Week 3 - Culture & Pediatric Assessment Flashcards
What is health promotion & in what ways can nurses practice it?
Activities encompassing well-being & enhancing wellness or health
- Maintenance – screening, vaccinations, safety to prevent injury
- Supervision – well-child
What are the main health promotion items that are focused on by patient age?
- newborn / infant
- toddler / pre-schooler
- school age / adolescent
- Newborn / Infant: close to caregiver, parent’s mood, behave as expected, oral health, bottle use
- Toddler / Pre-schooler: respond to questions, age-appropriate play, interaction with staff
- School-age / Adolescent: interaction with parents, praising / partnering, divorce / separations, patient answers, independence
What is goodness of fit? What does it mean? What recommendations a nurse could offer parent?
Parent’s expectation of their child’s behavior consistent with the child’s temperment type
* Easy - 40%
* Difficult - 10%
* Slow to warm up - 15%
* Mixed - 35%
Recommendations:
* Active - many periods of play then rest before sleep
* Shy - allow time to adapt
* Easily Stimulated - quiet room
* Short Attention Span - projects completed in short time; gradually encourage longer periods at activities
Sequence of Physical Assessment in young children vs. older children
- Young Children = toe-to-head
- Older Children = head-to-toe
What is the HEEADSSS screening tool for adolescents?
- Home environment
- Education & employment
- Eating
- Activities
- Drugs (substance use)
- Sexuality
- Suicidal thoughts
- Safety, savagery (exposure to violence)
Normal Heart Rate Ranges for each age group when awake & asleep
- Neonate
- Infant
- Toddler
- Preschool
- School age
- Adolescent
Neonate: 80 - 180
Infant: 75 - 160
Toddler: 60 - 110
Preschool: 60 - 110
School-Age: 60 - 110
Adolescent: 50 - 90
Normal Heart Rate for Neonates
KNOW THIS!!!!!
80 - 180
- A: 100 - 180
- S: 80 - 160
Normal Heart Rate for Infants when awake & asleep
KNOW THIS!!!!!
80 - 180
Normal Heart Rate for Toddlers when awake & asleep
KNOW THIS!!!!!
60 - 110
- A: 80 - 110
- S: 60 - 90
Normal Heart Rate for Preschoolers when awake & asleep
KNOW THIS!!!!!
60 - 110
- A: 70 - 110
- S: 60 - 90
Normal Heart Rate for School-Age when awake & asleep
KNOW THIS!!!!!
60 - 110
- A: 65 - 110
- S: 60 - 90
Normal Heart Rate for Adolescents when awake & asleep
KNOW THIS!!!!!
50 - 90
- A: 60 - 90
- S: 50 - 90
Normal Respiration Ranges fro each age group
- Infant
- Toddler
- Preschool
- School Age
- Adolescent
KNOW THIS!!!!!
- Infant: 30 - 60
- Toddler: 24 - 40
- Preschool: 22 - 34
- School Age: 18 - 30
- Adolescent: 12-16
Normal Respiration Range for Infants
KNOW THIS!!!!!
30 - 60 breaths per minute
Normal Respiration Range for Toddlers
KNOW THIS!!!!!
24 - 40 breaths per minute
Normal Respiration Range for Preschoolers
KNOW THIS!!!!!
22 - 34 breaths per minute
Normal Respiration Range for School-Aged Children
KNOW THIS!!!!!
18 - 30 breaths per minute
Normal Respiration Range for Adolescents
KNOW THIS!!!!!
12 - 16 breaths per minute
Normal Temperature Range for Pediatrics
KNOW THIS!!!!!
< 36.5°C
& ≥
38°C
- 97.7 - 100.4 °F
How do you estimate the “normal” SBP for children 1+ years?
KNOW THIS!!!!!
90 mmHg + (2 x age in years)
Chest circumference?
KNOW THIS!!!!
- taken for first year of life
- Chest circumference is measured across the nipple line
Head circumference
KNOW THIS!!!!
- Until age 3
- Measure twice = Should be 2 cm larger than chest until 2 years
Expected weight changes during first year of life
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- 2x birth weight at 5-6 months
- 3x birth weight at 1 year
Neonate Vitals (HR, RR, SBP)
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HR: 80 - 180
* 100 - 180 (awake)
* 80 - 160 asleep
RR: 30 - 60
SBP: < 60 mmHg
Infant Vitals (1 - 12 months) (HR, RR, SBP)
KNOW THIS!!!!
HR: 75 - 160
* awake: 100 - 160
* asleep: 75 - 160
RR: 30 - 60
SBP: < 70 mmHg
Toddler Vitals (1-3 yr) (HR, RR, SBP)
KNOW THIS!!!!
