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Health Assessment > Infant, Child, Adolescent (Exam 3) > Flashcards

Infant, Child, Adolescent (Exam 3) Flashcards

1
Q

APGAR Score

A

AT 1 AND 5 MINUTES

provides evidence of newborns immediate adaptation to extra uterine life

*max: 10 points
*7 or less needs attention!
*min: 0 (needs reanimation)

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2
Q

APGAR

A

APPEARANCE

2: pink
1: extremities blue
0: pale of blue

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3
Q

APGAR

A

PULSE

2: >100 BPM
1: <100 BPM
0: no pulse

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4
Q

APGAR

A

GRIMACE

2: cries and pulls away
1: grimaces or weak cry
0: no response to stimulation

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5
Q

APGAR

A

ACTIVITY

2: active movement
1: arms, legs flexed
0: no movement

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6
Q

APGAR

A

RESPIRATION

2: strong cry
1: slow, irregular
0: no breathing

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7
Q

Sequence of Infant Assessment may be reordered based on…

A

• infants sleep and wakefulness state
• physical condition
• infant is supine on warning table with overhead heating unit

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8
Q

Infant Assessment Sequence Step 1

A

VITALS

HR, RR, temp

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9
Q

Infant Assessment Sequence Step 2

A

MEASUREMENT

weight, length, head circumference

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10
Q

Infant Assessment Sequence Step 3

A

APPEARANCE

• body symmetry, spontaneous position and movement, flexion of head and extremities
• skin color and characteristics, any obvious deformities
• symmetry and positioning of facial features
• alert, responsive affect
• strong, lusty cry

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11
Q

Infant Assessment Sequence Step 4

A

CHEST AND HEART

inspect, palpate, auscultate

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12
Q

Inspecting the chest and heart of an infant

A

Inspect…

• skin condition, chest configuration, nipples, breast tissue

note movement of abdomen with respirations and any chest retractions

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13
Q

Palpating the chest and heart of an infant

A

apical impulse (note location), chest wall (thrills), tactile fremitus if the infant is crying

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14
Q

Auscultating the chest and heart of an infant

A

• breath sounds
• heart sounds in all locations
• bowel sounds in abdomen and chest

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15
Q

Infant Assessment Sequence Step 5

A

ABDOMEN

inspect, palpate, percuss

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16
Q

Inspecting the abdomen of an infant

A

• shape of abdomen and skin condition
• umbilicus (count cord vessels, condition of cord/stump, detection of hernia!!)
• skin turgor

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17
Q

Palpating the abdomen of an infant

A

light palpation to note muscle tone, liver, spleen tip and bladder

deep palpation to note kidneys and potential masses

femoral arteries and inguinal lymph nodes!

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18
Q

Percussing the abdomen of an infant

A

all quadrants!

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19
Q

Infant Assessment Sequence Step 6

A

HEAD AND FACE

palpate, inspect, opening neonate eyes

NOTE MOLDING AFTER DELIVERY, SWELLING ON CRANIUM, BULGING OF FONTANELLE WITH CRYING OR AT REST!!

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20
Q

Palpating the head and face of an infant

A

fontanelles, suture lines, and any swellings

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21
Q

Inspecting the head and face of an infant

A

positioning and symmetry of facial features at rest and while infant is crying

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22
Q

How to open neonates eyes

A

• support head and shoulders
• gently lower baby backward OR ask parents to hold baby over their shoulder while you stand behind the parent

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23
Q

Infant Assessment Sequence Step 7

A

EYES, EARS, NOSE

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24
Q

Inspecting the eyes of an infant

A

• inspect the lids (edematous in the neonate), palpebral slant, conjunctivae, any nystagmus, and any discharge
• elicit pupillary reflex, blink reflex, and corneal light reflex using penlight (assess movement and tracking of light)
• elicit red reflex using an ophthalmoscope

25
Q

Inspecting the ears of an infant

A

• inspect size, shape, alignment of auricles, patency of canals/any extra skin tags or pits (note startle reflex in response to a loud noise)
• defer otoscopic exam until the end of the exam

26
Q

Inspecting the nose of an infant

A

• determine patency of nares
• note nasal discharge, sneezing, and flaring with respirations

27
Q

Infant Assessment Sequence Step 8

A

MOUTH, THROAT, NECK

inspect and observe

lift shoulders and let head lag to inspect the neck/note midline trachea
palpate lymph nodes and thyroid to observe for any masses; with infant supine, elicit TONIC-NECK REFLEX

28
Q

Inspecting the mouth, throat and neck of an infant

A

• lips and gums, high arched palate, buccal mucosa, tongue size, frenulum of tongue
• absent or minimal salivation in an infant

29
Q

Observing the mouth, throat and neck of an infant

A

rooting reflex, sucking reflex and palpate the palate using gloved finger

30
Q

Infant Assessment Sequence Step 9

A

UPPER EXTREMITIES

inspect

31
Q

Inspecting the UE of an infant

A

• ROM, muscle tone, absence of scarf sign
• count fingers, palmar creases, note color of hands and nail beds

place thumbs in infants palm to note grasp reflex

wrap hands around infants hands to pull up and note head lag

32
Q

Infant Assessment Sequence Step 10

A

GENITALIA

male, female

life the infant under the axillae and hold them facing you at eye level

33
Q

Female infant genitalia

A

inspect labia and clit (edematous in newborn), vernix caseosa between labia and patent vagina

34
Q

Male infant genitalia

A

inspect position of urethral meatus (do NOT retract foreskin), strength of urine stream is possible, rugae on scrotum and palpate testes

35
Q

Infant Assessment Sequence Step 11

A

NEUROMUSCULAR

note shoulder muscle tone; rotate the infant slowly from side to side (note dolls eye reflex)

