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