Comparison Of The Physical Assessment Of Children By A Pediatric Nurse

1. This report is an evaluation of the ability of pediatric nurse practitioners
to perform accurate, comprehensive physical examinations by comparing
their appraisal with that made by pediatricians. The study demon-
strates the competence of the nurse practitioners trained
in this program.
COMPARISON OF THE PHYSICAL ASSESSMENT OF
CHILDREN BY PEDIATRIC NURSE PRACTITIONERS
AND PEDIATRICIANS
Burris Duncan, M.D.; Ann N. Smith, R.N., M.S.; Henry K. Silver, M.D.
THE pediatric nurse practitioner pro- practitioners. A pediatrician from a
gram developed by Silver et all2 pre- three-man private office was available
pares nurses to assume a significantly one-half day per week to see patients in
expanded role in meeting the health consultation and to provide medical
needs of children. The program consists supervision. Periodic evaluation of all
of a four-month course of intensive children was carried out by a physician.
theory and practice in pediatrics at a When a physician was not available in
medical center. Nurses increase their the office, a physician could be reached
skills and become capable of assessing by telephone for consultation. Children
and managing the total care of the well could also be referred to a neighborhood
child, as well as a variety of acute and health center several miles away for
chronic disorders which together make further evaluation and care by pediatri-
up the majority of the problems seen in cians.
the office practice of pediatrics. This re- All initial assessments of children com-
port evaluates the ability of pediatric ing to the health station were performed
nurse practitioners to perform accurate by nurse practitioners. In the year of the
and comprehensive physical assessments study, there were 4,600 patient visits to
by comparing the nurse's appraisal of the the health station; slightly over half of
physical status of children with that of the visits were for well child care and in
pediatricians. approximately one-half of the remaining
visits, the child was brought in for a
Method minor illness or other medical problem
which was managed by the nurse without
The children in this study were seen referral to a physician. Physicians and
at Denver's Stapleton Health Station nurses recorded the pertinent and sig-
located in a remodeled apartment in a nificant physical findings of all children
low-income housing project in a medically seen at the health station or in consulta-
isolated area with no readily accessible tion at some other facility. These became
physicians or health facilities. The health a part of the child's health record.
station was staffed by two pediatric nurse To determine the accuracy of the
1170 VOL. 61. NO. 6. A.J.PFH.

2. PHYSICAL ASSESSMENT OF CHILDREN
pediatric nurse practitioner's assessment, those where a significant difference ex-
a comparison of the nurse's assessment isted between the assessment of a condi-
with that of a pediatrician was made by tion by the physician and a nurse, and
reviewing clinic charts. In an unselected those where a difference in assessment
consecutive series of charts that were was present, but where the difference
reviewed, 182 children were first seen was not considered to be significant. Sig-
by the nurse and subsequently by a nificant difference was defined as apply-
pediatrician. Each of the 182 children ing to an incorrect assessment or a failure
had one or more physical "conditions" to recognize a condition which could be
which could and should have been noted favorably affected by treatment.
by the nurse. Wellness, any significant
deviation from normal, or any illness or Results
injury were all considered as "condi-
tions". Many children were found to There was total agreement in the find-
have more than one condition on a single ings of the pediatric nurse practitioner
examination; a total of 278 conditions and the consulting pediatrician in 239
were noted by the nurses and/or physi. of the 278 conditions noted in the 182
cians in the 182 children in this study. children in this study (Tables 1 and
Chronic or static conditions or deviations 2A). There was a difference in assess-
were counted only once. The ability to ment of 39 conditions (Table 2B). In
obtain historical information or to 37, the difference in assessment was not
evaluate subjective complaints or labora- considered to be significant. These in-
tory results was not evaluated in this cluded several cases where the nurse felt
study. that the tympanic membranes were sig-
The assessments by nurses and phy- nificantly injected while the physician
sicians of the 278 conditions were di- did not; two instances where the nurse
vided into (1) those where the assess- reported hearing a heart murmur which
ment was in total agreement by both was not heard by the physician; and
health professionals, and, (2) those that four occasions where the physician heard
were assessed differently by the two. an innocent murmur which was not re.
