2 - Physical Assessment Findings Flashcards
It is best to perform exams in _____ environments.
nonthreatening
T/F: Take time to play and develop rapport prior to beginning an exam.
True
T/F: Exam don’t need to be altered to accommodate developmental needs.
False ALTER exams to accommodate developmental needs
What are things to observe for to determine the child’s readiness to cooperate?
- interacting with nurse - making eye contact - permitting physical touch - willing sitting on exam table
If the child is uncooperative, what can be done?
- assess reasons - be firm and direct about expected behavior - complete the assessment quickly - use a calm voice
T/F: Do not involve family members in exams.
False Involve children AND family members in exam
Praise children for ____ during exams.
cooperation
List some nursing considerations for physical assessments:
- 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
Recommended routes of taking temp for birth to 1 year?
Axillary or rectal (rectal if exact measurement is needed)
Recommended routes of taking temp for 3 to 5 years?
Axillary, Tympanic, Oral, Rectal
Recommended routes of taking temp for 7 to 13 years?
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)
Expected temp for 3 mo & 6 mo:
37.5
Expected temp for 1 year:
37.7
Expected temp for 3 years:
37.2
Expected temp for 5 years:
37.0
Expected temp for 7 years:
36.8
Expected temp for 9 and 11 years:
36.7
Expected temp for 13 years:
36.6
Pulse rate newborn:
80 - 180/min
Pulse rate 1 week to 3 months:
80 - 220/min
Pulse rate 3 month to 2 years:
70 - 150/min
Pulse rate 2 to 10 years:
60 - 110/min
Pulse rate 10 years and older:
50 - 90/min
RR newborn to 1 year:
30 - 35/min
RR 1 to 2 years:
25 - 30/min
RR 2 to 6 years:
21 - 25/min
RR 6 to 12 years:
19 - 21/min
RR 12 years and older:
16 - 19/min
What influences blood pressure?
- age
- height
- gender
Infant systolic? Diastolic?
65 - 80
40 - 50
Blood pressure by age…
Refer to chart on p. 10 of ATI book
Physical Assessment:
General Appearance…what do you look for?
- 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
Physical Assessment:
Skin…what do you look for?
- color appropriate for ethnicity
- temp warm or slightly cool
- turgor…brisk elasticity
- texture smooth and dry, not oily
- no lesions
- skin folds symmetric
Physical Assessment:
Hair and scalp…what do you look for?
- hair evenly distributed, smooth, and strong
- assess for secondary hair growth in adolescence
- scalp clean and no scaliness, infestations, and trauma
Hair that is stringy, dull, brittle, or dry may indicate what?
Nutritional deficiencies
Physical Assessment:
Nails…what do you look for?
- pink nail bed, white at tips
- smooth and firm (infant nails slightly flexible)
- no clubbing
Physical Assessment:
Lymph nodes…what do you look for?
- nonpalpable
** Lymph nodes that are small, palpable, nontender, and mobile may be an expected finding in children
Physical Assessment:
Head…what do you look for?
- shape symmetric
- fontanels flat
Posterior fontanel closes by ___ weeks.
Anterior fontanel closes by ___ weeks.
Posterior: 8 weeks
Anterior: 18 weeks
Physical Assessment:
Face…what do you look for?
- symmetric appearance and movement
- proportional features
Physical Assessment:
Neck…what do you look for?
- short in infants
- no palpable masses
- midline trachea
- full range of motion
Where do you check skin turgor in babies/children?
inner thigh or abdomen
Physical Assessment:
Eyes…what do you look for?
- 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
How can visual acuity be assessed in infants?
Hold object in front of eyes checking to see if infant is able to fix on the object and follow it.
For children unable to read letters and numbers, which vision charts are used?
- tumbling E
- HOTV test
What charts are used to test vision in older children?
- Snellen chart
- symbol chart
How is color vision assessed?
- Ishihara color test
- Hardy-Rand-Rittler test
