Fragile X syndrome practitioner where • Poor expression or diminishing of primitive indicative of central reflexes persist delay in response o Stickler syndrome reflexes, including: nervous system o Cerebral palsy beyond expected time • Palmar grasp function • Persistence of o Trisomy 21/Down frame, especially in primitive reflexes association with other • Primitive reflexes Syndrome • Asymmetrical tonic beyond 4-6 months concerns diminish from 3-4 neck reflex • Trauma months of age with • Delay in development • Moro reflex cerebral cortex of postural reflexes • Brachial palsy
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Stepping reflex maturity, and and voluntary • Hypotonia disappear by 4-6 movements by 9 • Rooting response months months of age • Sucking response • As primitive reflexes Assess gradual age- diminish, infant appropriate develops postural development of postural reflexes and voluntary and voluntary movements which movement, including: support control of balance, posture and • Head control movement in a gravity • Facial expressions based environment • Grasp • Reach • Weight bearing capacity Back and Spine (continued next page)
Assess general • The spine is initially • Sacral dimple or sinus • Intrauterine growth Ensure medical appearance of the back, C-shaped and in conditions practitioner review of • Tufts of hair, noting: midline any pilonidal dimple or particularly in sacral • Spina bifida sinus • Symmetry • The head should be area • Genetic conditions aligned directly over • Flexibility • Pronounced curvature the sacrum • Abnormalities in spinous • Curvature • Swelling processes • Spine gradually • Skin develops a cervical • Asymmetry
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
curve by 3-4 months • Masses and lumbar curve as the infant bears • Lesions weight and begins to walk Upper Limbs (continued next page)
Palpate the clavicles, • Infant will gradually • Swelling • Trauma including, and observe range of develop capacity to fracture, subluxation, or • Distortion arm movement lift chest up when dislocation including: lying on abdomen, • Bruising • Brachial palsy supporting at first on • Hands • Limited, reluctance or forearm, and later on • Intrauterine exposure to discomfort on • Elbows extended arms and teratogens movement flattened palms • Wrists • Cerebral palsy • Erythema • Age-appropriate • Shoulders • Environmental conditions development in use of • Extra digits Assess through both hands. May • Genetic conditions observation of: • Syndactyl show a preference for o Edwards syndrome • Flexion/extension one by 18 months • Webbing o Marfan syndrome • Adduction/abduction • Develops capacity to • Digital clubbing o Rubinstein-Taybi pick up small objects syndrome • Internal/external • Persistent clenched with a pincer grasp by rotation fists or thumbs in fist o Achondroplasia 12 months beyond 3 months • Symmetry • Limbs gradually • Early preference for • Strength become more pliable one hand • Flexibility and movements
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
become smoother • Asymmetrical and continuous movement or muscle • Should have full tone range of movement when extending the arms in all directions • Movements are equal in flexibility and in strength
Hips
Follow Hip Assessment • Skin folds are • Uneven leg length • Intrauterine growth Refer any hip procedure to assess symmetrical conditions concerns to medical • Asymmetrical buttock hips for stability, practitioner, or directly • Hips are stable, and folds and thigh creases • Genetic conditions abduction, limb length to PCH Orthopaedic thighs are easily and symmetry. • Movement restriction • Developmental Clinic if the infant is adducted and Dysplasia of Hip less than 4 months of abducted • Reluctance to move age • Trauma • Knees are equally • Not crawling by 8 aligned months • Environmental conditions, including • Bottom shuffling or constrictive wrapping alternative crawling method • Limping or waddling gait
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Lower Limbs (continued next page)
Assess while infant is • Legs are equal in • Unequal leg length • Birth trauma supine or in standing length with symmetry • Asymmetry in skin • Trauma, including position, noting: in skin folds folds fractures or dislocations • length • Legs are equal in • Asymmetrical • Intrauterine growth movement, strength • strength movement conditions and flexibility • flexibility • Asymmetrical muscle • Tibial torsion • Knee and hip joints tone • movement extended and aligned • Nutritional deficiency • Genu varum • skin folds • Knees will naturally • Genetic conditions Through observation of: lie apart with soles of • Genu valgum o Edwards syndrome the feet turned slightly • flexion/extension • Talipes – positional or o Rubinstein-Taybi inward genetic syndrome • adduction/abduction • Bow leggedness is o Achondroplasia • • internal/external common until 4-5 o Duchenne muscular rotation years dystrophy • As the ability to walk is developed, the infant’s stance is wide with small steps and rapid cadence
Foot and heel • Foot is supple • Rigidity or limited • Intrauterine growth Parent education and range of movement, conditions support may include: • Visible plantar crease including: • Genetic conditions • Use of passive stretching
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Assess forefoot and • In the supine position, • Limited dorsiflexion o Talipes exercises for minor heel for position and positional the medial and lateral • Adduction of forefoot • Metatarsus adductus alignment malleoli are parallel deviations where • Fixed position of • Trauma feet can easily be • Assess ankle and hindfoot returned to midline plantar arch for range of motion • Polydactyly • Monitoring and • Absent plantar crease review for resolution • Webbing Referral to medical practitioner or allied health professional where an inflexible deviation exists
Abdomen (continued next page)
