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ATI Peds > 2 - Physical Assessment Findings (2) > Flashcards

2 - Physical Assessment Findings (2) Flashcards

1
Q

Physical Assessment:

Ears…what do you look for?

A
  • ALIGNMENT (top of the auricles even with outer canthus)
  • EXTERNAL EAR (free of lesions, nontender, ear canal clear, normal cerumen)
  • INTERNAL EAR (ear canal pink with fine hairs, tympanic membrane pearly pink or gray, light reflex visible, umbo and manubrium visible)
  • HEARING (infants have blink reflex to sound, turn toward sounds, older children use whisper test)
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2
Q

Infants and toddlers, pull pinna ____ and back.

Children older than 3 years, pull pinna ____ and back.

A

down

up

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3
Q

Physical Assessment:

Nose…what do you look for?

A
  • midline
  • patency present w/o excessive flaring
  • internal structures (septum midline and intact; mucosa pink, moist, no discharge)
  • smell assessed in older children
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4
Q

Physical Assessment:
Mouth and throat
(don’t memorize…just read over and be familiar with this)

A 
LIPS
- lips (darker than facial skin)
- smooth, soft, moist, and symmetric
GUMS
- coral pink
- tight against teeth
MUCOUS MEMBRANES
- no lesions
- moist, pink, smooth, glistening
TONGUE
- infants may have white coating on their tongues from milk that is easily removed...oral candidiasis coating is not easily removed
- pink, symmetric tongues that can be moved beyond the lips
TEETH
- infants have 6-8 teeth by age 1 yr
- 20 deciduous teeth...32 permanent teeth
HARD AND SOFT PALATE
- intact, firm, concave
UVULA
- intact, moves with vocalization
TONSILS
- infants...may not visualize
- children...barely visual to prominent, same color, deep crevices that hold food particles
SPEECH
- infants...strong cry
- children and adolescents...clear and articulate
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5
Q

Physical Assessment:

Thorax and lungs

A
  • CHEST SHAPE (infant, almost circular; child/adol, 2:1 AP to transverse diameter)
  • RIBS AND STERNUM (infants flexible, symmetric and smooth, no protrusions or bulges)
  • MOVEMENT - symmetric, no retractions (infants, irregular rhythms common; children younger than 7, more abd. movement seen during respirations)
  • BREATH SOUNDS (inspiration longer/louder than expiration; vesicular or soft, swishing sounds heard over most of the lungs)
  • BREASTS (newborns breasts may be enlarged during first few days; child/adol - nipples and areolas darker pigmented and symmetric)
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6
Q

Females develop breasts between ___ and ___ years of age. They can be _____, with no masses and be palpable.

A

10 to 14 years

asymmetric

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7
Q

Males may develop breasts during puberty, this is called _____. They may be unilateral or bilateral.

A

gynocomastia

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8
Q

Physical Assessment:

Heart sounds

A

S1 S2 are clear and crisp

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9
Q

S1 is louder at the ____ of the heart.

S2 is louder at the ____ of the heart.

A

apex

base

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10
Q

T/F: Physiologic splitting of S2 and S3 heart sounds are expected findings in some children.

A

True

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11
Q

Which pulses are palpable, full, and localized in INFANTS?

A

brachial
temporal
femoral

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12
Q

Children and adolescents have the same palpable pulses as _____.

A

Adults

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13
Q

Physical Assessment:

Abdomen

A
  • No tenderness or guarding
  • Peristaltic waves may be visible in thinner children
  • Symmetric, no protrusions around the umbilicus
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14
Q

What shape abdomens do infants and toddlers have?

What shape do child/adol have?

A

round

flat

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15
Q

Bowel sounds should be heard every ____ to ____ seconds.

A

5 to 30

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16
Q

Physical Assessment:

Genitalia (male)

A
  • hair distribution is diamond shaped after puberty
  • penis straight
  • urethral meatus at the tip of the penis
  • foreskin may not be retractable in infants and small children
  • enlargement of penis occurs during adolescence
  • the penis may look abnormally small in males who are obese b/c of skin folds partially covering the base
  • scrotum hangs separately from penis
  • skin on the scrotum has a rugated appearance and is loose
  • left testicle hangs slighter lower than the right
  • the inguinal canal should be absent of swelling
  • during puberty, the testes and scrotum enlarge with darker scrotal skin
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17
Q

Physical Assessment:

Genitalia (Female)

A
  • hair distribution over mons pubis should be documented in terms of amount and location during puberty
  • hair in inverted triangle
  • labia symmetric, w/o lesions, moist on inner aspects
  • clitoris small w/o bruising or edema
  • urethral meatus slit-like appearance w/ no discharge
  • vaginal orifice hymen absent, or covers the vaginal opening prior to sexual intercourse
18
Q

Physical Assessment:

Anus

A

surrounding skin intact with sphincter tightening noted if the anus is touched.

19
Q

T/F: Routine rectal exams are always done with the pediatric population.

