chapter 33 peds physical assessment
Card Set Information
chapter 33 peds physical assessment
peds physical assessment
2 ways to reduce anxiety in peds pt?
Involve parents and allow pt to handle safe equipment
Systematic approach to physical assessment?
Head to toe
Where is a good place to put an infant birth to 6 months for their physical exam?
Is it necessary to wake them up?
In parent's lap
When should uncomfortable procedures be done when examining an infant birth to 6 months?
What should an infant birth to 6months be wearing during physical exam ?
Males - diaper
Females - nothing
How do I rants over 6 months differ from birth to 6 months?
They feel stranger anxiety
Why are toddlers the most difficult to examine?
They do not cooperate
How should the examination of a toddler be done?
Least to most invasive, be flexible and allow them to hold toys or medical equipment and explain things for them
Who is the most important in gaining the cooperation of a toddler and why?
Parent because their soothing techniques are familiar
What is the best approach when examining a preschooler? Why?
Allow them to participate
Because they like showing what thy can do
How does the nurse establish a trusting relationship with a school age child ?
Ask them questions they can answer
What should a schoolage child wear during exam?
Drape over underpants or a colorful exam gown
At what ate should the nurse start to consider a child's modesty?
How is exam of school aged child conducted?
Head to toe
What should the nurse teach about while performing a physical exam on a school aged child?
The body and personal care
What approach works best with adolescents?
Straightforward and not condescending
Should parents be present during the exam of an adolescent?
Ask the pt
Order of exam for an adolescent?
Head to toe
When should the genital exam of an adolescent be done?
In the middle of the exam
What type of teaching should the nurse give an adolescent during their exam?
Puberty, normal development, and answer questions
What should an adolescent wear during exam?
Four basic techniques of exams in order?
Inspection, palpation, percussion, auscultation
Nurse uses their own sight and hearing
Nurse uses tools to see and hear
What is the purpose of palpation?
Locating structures and masses
What 5 things can be determined by palpation?
Warmth, texture, size, tenderness, mobility
What part of the hands is used to palpate breasts?
Pads of fingers
What part of the hand is used to palpate lymph. Odes and pulses?
What part of the hand is used to palpate temp?
Back of the hand
What part of the hand is used to palpate vibrations?
Procedure for performing light palpation?
Apply pressure with fingertips and depress skin 1/2 to 3/5" and move fingers in a circular motion
Procedure for deep palpation?
When should it be done?
Surface depressed 1&1/2 to 2 "
After light palpation
What is the purpose of deep palpation
Identifying abdominal structures and masses
Use 2 hands to trap a mass or organ between them
Quick tapping of fingers or hands to produce sounds
To locate the position, size, and density of underlying structures
3 types of percussion?
Finger of one hand placed against the body and finger of other hand acts as a hammer
Strike finger of one hand directly against the body?
Ulnar aspect of the fist is used to deliver firm blow directly to are
What part of the stethoscope is better for high- pitched sounds?
2 examples of high pitched sounds?
Heart and breath sounds
What part of the stethoscope is best for low pitched sounds?
What makes low pitched sounds?
Vascular sounds and BP
4 characteristics used to describe auscultation sounds?
Pitch, intensity, duration, and quality
What can be determined by smell during exam?
Hygiene, infection, some conditions
What is the first step of the exam?
What is done?
Get general info through observation about child's behavior, sex, race, physical appearance
How is the parent included in the general survey?
Observe their interactions with child
What is the most important component of the physical exam?
Taking an accurate history
3 types of histories that may be obtained and what are they?
1. Complete/ initial history- data gathered from conception to current
2. Well/ interim history - data gathered from last well visit to current visit
3. Episodic/ problem oriented - info gathered about a current problem
What is included in a complete history?
Patient profile- regular habits
Lifestyle and patterns - interactions with environment and social
Review of systems
Normal temp, pulse, RR, and BP of a newborn?
97.7 - 99.1 axillary
30-60 breaths/ minute
65/30 - 95/60
Normal vital signs for 4 year old?