Visual inspection, and • Protuberant and • Tension • Changes in oral intake Urgent referral to palpation where round (pot-bellied) medical practitioner • Distension • Infection indicated, noting: for: • Symmetrical • Sunken or scaphoid • Constipation • Size • Sustained vomiting • Moves with shape • Intolerance or atopy • Shape respiration • Projectile vomiting • Asymmetry • Malrotation of bowel • Symmetry • Soft • Reduced bowel • Visible peristalsis • Obstruction sounds • Sounds • Bowel sounds are • Vomiting • Contours present and generally • Intussusception heard every 10-20 • Hyperactive or absent • Paralytic ileus • Skin integrity seconds bowel sounds
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Evidence of pain or • Pyloric stenosis (usually discomfort between 2-6 weeks of age • Hirschsprung’s disease Umbilicus (continued next page)
Visual inspection, • The umbilical cord • Intermittent or constant • Umbilical hernia Parent education and noting: has separated and is bulging or swelling, support may include: • Diastasis rectus dry and healed more pronounced with • Size • Routine umbilical increased abdominal • Infection • Lies at vertical level care • Shape pressure (crying and corresponding to • Omphalomesenteric duct defecation) • Strategies for • Integrity remnant between L3 and L5 management of • Discharge from • Separation of cord • Size, shape, depth, • Urachal remnant minor infections umbilicus length, and overall • Healing of cord • Cyst Prompt referral to appearance is • Erythema stump medical practitioner variable • Umbilical polyp • Inflammation for umbilical discharge • Forms a visible • Granuloma • Lesions depression on skin in • Cellulitis 90% of infants • Masses • Environmental conditions • Protrusion may occur • Omphalitis in10% of infants • Umbilical lint • Underlying abdominal muscles surrounding umbilicus are concave
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Buttocks and Rectal Area (continued next page)
Visual inspection and Patency demonstrated Buttock deviations: • Birthmarks Parent education and discussion with parent, through passing of support may include: • Lesions or rashes • Trauma noting: faeces which is normally: • Dietary needs • Discolouration • Genetic conditions • Anal patency • Human milk fed – • Normal patterns of yellow (brown and • Sacral sinus, dimples • Response to change in • Stool consistency, output colour and frequency dark green may be or tufts of hair dietary and fluid intake normal in the • Strategies to • Rectal deviations: • Constipation • Skin integrity absence of address minor • Skin features deviations) with • Changes in frequency • Infection: bacterial, viral deviations texture from loose, of bowel motions or parasitic • Referral to medical granular to curdled • Changes in colour or • Fissures practitioner for: • Infant formula fed - consistency of bowel • Rectal tears • Sacral sinus pale yellow to yellow, motions brown, green or grey • Allergy or Atopy • Bleeding • Bleeding with paste to semi- • Recto-urethral formed texture fistula • Infant faeces become Consider referral to darker, more formed specialist services and odour increases where child protection with introduction of issues are suspected solid food Refer to Guidelines for Protecting Children 2020 for further information, including
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies information on mandatory reporting
Urinary System
Assess urinary output • Normal urine output is • Change in urine: • Urinary Tract Infection Parental education through parental report, >2 ml/kg/hour in and support may o Volume • Pyelonephritis or visual inspection infants include: where possible, noting: o Frequency • Dehydration • Infants void an • Expected urinary • Volume average of 20 times o Colour • Changes in fluid intake output for age and per day/once per hour how to monitor • Frequency • Presence of blood • Urinary reflux • Fluid requirements • Infant bladder will • Colour • Weight loss • Jaundice completely empty at Note: Nutritional least once during a • Behavioural irritability • Diabetes assessment may four hour period contribute to findings • Congenital abnormalities of kidneys and urinary tract Genitourinary – Male (continued next page)
Visual inspection of • Urinary orifice is • Ambiguous genitals • Genetic conditions Parent education and penis, scrotum and patent, uncovered by support may include • Curvature of penis • Intrauterine exposure to inguinal areas, and the prepuce, located routine hygiene needs teratogens palpation of testes, at the tip of the glans • Microphallus and age appropriate noting: penis • Infection expectations • Deviation in position of • Position • Foreskin does not urethral meatus, • Testicular torsion Urgent referral • Size retract until 2-3 years including hypospadias to emergency old. Complete and epispadias department for
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Patency of urethra separation of the • Phimosis (tight • Intrauterine growth paediatric foreskin and glans foreskin) conditions surgical review • Skin penis is usually for signs of • Paraphimosis • Hydrocele • Testicular descent complete by 6 years torsion
N.B. Do not attempt to • Spontaneous • Chordee Refer to medical forcibly retract the testicular descent • Balanitis practitioner for review foreskin usually occurs before of any deviation in birth and may retract • Balanoposthitis testicular descent
during the first 6 • Scrotal swelling, acute over 4 months of age months or persistent • Cremasteric reflex • Abnormal distance can be activated by from scrotum to anus cold, emotion, or touch • Circumcision – healing complications include bleeding, redness, cyanosis, discharge, or swelling • Testis absent or outside of scrotal sac
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Genitourinary – Female
