• Perimenopause is the transition

MODULE #17 period leading to menopause.

●​ Female Reproductive System • Postmenopausal bleeding is any

Assessment bleeding occurring 6 months or more
after menses has stopped.
Phases of Reproductive Health
The five phases include prepuberty • Amenorrhea is the absence of menses.
before menstruation begins, puberty
marked by the first period or menarche, • Dysmenorrhea is pain, cramping, or
childbearing years involving regular aching in the lower abdomen during
menstruation, perimenopausal transition menses.
years, and menopause which is the end
of menses. • Premenstrual syndrome or PMS is a
group of emotional and physical
Reproductive Health History symptoms occurring 5 days before
The history consists of three parts: menses for three cycles in a row.
menstrual, obstetric, and sexual history.
Nurses should start with menstrual and • Abnormal uterine bleeding is
obstetric questions to help the patient bleeding between periods or flow that is
feel comfortable before asking about infrequent, excessive, or prolonged.
sexual history. If a patient has a specific
sexual problem, the nurse follows their • Frequency is the time from the first
lead. If no problem is reported, the nurse day of one period to the first day of the
obtains a baseline history starting with next, usually 24 to 32 days.
menses.
• Duration is how many days the flow
Menstrual History Terms lasts, typically 3 to 7 days.
Menstrual history focuses on the
monthly flow of bloody fluid from the Obstetric and Sexual Health History
uterus known as menses. Obstetric history covers pregnancies,
contraception use, and vulvovaginal
• Menarche is the age when menses symptoms. When taking a sexual history,
starts. the nurse explains why the questions are
asked, acknowledges the personal nature
• Menopause is the absence of menses of the info, encourages openness,
for 12 months, usually occurring mentions that these questions are asked
between ages 48 and 55. of all patients, and ensures
confidentiality.
 • Abnormal findings include no pubic
This history includes sexual orientation, hair by age 13, swelling, lesions,
gender identity, sexual response, and foul-smelling discharge, or hard areas
history of sexually transmitted infections along the urethra.
or STIs.
External Palpation Procedure
External Physical Examination • The nurse uses water-soluble lubricant
The nurse inspects the mons pubis, labia on gloved fingers to prevent trauma.
majora and minora, urethral meatus,
clitoris, vaginal introitus, and perineum. • The index finger is inserted into the
vagina to milk the urethra by applying
• The skin color is assessed and hair pressure up and out; this should be
distribution should follow an inverted painless and free of discharge.
triangle.
• To assess Bartholin’s glands, the nurse
• Labia majora should be symmetric palpates the back of the labia majora
and plump. In women who haven't given with an index finger inside and thumb
birth, the labia meet in the middle; after outside; it should feel soft. Pain or
delivery, they may be gaping and swelling here is abnormal.
shriveled. There should be no lesions.
• To check pelvic muscles, the nurse
• The labia majora are separated to palpates the perineum, which feels thick
check the clitoris for nodules or rashes and muscular in women who haven't
and the labia minora, which should be given birth and thin in those who have.
dark pink, moist, and symmetric.
• The patient is asked to squeeze the
• The urethral opening is a slit located vaginal opening around the fingers to
in the midline. check tone.

• The vaginal opening or introitus • The nurse separates the vaginal orifice
appears as a narrow vertical slit or larger and asks the patient to bear down to
opening. check for bulging walls or urinary
incontinence.
• The perineum is smooth; a healed Internal Speculum Examination
episiotomy scar may be present if the Procedure
patient has given birth.
• The nurse selects the correct speculum
• The anus has darker, coarse skin. size and lubricates it with warm water.
• To ease insertion, the nurse pushes the
introitus down and asks the patient to ●​ Male Reproductive System
bear down to relax muscles. Assessment

• The speculum is inserted at a 45-degree The Penis

angle downward to follow the natural Inspection involves checking the skin,
curve of the vagina. which is normally wrinkled and hairless.

• The blades are opened to view the • The dorsal vein is often visible.
cervix and its opening or os.
• The glans penis should be smooth.
• The cervical mucosa is normally pink.
It appears blue during the second month • If uncircumcised, the foreskin is
of pregnancy (Chadwick’s sign) and retracted to inspect the area and then slid
pale after menopause. back; it should move easily.

• The cervix is midline and projects 1 to • The urethral meatus should be in the
3 cm into the vagina with a diameter of center of the tip.
2.5 cm.
• Pubic hair at the base should be
• The os is small and round in women appropriate for age and free of lice.
who haven't given birth and a horizontal • Palpation involves compressing the
slit in those who have. glans to check the meatus, which should
be pink and smooth without discharge.
• Secretions should be odorless and can
be clear, thin, or thick depending on the The Scrotum
menstrual cycle. The nurse inspects the scrotum while the
patient holds the penis away.
Cervical Smears and Health
Promotion • Scrotal size changes with temperature.