The latter were further subdivided into ported by the nurse. In only two in-
stances (0.7%o) was the difference be-
Table I-Comparison of the assessment tween the nurse's and physician's assess-
of the physical findings in 182 children ment considered to be significant. One
with 278 "conditions"* recorded by case involved a twelve-month-old boy
both pediatric nurse practitioners who had fever, cough and lethargy. The
(PNPs) and pediatricians (Peds) pediatric nurse practitioner noted ery-
Incidence Percentage thema of the throat and believed this
to be the primary site of his illness; she
PNP and Ped agree in felt the infant was sick enough to be re-
their assessment 239/278 86% ferred to a physician for further evalua-
PNP and Ped disagree tion and therapy. The physician agreed
in their assessment 39/278 14% with the nurse regarding the severity of
Disagreement- disease but felt the site of the disease
significant 2/278 0.7% primarily affected the lower respiratory
Disagreement- tract; a roentgenogram revealed patchy
not significant 37/278 13% infiltration of the left lung. The other
case with a significant difference in
* Wellness, any significant deviation of a physical
finding from niormal, or any illness or injury were all assessment involved a thirteen-month-old
considered to be "conditions". boy who had fever and erythema of the
JUNE, 1971 1171

3. Table 2A-"Conditions" present on physi- throat when evaluated by the nurse prac-
cal examination of 182 children seen titioner. At that time, the nurse did not
by pediatric nurse practitioners and feel that the child was sufficiently ill to
pediatricians
Conditions noted both by nurse and physician
need immediate referral to a physician;
she recommended that he be brought
Number of back to the health station the following
Condition times noted day. During the night, he developed in-
creased irritability and neck stiffness. He
Well child 63 was seen by a physician who diagnosed
Middle ear abnormality 35
Erythematous inflamed throat 21 meningitis. Examination of the cerebro-
Skeletal abnormality (fracture 2) 18 spinal fluid revealed one white cell;
Visual loss 11 sugar, 70 mg. per 100 ml.; protein, 19
Developmental retardation 9 mg. per 100 ml.; LDH, 20 units; and
Heart murmur 9 a negative culture. Blood culture was
Anemia 7 also negative but a throat culture was
Upper respiratory infection 6 positive for Group A beta hemolytic
Rashes-Allergic 6 streptococcus. Despite the absence of
Diaper 3
Infected 6 cerebrospinal fluid findings, the infant
was treated with combined antibiotic
Strabismus 3 therapy for possible meningitis. He made
Lower respiratory infection an uneventful recovery except for the
(pneumonia) 3
Hearing loss 3 neck stiffness which persisted for several
Caries 2 days.
Conjunctivitis 2
Fever of unknown etiology 2 Discussion
Significant short stature 2
Laceration 2 Certain segments of the medical and.
Ringworm 2 nursing professions have resisted the ex-
Bronchitis 2 pansion of the nurse's role and this new
Sprained ankle 2 method of delivering health services be-
Umbilical hernia 2 cause of a fear that the pediatric nurse
Adenopathy 1 practitioner, in performing a physical
Asymmetry of the skull 1 examination and making an assessment
Bleeding right ear 1 of the physical status of the child, might
Cellulitis 1
Contusion 1 miss significant problems or deviations
from the norm which would have been
Croup 1 recognized by a pediatrician.
Excessive skin on hands and feet
(hyperkeratosis) 1
This study demonstrates that pediatric
Fontanell bulging 1 nurse practitioners trained by Silver
Hypotonia 1 et al are highly competent health pro.
Large scrotal sac (hydrocele) 1 fessionals in assessing normal and ab-
Lethargy I normal physical findings in children. In
Nevus 1 only 0.7% of all "conditions' occurring
Ptosis 1 in a group of 182 children who were
Stomatitis 1 seen within a short time of each other
Sty 1
Teeth mottling 1
by pediatric nurse practitioners and
Trauma to tympanic membrane 1 pediatricians was there a significant
Weak abdominal musculature 1
* Wellness any significant deviation of a
239 physical finding from normal, or any illness or
injulry vere all considered to be "conditions".