Visual inspection of: • Clitoris is about 3mm • Rashes • Trauma Parent support and in length and 3mm in education may • Labia • Lesions • Allergy or atopy transverse diameter include routine • Vaginal orifice • Redness • Environmental conditions hygiene needs and • The labia minora are or irritants age appropriate • Urethral meatus thin ridges of tissue • Lacerations expectations which cover the • Infection, commonly • Perianal area • Bruising urethral and vaginal bacterial or fungal Consider referral to • Clitoris orifices and meet at • Swelling specialist services • Genetic conditions the clitoris where child protection Noting the following: • Pain o Imperforate hymen issues are suspected • Shape • Labia minora • Discharge • Hernia Refer to Guidelines • Position frequently protrude from the labia majora • Odour for Protecting Children • Contours 2020 for further Hydrocolpos • Urethral meatus may • information, including • Patency be difficult to visualise • Ambiguous genitals information on • Skin integrity due to thickened mandatory reporting hymen N.B. Careful examination should be • Vaginal orifice is conducted where patent, surrounded by discharge exists hymen, with no discharge
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Inguinal Area
Visual inspection, and • A horizontal chain of • Masses – either firm • Prematurity Prompt medical palpation of inguinal inguinal nodes run and reduced with review is indicated • Genetic conditions area along the: along the inferior pressure, or hard and where any inguinal o Coarctation of the • Juncture of the thigh groin immobile swelling is reddened, aorta painful, or does not and abdomen • Regular femoral • Tenderness change size when the pulses can be felt • Lymphadenopathy • Along the inguinal • Enlarged glands infant cries, especially midpoint between the ligament and the • Infection if accompanied by iliac crest and • Poor, unequal or saphenous vein other signs of illness symphysis pubis absence of femoral • Inguinal hernia such as fever, pulses vomiting or distended abdomen
Skin (continued next page)
Visual inspection, and • The skin is smooth, • Pallor, redness, • Jaundice Parent education and palpation where even, clear and intact cyanosis support may include • Erythema toxicum required, noting the strategies for • Mucous membranes • Unusual pigmentation neonatorum following: management of are moist or discolouration • Colour • Milia deviations such as: • Normal colour • Plethora of protein • Trauma • Minor infections • Texture according to race • Bruising • Genetic conditions • Infestation • Integrity • Skin is elastic and • Rashes, lesions, scars o Congenital dermal • Turgor returns rapidly to • Allergy and original shape • Thickening, drying, melanocytosis eczema (atopic following gentle cracking, flaking or (Mongolian blue dermatitis) pinching scaling of skin spot)
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Hydration of • Capillary refill is • Blistering o Cutis marmorata • Environmental exposed skin and under 2 seconds influences • Itching • Macular or cavernous mucous membranes • Pigmentation haemangioma • Expected fluid • Papules, Plaques, • Temperature variations occur in intake and output Vesicles, Nodules • Nevus vasculosus N.B. Skin should be darker skinned infants for age in nail-bed, palm, sole • Skin tags, dimples, • Telangiectatic nevi inspected in areas of Referral to a and genital areas cysts natural light, or a well-lit • Dehydration medical practitioner space with fluorescent • Hydration deviations: • Allergy for birthmarks and lighting where possible rashes, particularly • Reduction in skin • Eczema (atopic elasticity dermatitis) where birthmarks are • Flushed appearance located on face, • Infection - bacterial, viral head or buttock or fungal • Xerosis (dry skin) areas • Skin takes > 3 secs to • Fever or overheating Prompt referral to a return to original shape • Infestation, including medical practitioner scabies where deviations are • Intrauterine exposure to accompanied by other teratogens signs of illness
Hair (continued next page)
Visual inspection, • Fine soft, downy • Absent hair or bald • Seborrheic dermatitis Parent education and noting: lanugo hair is present patches (cradle cap) support may include at birth and can strategies for • Distribution • Dryness persist for up to 3-4 management of: • Colour months • Oiliness
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Hair line • Lanugo is gradually • Infestation • Environmental • Seborrhic shed and replaced by conditions, including • Quantity • Coarse texture dermatitis vellus hair which is friction on surfaces • Texture short, fine, soft, • Change in growth rate • Hygiene needs • Infection, e.g. tinea poorly pigmented and • Growth pattern • Irritation, dryness, capitus (ringworm) or • Control of covers most of body lesions or scaling of impetigo environmental • Vellus type hair is scalp factors • Trauma also present on the scalp from birth, • Nutritional deficiency gradually replaced • Stress or recent illness from 3-7 months of age by intermediate • Pallister-Killian syndrome scalp hair • Terminal hair is pigmented, longer, thicker and replaces vellus hair on the scalp by 2 years of age • Growth is uniform, and specific to body area
Nails (continued next page)
Visual inspection, • Nails are soft, pliable • Short and thick • Infection: bacterial, viral Parent education and noting: and fast growing or fungal support may include:
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1-12 months - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Colour • Nails are adherent to • Fragile or thin • Environmental • Routine care and nail bed • Contour • Nail shedding conditions, including hygiene strategies • Nail beds are pink, (onychomadesis) exposure to moisture • Shape • Expected growth smooth, flat or slightly • Dryness • Psoriasis patterns • Texture convex, with uniform thickness • Transverse • Ectodermal dysplasia • Cleanliness depressions or • Trauma grooves (Beau’s lines) • Stress or significant • Pruritus illness • Clubbing • Paronychia • Odour • Cyanosis • Nail atrophy/ absence