Papanicolaou (Pap) smears are used to • The left side is usually lower than the
detect cancer cells. Specimens should not right.
be collected during menstruation.
Patients must avoid douching, • The nurse spreads the skin folds (rugae)
intercourse, or putting anything in the to check the back surface.
vagina for 24 hours before the test.
Health promotion includes education • Sebaceous cysts (firm, non-tender 1 cm
on menopause, cancer screening, HPV, nodules) are common and normal.
prenatal care, family planning, and STIs.
• Palpation is done gently between the Domestic violence includes intimate
thumb and first two fingers. partner violence, child abuse, and elder
abuse.
• Testes should feel oval, firm, rubbery,
smooth, and non-tender. Nurses are responsible for assessing,
documenting, and reporting these
• The spermatic cord is palpated from serious health problems because they
the epididymis to the groin; it should feel affect every dimension of a person's life
smooth. and health.

• Transillumination is performed if a Intimate Partner Violence (IPV)

mass or swelling is found. This involves physical or sexual force, or
the threat of such violence.
Abnormal Male Findings
It also includes psychological and
• Penis: Inflammation, ulcers (chancre), emotional abuse or coercive tactics
warts, or phimosis (unable to retract between current or former spouses and
foreskin). non-marital partners, such as dating
couples.
• Meatus: Hypospadias (opening on the
underside), epispadias (opening on the Child Abuse and Neglect
topside), or discharge indicating Child abuse often occurs in homes
urethritis. where adult abuse is also present. It is
categorized into four main types:
• Scrotum/Testes: Swelling (may
indicate heart or renal failure), • Neglect is the failure to provide for a
cryptorchidism (undescended testes), child's basic physical, educational,
atrophied testes (small and soft), or medical, and emotional needs.
varicocele (dilated veins).
• Physical Abuse involves physical
• Priapism is a prolonged, painful injury from acts like punching, beating,
erection without sexual desire. kicking, biting, or shaking. These acts are
considered abuse if done purposely, even
if harm was not intended.

MODULE #18 • Sexual Abuse includes fondling,

incest, rape, sodomy, and commercial
Domestic Violence Assessment exploitation like prostitution or
Overview pornography.
• Emotional Abuse is a pattern of • The Abuse Assessment Screen
behavior harming a child's self-worth, (AAS) is a reliable tool for IPV.
including belittling, rejection, and
withholding love. • Nurses should introduce the topic by
explaining that violence is common and
Elder Abuse and Neglect they now ask all patients about it.
Elderly individuals are vulnerable to
abuse from family members and • Specific AAS questions include asking
caregivers. if the patient is afraid of their partner, if
the partner is emotionally abusive or
• Physical Abuse consists of violent acts controlling, and if there has been any
causing injury, pain, or disease. physical or forced sexual contact.

• Physical Neglect is the failure to • If a patient answers yes to any question,

provide basic goods like food, shelter, the nurse should thank them and ask for
and medication. more details about the last incident.
Screening for Elder and Vulnerable
• Psychological Abuse includes Persons
behaviors that cause mental anguish.
• The AMA Nine-question screen is
• Psychological Neglect is the failure to used for elderly patients who are
provide basic social interaction. cognitively intact.

• Financial Abuse is the intentional • Nurses must assess for cumulative

misuse of an elderly person's money or trauma, which leads to severe physical
resources without consent. and mental health issues.

• Financial Neglect is the failure to use • Survivors must receive a mental status
an elder's assets to provide for their exam to check for depression, suicidal
needed services. thoughts, PTSD, substance abuse, and
anxiety.
Screening Procedures and Tools
Nurses must use specific tools to identify Screening for Child Abuse
survivors and assess risks.
• Assessment must consider the child's
Screening for Intimate Partner age and developmental level; for
Violence example, a 6-month-old is not
Routine screening involves asking every developmentally able to climb and fall
woman at every health care visit if she from a chair.
has been abused by a partner.
• Indicators include multiple injuries in • Petechiae are tiny, round, purplish-red
different stages of healing, unexplained spots caused by minor bleeding under
fractures or burns, poor hygiene, and the skin.
venereal diseases.
• Puncture is a wound from a pointed
Physical Examination and object.
Terminology
A head-to-toe visual exam is required for • Stab Wound is a sharp injury that is
survivors. Common medical forensic deeper than it is wide.
terms include:
• Hematoma is a collection of blood
• Abrasion is a wound from rubbing the often caused by blunt force.
skin.
Specific Examination Findings
• Avulsion is the tearing away of a body
structure. • Bruises on the neck, ears, genitalia, or
soles of the feet in elders are concerning.
• Bruise (Ecchymosis/Contusion) is
discoloration from ruptured blood • Bruising in infants who cannot yet
vessels without broken skin. crawl (under 9 months) is a high alert for
abuse.
• Hemorrhage is blood escaping from a
vessel, which can be internal or external. • Bruises on the buttocks, hands, feet, or
abdomen of children are suspicious,
• Incision (Cut) is a wound made by a whereas bruises over bony prominences
sharp instrument. on the front of the body are common in
walking children.
• Laceration is a wound from tearing or
splitting tissue, usually from blunt Documentation Standards
impact over bone. Documentation must be detailed,
non-biased, and include injury maps or
• Lesion is any traumatic discontinuity photographs.
of tissue or loss of function.
• Histories of abuse should be
• Patterned Injury is a wound leaving a documented verbatim (word-for-word).
distinct print from an object, like an
extension cord or "glove" burns. • Do not "sanitize" or soften the
language; including the perpetrator's
curses or threats is useful for court
proceedings.
• Use the child's own words to describe Give a clean gown for comfort and
how an injury happened; if the child is hygiene.
non-verbal, use the caregiver's words.
2. EQUIPMENT – Tools and Uses
Assessing Risk of Homicide Equipment are tools used to assess
different body systems and gather
• The Danger Assessment (DA) is a accurate data.
valid tool used to determine the risk of
homicide for abused patients. Medical mechanical physician scale is
used to measure the patient’s weight.
• Research indicates that homicide
victims typically scored an average of 7.1 Digital thermometer is used to check
on the original 15-item DA. body temperature.