Temp- 97.5 to 98.6 axillary
Pulse - 80-125
BP- 91/52 - 104/66
Normal VS for 10 year old?
Temp - 97.5- 98.6 oral
Pulse - 70-110
RR 16- 22
BP- 102/60 - 115/74
Normal VS for 16 year old?
What is included in a
Problem oriented exam?
1. Chief complaint in child's words
2. Location on body
3. Quality- what problem is like for the child
4. Quantity - intensity of prob
5. Chronology - when began, frequency, course
6. Setting - where prob occurs
7. Aggravating and alleviating factors
8. Associated manifestations- other related info
9. Treatment- what has.been used to treat it
Where are parents encouraged to take temp over rectal?
Because of risk for injury, feces retains heat long after fever has go e, and invasive
What should be noted when taking a tympanic temp?
What side it is taken from
When can oral temp be taken?
Children around age 5 and up
In what children are apical pulse rates measured?
Children younger than 2 years and those with irregular heart beat or known heart prob
At what ate do you start taking radial pulse rates?
How long should pulse be counted?
To compensate for normal irregularities
How does the nurse determine the position of the heart in children you get than 6?
Palpating the apical pulse
In what situation is the apical
Pulse and location always noted?
For what age?
Acute care settings
What pulses are compared in children of any age?
Femoral, radial, and carotid
What pulse do infants have that others don't
What does an irregular pulse in an infant usually indicate?
Usually response to changes in respiration
3 things to observe in respiration?
Rate, depth, ease of respirations
What is the difference in observing RR of infants and toddler and up children?
Infant- ABD excursion
Toddler and up- thoracic excursion
How long should RR be observed
What is strider and where is it heard the loudest?
What can it indicate in children?
Crowing noise heard on inspiration and louder over the neck
Croup or eppiglotitis
What does inspiratory strider indicate?
Partial Obstruction of airway
Continuous inspiratory and expiratory stridot indicates _____.
Delayed dev of cartilage in trachea or small larynx
when is it recommended that all children have BP Becker regularly?
Beginning at age 3
How often should BP be taken in acute care setting?
At least every day
If a child's BP indicates hypertensive what must be done before it is recorded?
Must be confirmed
When does a child's BP require further evaluation
Avg of 3 abnormal BP taken at Esperanto occasions
Adolescent prehypertensive point?
What will too small/ too large BP CUFF CAUSE?
Elevated/ low BP reading
What should the nurse tell the child before getting BP?
The cuff will squeeze/ give the arm a hug
What is important when evaluating pain?
Using dev appropriate pain assessment tool
What is anthropometrics?
Measuring human body and assessing nutrition, growth, and dev
What anthropometric measures are always taken in children
Head circumference, height, and weight
How to calculate BMI?
Weight(lb) x 703 / height in inches squared.
What provides info about SQ tissue, muscle, and fat in body?
Mid arm muscle circumference, ski fold thickness, weight
What do the serial physical measurements show?
Rate of growth
What is the most significant indicator of change in child's health status related to serial growth?
When the child's height/ weight drops off their own growth chart
How is height of infant - toddler taken?
When does this change
Lying down on flat measuring board
When the child is able to stand aline
Two methods for measuring lying down child?
Which is more accurate?
Measuring board- head is held to board a d footboard is moved to touch heels
Lay on paper and mark where heels and top of head are and measure with measuring tape
How is a standing child measured?
How might his measurement compare to the lying measurement?
Same as adult
May be slightly differnet
What should be done to all scales before measuring the child?
Zeroed or balanced
How are infants measured?
Naked on a baby scale
How are children who can stand weighed?
Like adults in nothing but underwear
What children have their head circumference measured?
All age birth to 36 months and all above 3 with questionable head size macrocephaly or microcephaly
How is head circumference measured?
No stretch measuring tape around largest part of head/ forehead
During the first year of life the head circumference usually increases by _____ cm.
What can hear circumference indicate?