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Appendix C: Children - Twelve months to four years
1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
General Appearance
• Facial expressions • Initial presentation of • Deviations from the • A range of congenital or Observation of the child is consistent norm may be initially non-congenital conditions general appearance • Posture with the situation identified through should be completed • Genetic conditions • Activity level (e.g. crying due to overall assessment of prior to a more tiredness or pain) general appearance of • Environmental conditions detailed • Temperament the child assessment. Any • Child appears • Child abuse – consider • Responsiveness areas of concerns healthy and • Recognise indicators indicators outside of what will be documented • Interaction with appropriately for child abuse, may be expected given the and noted for others developed including but not child’s age and additional monitoring limited to: injury, development • Proportion and and/or referral to a bruising, burns, retinal symmetry of body medical practitioner haemorrhages, bite parts marks, fractured • Movement bones, bleeding, pain Refer to the or physical discomfort • Nutritional status Guidelines for or poor standard of protecting children • Skin Integrity hygiene. 2020 publication for Observe appearance • Assess appearance of more information. prior to comprehensive child with assessment consideration of their age, level of mobility and development.1
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Head
Visual inspection with • Rounded • Asymmetrical • Plagiocephaly the head at midline, • Symmetrical • Circumference outside • Dehydration- more easily while sitting supported, expected trajectory observed in younger child noting: • When child is upright, • General shape head will comfortably • Microcephaly • Trauma sit in the midline • Size • Macrocephaly • Space-occupying Head circumference intracranial lesions • Bruising • Circumference averages: • Gastro-oesophageal reflux • Swelling • Symmetry • males: 43.5–53 cm disease (GORD) where • Lesions overfeeding contributes to • Alignment • females: 42.5-52cm6 torticollis • Positional head • Range of, • Brain reaches 80% of preference or tilt movement, tone and adult size by 2 years • Intrauterine growth conditions and exposure to flexibility • Jerking, tremors or • Sutures are tetragons involuntary spasms proximate and • FASD immobile • Persistence or premature closure of • Skin is flush with • Craniosynostosis anterior fontanelle scalp • Neurological condition • Bulging or sunken • Anterior fontanelle o Epilepsy anterior fontanelle in closes by around 18 o Brain injury younger child months of age • Visual or hearing deficit • Hydrocephaly
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Neck
Visual inspection, • Neck lengthens at 3- • Stiffness or resistance • Torticollis Urgent referral for noting the following: 4 years, and neck to to movement or range medical review of any • GORD • Symmetry body proportion of motion child with neck becomes closer to • Raised intracranial stiffness • Pain • Shape adult size pressure accompanied by • Lateral inclination of signs of acute illness • Mobility • Trachea is at midline • Meningitis the head
• Musculature • Lymph nodes are • Infection • Lymphadenopathy non-visible, mobile, • Lymph nodes • Cerebral palsy non-tender and not • Positional shift of Consider relevant warm to touch Trachea • Hypotonia history from parent report, including: injury, • Genetic conditions head tilt, pain, stiffness, o Turner’s syndrome persistent lymph gland o Trisomy 21/Down swelling and respiratory Syndrome infection
Face (continued next page)
Through visual • Face is relaxed and • Bruising • Trauma Child Abuse - inspection observe symmetrical consider indicators • Swelling or oedema o child abuse facial features and outside of what may • Nose should be expressions, noting: • Alteration in skin • Fatigue be expected given symmetric and in integrity the child’s age and • Symmetry centre of child’s face • Allergy development • Asymmetry • Spacing and size • Environmental conditions
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Movement • Facial expressions • Lesions • Infection are spontaneous and • Emotional • Dark circles under • Genetic conditions Refer to the responsive to Guidelines for expression eyes o Russell-Silver situation protecting children • Neurological deficit o Trecher-Collins • Symmetry of smile, 2020 publication for laugh, creases and • Lack of, or • Medication side effect more information wrinkles reveal inappropriate, • Mental illness normal function/ emotional expression innervation • Myotonia • Involuntary movements Eyes (continued next page)
Visual inspection, • Eyebrows extend to • Discharge, watery or • Acquired head injury Parent education and noting: just beyond the outer purulent support for infection • Infection, bacterial, viral or canthus control measures and • Shape • Conjunctival redness fungal hygiene where eye • Raising and lowering or inflammation • Size • Allergy infection is suspected of eyebrows is • Crusting or scaling • Symmetry symmetrical • Dehydration • Eyelid inflammation, • Position and • Eyelashes are full • Trauma swelling, lesions, or spacing and evenly discoloration • Visual engagement distributed • Sunken eyelids • Upper and lower eyelids and palpebral • Ptosis fissures symmetrical • Loss of hair - • Gaze is symmetrical eyelashes or eyebrows
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Eyes are • Subconjunctival symmetrical, haemorrhage horizontal and in line with top of pinna • Conjunctiva and sclera are smooth, clear, whitish and glistening (yellow tinge normal in children with dark skin) Vision Behaviours (continued next page)