Stethoscope is used to listen to heart,

lung, and bowel sounds.
MODULE #19
Manual aneroid sphygmomanometer
PUTTING IT ALL TOGETHER is used to measure blood pressure.
Complete physical assessment is a
step-by-step process to gather full patient Penlight is used to check pupil reaction
data, including preparation, equipment and inspect the mouth or throat.
use, and systematic examination.
Tongue depressor is used to hold down
1. THE PATIENT – Preparation the tongue for oral examination.
Preparation means getting the patient
ready physically and mentally before the Ophthalmoscope is used to examine the
procedure. eyes internally.

Prepare the patient physically and Otoscope is used to inspect the ears.
psychologically to reduce anxiety.
Tuning fork is used to assess hearing
Provide privacy by closing the door or and vibration sense.
curtains to avoid embarrassment.
Taylor reflex hammer is used to test
Explain the procedure, what will reflexes.
happen, and what the patient should do
to gain cooperation. Gloves are used to maintain cleanliness
and prevent infection.
Pulse oximeter is used to measure Parts of Health History:
oxygen level in the blood.
Biographic data includes name,
Cusco vaginal speculum is used to address, contact number, age, and
examine the vaginal canal. birthdate.

Soft measuring tape is used to measure Chief complaint is the main reason for
body parts like head, chest, or abdomen. seeking care.

Snellen chart is used to test visual History of present illness explains

acuity. current condition in detail.

Wristwatch is used to count pulse and Past health history includes previous
respiration accurately. illnesses or treatments.

3. SEQUENCE OF COMPLETE Family history identifies genetic or

PHYSICAL ASSESSMENT hereditary conditions.
Sequence is the correct order of steps in
examining the patient. Lifestyle and personal habits include
daily activities and behaviors.
Upon entering, wash hands, introduce
self, explain purpose, and start history Review of systems checks each body
taking while the patient is seated and system for symptoms.
dressed.
Functional assessment evaluates ability
General observation is done during the to perform daily activities.
interview and throughout the
assessment. PATIENT SEATED – Initial
Assessment
THE HEALTH HISTORY – Patient seated means the patient is sitting
Meaning and Parts during assessment.
Health history is the collection of
subjective data from the patient. General survey and observation
assesses surroundings and patient
Purpose is to collect subjective appearance.
information.
Mental status checks awareness,
Use proper communication or interview behavior, and thinking.
techniques.
Vital signs include temperature, pulse, Cardiovascular checks heart and blood
respiration, blood pressure, and pain. flow.
Body measurement includes height and
weight. Breast examination assesses breast
tissue further.
Integument examines skin, hair, and
nails. Abdomen examines organs and
digestion.
Head, face, and eyes assess structure
and function. Peripheral vascular checks circulation
in limbs.
Ears check hearing and condition.
Musculoskeletal (lower body) assesses
Nose and sinuses assess airflow and legs, joints, and movement.
tenderness.
PATIENT SEATED – Follow-up
Mouth and pharynx examine oral Assessment
cavity and throat.
Patient returns to sitting position.
Neck checks lymph nodes and
movement. Musculoskeletal (upper body) assesses
arms and upper joints.
Posterior thorax examines back and
lungs. Neurologic motor checks movement
and strength.
Anterior thorax examines chest and
breathing. Neurologic sensory checks sensation
like touch and pain.
Cardiac and breast assess heart and
breast condition. PATIENT STANDING – Final
Assessment
Axillary nodes check lymph nodes in
the armpit. Patient stands for last part of
examination.
PATIENT LYING DOWN – Supine
Assessment Musculoskeletal (spine) checks posture
and spinal alignment.
Patient lying down means the patient is
flat on the bed. Neurologic assesses balance and
coordination.
Visual acuity measures clarity of vision Cognitive and language development
using eye chart. includes thinking, learning, and
communication.