HR: 60 - 110
* awake: 80 - 110
* asleep: 60 - 90
RR: 22 - 40
SBP: < 90 mmHg + ( 2 x age in years)
3 year old normal SBP would be:
90 + (2 x 3) = 90 + (6) = 96
School Age (6-10) (HR, RR, SBP)
KNOW THIS!!!!
HR: 60 - 110
* awake: 65 - 110
* asleep: 60 - 90
RR: 18 - 30
SBP: < 90 mmHg + (2 x age in yr)
Adolescent Vitals (10+) (HR, RR, SBP)
KNOW THIS!!!!
HR: 50 - 90
* awake: 60 - 90
* asleep: 50 - 90
RR: 12 - 16
SBP: < 90 mmHg + (2 x age in yr)
Skin Assessment Components
KNOW THE BOLD!!!!
- color
- temperature
- moistness
- check skin for color variation
- abnormalities: decreased pigment, Mongolian spot, moltting, bruises, erythema, pallor, cyanosis, jaundice
- texture
- hair texture
- turgor = assess abodmen
- edema = boggy skin
- Cap refill < 2 seconds
- lesions
Primary Lesions
Lesions arising from previously normal skin
* pimples / acne
Secondary lesions
lesions that result in changes in primary lesions
* scratching at a pimple
* ulcers
* scars
Head Assessment
KNOW THE BOLD!!!!
- Sutures
- Flat & soft fontanelles
- posterior fontanelle closed by 2-3 months
- anterior fontanelle closed by 12-18 months
- Prominent occipital area
- no significant head lag after 6 months
Eye Assessment
KNOW THE BOLD
- conjunctivae pink & glossy
- visual acuity at 3 months (infant should be able to follow an object)
- Binocularity by 3-4 months (infant should be able to focus on object with both eyes)
- 6 cranial fields of gaze
- Pupils round, clear, & reactive
- sunset sign (visual gaze downward = hydrocephalus)
Sunset Sign
White sclera visible above colored pupil
- indicates retracted eyelids or hydrocephalus
White Reflex
Reflex indicatvie of retinoblastoma or leukocoria
Ear Assessment
KNOW THE BOLD
- < 3 = pull pina down & back
- > 3 = pull pina up & back
- Position, shape, & symmetry
- tympanic membranes = pearly, translucent, reflective
- hearing loss indications: no speech by 2, regression in speech, no startle
Nose Assessment
KNOW THE BOLD!!!!
- size, shape, symmetry
- nasal flaring = respiratory distress
- color, discharge, swelling, patency, smell
Mouth Assessment
KNOW THE BOLD
- Lips
- Teeth # & dental caries
- Mucosa
- Tongue
- palate
- Throat
- Tonsils (0 - 4+)
Neck Assessment
KNOW THE BOLD
- Inspect for symmetry, color, swelling
- **Palpate for tenderness, teachea deviations, & thyroid enlargement **
- Range of motion; indicates torticollis or meningismus
Lymph Node Assessment
KNOW THE BOLD
- Palpate in circular motion
- Usually non-palpable if small/non-tender
**Chest Assessment **
KNOW THE BOLD
- Inspect for shape/size
- Diameter of 2:1 = normal
- Pectus carnatum & pectus excavatum
- scoliosis causes lateral deviation
Pectus Carnatum
KNOW THIS!!!!
Forward protrusion of sternum; pigeon chest
Pectus Excavatum
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Sunken sternum & adjacent cartilages; funnel chest
Respiratory Assessment
KNOW THE BOLD
- Inspect for chest / abdominal expansion
- Retractions between ribs indicate distress
- “Headbobbing” in young infants = distress
- Palpation (crepitus or tactile fremitus)
- Auscultation (fine crackles, coarse crackles, wheezing, rhonchi, stridor)
Respiratory Expansion in children under 6
- Inspect abodmen
- Diaphragm muscle primarily used
Respiratory Assessment in children over 6
- Inspect chest
What should be inspected when looking at respiratory expansion in children under 6 versus children over 6?
Under 6 = inspect the abdomen
* diaphragm muscle primarily used
Over 6 = inspect the chest
Cardiac Assessment
KNOW THE BOLD
- Inspect shape & symmetry of chest
- Palpate apical pulse
- Thrills = palpable murmur
- Auscultate (S1 & S2)
What is a thrill?
