Safety alertNuchal rigidity,pain with neck flexion or hyperextension of head,
may indicate meningeal irritation and possible meningitis.Report any shift in trachea (possible lung problem) or mass in the neck.Eye and Vision
Note size, symmetry, color, and movement of eye, as well as exterior
structures and spacing between the eyes. Report deviations from expected
straight palpebral fissures (upward slant normally noted in Asian clients).
Down syndrome may be characterized by epicanthal folds, upward
palpebral slant, and hypertelorism(large spacing between eyes).
Eyelids should be smooth without drooping or malposition; note blink
reflex.
Examine pupil for roundness, equal size, reactivity to light, accommo-
dation, and size, color, and clarity of iris (black and white speckling seen
in Down syndrome).
Lens of the eye normally not visible; white or gray spots could indicate
cataracts.
Report unusual eye movement, strabismus, excessively cross eyed.
Prepare child for eye exam with ophthalmoscope, by showing instrument
and explaining that light will be bright. Red reflex presence can rule out
many conditions.
Vision testing should be age appropriate; use Snellen chart for older children.Ears and Hearing
Inspect external ear structures for alignment, general hygiene, presence
and amount of wax (can view partially without otoscope).
Infant and children should respond to human voice.
Use a game approach to encourage child’s cooperation.Safety alert Gently restrain infant and young child during otoscope use to
avoid injury.Pull pinna of the ear down and back for infants and up and back for chil-
dren >3 years of age to straighten the ear canal and visualize the inner
ear structures.
Auditory testing should be appropriate to age, ranging from loud noise
to elicit startle reflex in infants to use of audiometry for detection of type
and degree of hearing loss, if present.Mouth, Throat, Nose, Sinuses, and Neck
History can reveal high-risk circumstances: Frequent oral lesions, dental
problems, or nose bleeds require in-depth examination.(^40) Pediatric Nursing Demystified