Social and emotional development

MODULE #20 includes relationships and feelings.

FOUR PRINCIPLES OF CHILD THE HEALTH HISTORY – Parts

DEVELOPMENT Health history collects background and
These are general rules that explain how health information of the infant.
children grow and develop.
Birth history includes details during
Child development follows a predictable pregnancy and delivery.
pattern or sequence.
Past history includes previous illnesses or
Normal development has a wide range, conditions.
meaning children can develop at
different speeds. Family history includes genetic or
hereditary conditions.
Physical, social, environmental factors,
and diseases can affect development and Health maintenance includes
health. immunizations and routine care.
Health patterns include daily habits and
Developmental level affects how history behaviors.
taking and physical examination are
done. TESTING FOR
DEVELOPMENTAL MILESTONES
ASSESSING THE INFANT – Milestones are skills expected at certain
Overview ages.
Assessment of infants includes
development, health history, milestones, Denver II is used to assess developmental
and physical exam. progress.

DEVELOPMENT – Areas PHYSICAL EXAMINATION OF

Development refers to growth and THE INFANT – Overview
changes in abilities. Systematic check of the infant’s body
and functions.
Physical development includes body
growth and changes. General survey and vital signs assess
overall condition.
Somatic growth measures body size. Posterior fontanelle measures 1 to 2 cm
and closes by 2 months.
Length, weight, and head circumference
are measured. Skull symmetry and head circumference
assess shape and size.
Vital signs include blood pressure, pulse,
respiratory rate, and temperature. Plagiocephaly is flattening of one side of
the head due to position.
THE SKIN – Description
Skin assessment includes normal Macrocephaly is abnormally large head.
markings.
Microcephaly is abnormally small head.
Benign birthmarks are harmless skin
findings. Facial symmetry checks equal facial
features.
Eyelid patch is a light mark on eyelids.
Position in the womb may cause
Café-au-lait spot is a light brown patch. temporary asymmetry.

Salmon patch is a pink mark often on Flexed head may cause small chin called
neck or face. micrognathia.

Mongolian spot is a bluish patch usually EYES, EARS, NOSE, MOUTH,

on lower back. AND NECK – Assessment
Eyes are checked for movement and
THE HEAD – Structure and tracking.
Assessment
Head assessment includes skull, Colorful toys help assess focus.
symmetry, and size.
Newborns may follow light when alert.
Sutures and fontanelles are openings and
joints of the skull. By 2 months, infants can follow objects.
Some infants may have temporary
Sutures feel like ridges and fontanelles crossed or deviated eyes.
feel soft.
Visual acuity cannot be measured in
Anterior fontanelle measures 4 to 6 cm infants.
at birth and closes at 4 to 26 months.
Ears are assessed for position and shape.
Pull auricle downward to view eardrum Assess general appearance, respiratory
because canal is downward. rate, color, nasal flaring, breath sounds,
and effort.
Nose and sinuses are checked for airflow.
Palpation includes checking tactile
Test nasal patency. fremitus.

Infants are obligate nose breathers. Auscultation includes listening to breath

sounds.
Do not block both nose and mouth at
the same time. Infant breath sounds are louder and
harsher.
Mouth and pharynx are examined for
structure. Check for normal and abnormal sounds.

Newborns have no teeth and smooth THE HEART – Assessment

gums. Heart assessment checks circulation and
function.
Epstein pearls are small white cysts on
the palate that disappear. Inspection includes checking for
cyanosis and overall health.
Observe for abnormal cry.
Observe breathing pattern to
Neck is assessed for lymph nodes and differentiate heart and lung problems.
masses.
Palpation includes checking pulses.
Check for congenital cysts.
Brachial pulse is easier than radial in
Palpate clavicles for possible fractures. infants.

THORAX AND LUNGS – Check femoral, dorsalis pedis, and

Assessment posterior tibial pulses.
Thorax and lungs are assessed for
breathing and respiratory status. Assess apical impulse, chest wall, and
thrills.
Inspection includes observing breathing
before touching the infant. Auscultation includes listening to heart
rhythm and sounds.
Heart sounds are easier to hear than feel GENITALIA AND RECTUM –
in infants. Assessment

Assess third and fourth heart sounds and Male genitalia are inspected for
murmurs. structure.

THE ABDOMEN – Assessment Foreskin covers glans and is not

Abdomen assessment checks digestion retractable at birth.
and organs.
Check penis shaft and straightness.
Inspection shows a rounded abdomen
due to weak muscles. Inspect scrotum and rugae.

Blood vessels and movements are visible. Check testes and inguinal area.

Check umbilicus for redness or swelling. Assess for hydrocele and hernia.

