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Pediatric > Physical Assessment Findings > Flashcards

Physical Assessment Findings Flashcards

1
Q

Nursing Considerations of Physical Assessment

A
  1. keep the room warm and well lit
  2. perform examinations in nonthreatening environments. keep medical equipment out of sight
  3. provide privacy. determine whether older school-age children and adolescents prefer a caregiver to remain during examination
  4. take time to play and develop rapport prior to beginning examinations
  5. observe for behaviors that demonstrate child’s readiness to cooperate, such as interacting with RN, making eye contact, permitting physical touch, and willingly sitting on the exam table.
  6. explain each step of the examination to the child. (use age appropriate language. demonstrate what will happen using dolls, puppets, or paper drawings. allow the child to manipulate and handle equipment. encourage the child to sue equipment on others)
  7. examine the child in a secure, comfortable position.
  8. . proceed to examine the child in an organized sequence when possible.
  9. if the child is uncooperative, assess reasons, be firm, and direct about expected behavior, complete the assessment quickly and use a calm voice.
  10. encourage the child and family to ask questions during physical exams. discuss findings with family after the exam.
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2
Q

Temperature for 3 month old

A

37.5 or 99.5

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3
Q

Temperature of 6 month old

A

37.7 or 99.9

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4
Q

Temperature of 1 year old

A

37.2 or 99.0

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5
Q

Temperature of a 3 year old

A

37.2 or 99.0

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6
Q

Temperature of a 5 year old

A

37.0 or 98.6

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7
Q

Temperature of a 7 year old

A

36.8 or 98.2

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8
Q

Temperature of a 9 and 11 year old

A

36.7 or 98.1

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9
Q

Temperature of a 13 year old

A

36.6 or 97.9

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10
Q

Pulse of a newborn

A

80-180 (depending on activity)

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11
Q

Pulse of 1 week old to 3 month old

A

80-220 (depending on activity)

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12
Q

Pulse of 3 month old to 2 year old

A

70-150 (depending on activity)

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13
Q

Pulse of 2-10 year old

A

60-110 (deepening on activity)

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14
Q

Pulse of 10 years and older

A

50-90 (depending on activity)

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15
Q

Respirations of newborn to 1 year old

A

30-60

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16
Q

Respirations of 1-2 year old

A

25-30

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17
Q

Respirations of 2-6 year old

A

21-25

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18
Q

Respirations of 6-12 year old

A

19-21

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19
Q

Respirations of 12 years and older

A

16-19

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20
Q

Blood Pressure

A

Readings should be compared with standard measurements.

Age, height, and gender all influence blood pressure readings.

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21
Q

Growth

A

Growth can be evaluated by using weight, length/height, BMI, and head circumference. Growth charts are tools that can be used to assess the overall health of the child.
It is recommended to use the WHO growth standards for infants and children ages 0-2 in the US and the CDC charts for children 2 and older.

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22
Q

General Appearance

A

appears undistressed, clean, well kept, and without body odors.
Muscle tone: Erect head posture is expected in infants after 4 months of age.
Makes eye contact when addressed (except infants).
Follows simple commands as age-appropriate.
Uses speech, language, and motor skills appropriately.

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23
Q

Skin

A

Variations in skin color are expected based on race and ethnicity.
Temperature should be warm or slightly cool to the touch.
Skin texture should be smooth and slightly dry, not oily.
Skin turgor exhibits brisk elasticity with adequate hydration.
Lesions are not expected.
Skin folds should be symmetric

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24
Q

Hair and Scalp

A

Hair should be evenly distributed, smooth, and strong.
Manifestations of nutritional deficiencies include hair that is stringy, dull, brittle, and dry.
Scalp should be clean and absent from any scaliness, infestations, or trauma.
Assess children approaching adolescents for presence of secondary hair growth.

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25
Q

Nails

A

Pink over the nail bed and white at the tips.

Smooth and firm (but slightly flexible in infants)

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26
Q

Lymph Nodes

A

Lymph nodes should be nonpalpable. Lymph noes that are small, palpable, contender, and mobile can be expected finding in children.

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27
Q

Head

A

The shape of the head should be symmetric.
Fontanels should be flat.
The posterior fontanel usually closes by 6-8 weeks of age.
The anterior fontanel usually closes between 12-18 months of age.

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28
Q

Face

A

Symmetric appearance and movement.

Proportional features.

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29
Q

Neck

A

Short in infants.
Nonpalpable masses.
Midline trachea.
Full range of motion present whether assessed actively or passively.

