Assessment of Kids 32 Flashcards
1
Q
What does the focus of the assessment depend on?
A
Purpose of visit and needs of the child
2
Q
What is the foundation upon which the nurse determines the needs of the child?
A
A thorough and thoughtful assessment
3
Q
What will a health history provide the nurse?
A
A picture of the child’s experiences and highlights areas of concerns
4
Q
When should you gather materials for an interview?
A
Before the interview begins
5
Q
What should you consider before/during taking a health history?
A
- Family roles/values
- Age/developmental stage of child
- Observe child-parent interaction
6
Q
What to do when approaching the caregiver?
A
- greet parent/child by name
- occupy child
- open ended questions
- be patient
- keep parents focused
7
Q
How to approach the child?
A
- professionally friendly
- NO white coats
- appear non-threatening
- catch child’s attention
- approach at eye level
- give child some control
8
Q
You should always approach a child at what level?
A
Eye level
9
Q
Communicating w/ Toddler/Preschool
A
- involve in convo and verify w/ parent
- point to where it hurts
10
Q
Communicating w/ School-aged Children
A
- get all info from child first
- fill in the gaps w/ parents
11
Q
Communicating w/ Adolescents
A
- establish trust
- ask if they want family in the room
- ask about interest
- be careful w/ non-verbal com
- do NOT use slang words
12
Q
Therapeutic Communication Techniques
A
- active listening
- open-ended questions
- eliminate barriers
- establish medical home
- questionnaires
13
Q
What should you establish w/ questionnaires?
A
- appropriate reading level
- primary language
14
Q
What are the components of a health history?
A
- demographics
- past health history
- review of systems
- family history
- developmental history
- functional history
- home environment
15
Q
Demographics
A
name, birthday, gender, primary language
16
Q
Past Health History
A
allergies, immunizations, operations, medication, menstrual history, health problems
17
Q
How far back should you go in the families health history?
A
3 generations
18
Q
Developmental History
A
milestones, speech, feeding, daycare/school
19
Q
Functional History
A
dental, nutrition, physical activity, tv time, sleep, elimination, sexual activity
20
Q
Home Environment
A
- who lives in the home
- do parents work
- when was their home built
21
Q
How to prepare for the physical examination?
A
- gather supplies
- one tool at a time
- toys/distractions
- be confident
- warm is better than cold
22
Q
When should you count the babies respiratory and heart rate?
A
before undressing the baby
23
Q
When is it best to examine the infant?
A
1-2 hours before feeding
24
Q
What to do for Baby Physical Exam?
A
- parent/caregiver hold baby
- auscultate heart, lungs, and abdomen while quiet
- head-to-toe assessment
- warm hands and stethoscope
- soft soothing voice
- bright colors
25
What to do for Toddler Exam?
- incorporate play
- sit with caregiver/parent
- let them touch equipment
- praise them
- tell them what you're going to do
26
What to do for Preschooler Exam?
- may fear body invasion
- withdraw from procedure viewed as intrusive
- have sense of initiative
- give them choices
- praise them
27
What to do for School Age Exam?
- be concrete, objective, and realistic
- do NOT use medical jargon
- explain how things work
- privacy
28
What to do for Teen Exam?
- provide privacy
- attitude of respect
- head-to-toe approach
- limit exposure to area being examined
29
Steps of Physical Examination
Observation
Palpation
Percussion
Auscultation
30
How would you take the temperature of a child < 3 years?
pull earlobe back and down
31
How would you take the temperature of a child > 3 years?
pull earlobe up and back
32
Infant heart rate
80-150
33
Infant respirations
25-55
34
Toddler heart rate
70-120
35
Toddler respirations
20-30
36
Preschool heart rate
65-110
37
Preschool respirations
20-25
38
School-age heart rate
60-100
39
School-age respirations
14-22
40
Adolescent heart rate
55-95
41
Adolescent respirations
12-18
42
Where should you check a child < 10 years pulse?