Palpable murmur on cardiac assessment
Abdominal Assessment
KNOW THE BOLD
- Umbilical stump
- Shape
- Movements
- Auscultate bowel sounds 10-30 seconds
- Percussion
- Femoral pulses
Genital Assessment - Females
KNOW THE BOLD
- Color, size, symmetry
- Masses, swelling inflammation, lacerations, or discharge
- Tanner Staging
Genital Assessment - Male
KNOW THE BOLD
- Structural development
- Hypospadias
- Foreskin
- Testicles
- Tanner Staging
- Have child sit in the tailor position
When palpating the scrotum for discended testicles & spermatic cords, place the index finger over the inguinal canal to keep the testicle in the scrotum. Gently palpate the testicle with only enough pressure to detect the size & shape
Hypospadias
KNOW THIS TERM!!!
opening of penis is on the underside rather than at the tip
Tanner Staging
KNOW THE BOLD
Sexual maturity rating used widely to assess & monitor the degree of maturation of an adolescent’s primary & secondary sexual characteristics. – stages 1-5
- Stage 1 = Pre-pubertal
- Stage 5 = Adult
Stage 1 (pre-pubertal): No pubic hair present in either sex
* Male - small penis & testes
* Female - have flat chest
Stage 2: soft pubic hair appears
* Male - measurable testes enlargement
* Female - breast buds appear
Stage 3: pubic hair becomes coarser
* Male - penis begins to enlarge in size & length
* Female - breast mounds form
Stage 4: pubic hair begins to cover pubic area
* Male - penis begins to widen
* Female - breast enlargement forms “mound-on-mound” breast contour
Stage 5 (Adult): Pubic hair extends to inner thigh
* Male - penis & testes enlarge to adult size
* Female - Breast takes on adult contour
Explain each stage of Tanner Staging
KNOW THE BOLD
Stage 1 (Pre-Pubital): No pubic hair present in either sex
* Male - small penis & testes
* Female - flat chest
Stage 2: soft pubic hair appears
* Male - measurable enlargement of testes
* Female - breast buds
Stage 3: Pubic hair becomes coarser
* Male - penis begins to increase in size & length
* Female - breast mounds
Stage 4: Pubic hair begins to cover pubic area
* Male - penis widens
* Female - breast enlargement forms “mound-on-mound” breast contour
Stage 5 (Adult): pubic hair extends to inner thigh
* Male - penis & testes enlarged to adult size
* Female - breasts take on adult contour
Musculoskeletal Assessment
KNOW THE BOLD
- Inspect legs & arms for symmetry / deformities
- Skin folds bilaterally
- Redness / swelling / pain
- Palpate bones & muscles for tone
- Observe ROM during play
- Muscle strength
- Posture
- Allis’ Sign = hip dislocation
Signs / Symptoms of Hip Dysplasia
KNOW THE BOLD
- Asymmetrical gluteal / thigh folds
- Limited hip abduction
- Shortening of femur
- Ortolani click (< 4 weeks old)
Hip Dysplasia = shallow hip socket
- Positive Ortolani or Barlow Test is indicative of developmental dysplasia of the hip (hip dysplasia)
Neuro Assessment
KNOW THE BOLD
- Behavior
- LOC
- Cranial nerve function
- Reflexes (grasp, rooting, moro, tonic neck, Babinski sign, Parachute)
Tactile Fremitus
Vibrations produced by crying or talking (usually palpated over the entire chest)
- Decreased sensations indicate that air is trapped in the lungs (as occurs with ashtma)
Crepitus
crackling sound & sensation that occurs when air is trapped under the skin
Fine Crackles
Definition & Cause KNOW THE BOLD!!!!
High-pitched, discrete, non-continuous crackling
- heard at the end of inspiration
- NOT cleared by coughing
CAUSE: air passing through watery secretions in the smaller airways (alveoli & bronchioles)
Coarse Crackles
Definition & Cause KNOW THE BOLD!!!!
Loud, low-pitched, bubbling & gurgling
- Heard during / on inspiration
- NOT cleared by coughing
CAUSE: air passing through thicker secretions in airway
sibilant Wheezing
Definition & Cause KNOW THE BOLD!!!!
High-pitched, musical, squeaking or hissing
- heard continuously during/on inspiration or expiration
- does NOT clear by coughing
CAUSE: air passing through mucus or fluids in a narrowed lower airway (bronchioles)
- typically asthma
Rhonchi (sonorous wheezing)
Definition & Cause KNOW THE BOLD!!!!
Coarse, low-pitched sound (like a snore)
- heard during / on inspiration or expiration
- may clear with coughing
CAUSE: air passing through thick secretions that obstruct large bronchi and/or trachea
Stridor
Definition & Cause KNOW THE BOLD!!!!
High-pitched, piercing sound
- most often heard during / on inspiration without a stethoscope
CAUSE: whistling as air passes through narrowed trachea & larynx
- associated with croup
