Using good timing, i.e. not when the patient is hungry or has just undergone a procedure, use patience and distraction if possible, take time to assess the whole child. Consider their general appearance: do they appear in good health? Are there any obvious dysmorphic features? Are there any scars or signs of previous surgery? Is there cyanosis or low Sa02? Are they mottled? Are they sweaty? Do they appear to using an increased effort to breathe? Also how do they interact with their parent or carer? It is always important to bear in mind other parts of a child’s or infant’s life, for example, their social situation. Be mindful this quiet inspection may also present safeguarding concerns.

After seeking permission to physically examine the patient, palpate pulses in the following areas: first, check radial, brachial and femoral, then attempt palmer, axillary, carotid (older children), popliteal, posterior tibialis and dorsalis pedis. This is also useful when considering sites for taking blood pressure measurements. Are pulses present? Are they even? Consider the rate, rhythm, volume and any other notable findings, for example, thrill. The apex beat is usually found in the 4th to 5th intercostal space in the mid-clavicular line. If it is not found in this position, this may be significant and requires reporting, as it may indicate a cardiac abnormality. Is the heart rate within normal limits? Attempt to palpate the liver, just below the diaphragm, usually on the right in the mid-clavicular line – this should not be palpable, a palpable liver may indicate fluid overload and needs reporting.

Using a stethoscope, warm the diaphragm of the bell (round disk) and auscultate the four main areas: aortic, pulmonary, tricuspid and mitral/apex, listening for heart sounds, added sounds and murmurs. Added sounds and murmurs are difficult, however, to discern, so concentrate primarily on heart sounds. First sound (S1): closing of the mitral and tricuspid valves. Second sound (S2): closure of the aortic and pulmonary valves.

This should be calculated at a minimum hourly in the sicker patient, less frequently in the more stable patient. The importance of this inspection, indicating cardiac, respiratory and renal function should not be underestimated. Ensure the fluid total is taken into account in this assessment as any significant discrepancies may account for abnormalities found and will indicate a possible solution. If this is part of an initial assessment, take time to discuss the number of wet nappies an infant has had in the past 24 hours, most parents or carers will know this and it is a strong indicator regarding fluid status. At this time consider the condition of the skin and mucous membranes; decreased skin turgor is indicated when skin is gently pulled upwards and it remains in place for a few seconds – this is a significant sign of dehydration as are dry mucous membranes (mouth, eyelids), also an absence of tears in a child who appears distressed may indicate significant dehydration.