Assess by examining • Pupils are round, • Fixed or unequal pupil • Retinoblastoma Prompt referral the pupil and iris, and clear, equal in size size to medical • Cataract by shining a light into and reactivity to light practitioner for any • Sluggish reactivity to the eyes, noting: • Scleral icterus visual impairment, • Pupils may be larger light opacity or • Size than adults • Photophobia • Corneal cloudiness or strabismus • Symmetry • Irises are circular opacity • Glaucoma Urgent referral to • Colour • Eyes move in unison • Strabismus • Optic nerve deficit ophthalmologist through medical • Clarity • Shifts between near o Hypertropia • Neurological deficit practitioner for and far vision tasks o Hypotropia • Shape • Trauma opacities in the and tracks an object • Limitation in expected pupil or corneal • Movement across 180° from 12 • Nystagmus eye movements abnormalities • Pupillary months • Coloboma • Strabismus – intermittent constriction or constant
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Light sensitivity • Discolouration of sclera • Ability to fix and follow
Ears (continued next page)
Assess external ear • The superior portion • Inflammation • Otitis Externa Parent education and including mastoid of the auricle is equal support related to • Erythema • Mastoiditis process, auricles, tragi in height to the outer external ear may and external auditory canthus of the eye • Oedema • Other infection include: meatus, noting: • Auricles are vertical • Tenderness • Sebaceous cysts • Wax production • Position with less than 10° tilt • Discharge • Trauma • Hygiene • Size • The pinna is 80% of • Lesions or masses • Environmental conditions • Infection control • Shape adult size by 4 – 5 years of age • Abrasions Refer to medical • Symmetry practitioner for any • The pinna is soft and • Piercings – deviations suspected infection • Colour pliable and recoils may include • Skin integrity readily when folded inflammation, scar and released tissue, trauma • Patency Child Abuse - • Colour is similar to • Bruising around ear consider indicators • Firmness of ear facial skin outside of what may cartilage be expected given • Observe for the child’s age and infection or development discharge of preauricular sinus/
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Examine ear canal and • Skin of distal two • Erythema • External ear infection Referral options visualise tympanic thirds of ear canal is and parent education • Bulging • Trauma membrane using similar to external and support for: otoscopy ear, and is covered • Retracted • Foreign objects, which may • Foreign bodies with fine hair precipitate wax production Visible tympanic • Perforated or discharge • Discharge membrane landmarks • Tympanic membrane • Discharge include cone of light, is thin oval shaped • Inadequate middle ear • Excessive wax or umbo, and handle of and concave • Grommet drainage suspected malleus infection • Cerumen is a normal • Thickening and • Middle ear infection protective secretion, scarring of membrane ranging from grey, typically appears as dry and flaky to wet, white area honey to dark brown colour and texture • Cone of light position: 4-6 o’clock
on the right and 6-8 o’clock on the left
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Nose
Visual and auditory • Septum is straight • Mucous or other nasal • Infection inspection, noting in and in midline of the secretions • Inflammation relation to nasal bridge, nose • Oedema nares, columella and • Foreign body • Nasal passages septum: • Epistaxis enlarge in early • Allergy • Symmetry childhood, allowing • Nasal flaring • Nasal polyps easier airflow • Shape • Asymmetry • Trauma • Nares can be easily • Size • Narrowing of the occluded • FASD • Skin integrity nares • Child removes • Flattening • Alignment obstructions by • Patency of nares sneezing • Discolouration or lesions
Mouth (continued next page)
Using the Oral health • Oral mucosa is shiny, Gum deviations: • Dehydration Parental support and examination procedure smooth, moist, and education for minor • oedema • Infection: bacterial, viral or and ‘Lift the Lip’, pink (bluish or pale in deviations may fungal inspect: child with dark skin) • Lesions include: • Trauma • Gums • Upper frenulum • Inflammation • Teething Allergy processes • Mucosa gradually disappears • Friable • with growth of maxilla Environmental conditions • Drooling • Lips • Halitosis •
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Tongue • Lingual frenulum Lip deviations: • Poor hygiene • Minor lesions or allows child to poke infections • Teeth • Oedema • Neurological impairment tongue out past lips • Dental hygiene Noting the following: and move from side • Dryness • Tooth eruption • Colour to side • Healthy eating • Lesions • Nutritional deficiency • Symmetry • Deciduous teeth Direct referral to • Fissures • FASD appear between 6– Dental practitioner is • Integrity 24 months • Persistent drooling • Myotonia recommended for • Moisture parental or • Drooling is normal • Persistence of upper • Medications professional concerns • Movement of tongue between 3 and 15 frenulum • Congenital and genetic regarding teeth months of age Tongue deviations: abnormalities • Tooth eruption • Dorsal surface of • Odour • Coated o Trisomy 21/Down tongue is slightly Syndrome The ‘Lift the Lip’ • Plaque or lesions rough, moist and o Hypothyroidism resource should be pink, sometimes • Geographic tongue used from 12 months of patterned; ventral age, to assess oral surface thin, with • Macroglossia health. prominent vessels • Ankyloglossia • Difficulty swallowing Tooth deviations: • Plaque • Lesions • Trauma
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Vocal Behaviour