Check for diastasis recti. Female genitalia are inspected for

structure.
Auscultation detects bowel sounds.
Labia color varies depending on skin
Increased sounds may indicate tone.
gastroenteritis or obstruction.
Assess clitoris, labia majora and minora,
Percussion produces more tympanic urethral opening, and hymen.
sounds due to swallowed air.
Rectum is usually not examined.
Used to assess organ size and masses.
Check anal opening and abdominal
Palpation is done with legs flexed. masses.

Use one hand to hold legs and one to Refer if imperforate anus is present.
palpate.
MUSCULOSKELETAL SYSTEM –
Start with liver from lower abdomen Assessment
upward. Musculoskeletal system includes bones,
joints, and movement.
Palpate liver, spleen, and other
structures. Palpate clavicle for lumps or fractures.
Inspect spine for skin changes like spots Cranial nerves are tested using
or pits. infant-specific methods.

Palpate lumbosacral spine for Deep tendon reflexes may vary due to
deformities. immature nervous system.

Barlow test checks hip stability; positive Babinski reflex is normal and shows toe
means possible dislocation. extension.

Ortolani test checks hip dislocation with Primitive reflexes are automatic
limited movement. responses present at birth.

Galeazzi or Allis test checks leg length Palmar grasp reflex holds objects.
difference. Plantar grasp reflex curls toes.

NERVOUS SYSTEM – Assessment Moro reflex is startle response.

Nervous system includes brain, nerves, Asymmetric tonic neck reflex shows
and responses. head turning response.

Mental status checks alertness and Positive support reflex supports weight
response to faces and voices. briefly.

Behavior should match age. Rooting reflex helps find food.

Motor function checks tone and Trunk incurvation reflex curves body
movement. when stroked.

Observe resting position and resistance Stepping reflex mimics walking.

to movement. Landau reflex shows body extension.
Parachute reflex protects from falling.
Move joints and check for stiffness or
flaccidity. Development is further assessed using
milestones or Denver II test.
Sensory function checks response to
pain.

Flick palm or sole and observe reaction.

Do not use sharp objects.

 Toddlers transition from learning
through touch (sensorimotor) to
symbolic thinking and simple
MODULE #21 problem-solving.

CHILD DEVELOPMENT They generally remain focused on the

OVERVIEW present with limited understanding of
Developmental stages are divided into abstractions.
early childhood (1 to 4 years) and
middle childhood (5 to 10 years). Language grows rapidly: an
18-month-old uses 10 to 20 words, a
Physical Development 2-year-old uses three-word sentences, and
Growth slows to about half the rate of a 3-year-old converses well.
infancy after the first year. After age 2,
children typically gain 2 to 3 kg and By age 4, they use complex sentences but
grow 5 cm annually. lack sustained logical thought.
School-aged children become "concrete
Toddlers lose their "chubby" appearance operational," capable of limited logic.
and become leaner and more muscular
preschoolers. A major task in this stage is developing
self-efficacy to thrive in various
Gross motor skills progress from walking situations.
at 15 months to running by age 2 and
pedaling a tricycle by age 4. Social and Emotional Development
Toddlers strive for independence but are
Fine motor skills advance from impulsive, leading to common temper
scribbling at 18 months to drawing lines tantrums.
at age 2 and circles by age 4.
As they age, children initiate more
In middle childhood, growth is steady activities and gain self-esteem through
but slower, while coordination and achievements in family, school, and peer
strength improve significantly. groups.

This is also when children with Guilt or poor self-esteem can also emerge
disabilities become more aware of their depending on their environment. Moral
physical limitations. development at this stage is simple,
focusing on a concrete sense of right and
Cognitive and Language wrong.
Development
THE HEALTH HISTORY
The health history is a continuous For children under 3 who cannot use eye
process updated at every visit, or charts, assess fixation preference.
performed completely for new patients.
1.​ Cover one eye at a time.
Observation and Interaction 2.​ Observe the child's reaction; a
The exam allows for the observation of child with normal vision will not object
parent-child interactions to assess to a cover, but a child with poor vision in
"goodness of fit" and age-appropriate one eye will object when their "good" eye
behavior. is covered.

Unstructured play in the room can reveal 3.​ Ensure both eyes show the
physical or cognitive abnormalities. same result.
While toddlers may be uncooperative or 4.​ For the cover-uncover test, turn
terrified initially, most eventually warm it into a game by asking the child to look
up; persistent uncooperative behavior at your nose or tell if you are smiling.
may suggest underlying issues.
●​ The Ears
Older children are generally more Examination techniques change as the
cooperative due to better self-control. ear canal develops.

PHYSICAL EXAMINATION: Otoscopic Exam Procedure

SENSORY AND HEAD 1.​ For children under 3, pull the
auricle downward and backward because
●​ The Eyes the canal is directed downward.
The primary goals are checking visual
acuity and ensuring the gaze is conjugate 2.​ For children over 3, pull the
(symmetric). auricle upward and backward as the
canal assumes an adult-like slope.
Conjugate Gaze and Fields
Assess the alignment of the eyes and 3.​ Use one hand to hold the
extraocular muscle function. child's head and pull the auricle, and the
other hand to position the otoscope.
The corneal light reflex and
cover-uncover tests are highly effective. Hearing Test Procedure (Whispered
For visual fields, have the child sit on a Voice)
parent's lap and bring an object into 1.​ Stand behind the child so they
their field of vision from behind. cannot read your lips.