1172 VOL. 61, NO. 6, A.J.P.H.

4. PHYSICAL ASSESSMENT OF CHILDREN
Table 2B-"Conditions" present on physical examination of 182 children seen by
pediatric nurse practitioner and pediatricians
Conditions noted by either nurse or physician where there was a difference in assessment that
was not considered to be significant*
Assessment by Age in
pediatric nurse practitioner Assessment by pediatrician years
Cardiac murmur
Heart murmur No murmur heard 4 0/12
Heart murmur No murmur heard 4 5/12
No murmur Grade ii/vi systolic murmur (no organic
disease) 5 5/12
No murmur Innocent murmur (no organic disease) 2 4/12
No murmur Grade ii/vi vibratory nonradiating murmur
(no organic disease) 5 2/12
No murmur Grade i/vi murmur not transmitted (no
organic disease) 9 8/12
Abnormal lower respiratory findings
Diffuse wheezing No wheeze, congested upper airway 5/12
Diffuse wheezing *No pathology 4/12
Wheeze, rhonchi, rales with otitis U.R.I., otitis, transmitted sounds 1 6/12
Questionable infection Lungs clear 2 8/12
Rhonchi Lungs clear 1 10/12
Skeletal abnornalities
Asymmetric gluteal folds "Normal" (seen one month later) 3/12
Asymmetric gluteal folds "Normal" (seen one month later) 1/12
Questionable bowing of legs "Normal" (seen one month later) 3/12
Normal extremities Left foot eversion and pronation (no
therapy necessary) 1 11/12
Normal skull Flattened right occiput 1 4/12
Abnormality of middle ear
Resolving infection U.R.I. 1 0/12
Tympanic membranes injected Retracted, no infection 3 5/12
Tympanic membranes injected, dull No infection 1 3/13
Developmental lag
Lag in gross motor development Within normal limits 5/12
Lag in fine motor development Within normal limits (seen one month
later) 3/12
Abnormality of throat
Erythematous inflamed throat "Clear" 9 9/12
Erythematous inflamed throat U.R.I. 3 4/12
Strabismus
Strabismus No strabismus 2 8/12
Strabismus Strabismus diagnosed by pediatrician
(Ophthalmologist found no strabismus;
only prominent epicanthic folds) 1
Anal abnormality
Normal anus (rectal bleeding, pain Anal fissure (seen 3 days later) 14 7/12
on defecation)
Normal anus (constipation) Anal fissure (seen 2 days later) 1 4/12
(Continued on following page.)
JUNE, 1971 1173

5. Table 2B-(Continued)
Miscellaneous
U.R.I. Parotitis (seen 1 day later) 13 11/12
Brawny edema over rt. mandible, "Doubt mumps" 4 6/12
( ?) parotitis
Thrush not noted Thrush (seen 1 day later) 9/12
Vomiting, probably gastroenteritis Viral pharyngitis, conjunctivitis 5 3/13
Weight loss (anorexia) Viral gastroenteritis 4 6/12
Rash (?) measles Heat rash (cleared in 1 day) 4/12
Failed screening test for hearing Normal hearing (audiologist) 13 0/12
Small cyst left nipple Supernumary nipple 2 7/'12
Well child, no hernia noted Small umbilical hernia 1 11/12
Well child, (liver down 1/2 cm.) Liver down 21/2 cm. 4 4/12
Conditions noted by either nurse or physician where the difference in assessment was considered
to be significant*
Assessment by Age in
pediatric nurse practitioner Assessment by pediatrician years
Red throat (?) infection Pneumonia (confirmed by x-ray) 1
Red throat (?) infection "Meningitis" (CSF negative on
examination and culture) 1 1/12
* Significant was defined as an incorrectly or unrecognized condition which could have been favorably affected by
treatment.