Auditory observation, • Will vocalise • High pitch • Raised intracranial Parental education and parent report, deliberately using a pressure and support for minor • Continuous noting the following: range of volume and deviations, may • Infection, particularly in pitch as a means of • Hoarseness, acute or include: • Speech patterns upper respiratory tract interpersonal prolonged • Croup and other • Pitch of sounds communication • Allergy • Excessive crying upper respiratory • Language • May scream in • Hypothyroidism infection • Speech sounds acquisition annoyance strategies inconsistent with • Dehydration • Gradual age- developmental • Allergy control • Pain expectations appropriate Consider further • GORD development of assessment and speech and language • Laryngeal trauma referral to speech therapist for parental • Neurological condition or professional • Hearing impairment concerns with speech
Chest and Respiratory Function (continued next page)
Visual and auditory • Chest shape is • Noisy breathing, • Infection, including Parent education and assessment, with child round, barrel like and including grunting or bronchiolitis and epiglottitis support may include: sitting upright, noting: equal to head stridor • Laryngomalacia • Hygiene practices circumference until • Chest shape • Snoring for respiratory • Trauma about 2 years infection control • Movement • Crackles • After 2 years, chest • Foreign body aspiration • Respiratory rate becomes adult • Wheezing • Asthma shaped, gradually
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Respiratory effort exceeding head • Rhonchi • Croup • Asthma education circumference by 5-7 and action plan as • Breathing pattern • Stridor • Pneumothorax cm appropriate • Breathing sounds • Cough • Increased intracranial • Respirations regular Seek urgent pressure N.B. Assessment of at rate of 20-30 per • Apnoea medical review for sleep patterns through minute from 1-5 • Adenoid or tonsillar any signs of • Breath-holding parent report may give years hypertrophy respiratory distress information related to • Cheyne-Stokes which may include • Symmetrical chest • Cardiac conditions respiratory tract, allergy rise and fall breathing stridor, grunting and or infection • Genetic conditions wheezing, intercostal • Child may use oral • Tachypnoea o Cystic fibrosis retraction airway • Intercostal retraction spontaneously or in o Joubert syndrome response to nasal • Accessory muscle use occlusion • Persistent barrel chest Musculoskeletal – General (continued next page)
Observe for overall • Movements are • Muscular pain or • Trauma Parent education and symmetry, including: equal in flexibility and tenderness o Sprain, Strain, support regarding strength safety, and avoidance • Length • Bone or joint pain Fracture of common injuries • Upper and lower o Subluxation/dislocation • Strength and tone • Oedema related to limbs are • Synovitis developmental • Flexibility symmetrical in length • Warmth milestones • Skin folds • Neurological disorder • Laxity of ligaments • Movement limitation Be alert to non- predisposes to • Scoliosis • Range of motion • Unilateral weakness accidental injury, musculoskeletal • Mobility of joints • Spina bifida which may manifest commonly with rib,
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Circulation injury in young • Disproportionate limb • Rheumatoid arthritis clavicular, sternal or children or digit size, outside spinal • Sensation • Haemophilia musculoskeletal • Movements gradually normal expectations Assess range of • Genetic conditions injuries become smoother • Hypermobility of joints movement through and continuous o Trisomy 21/Down Consider referral to observation of activity • Palpable masses specialist services • Mature pattern of Syndrome or play, noting: where child protection muscle action and • Muscle contracture o Duchenne muscular • Flexion and issues are suspected motion by 3 years of dystrophy extension age o Marfan syndrome Refer to Guidelines • Adduction and o Osteogenesis for Protecting • Gradual age- abduction Children 2020 for appropriate increase imperfecta further information, • Internal/external in fine and gross • FASD including information rotation motor control and on mandatory capacity • Osteomalacia Palpation and passive reporting movement assessment • Tumour may be required to • Leukaemia reinforce visual findings
Back and Spine (continued next page)
Assess general • Lumbar curve forms • Rigidity, particularly • Genetics appearance of back as the infant begins while sitting • Trauma while the child is to bear weight and • Lateral curvature standing erect, noting: begin to walk • Kyphosis • Pronounced curvature • Symmetry, including • Exaggerated lumbar • Scoliosis hips, shoulders and lordosis is normal in • Pain rib cage young children
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Curvature • Normal curvature (C- shaped) develops by • Flexibility 3- 4 years, including • Range of movement neck and lumbar lordosis, and thoracic • Skin kyphosis • Bending and stretching should be without resistance
Upper Limbs (continued next page)
Assess range of • Able to use both • Oedema • Trauma Parent education and movement in: hands and arms support for: • Distortion o fracture, subluxation, equal in strength and • Hands or soft tissue injury • Expected range of • Limited or reluctance flexibility movement and • Elbow with movement • Neurological deficit • May show hand ability for age • Wrists preference by 18 • Pain or discomfort on • Genetic conditions • Injury prevention movement • Shoulders months of age o Edwards syndrome e.g. radial-ulnar Noting the following: • Development and • Asymmetrical tone on o Marfan syndrome joint subluxation ossification of the movement, including o Rubinstein-Taybi and shoulder • Strength hands continues until limpness syndrome dislocation are 11-12 years of age o Achondroplasia common from 2-4 • Flexibility • Digital clubbing years of age • Normal arm swing o Cerebral palsy • Persistent fist begins from 18 Child Abuse - formation • Environmental conditions months and arms Consider sign of child • Child Abuse
Page 70 of 82 Clinical Nursing Manual Physical Assessment 0-4 Years
1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies move reciprocally abuse and conduct with legs by 2 years further assessment Refer to Guidelines for Protecting Children 2020 for further information.