Visual Acuity Procedure 2.​ Cover one ear canal and rub
the tragus in a circular motion.
3.​ Whisper letters, numbers, or a Assessment: Check for neck mobility.
word and ask the child to repeat them. In children, nuchal rigidity (neck
stiffness) is a more reliable sign of
4.​ Repeat for the other ear. meningeal irritation than the Brudzinski
or Kernig signs.
The Nose, Sinuses, Mouth, and
Pharynx PHYSICAL EXAMINATION:
Nasal membranes and septal alignment BODY SYSTEMS
are inspected using an otoscope
speculum. ●​ Thorax and Lungs
Auscultation is easiest when the child is
Maxillary sinuses are visible on X-ray by distracted or on a parent's lap. The
age 4, sphenoid by age 6, and frontal by normal ratio of inspiration to expiration
age 6 or 7. is 1:1.

Mouth and Pharynx Procedure Breathing Assessment Procedure

1.​ Perform this late in the exam 1.​ Let fearful toddlers play with
for anxious children. the stethoscope first.
2.​ Have the child sit on the 2.​ Do not ask preschoolers to
parent's lap. "take deep breaths," as they often hold
their breath; let them breathe normally
3.​ Ask the child to say "ahhh" to instead.
view the pharynx; if they cooperate, a
tongue blade may not be needed. 3.​ For older children,
4.​ If a tongue blade is necessary, demonstrate quiet, deep breaths as a
push down and pull slightly forward. Do game.
not place it too far back to avoid the gag 4.​ Use a "forced expiratory
reflex. maneuver" by asking the child to blow
out imaginary birthday candles.
5.​ Inspect teeth for eruption
timing, number, and condition. ●​ The Heart
Benign murmurs are common in
●​ The Neck preschoolers and school-aged children.
Lymphadenopathy (enlarged nodes) is The "Still murmur" is musical and
common in childhood, peaking between vibratory, heard at the left sternal border.
ages 8 and 16.
Heart Exam Procedure
Most enlarged nodes are due to infection 1.​ Distract the child by giving
rather than malignancy. them an object to hold in each hand so
they cannot push you away.
2.​ Use constant "chatter" to keep the child is relaxed and your hands are
their attention. warm.

3.​ A 2-year-old can be examined 2.​ Palpate the lower abdomen and
while sitting on a parent's lap facing the work downward toward the scrotum
parent's shoulder. along the inguinal canal.

4.​ To check a Still murmur, 3.​ Have the boy sit cross-legged to
compress the carotid artery; the murmur minimize retraction.
should disappear.
4.​ To test the reflex, scratch the
●​ The Abdomen medial thigh; the testis on that side
Toddlers often have protuberant should move upward.
(rounded) abdomens.
Female Genitalia Procedure
Palpation Procedure 1.​ Use the "frog-leg" position on
1.​ Place the whole hand flush on the exam table or parent's lap.
the surface for a few moments to reduce
ticklishness before probing. 2.​ Avoid using stirrups.

2.​ If the child is sensitive, place 3.​ Separate the labia with fingers
their hand under yours during palpation. to visualize structures.

3.​ Flex the knees and hips to relax 4.​ Avoid touching the hymenal
the abdominal wall. edges, as they are very tender.

4.​ Palpate lightly in all areas first, 5.​ Check for discharge, labial
then deeply. adhesions (fused labia), or signs of abuse.

5.​ Save the area of suspected pain Musculoskeletal System

or pathology for last. Observe the child standing and walking
barefoot to detect abnormalities like
●​ Genitalia scoliosis or gait issues. Children may "toe
This can be anxiety-provoking; explain in" until age 4, which usually disappears
that it is a routine part of the exam. by age 10.

Male Genitalia Procedure Hip and Gait Procedure

1.​ To prevent the cremasteric 1.​ Check for hip disease using the
reflex (testis retracting upward), ensure Trendelenburg sign: watch the child
shift weight from one leg to the other
from behind.

2.​ A negative sign means the

MODULE #22
pelvis stays level.
Adolescent Physical Assessment
3.​ A positive sign (hip disease) Guide
means the pelvis tilts toward the
unaffected hip when weight is on the General Assessment Principles
affected side. Interview and examination techniques
change based on the adolescent's
THE NERVOUS SYSTEM physical, mental, and social
The exam combines neurologic and development.
developmental assessments, often using
the DENVER II tool for children up to The provider should use a gentle and
age 6. reassuring approach because patients are
often anxious.
Neurologic Procedures
Vital Signs and Somatic Growth
• Sensation: Use a cotton ball with the Adolescents should wear gowns or
child's eyes closed; never use pins. remove shoes and heavy clothing for
weighing.
• Strength: Have the child lie on the
floor and stand up. Normally, they sit This is crucial when evaluating girls for
up, flex knees, and push off with arms. underweight issues.