Apical pulse
43
Where should you check a child > 10 years pulse?
Radial pulse
44
How should you count the infant's respiratory rate?
by abdominal movements
45
After age 1 how should you count a child's respiratory rate?
thoracic movement
46
How do you check a child's oxygen saturation?
- finger, toe, ear, foot, or forehead
- don't restrict blood flow
- cover the sensor to prevent disruption from ambient light
47
How often should a child > 3 years have their blood pressure checked?
once during every healthcare visit
48
When should you check a child < 3 years BP?
if they have risk factors
49
What are the risk factors for checking a child < 3 years BP?
- history of prematurity; low birth weight
- congenital heart disease
- recurrent UTI, hematuria, proteinuria
- malignancy, organ transplant
- increased intracranial pressure
50
Which pain scale should be used for children too young to verbally or conceptually quantify pain?
FLACC pain scale
51
Older children that can express how pain is worsening or improving should use which pain scale?
Pain Faces Scale
52
What ages should have their head circumference checked?
children < 2
53
The length of the child in a lying position should be taken until what age?
2 years
54
Should you weigh an infant with their diaper?
No, remove just before weighing
55
What percentiles are considered normal growth?
5th-90th percentile
56
Acrocyanosis
normal blueness of the hands and feet in babies
57
Mottling
vasomotor response to warming or cooling
58
Dark pigmentation
babies will start out paler than parents until melanocytes begin production
59
Hyperpigmentation
common in dark skinned infant's areolas, genitals, linea nigra
60
Lanugo
soft, downy hair on the body, particularly the face and back
61
Salmon nevi
light pink macule usually on eyelids, nasal bridge, or back of neck; birth marks
62
Strawberry Nevus
raised reddish papule made of blood vessels
63
Nevus flammeus
"port wine stain"; dark purple-red flat patch, grows with the child
64
Ecchymosis
purplish discoloration changing to blue, brown, black
65
What is the key indicator for good health?
good growth
66
When measuring a child's height what should you ALWAYS ask them to do?
take off their shoes
67
Mongolian Spots
hyper-pigmented nevi, looks likes bruising
68
Petechiae
pin point purple-blueish rash; common in patients who vomit or cough frequently; also in children with leukemia
69
Skin Assessment Palpation
```
temperature
moisture
texture
turgor
edema
```
70
What are the two fontanels?
Posterior and Anterior
71
Which fontanel is smaller and closes around 2 months?
Posterior
72
Anterior Fontanel
larger fontanel; closes around 9-18 months
73
What does a sunken fontanel indicate?
dehydration
74
Large fontanels may be associated with what?
Down syndrome or congenital hypothyroidism
75
PERRLA
pupils are equal, round, and react to light and accommodate
76
Low set ears may indicate what?
down syndrome
77
If a fontanel continues to grow larger it could indicate what?
hydrocephalus
78
Foul discharge from the ear would indicate what?
ear infection
79
Ear tags
extra skin near the ear
80
Abdomen assessment you would report?
firmness
tenderness
masses
81
Why is it important to inspect an infants clavicles?
may fracture during labor
82
Why is it important to inspect an infants hips?
congenital hip dysplasia
83
Neuro Assessment
```
LOC
Balance
Coordination
Sensory testing
Reflexes
```
84
A capillary refill less than 3 seconds indicates what?
adequate perfusion
85
Heart rate can increase with what?
inspiration
86
Heart rate can decrease with what?
exhalation
87
Sinus arrhythmia
common and normal in children/adolescents
88
Grade 1 Heart Murmur
soft murmur heard only under quiet conditions
89
Grade 2 Heart Murmur
soft murmur heard even under noisy conditions
90
Grade 3 HM
easily heard prominent murmurs
91
Grade 4 HM
Loud murmur associated w/ a thrill
92
Grade 5 HM
Loud murmur w/ edge of stethoscope tilted against chest plus thrill
93
Grade 6 HM
Very loud can be heard 5 mm to 10 mm from the chest plus thrill
