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ATI Peds > 2 - Physical Assessment Findings > Flashcards

2 - Physical Assessment Findings Flashcards

1
Q

It is best to perform exams in _____ environments.

A

nonthreatening

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2
Q

T/F: Take time to play and develop rapport prior to beginning an exam.

A

True

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3
Q

T/F: Exam don’t need to be altered to accommodate developmental needs.

A

False ALTER exams to accommodate developmental needs

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4
Q

What are things to observe for to determine the child’s readiness to cooperate?

A
  • interacting with nurse - making eye contact - permitting physical touch - willing sitting on exam table
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5
Q

If the child is uncooperative, what can be done?

A
  • assess reasons - be firm and direct about expected behavior - complete the assessment quickly - use a calm voice
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6
Q

T/F: Do not involve family members in exams.

A

False Involve children AND family members in exam

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7
Q

Praise children for ____ during exams.

A

cooperation

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8
Q

List some nursing considerations for physical assessments:

A
  • keep room warm and well lit - keep medical equipment out of sight - provide privacy, include caregiver if needed - explain each step of the exam to the child - examine the child in a secure, comfy position - exam child in an organized sequence - encourage questions
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9
Q

Recommended routes of taking temp for birth to 1 year?

A

Axillary or rectal (rectal if exact measurement is needed)

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10
Q

Recommended routes of taking temp for 3 to 5 years?

A

Axillary, Tympanic, Oral, Rectal

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11
Q

Recommended routes of taking temp for 7 to 13 years?

A

Oral, Axillary, Tympanic, Oral (This is how it’s listed in ATI on p. 9, but it may be a misprint…2 orals? maybe rectal instead)

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12
Q

Expected temp for 3 mo & 6 mo:

A

37.5

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13
Q

Expected temp for 1 year:

A

37.7

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14
Q

Expected temp for 3 years:

A

37.2

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15
Q

Expected temp for 5 years:

A

37.0

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16
Q

Expected temp for 7 years:

A

36.8

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17
Q

Expected temp for 9 and 11 years:

A

36.7

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18
Q

Expected temp for 13 years:

A

36.6

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19
Q

Pulse rate newborn:

A

80 - 180/min

20
Q

Pulse rate 1 week to 3 months:

A

80 - 220/min

21
Q

Pulse rate 3 month to 2 years:

A

70 - 150/min

22
Q

Pulse rate 2 to 10 years:

A

60 - 110/min

23
Q

Pulse rate 10 years and older:

A

50 - 90/min

24
Q

RR newborn to 1 year:

A

30 - 35/min

25
Q

RR 1 to 2 years:

A

25 - 30/min

26
Q

RR 2 to 6 years:

A

21 - 25/min

27
Q

RR 6 to 12 years:

A

19 - 21/min

28
Q

RR 12 years and older:

A

16 - 19/min

29
Q

What influences blood pressure?

A
  • age
  • height
  • gender
30
Q

Infant systolic? Diastolic?

A

65 - 80

40 - 50

31
Q

Blood pressure by age…

A

Refer to chart on p. 10 of ATI book

32
Q

Physical Assessment:

General Appearance…what do you look for?

A
  • Undistressed
  • Clean and well-kept
  • Muscle tone (hold head up after 4 mo)
  • No body odor
  • Eye contact (except infants)
  • Follows simple commands
  • Uses speech, language, and motor skills spontaneously
  • Growth
33
Q

Physical Assessment:

Skin…what do you look for?

A
  • color appropriate for ethnicity
  • temp warm or slightly cool
  • turgor…brisk elasticity
  • texture smooth and dry, not oily
  • no lesions
  • skin folds symmetric
34
Q

Physical Assessment:

Hair and scalp…what do you look for?

A
  • hair evenly distributed, smooth, and strong
  • assess for secondary hair growth in adolescence
  • scalp clean and no scaliness, infestations, and trauma
35
Q

Hair that is stringy, dull, brittle, or dry may indicate what?

A

Nutritional deficiencies

36
Q

Physical Assessment:

Nails…what do you look for?

A
  • pink nail bed, white at tips
  • smooth and firm (infant nails slightly flexible)
  • no clubbing
37
Q

Physical Assessment:

Lymph nodes…what do you look for?

A
  • nonpalpable

** Lymph nodes that are small, palpable, nontender, and mobile may be an expected finding in children

38
Q

Physical Assessment:

Head…what do you look for?

A
  • shape symmetric
  • fontanels flat
39
Q

Posterior fontanel closes by ___ weeks.

Anterior fontanel closes by ___ weeks.

A

Posterior: 8 weeks

Anterior: 18 weeks

40
Q

Physical Assessment:

Face…what do you look for?

A
  • symmetric appearance and movement
  • proportional features
41
Q

Physical Assessment:

Neck…what do you look for?

A
  • short in infants
  • no palpable masses
  • midline trachea
  • full range of motion
42
Q

Where do you check skin turgor in babies/children?

A

inner thigh or abdomen

43
Q

Physical Assessment:

Eyes…what do you look for?

A
  • visual acuity (difficult in children under 3 years)
  • color vision
  • correctly identify shapes, symbols, or numbers
  • peripheral visual fields (up 50, down 70, nasally 60, temporally 90)
  • extraocular movements may not be symmetric in newborns
  • eyebrows symmetric and evenly distributed from inner to outer canthus
  • eyelids open and close completely
  • eyelashes curve outward, evenly distributed, no inflammation around hair follicles
  • conjunctiva (palpebral pink, bulbar transparent)
  • lacrimal apparatus w/o excessive tearing, redness, or discharge
  • sclera white
  • corneas clear
  • pupils round, equal, reactive to light, accommodating
  • irises round; permanent color around 6 - 12 mo
  • red reflex present in infants
  • arteries, veins, optic discs, and maculas may be visualized in older children and adolescents
44
Q

How can visual acuity be assessed in infants?

A

Hold object in front of eyes checking to see if infant is able to fix on the object and follow it.

45
Q

For children unable to read letters and numbers, which vision charts are used?

A
  • tumbling E
  • HOTV test
46
Q

What charts are used to test vision in older children?

A
  • Snellen chart
  • symbol chart
47
Q

How is color vision assessed?

A
  • Ishihara color test
  • Hardy-Rand-Rittler test

ATI Peds (4 decks)

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