• Coordination: Use toys for the upper Ongoing blood pressure monitoring is
extremities or "finger-to-nose" games for important.
cerebellar function.
Average heart rate for ages 10 to 14 is 85
• Reflexes: Demonstrate the hammer on beats per minute, with a normal range of
the child's hand first to show it doesn't 55 to 115.
hurt. To keep them relaxed, ask them to
pretend their limb is "asleep". Average heart rate for those 15 years and
older is 60 to 100 beats per minute.
• Cognition: Ask children over age 3 to
draw a picture and talk about it to test Skin, Head, Ears, Eyes, Nose, and
motor skills, language, and thought Throat
processes simultaneously. The examination of the head, ears, eyes,
throat, and neck is the same as in adults.
Carefully check the skin for lesions like Breast stage 4 occurs when the areola
acne, pimples, blemishes, and moles, as forms a secondary mound above the
these are common teen concerns. breast contour.

Look for signs of tanning and use the Breast stage 5 is fully mature with a
exam to counsel on the dangers of smooth contour as the secondary mound
ultraviolet exposure, tanning salons, and recedes.
the need for sunscreen.
Menarche typically occurs during breast
Teach the adolescent how to perform stage 3 or 4, after the peak growth spurt.
regular skin self-examinations.
Older girls should receive a full breast
Heart Examination exam and instructions on
Techniques and sequences match adult self-examination.
exams.
A second person, such as a parent or
Murmurs are the primary cardiovascular another provider, should be present
issue for evaluation. during the exam.

A benign pulmonary flow murmur is a In boys, puberty may cause a firm

grade I-II/VI soft, nonharsh sound that button of tissue 2 cm or larger in one
starts after the first heart sound and ends breast for about one-third of individuals,
before the second. while obese boys may develop
substantial tissue.
Breast Development and
Examination Abdomen
Breast changes are often the first sign of Techniques are the same as for adults.
puberty in girls and follow a systematic The liver size increases toward adult size
5-stage progression called Tanner stages during puberty and correlates with the
over about four years. patient's overall height.

Breast stage 1 is prepubertal with Female Genitalia

elevation only of the nipple. The external exam is similar to that for
school-age children. A first pelvic exam
Breast stage 2 involves the formation of a should be done by an experienced
"breast bud" below the areola. provider; if a full pelvic exam is needed,
adult techniques are used.
Breast stage 3 shows further enlargement
of the breast and areola without
separation of their contours.
Initial puberty signs include hymenal Stage 3 shows darker, curlier hair that
changes from estrogen, hip widening, increases in quantity.
and the start of a height spurt.
Stage 4 hair resembles adult hair but
The first easily detectable sign is usually covers a smaller area.
breast buds, though pubic hair can
appear as early as age 7. Stage 5 hair is adult in volume and
spreads to the inner thighs.
Every female should be assigned a sexual
maturity rating (SMR) based on breast In 80% of men, hair continues to spread
and pubic hair development. toward the umbilicus in a triangle until
their 20s.
Male Genitalia
The exam follows adult male procedures, Musculoskeletal and Scoliosis
but providers must be sensitive to the Assessment
patient's potential embarrassment. General musculoskeletal exams are the
same as for adults, focusing heavily on
The first reliable sign of puberty is scoliosis and sports participation
increased testicular size, occurring screenings.
between ages 9 and 13.5.
Procedure for Scoliosis Assessment:
This is followed by pubic hair Check for asymmetry of the shoulder
appearance and penis enlargement. blades or gluteal folds while the patient
stands.
The full transition to adult anatomy
takes about 3 years on average, with a Perform the Adams bend test by having
range of 1.8 to 5 years. the teen bend forward with knees
straight.
Every male should be assigned a sexual
maturity rating based on changes in the Observe the patient from behind to look
penis, testes, and scrotum. for rib prominence or gait asymmetry.

Pubic Hair Stages (Tanner Staging) If scoliosis is suspected, use a scoliometer

Stage 1 is prepubertal with only fine at the point of maximum prominence.
vellus hair like that on the abdomen.
Ensure the spine is parallel to the floor
Stage 2 involves sparse, straight hair at during measurement.
the base of the penis or along the labia.
Have the patient bend fully forward for Pacemaker cells in the heart decline,
lumbar assessment and less so for which affects how the body handles
thoracic assessment. physical stress.

Use a plumb line dropped from C-7; it Respiratory rate remains unchanged
should extend straight to the gluteal with age.
crease.
Temperature regulation weakens,
Nervous System making older adults more likely to get
The neurologic exam is identical to an hypothermia.
adult's. Providers must still assess if the
adolescent is meeting age-specific ●​ Skin, Nails, and Hair
developmental milestones. These parts show visible signs of aging
related to tissue loss and pigment
changes.