Hips
Follow Hip Assessment • Gait is symmetrical, • Waddling or limping • Conditions which may be Referral for procedure to assess though may be gait associated with hip medical review where gait and toe walking disjointed in toddler deviations include: any previously • Unilateral toe walking undiagnosed hip • Genetic conditions dysplasia is o Trisomy 21/Down suspected Syndrome o Larson’s syndrome • Congenital Arthrogryposis • Spina bifida • Scoliosis • Developmental Dysplasia of Hips
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Lower Limbs (continued next page)
Assess lower limbs • Legs are equal in • Asymmetrical • Trauma, including fractures Parent education and through observation of length, movement, • skin folds or subluxation reassurance of child standing and gait, strength and common deviations • Talipes noting: flexibility • Movement which should resolve • Tibial torsion spontaneously, • Muscle tone • Stance includes wide • Tone including: • Strength base of support, • Rotation • Nutritional deficiency hyperextension of • Tibial torsion by 4- • Unequal limb length o Vitamin D, calcium and knees and hips, and protein 5 years Observe for disjointed (toddling) • Bowed legs with Genu valgum by 7 • Genetic Conditions • symmetry in; pattern when space greater than 5 years walking. Stance is • Length cm between knees o Edwards syndrome slightly apart by 2 after 2.5–3 years o Rubinstein-Taybi • Genu varum by • Strength years and in line with syndrome 2.5–3 years body by 4 years. • In-toeing affecting • Flexibility o Achondroplasia which gradually mobilisation • Movement becomes more Consider referral smooth to GP relevant allied • Skin folds health services for • In-toeing normal from specialised treatment 15 months and of positioning or usually resolves by 4 movement deviations years • Genu varum (Bowleggedness) - normal to 2.5–3 years
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Genu valgum (Knock knees) - common until 7 years
Assess foot and heel, • Feet are supple • Rigidity or limited • Trauma Parent education and noting: range of movement, support may include: • Plantar crease is • Genetics • Position and including dorsiflexion visible on each foot o Duchenne muscular • Discourage the alignment • Flat feet (Pes planus) use of equipment • When supine, the dystrophy persistent after 2-3 such as walkers • Range of motion lateral malleoli may years • Cerebral palsy and jolly jumpers normally rotate up to 20 degrees • Heel or arch pain • Short Achilles tendon posteriorly • Toe-walking most of • Autism Consider referral • Pes planus (flat feet) the time 6 months to relevant allied are normal in early after started walking health services for walking phase or persisting beyond 3 specialised treatment years of positioning or • Longitudinal arch movement deviations develops by 2-3 years • Walking mostly with heal toe gait and toe walking lessens 6 months after walking and resolves by 3 years
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Abdomen
Visual inspection and • Protuberant and • Reduction or increase • Gastrointestinal infection palpation where round (pot-bellied) in bowel motions, • Constipation Urgent referral to required, noting: normal until 4 years including consistency, medical practitioner or colour • Normal response to dietary • Size • Abdomen moves with for: changes respiration • Vomiting • Shape • Sustained • Peritonitis • Symmetry • Soft • Pain, tenderness or vomiting guarding • Full bladder • Contours • Symmetrical • Reduced bowel • Distension • Obstruction sounds • Bowel sounds • Bowel sounds present • Tension or rigidity • Paralytic ileus • Pain on palpitation • Skin texture, colour and/or • Visible peristalsis • Trauma and integrity guarding/rigidity • Palpable masses or • Malnutrition • Nutritional status protrusions • Foreign body • Swelling or lesions • Coeliac disease • Hyperactive or absent • Cystic fibrosis bowel sounds • Hirschsprung’s disease Umbilicus (continued next page)
Visual inspection, • Forms a visible • Swelling • Herniation Parent education and noting: depression or support may include: • Masses • Polyp protrusion on skin • Size • Routine umbilical • Lesions • Granuloma • Shape care
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Contours • Size shape, depth, • Discharge • Dermoid Cyst length, and overall • Skin integrity • Lint • Diastasis recti abdominis appearance is variable
Buttocks and Rectal Area
Inspection should • Stools may be • Lesions • Response to change in Parental support and include discussion with passed normally from nutritional intake education may • Lacerations or tears parent, noting: 1-3 times per day include strategies to • Genetics • Anal patency through to 2-3 times • Bruising address minor per week • Infestation deviations with • Skin • Discolouration • Stool consistency is • Constipation • Elimination • Tufts of hair, • Elimination patterns highly variable, but patterns particularly in crease • Infection should be soft, • Toilet training • Nutritional needs formed, and easy to • Evidence of itching • Polyps History of dietary pass without pain or • Physical activity • Erythema • Trauma intake and growth trauma needs for normal pattern may • Inflammation • Child Abuse bowel function contribute to • Continence develops assessment from 2 years of age • Fissures • Hygiene with an average of 3 • Skin Tags • Toilet training years • Changes in frequency Consider referral to or consistency of specialist services bowel motions where child protection issues are suspected Refer to Guidelines for Protecting Children 2020 for
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies further information, including information on mandatory reporting
Urinary System
Assess fluid intake and • Young child’s urine • Decrease in volume • Diabetes Parental education urinary output by output is >1 ml/kg/h and frequency and support may • Urinary tract infection parental report, noting: include: • Bladder capacity is • Cloudy urine • Urinary reflux • Frequency about 1% of child’s • Fluid • Weight loss • Volume body weight • Pyelonephritis requirements • Signs of dehydration • Colour • Toddlers and pre- • Glomerulonephritis • Expected urinary schoolers will void on • Haematuria output • Other infection • Bladder control average between 8- • Strong smelling urine • Timing and 14 times per day • Changes in fluid intake Visual assessment and strategies for • Behavioural irritability dip stick analysis of • Kidneys immature developing urine sample where until 2 years, • Fever bladder control relevant predisposing child to • Vomiting Refer for medical dehydration and review of any signs of hypovolaemia urinary tract infection • Urine colour is clear, and pale yellow to amber
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Genitourinary – Male