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30
Q

Eyebrows

A

should be symmetric and evenly distributed from the inner to the outer canthus

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31
Q

Eyelids

A

should close completely and open to allow the lower border and most of the upper portion of the iris to be seen.

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32
Q

Eyelashes

A

should curve outward and be evenly distributed with no inflammation around any of the hair follicles.

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33
Q

Conjunctiva

A

Palpebral is pink.

Bulbar is transparent.

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34
Q

Lacrimal Apparatus

A

is without excessive tearing, redness, or discharge.

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35
Q

Sclera

A

should be white

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36
Q

Corneas

A

should be clear

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37
Q

Pupils

A

should be round, equal in size, reactive to light, accommodating.

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38
Q

Irises

A

should be round with the permanent color manifesting around 6-12 months of age.

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39
Q

Visual Acuity

A

Can be difficult to assess in children younger than 3 years old.
Visual acuity in infants can be assessed by holding an object in front of the eyes and checking whether the infant is able to fix on the object and follow it.
Use the tumbling E or HOTV test to check visual acuity of children who are unable to read letters and numbers.
Older children should be tested using Snellen char or symbol chart.

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40
Q

Peripheral Fields

A

upward 50 degrees
downward 70 degrees
nasally 60 degrees
temporally 90 degrees

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41
Q

Extraocular Movements

A

Might not be symmetric in newborns.
Corneal light reflex should be symmetric.
Cover/Uncover test should demonstrate equal movements of the eyes.
Six cardinal fields of gaze should demonstrate no nystagmus.

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42
Q

Color Vision

A

Should be assessed using the Ishihara color test or the Hardy-Rand-Rittler test.
The child should be able to correctly identify shapes, symbols, or numbers

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43
Q

Internal Exam

A

Red relex should be present in infants.

Arteries, veins, optic discs, and maculae can be visualized in older children and adolescents.

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44
Q

Alignment of Ears

A

the top of the auricles should meet in an imaginary horizontal line that extends from the outer canthus of the eye.

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45
Q

External Ear

A

Should be free of lesions and contender.
Ear canal should be free of foreign bodies or discharge.
Cerumen is an expected finding.

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46
Q

Internal Ear

A

In infants and toddlers, pull the pinna down and back to visualize the tympanic membrane.
In children older than 3 years old, pul the pinna up and back to visualize.
The ear canal should be pink with fine hairs.
The tympanic embrace should be pearly pink or gray.
The light reflex should be visible
Umbo (tip of the malleolus) and manubrium (long process or handle) are the bony landmarks that should be visible.

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47
Q

Hearing

A

Newborns should have intact acoustic blink reflexes to sudden sounds.
Infants should turn towards sounds.
Older children can be screened by whispering a word from behind to see whether they can identify the word

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48
Q

Nose

A

The portion should be midline.
Patency should be present for each nostril without excessive flaring.
Smell can be assessed in older children.

49
Q

Internal Structure of Nose

A

The septum is midline and intact.

The mucous is deep pink and moist without discharge.

50
Q

Lips

A

Darker pigmentation than facial skin.

Smooth, soft, and symmetric.

51
Q

Gums

A

Coral pink.

Tight against the teeth.

52
Q

Mucous Membranes

A

Without lesions.

Moist, pink, smooth, and glistening.

53
Q

Tongue

A

Infants can have white coating on their tongues from milk that can be easily removed. Oral candidiasis coating is not easily removed.
Children and adolescents should have pink, symmetric tongues that they are able to move beyond their lips.

54
Q

Teeth

A

Infants should have 6-8 teeth by 1 year of age.
Children and adolescents should have teeth that are white and smooth, and begin replacing the 20 deciduous teeth with 32 permanent teeth.

55
Q

Hard and Soft Palates

A

intact, firm, and concave

56
Q

Uvula

A

Intact and moves with vocalization

57
Q

Tonsils

A

Infants: might not be able to visualize
Children: barely visible to prominent, same color as surrounding mucosa

58
Q

Speech

A

Infants: strong cry

Children and adolescents: clear and articulate.

59
Q

Chest Shape

A

Infants: shape is almost circular with anteroposterior diameter equalling the transverse or lateral diameter.
Children: the transverse diameter to anteroposterior diameter changes to 2:1

60
Q

Ribs and Sternum

A

more soft and flexible in infants; symmetric and smooth, with no protrusion or bulges

61
Q

Movement of Chest

A

Symmetrical, no retractions.
Infants: irregular rhythms are common
Child: more abdominal movement is seen during respirations

62
Q

Breath Sounds

A

Inspiration is longer and louder than expiration.