difference between the assessment made practitioners, it was emphasized that
by the nurses and those made by the they should refer not only all children
physicians. whom they felt definitely should be
The pediatric nurse practitioners seen by a physician, but also those in
evaluated in this study were graduate whom any question existed as to the
nurses with a baccalaureate degree in normalcy or significance of a particular
nursing who had received a four months finding. It was recognized that this would
course of study in Silver et al's pediatric result in over-referral of patients to
nurse practitioner program.12 They were physicians and that this would increase
skilled in taking complete pediatric his- the number of instances where there
tories and performing comprehensive would be a difference in assessment by
physical examinations including the the nurse and the physician. However, it
basic skills of inspection, palpitation, per- was felt that these over-referrals served
cussion and auscultation and the use of as an added safeguard for the children.
such tools as the otoscope, stethoscope Examples of over-referral included chil-
and ophthalmoscope. They determined dren with asymmetric skin folds of thighs
the developmental status of children and in whom the physician decided that no
tested for hearing defects, speech diffi- significant abnormality existed; chil-
culties, physical impairments and various dren in whom the nurse heard a slurring
congenital deformities. They were capa- of the heart sounds which was in-
ble of assessing the over-all status of an terpreted by the physician as being
ill child in order to determine the acute- within normal limits with no significant
ness and severity of disease. They also cardiac murmur; or cases where the
assessed various aspects of parent-child nurse was concerned about intermittent
relationships, normal growth and de- mild imbalance of the eye muscles, but in
velopment, variations of growth patterns, whom the physician decided that the im-
and psycho-sexual development. balance was not clinically significant.
In the training of pediatric nurse Evaluation of the competency of
1174 VOL. 61. NO. 6. A.J.P.H.

6. PHYSICAL ASSESSMENT OF CHILDREN
pediatric nurse practitioners has not to pediatricians for consultation and for
previously been determined. Anderson3 confirmation of the nurse5' assessment.
concluded that nurses or trained physi- The results of our study, therefore, apply
cian's assistants could have detected 88% only to the select group of patients who
of "significant abnormalities" of infants were seen by both health professionals.
in the first year of life which were dis- The nurse's ability to ascertain pertinent
covered by pediatricians because these findings in the history or to assess other
abnormalities had inherent visibility or factors was not part of this study.
susceptibility to identification by simple
screening procedures.
A number of surveys evaluating other Summary and Conclusions
aspects of the performance of pediatric
nurse practitioners have been carried This report is an evaluation of the
out. Nurse practitioners have been shown ability of pediatric nurse practitioners
to be capable of caring for the majority to perform accurate, comprehensive
(more than three-fourths) of children physical examinations by comparing the
coming to health stations in low income appraisal of the physical status of chil-
areas4; they are well accepted by more dren made by pediatric nurse practi-
than nine-tenths of patients and parents tioners with that made by pediatricians.
and in one survey 57% of the parents A consecutive series of charts of chil-
indicated that the care given jointly by a dren enrolled in a neighborhood health
physician and a pediatric nurse practi- station were reviewed. Of these charts,
tioner was better than the care that had 182 children had been seen first by the
previously been provided by a pediatri- nurse and subsequently by the physician.
cian alone.5 It has also been found that A total of 278 conditions were noted by
an association with a pediatric nurse the nurses and/or physicians in these
practitioner provided pediatricians in 182 children.
private practice with at least one-third There was total agreement between
more patients.6 The association with the the findings of the pediatric nurse prac-
nurse practitioner was a definite eco- titioner and the consulting pediatrician
nomic boon to the physicians.6 in 240 of the 278 conditions (86%) .