MODULE #23 Skin loses turgor, becomes loose,

wrinkles, and looks paler or more
Physical Assessment of Older Adults opaque.

●​ Vital Signs Actinic purpura are purple patches on

Vital signs measure the body’s basic the forearms and hands caused by blood
functions and indicate how the leaking from thin capillaries.
cardiovascular and respiratory systems
are adapting to age. Nails may turn yellow, thicken, and lose
their shine, especially on the toes.
Systolic blood pressure often rises
because the aorta and large arteries Scalp hair loses pigment and turns gray.
stiffen.
Hair loss on the scalp is common in both
Widened pulse pressure occurs men and women, with hairs becoming
because diastolic blood pressure stops thinner in diameter.
rising around age 60.
Normal hair loss also occurs on the
Orthostatic hypotension is a sudden trunk, limbs, armpits, and pubic areas.
drop in blood pressure that happens
when standing up. Women over age 55 may develop coarse
hair on the chin and upper lip.
Resting heart rate stays the same, but the
maximum heart rate decreases. ●​ Eyes and Vision
Aging affects the clarity and focus of the higher tones are lost while lower tones
eyes due to changes in the lens and remain.
pupils.
●​ Mouth, Teeth, and Neck
Pupils become smaller and may look Structural changes in the mouth can
slightly irregular, though they still react affect taste, eating, and facial appearance.
to light.
Saliva production decreases and the sense
Visual acuity stays stable until age 50, of taste changes.
drops slowly until age 70, and then
drops fast. Sensitivity to saltiness and bitterness
increases, while the sense of smell
Presbyopia is the loss of near-vision decreases.
focus caused by the lens losing its
elasticity. Teeth may wear down or be lost due to
cavities or periodontal disease.
Cataracts involve the yellowing and
thickening of the lens, which blocks If teeth are missing, the lower face looks
light. sunken with wrinkles around the mouth.

Glaucoma risk increases because the Angular cheilitis is the breakdown of

growing lens can push the iris forward skin at the corners of the mouth.
and narrow the eye's internal angle.
Jaw bones are slowly absorbed by the
●​ Hearing body over time.
Hearing loss often affects the ability to
process specific sound frequencies. Cervical lymph nodes become harder to
feel, but submandibular glands become
Acuity of hearing usually drops as people easier to feel.
get older.
●​ Heart and Blood Vessels
Early hearing loss starts with Changes in the heart and arteries can
high-pitched sounds that are outside the lead to new sounds and physical
range of human speech. markings in the neck.

Presbycusis is the age-related hearing A tortuous or kinked carotid artery in

loss that becomes obvious after age 50. the neck may look like a pulsing mass.
Systolic bruits in the neck of an older
Words may sound distorted or hard to adult might suggest partial artery
understand in noisy rooms because blockage.
 Signs of serious stomach disease, like
An S3 heart sound after age 40 often pain or fever, may be muted or absent in
suggests heart failure or volume overload. older adults.

An S4 heart sound is common in healthy ●​ Musculoskeletal System

older people but can indicate stiff heart Aging causes a loss of height and changes
ventricles. in the strength of muscles and joints.

Systolic aortic murmurs are very Height loss occurs because intervertebral
common due to the thickening and discs thin and the spine shortens.
calcification of the aortic valves.
Kyphosis is the curving of the upper
Aortic sclerosis is the process of valve back that increases the chest's
thickening that usually does not block front-to-back diameter.
blood flow.
Limbs may look long compared to the
Peripheral arteries may feel harder and trunk because of the shortening of the
longer, but this does not always mean spine.
disease is present.
Skeletal muscles lose bulk and power,
●​ Breasts and Abdomen and ligaments lose strength.
Fat redistribution and tissue atrophy
change the shape and feel of the torso. Range of motion in the joints decreases
due to osteoarthritis.
Female breasts become smaller, flaccid,
and pendulous as glandular tissue turns ●​ Mental Status and Nervous
into fat. System
Brain and nerve function changes can
Ducts around the nipple may feel like affect memory, speed, and physical
firm or stringy strands. reflexes.

Axillary hair decreases. Benign forgetfulness is the normal

difficulty of recalling names or small
Fat tends to accumulate in the lower details.
abdomen and hips.
The abdomen may protrude more Information processing and learning
because the abdominal muscles become new materials happen more slowly.
weaker.
Significant life events, like retirement or
loss of friends, can impact mood and
affect.

Motor responses slow down, and agility

decreases.

Muscle wasting in the hands can create

hollow spaces between the thumb and
fingers.

Vibration sense is often lost in the feet

and ankles but stays in the fingers.

Reflexes in the ankles, abdomen, and gag

reflex may decrease or disappear entirely.

Position sense may occasionally diminish

or vanish.