A

False

RARELY done

20
Q

Physical Assessment:

Musculoskeletal system

A
  • length, position, and size are symmetric
  • joints are stable and symmetric with full ROM, no crepitus or redness
  • spine: infants should be w/o dimples or tufts of hair, midline with an overall C-shaped lateral curve
  • toddlers appear squat w/ short legs and protuberant abdomens
  • preschoolers more erect than toddlers
  • children develop cervical, thoracic, and lumbar curvatures like adults
  • adol remain midline, no scoliosis noted
  • gait, toddlers and young children - bowlegged or knock-knee appearance is common; feet face forward while walking
  • older child/adol - steady gait noted with even wear on the soles of shoes
21
Q 
Physical Assessment:
Neurologic System (What are the 8 infant reflexes)
A

1) Sucking and rooting
2) Palmar grasp
3) Plantar grasp
4) Moro
5) Startle
6) Tonic neck
7) Babinski
8) Stepping

22
Q

Name the infant reflex:
Elicited by stroking an infant’s cheek or the edge of an infant’s mouth –> the infant turns head toward the side that is touched and starts to suck.

A

Sucking and rooting

birth to 4 mo

23
Q

Name the infant reflex:

Elicited by placing an object in an infant’s palm –> the infant grasps the object.

A

Palmar grasp

birth to 3 mo

24
Q

Name the infant reflex:

Elicited by touching the sole of an infant’s foot –> the infant’s toes curl downward

A

Plantar grasp

birth to 8 mo

25
Q

Name the infant reflex:
Elicited by allowing the head and trunk of an infant in a semi-sitting position to fall backward to an angle of at least 30 degrees –> the infant’s arms and legs symmetrically extend, then abduct while fingers spread to form C shape.

A

Moro reflex

birth to 4 mo

26
Q

Name the infant reflex:
Elicited by clapping hands or by a loud noise –> the newborn will abduct arms at the elbows, and the hands will remain clenched.

A

Startle reflex

birth to 4 mo

27
Q

Name the infant reflex:
Elicited by turning an infant’s head to one side –> the infant extends the arm and leg on that side and flexes the arm and leg on the opposite side.

A

Tonic neck reflex (fencer position)

birth to 3-4 mo

28
Q

Name the infant reflex:
Elicited by stroking the outer edge of the sole of an infant’s foot up toward the toes –> the infant’s toes fan upward and out

A

Babinski reflex

birth to 1 year

29
Q

Name the infant reflex:

Elicited by holding an infant upright with his feet touching a flat surface –> the infant makes stepping movements.

A

Stepping reflex

birth to 4 weeks

30
Q

Physical Assessment:

Cranial nerves

A

Review p. 17 in ATI book

31
Q

Physical Assessment:

Deep tendon reflexes should demonstrate the following:

A
  • partial flexion of the lower arm at the biceps tendon
  • partial extension of the lower arm at the triceps tendon
  • partial extension of the lower leg at the patellar tendon
  • plantar flexion of the foot at the achilles tendon
32
Q 
Physical Assessment:
Cerebellar function (child/adol)...what tests are used to test this?
A
  • finger to nose test
  • heel to shin test
  • Romberg test
33
Q

What does the finger to nose test evaluate?

A

rapid coordinated movements

34
Q

What does the heel to shin test evaluate?

A

able to run the heel of one foot down the shin of the other leg while standing

35
Q

What does the Romberg test evaluate?

A

able to stand with slight swaying while eyes are closed

36
Q

What can be used to evaluate language, cognition, and fine and gross motor development can be screened by which test?

A

Denver II Developmental Screening Test

37
Q

A nurse is preparing to assess a preschool-age child. Which of the following is an appropriate action by the nurse to prepare the child?

A. allow the child to role-play using miniature equipment
B. use medical terminology to describe what will happen
C. separate the child from her parent during the exam
D. keep medical equipment visible to the child

A

A. allow the child to role-play using miniature equipment (reduces anxiety)

38
Q

A nurse is checking the vital signs of a 3 year old child during a well-child visit. Which of the following findings should the nurse report to the provider?

A. temp 37.2 C (99.0 F)
B. pulse 106/min
C. respirations 30/min
D. BP 88/54 mmHg

A

B. respirations 30/min (above 3 yo range)

39
Q

A nurse is assessing a child’s ears. Which of the following is an expected finding?

A. light reflex is located at the 2 o’clock position
B. tympanic membrane is red in color
C. bony landmarks are not visible
D. cerumen is present bilaterally

A

D. cerumen is present bilaterally

40
Q

A nurse is assess a 6 month old infant. Which of the following reflexes should the infant exhibit?

A. Moro
B. Plantar grasp
C. Stepping
D. Tonic neck

A

B. Plantar grasp (birth to 8 month)

41
Q

A nurse is performing a neurological assessment on an adolescent. Which of the following is an appropriate reaction by the adolescent when the nurse checks the TRIGEMINAL cranial nerve? (select all that apply)

A. clenching teeth together tightly
B. recognizing sour tastes on the back of the tongue
C. identifying smells through each nostril
D. Detecting facial touches with eyes closed
E. Looking down and in with the eyes

A

A. clenching teeth together tightly

D. detecting facial touches with eyes closed

ATI Peds (4 decks)

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