No attempt was made to determine There was a difference between the as-
whether the nurse practitioner or the sessment of the pediatric nurse practi-
pediatrician was "right" in their assess- tioner and the pediatrician in 39 condi-
ment of the conditions present in the pa- tions (14%) . In 37, the difference in
tients under study. The purpose of the assessment was not considered to be sig-
study was to determine the incidence and nificant. In only two instances of the con-
significance of the differences without as- ditions noted (0.7%) was the difference
signing a specific value judgment to the between the nurses and physicians assess-
assessments themselves. It would be of ment thought to be significant.
interest to compare the differences that Evaluation of the competency of
might be found between the assessment pediatric' nurse practitioners has not
of physical findings by members of a been previously determined although sev-
pediatric housestaff and pediatricians, or eral surveys have evaluated other aspects
by two groups of pediatricians. Such of the pediatric nurse practitioners. This
comparative studies are needed to de- study demonstrates that pediatric nurse
termine the significance of the results practitioners trained by Silver et al are
herein reported. The nurses may have highly competent health professionals in
failed to recognize significant abnormali- assessing normal and abnormal physical
ties in the patients who were not referred findings in children.
JUNE, 1971 1175

7. REFERENCES 4. Silver, H. K. Use of New Types of Allied
1. Silver, H. K.; Ford, L. C.; Stearly, S. G. Health Professionals in Providing Care for
A Program to Increase Health Care for Children. American Journal of Diseases of
Children: The Pediatric Nurse Practitioner Children 116:486490, 1968.
Program. Pediatrics 39(5) :756-760, 1967. 5. . The Pediatric Nurse Prac-
2. Silver, H. K.; Ford, L. C.; Day, L. R. The titioner and the Child Health Associate:
Pediatric Nurse Practitioner Program. New Types of Health Professionals. Paper
Journal of the American Medical Associa- presented at New York Academy of Sci-
tion 204:298-302, 1968. ences seminar on Education in Health-
3. Anderson, F. P. The Yield of Hitherto Related Professions, New York, N. Y.
Unrecognized Significant Abnormalities on (Mar.), 1969.
Routine Physical Examination of Infants 6. Schiff, D. W.; Fraser, C. H.; Walters, H.
in the First Year of Life. Paper presented L. The Pediatric Nurse Practitioner in the
at 9th Annual Meeting of the Ambulatory Office of Pediatrics in Private Practice.
Pediatric Association, Atlantic City, N. J. Pediatrics 44(1) :62-68, 1969.
(April), 1969.
Dr. Duncan is Assistant Professor of Pediatrics, Mrs. Smith is a Pediatric
Nurse Practitioner and Dr. Silver is Professor of Pediatrics, University of
Colorado School of Medicine, 4200 East Ninth Avenue, Denver, Colorado.
The study was done in cooperation with the Denver Department of Health
and Hospitals and its Neighborhood Health Program.
This paper was submitted for publication in March, 1970.
Key to Recycling Economics?
The aluminum industry is deep into research on the recycling of solid wastes-
for hard-headed reasons explained in a recent pamphlet, The Solid Waste Crisis:
One Answer. "Because of its high scrap value ($200 a ton), aluminum holds the key
to recycling economics," states the pamphlet. It goes on to say that, although alu-
minum is only 0.3 per cent of all solid waste (household wrap, TV trays, and a few
aluminum cans), it is worth ten times more in dollars and cents than any other com-
ponent in the waste stream-such as paper, glass, and ferrous materials. Therefore,
"the more aluminum in garbage, the more the garbage is worth," and the industry
is eager to buy back all aluminum that can be reclaimed through recycling.
Thus the pamphlet encourages increased use of aluminum because it is good
for business; but it also puts forward a broad recycling concept that might well
solve the universal solid waste crisis. Aluminum researchers have been working with
other materials industries on a total system which would sort out and re-use all com-
ponents of solid waste. Food waste, for example, would be burned for energy in a
water-jacketed incinerator, or processed into fuel oils, or gases and charcoal in a
pyrolysis unit. Paper could be made into pellets for new paper, glass ground up and
re-used in bottles, and metals sorted, melted down, and reprocessed.
Data on the concept is available to all groups interested in constructing an
operating facility from: The Aluminum Association, 750 Third Avenue, New York,
N. Y. 10017.
VOL. 61. NO. 6. A.J.P.H.