36
Q

Position for infant neuromuscular exam

A

turn the infant around so their back is to you, elicit stepping and placing reflex against the edge of exam table

turn infant over and hold them prone in your hands OR place infant prone on exam table

37
Q

Infant Assessment Sequence Step 12

A

SPINE AND RECTUM

inspect

NOTE PATENT ANAL OPENING; passage of meconium during first 24-48 hrs

38
Q

Inspecting the spine and rectum of an infant

A

• length of spine, trunk incurvation reflex, and symmetry of gluteal folds
• intact skin, note any sinus openings, protrusions or tufts of hair

39
Q

Infant Assessment Sequence Step 13

A

FINAL PROCEDURES

ELICIT MORO REFLEX

using an otoscope, inspect auditory canals and tympanic membranes

40
Q

The Young Child

A

DONT ASK FOR PERMISSION, GIVE CHOICES!

preschool child (2-6 yrs) displays developing initiative and takes on tasks independently (is cooperative and easy to involve, fearful of body injury, may recoil from invasive procedures)

young child is developing industry (cooperative and interested in learning about the body)

41
Q

Child Assessment Sequence

A
  1. health history
  2. general appearance
  3. evaluate and measurement
  4. UE, head, face, neck
  5. eyes
  6. nose, mouth, throat
  7. ears
  8. posterior thorax and breath sounds
  9. anterior thorax, heart, lungs
  10. abdomen and genitalia
  11. LE
42
Q

Child Assessment: Health History

A

collect history including developmental data

note data on general appearance!

43
Q

Child Assessment: General Appearance

A

• child’s ability to amuse while parent speaks
• caregiver and child interactions
• gross and fine motor skills as child plays with toys (gradually focus on and involve yourself with child, at first in a “play” period)

44
Q

Child Assessment: Evaluate

A

• developmental milestones
• posture while child is sitting and standing
• alignment of legs and feet while walking
• speech acquisition
• vision and hearing ability
• social interaction
• use age appropriate techniques to engage child

45
Q

Child Assessment: Measurement

A

height, weight, temp and BP

46
Q

Child Assessment: UE and head, face, neck

A

INSPECT: arms and hands for alignment, skin condition, fingers and note palmar creases

PALPATE: radial pulse

TEST: biceps and tricep reflexes with reflex hammer; inspect the size and shape of head and symmetry of face

PALPATE: cervical lymph nodes, trachea, and thyroid

47
Q

Child Assessment: Eyes

A

INSPECT: external structures (note any palpebral slant), conjunctivae and sclera

• elicit corneal light and pupillary light reflexes with penlight, observe cardinal gaze
• observe red reflex and inspect fungus using ophthalmoscope

if indicated, perform cover test, covering the eye with thumb in a young child or index card

48
Q

Child Assessment: Nose

A

• inspect external nose, noting skin condition
• inspect nares, mucosa, septum, and turbinates using penlight

49
Q

Child Assessment: Mouth and throat

A

inspect mouth, buccal mucosa, teeth and gums, tongue, palate, and uvula with penlight (use tongue blade as last resort)

50
Q

Child Assessment: Ears

A

INSPECT: auricles, ear canal and tympanic membranes using otoscope, tympanic membrane for color, position, landmarks, and integrity

PALPATE: auricles

• note any discharge from auditory meatus; check for foreign body

GAIN CHILDS COOPERATION BY LETTING CHILD HANDLE EQUIPMENT OR TO LOOK IN PARENTS EAR USING OTOSCOPE

51
Q

Child Assessment: Posterior thorax and breath sounds

A

INSPECT: posterior chest for configuration, skin characteristics, symmetry of shoulders and muscles

PALPATE: for lumps or tenderness over length of spinous processes

PERCUSS: over lung fields

AUSCULTATE: breath sounds, perform bilateral comparison in upper/lower lung fields; note any adventitious sounds

52
Q

Child Assessment: Anterior thorax, heart and lungs

A

INSPECT: size, shape and configuration of chest wall; pulsations on the precordium (note nipple and breast development)

ASSESS: RESPIRATORY MOVEMENT

PALPATE: apical pulse and note location, chest wall for thrills and for tactile fremitus

AUSCULTATE: breath and heart sounds in all locations, count RR and HR; S1 and S2 across precordium (note presence of murmurs)

53
Q

Child Assessment: Abdomen

A

INSPECT: shape, skin condition, periumbilical area

AUSCULTATE: bowel sounds

PALPATE: skin turgor, muscle tone, liver edge, spleen, kidneys, note presence of masses; femoral pulses and compare strength with radial pulses; inguinal lymph nodes

54
Q

Child Assessment: Genitalia

A

INSPECT: external genitalia

PALPATE-MALES ONLY: scrotum for testes (if masses are present, then transilluminate)

55
Q

Child Assessment: LE

A

INSPECT: toes, longitudinal arch

PALPATE: dorsalis pedis pulse bilaterally

• note alignment of legs and skin condition and feet
• check ROM of hips, knees, ankles
• elicit plantar, achilles and patellar reflex using reflex hammer

56
Q

The Adolescent

A

• perform sequence in same head to toe format as adult
• major task of adolescent is IDENTITY
• increasingly self conscious and introspective
• allow them to wear street clothes and work around them

57
Q

Sitting up for adolescent exam

A

• proceed with head, eyes, ears, neck and thoracic exam
• sit upright at edge of exam table

58
Q

Supine position for adolescent exam

A

• conduct cardiac, abdominal and LE
• place drape over lower abdomen when examining inguinal area
• ask adolescent to unzip and lower clothes under drape
• pant legs can be pulled up to examine lower legs and feet

Health Assessment (14 decks)

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