Use visual inspection of • Urinary orifice is • Balinitis • Genetics Urgent referral for penis and scrotum and patent, uncovered by paediatric surgical • Hypospadias • Infection inguinal areas, and the prepuce, located review of signs of palpation of testes, at the tip of the glans • Chordee • Undescended testis torsion which may noting: penis include: pain, scrotal • Phimosis (tight • Retractile testis swelling, unilateral • Position • Retraction of foreskin foreskin) • Hydrocele absence of is possible by 3 years • Size • Deviations in position cremasteric reflex, of age • Testicular torsion • Patency of urethra of testes nausea and/or • Scrotum is normally • Inguinal herniation vomiting and later, • Small flat scrotum • Skin loose and wrinkled scrotal oedema • Enlarged scrotum • Testicular descent • Testes descended (At 2 years enquire • Absent cremasteric • Cremasteric reflex is Refer to medical about testicular reflex descent) strong in early practitioner for review childhood initiated in • Scrotal pain of any deviations in N.B. Do not attempt to response to cold, wet testicular descent • Lymphadenopathy forcibly retract the or anxiety foreskin • Inguinal swelling • Circumcision – post surgical deviations may include bleeding, redness, cyanosis, discharge or swelling
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Genitourinary – Female
Visual inspection of: • Labia minora is thin, • Rashes • Allergy Parental education covers the urethral and support may • Labia • Lesions • Infection, including fungal, and vaginal orifices include: viral or bacterial • Vaginal orifice • Erythema • Labia minora • Normal age • Trauma • Urethral meatus frequently protrudes • Lacerations appropriate from the labia majora • Child abuse developmental • Perianal area • Bruising expectations • The vaginal orifice is • Foreign body • Inguinal area • Oedema partly covered by the • Hygiene • Allergy or atopy hymen membrane, • Pain requirements which varies but is • Infestation, e.g. pinworm Noting the following: • Discharge Refer the child for normally annular and • Shape immediate crescent shaped • Odour • Position specialised • No vaginal discharge • Labial adhesion or assessment where • Contours partial fusion there are any child • Urethral meatus is protection concerns • Patency small • Tenderness in the Refer to Guidelines • Skin integrity lower abdomen for Protecting • Bulging or tenderness Children 2020 for in inguinal area further information, • Lymphadenopathy including information on mandatory reporting
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
Skin (continued next page)
Visual inspection, and • Exposed skin areas • Pallor • Syncope Parental education palpation where normally feel dryer and support may • Redness • Anaemia required, noting the than body creases include strategies for: following: • Plethora of protein • Hypo or hyperthermia • Mucous membranes • Minor rashes, • Colour are moist • Bruising- consider • Trauma infections or signs of child abuse infestations • Texture • A child’s skin is • Child Abuse normally smooth and • Rashes, lesions, scars • Allergy and • Integrity • Stress even eczema (atopic • Thickening, drying, • Turgor • Dehydration dermatitis) • Skin colour variation cracking, flaking or • Hydration of occurs between and scaling, Blistering of • Burns • Hygiene exposed skin and within races and skin • Infection, including fungal, • Safety and mucous membranes affects assessment • Itching viral or bacterial avoidance of • Temperature findings common skin • Clamminess • Eczema (atopic dermatitis) N.B. • Darker skin is often injuries related to normally drier • Hairy patches, or • Infestation developmental • Skin should be dimpling in the milestones, • Nutritional deficit inspected in areas lumbosacral area including sun of natural light, or a • Raynaud’s phenomenon safety well-lit space with • Cyanosis, either fluorescent lighting extremities or central • Exposure to environmental Child Abuse - where possible extremes consider indicators • Jaundice outside of what may • Behavioural deviations, • Where colour • Clustered be expected given such as thumb or finger change is pigmentation the child’s age and sucking suspected, inspect development
skin in an area • Neurological disorder
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
where there is less • Endocrine disorders • Refer to melanin, and use Guidelines for palpation and • Liver disease Protecting temperature • Congenital heart or lung Children 2020 for assessment to add disease further to findings information, including information on mandatory reporting
Nails (continued next page)
Visual inspection, • Nail beds are pink, • Dry or brittle nails • Anaemia Parental education noting: smooth, flat or and support may • Paronychia • Nutritional deficiency slightly convex, with include strategies • Colour (inflammation of uniform thickness • Trauma related to: • Contour surrounding skin) • Nails are adherent to • Infection, commonly • Nail care • Tenderness • Thickness nail bed bacterial or fungal • Behavioural • Convex or concave • Texture • Capillary refill is 2-3 • Hypoxia deviations curving seconds or less Assess time of capillary • Endocrine disorder • Localised • Cyanosis refill (in relevant infections • Trachonychia settings) • Pallor • Nutritional needs • Ectodermal dysplasia • Yellow or white colour • Chronic respiratory or • Thickened nail bed cardiac disease
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
• Transverse • Behavioural deviations depressions or such as nail-biting, thumb grooves (Beau’s lines) sucking • Splinter • Stress or significant illness haemorrhages • Genetic conditions • Nail-biting or picking • Clubbing • Prolonged capillary refill
Hair (continued next page)
Visual inspection, • Short, fine, poorly • Coarse • Infection, e.g. tinea capitus Parental education noting: pigmented vellus hair (ringworm) or impetigo and support may be • Dull, dry or brittle covers all but the provided for common • Colour • Infestation palms, soles and • Delayed growth deviations such as: • Quality mucous membrane • Seborrheic dermatitis • Thin distribution • Infestation areas • Texture • Nutritional deficiency • Alopecia • Infection • Thick, mature • Quantity • Thyroid disorder terminal hair replaces • Irritation, dryness, • Dermatitis • Distribution lesions or scaling of • Immune disorder intermediate vellus • Hygiene needs hair on scalp by 2 scalp • Hormonal disorder years of age • Age appropriate • Infestation • Behavioural disorder, such behavioural • Terminal hair is more • Matting as hair pulling management coarse, thick longer related to hair and pigmented and • Oily or dirty hair • Ectodermal dysplasia
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1 to 4 years - Area Within the Norm Common Deviations Possible Causes Specific Strategies
grows on the scalp • Precocious or delay in • Neglect and eyebrows body hair distribution • Stress or recent illness • Environmental exposure e.g. chlorine, frequent washing
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