Vesicular, or soft, swishing sounds are head over most of the lungs.

63
Q

Breasts

A

Newborns: Breasts can be enlarged during the first few days.
Children: nipples and areoles are darker pigmented and symmetric.
Females: breasts typically develop between 10-14 years of age. The shape should appear asymmetric, have no masses, and be palpable.
Males: can develop gynecomastia, which is unilateral or bilateral enlargement that occurs during puberty.

64
Q

Circulatory system

A

A comprehensive assessment of the circulatory system includes assessment of pulses, capillary refill time, neck veins, clubbing of fingers, peripheral cyanosis, edema, BP, and RR.

65
Q

Heart Sounds

A

Ascultation should be done in both a sitting and reclining position.
S1 and S2 heart sounds should be clear and crisp. S1 is louder at the apex of the heart. s2 is louder near the base of the heart. Physiologic splitting of the S2 and S1 hear sounds are expected findings in some children. Sinus arrhythmias that are associated with respirations are common

66
Q

Pulses

A

Infants: Brachial, temporal, and femoral pulses should be palpable, full, and localized.
Children: pulse locations are expected findings are the same as those in adults.

67
Q

Abdomen

A

Without tenderness, no guarding. Peristaltic waves can be visible in thinner children
Shape: symmetric and without protrusions around the umbilicus.
Infants and toddlers have rounded abdomen.
Children should have a flat abdomen.
Bowel sounds should be heart every 5-30 seconds.

68
Q

Anus

A

surrounding skin should be intact with sphincter tightening noted if the anus is touched. Routine rectal exams are not done with the pediatric population.

69
Q

Male Genitalia

A

hair distribution is diamond shaped after puberty in adolescent males. No pubic hair is noted in infants and small children.

70
Q

Penis

A

Penis should appear straight.
Urethral meatus should be at the tip of the penis.
Foreskin might not be retractable in infants and small children.
Enlargement of the penis occurs during adolescence.
The penis can look abnormally small in males who are obese because of skin folds partially covering the base.

71
Q

Scrotum

A

The scrotum hands separately from the penis.
The skin on the scrotum has a rugs appearance and is loose.
The left testicle hands slightly lower than the right.
The inguinal canal should be absent of swelling.
During puberty the testes and scrotum enlarge with darker scrotal skin.

72
Q

Female Genitalia

A

Hair distribution over the mons pubs should be documented in terms of amount and location during puberty. Hair should appear in an inverted triangle. No pubic hair should be noted in infants or small children.

73
Q

Labia

A

Symmetric, without lesions, moist on the inner aspects.

74
Q

Clitoris

A

Small, without bruising or edema

75
Q

Urethral meatus

A

slit like in appearance with no discharge.

76
Q

Vaginal Orifice

A

The hymen can be absent or it can completely or partially cover the vaginal opening prior to sexual intercourse.

77
Q

Musculoskeletal System

A

length, position, and size of extremities are symmetric

78
Q

Joints

A

stable and symmetric with full ROM and no crepitus or redness.

79
Q

Spine (Infants)

A

spines should be without dimples or tufts of hair. They should be midline with an overall C-shaped lateral curve

80
Q

Spine (Toddlers)

A

appear squat with short legs and protuberant abdomens.

81
Q

Spine (Preschoolers)

A

appear more erect than toddlers

82
Q

Spine (Children)

A

should develop the cervical, thoracic, and lumbar curvatures like that of adults.

83
Q

Spine (adolescents)

A

should remain midline (no scoliosis noted)

84
Q

Gait (toddlers and young children)

A

a bowlegged or knock-knee appearance is common. Feet should face forward while walking.

85
Q

Gait (Older children and adolescents)

A

a steady gait should be noted with even wear on the soles of shoes.

86
Q

Deep Tendon Reflex

A

Should demonstrate the following:
Partial flexion of the lower arm at the bicep tendon.
Partial extension of the lower arm at the tricep tendon.
Partial extension of the lower leg at the patellar tendon.
Plantar flexion of the foot at the Achilles tendon.

87
Q

Cerebellar Function

A

Finger to nose test: rapid coordinated movements.
Heel to shin test: able to run the heel of one foot down the shin of the other leg while standing.
Romberg Test: able to stand with slight swaying while eyes are closed.