Rate of dev, nutritional status, hydrocephalus
What is hydrocephalus?
Abnormal accumulation of CSF
Circumference of _____ is routinely measured only in newborns and is usually smaller than head circumference.
When do head and chest circumference become nearly equal?
How to measure chest circumference?
Tape measure around chest at nipple line and measurement taken b/t inspiration and expiration
What does triceps skin fold indicate?
How is it obtained?
Total body fat
Mid arm circumference indicates ______& ______.
Muscle and fat
How to measure midarm circumference?
Measure midpoint between acromion and olecranon and record in cm
How to measure triceps skinfold?
With arms loosely at sides grasp skin gold at posterior midpoint of arm , ask child to flex muscle, take reading with. Alipet
How does nurse know when muscle is grasped along with fat when performing triceps skin fold test?
When the child flexes the it is felt
CDC recommends health providers use __________ growth standards to monitor growth for infants age ______years and ______ growth charts for children age _______.
WHO 0-2 years
CDC children 2 & over
Because WHO charts are based on breasted infants and show what growth should be
There are separate growth charts for ______ & ______.
Girls and boys
What 4 things are potted on WHO birth chart for age 0-2 years?
Length, weight, head circumference, and length to weight relationship
What. An length to weight relationship indicate?
What 3 things are plotted on CDC chart and what ages are included?
Height, weight, and BMI
What infants may require special growth charts?
Premature, down syndrome, other conditions that affect growth
On a growth chart the child's age is on the _____ axis and the corresponding measurement is on the ______ axis. The the chart is marked_______.
Weight and height measurements above _____ percentile or below ______ percentile indicate a growth disturbance.
How may brain growth be assessed?
Serial head circumference measurements
BMI from ______ to _____ percentile indicate risk for obesity.
85th to below 95th
BMI at or above _____ percentile I children older than 2 indicate overweight.
2 techniques used in skin assessment?
Inspection and palpation
4 characteristics of skin that are assessed?
Color, texture,turgor, and lesions
In dark- skinned infants erythema appears _______, cyanosis appears_______, and jaundice appears______.
dusky red or violet
What is the best way to assess skin color of darker skinned infants?
Determine normal skin color and compare
What skin alterations may indicate diabetes type 2 mellitus in children?
What is acanthosis nigricans?
Darker, thicker skin in folds (posterior neck, behind knees and elbows, and in armpits )
Areas of depigmentation
Areas of increased pigmentation
Where is it best seen?
Sclera/ whites of eyes
Where is it best seen?
Mucous membranes of the mouth especially under tongue
Where is it best seen?
Palms and soles of feet
Loss of skin color?
Discolored areas of skin
What 6 characteristics of skin may be assessed using palpation?
Moisture, temp, texture, turgor, edema, and lesions
Why is the back of the hand used to assess skin temp?
Because it is more sensitive to temp
What comparison should be used when palpating child's temp?
Compare 2 sides of the body
Where to test skin turgor in children?
Abdomen and upper arm
2 areas to palpate for edema in children?
Extremities and buttocks
Where is periorbital edema observed?
On the eyelids
What four characteristics of lesions should be noted?
Configuration, distribution, color, and size
What are primary and secondary lesions?
Primary- arise from normal skin ( freckle)
Secondary - results Tom an alteration in primary lesion (scab)
What does configuration of skin lesion refer to?
Arrangement/position of several lesions in relation to each other or arrangement of a single lesion
What does distribution of lesions refer to?
Location on body and symmetry or asymmetry of lesions
Hair usually covers all areas of the body except _____, _____, and some areas of _____.
Palms, soles of feet, genitalia
4 characteristics of hair that should be noted?
Texture, changes in color, unusual distribution, cleanliness
Fine, downy hair in non-infants and brittle hair may indicate ______ and ______ abnormalities.
Excessive hair growth
Unusual hair loss
Why are most cases of head lice discovered?
2 ways to identify clubbing of fingernails?
If angle between nail base and fingernail is > ______ degrees, then clubbing is present.