88
Q

Infant Blood Pressure

A

Systolic: 65-78
Diastolic: 41-52

89
Q

1 year old Girl Blood Pressure

A

Systolic: 83-114
Diastolic: 38-67

90
Q

3 year old girl blood pressure

A

systolic: 86-117
diastolic: 47-76

91
Q

6 year old girl blood pressure

A

systolic: 91-122
diastolic: 54-83

92
Q

10 year old girl blood pressure

A

systolic: 98-129
diastolic: 59-88

93
Q

16 year old girl blood pressure

A

systolic: 108-138
diastolic: 64-93

94
Q

1 year old boy blood pressure

A

systolic: 80-114
diastolic: 34-66

95
Q

3 year old boy blood pressure

A

systolic: 86-120
diastolic: 44-75

96
Q

6 year old boy blood pressure

A

systolic: 91-125
diastolic: 53-84

97
Q

10 year old boy blood pressure

A

systolic: 97-130
diastolic: 58-90

98
Q

16 year old boy blood pressure

A

systolic: 111-145
diastolic: 63-94

99
Q

Sucking and Rooting Reflexes

A

Elicited by stroking an infants cheek or the edge of an infants mouth. The infant turns her head toward the side that is touched and starts to suck.
Expected age: birth-4 months

100
Q

Palmar Grasp

A

Elicited by placing an object in an infants palm. The infant grasps the object.
Expected age: birth -3 months

101
Q

Plantar Grasp

A

Elicited by touching the sole of an infants foot. The infants toes curl downwards.
Expected age: birth -8 months

102
Q

Moro Reflex

A

Elicited by allowing the head and trunk of an infant in a semi-sitting position to fall backward to an angle of at least 30 degrees. The infants arms and legs symmetrically extend, then abduct while fingers to form a C shape.
Expected age: birth- 4 months

103
Q

Startle Reflex

A

Elicited by clapping hands or by a loud noise. The newborn abducts arms at the elbows, and the hands remain clinched.
Expected age: birth- 4 months.

104
Q

Tonic Neck Reflex (Fencer Positon)

A

Elicited by turning an infants head to one side. The infant extends the arm and leg on that side and flexes the arm and leg on the opposite side.
Expected Age: birth to 3 to 4 months

105
Q

Babinski Reflex

A

Elicited by stroking the outer edge of the sole of an infants foot up toward the toes. The infants toes fan upward and out.
Expected age: birth - 1 year

106
Q

Stepping

A

Elicited by holding an infant upright with his feet touching a flat surface. The infant makes stepping movements.
Expected age: birth- 4 weeks.

107
Q

CN 1

A

Olfactory
Infants: difficult to test.
Children: identifies smell through each nostril individually.

108
Q

CN 2

A

Optic
Infants: looks at face and tracks with eyes.
Children: had intact visual acuity, peripheral vision, and color vision.

109
Q

CN 3

A

Oculomotor
Infants: blinds in response to light. Has pupils that are reactive to light.
Children: has no nystagmus and PERRLA is intact

110
Q

CN 4

A

Trochlear

infants: looks at face and tracks with eyes
children: has the ability to look down and in with eyes.

111
Q

CN 5

A

trigeminal

infants: has rooting and sucking reflexes
children: is able to clench teeth together. detects touch on face with eyes closed.

112
Q

CN 6

A

abducens

infants: loos at face and tracks with eyes.
children: is able to see laterally with eyes.

113
Q

CN 7

A

facial

infants: has symmetric facial movements
children: has the ability to differentiate between salty and sweet on tongue. Has symmetric eye movements.

114
Q

CN 8

A

acoustic

infants: tracks a sound. blinds in response to a loud noise.
children: does not experience vertigo. Has intact hearing.

115
Q

CN 9

A

glossopharyngeal

infants: has an intact gag reflex
children: has an intact gag reflex. is able to take sour sensations on the back of the tongue.

116
Q

CN 10

A

vagus

infants: has no difficulties swallowing.
children: speech is clear, no difficulties swallowing. uvula is midline.

117
Q

CN 11

A

spinal accessory

infants: moves shoulder symmetrically
children: has equal strength of shoulder shrug against examiners hands.

118
Q

CN 12

A

hypoglossal

infants: has no difficulties swallowing. Opens mouth when nares are occluded.
children: has a tongue that is midline. is able to move tongue in all directions with equal strength against tongue blade resistance.

Pediatric (16 decks)

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