Observe index finger for bulging up of nail
Put nails together and see diamond
Cap refill should be less than ____ seconds. Longer cap refill may indicate what 4 conditions?
< 2 seconds
Decreased cardiac output
2 assessment techniques used on lymph nodes?
Inspection and palpation
What regions of the body should have lymph nodes assessed?
Head and neck, supraclavicular, axillary, arms, inguinal
Characteristics of lymph nodes that indicate infection?
Enlarged, warm, firm, and fluctuant
What is an enlarged supraclavicular lymph node on the left side in young children called?
What may it indicate?
Wilms tumor or other neoplasticism disease
What is a neoplastic disease?
the abnormal proliferation of benign or malignant cells. neoplastic
What 2 assessment techniques are used on the head and neck?
Inspection and palpation
4 characteristics of the head to evaluate?
Symmetry, paralysis, weakness, and movement
How should suture lines in infants be assessed?
When do they flatten?
Around 6 mo
Paralysis and weakness of the head are directly related to ________.
Paralysis and weakness of neck muscles
How is head control of infants observed?
Infant in supine position
Pulling infant up by arms
How long should 4 mo old be able to support own head?
What is indicated if the infant cannot do this?
Weak neck muscles
When is head lag an indication muscles may.not be dev properly?
What may be indicated by increased extensor and axial muscle tone in a infant?
Neuromuscular probs/ cerebral palsy
How to assess head of older child?
Full ROM - up, down, side to side
Characteristics of fontanel to assess?
Size, tenseness, and pulsation
When should the posterior fontanel be closed?
The anterior fontanel should be < ____ cm inlength and width after 12 mo, and should be completely closed by age ____ to _____ mo.
A sunken fontanel may indicate_____.
Bulging fontanel can indicate _______.
Increased intracranial pressure.
How is it indicated?
Premature closure of the anterior fontanel
Cannot palpate it
What normal activities may cause the anterior fontanel to bulge?
Coughing, crying, vomiting
2 assessment techniques used in neck?
Inspection and palpation
Neck is assessed for what 3 characteristics?
Symmetry, size, and shape
Related to use/ disuse of neck muscles
Webbing of the neck/ presence of an extra skin fold posteriorly is associated with __________?
Some chromosomal disorders
Down syndrome, trisomy
How to palpate child's thyroid gland?
Identify the isthmus of the thyroid across the trachea
How to ID enlarged thyroid gland in Child?
Displace thyroid gland and palpate with other hand
What may make the thyroid gland more palpable?
Having the child swallow
2 assessment techniques used on face?
Face is assessed for ______.
Inspection and palpation
The eyes are examined for _____,______,&______.
Size, position, and configuration
Eyes are wide spaced
Eyes close together
Shallow crease or absence of crease below nose
How are low- set ears ID'd?
Auricle of the ear does not cross or touch the eye- occupy line
The ear position should have no more than ____ degree posterior angle making the ear nearly vertical.
Which 2 cranial nerve functions are assessed during head exam?
V- trigeminal nerve
VII- facial nerve
What is cranial nerve V and how is it evaluated?
Trigeminal nerve- face sensations, chewing, and biting
Observe chewing and sucking / touch child's cheeks and forehead with a cotton ball & child should move head or bat it away
What is cranial nerve VII & it's function?
How is it evaluated?
Facial nerve- motor control of most muscles of facial expression
Ask child to frown, smile, or make a face / have child puff out cheeks or whistle
PPE required for all. ASAP exams?
Nurse should describe the _____, _______, &______ of drainage from nose.
Color, amount, consistency
How to assess latency of nostrils?
Occlude one side and have them sniff
What is indicated by a transverse crease on a child's nose?
Sense of smell is mediated by cranial nerve ______.
How is it tested?
I - olfactory
Close eyes, occlude one nostril, have them ID a familiar smell
The nasal mucosa is inspected for _____ & _____.
How should it normally appear?
Color and moisture
Smooth, moist, & bright pink
Appearance on nasal mucosa in children with allergies?
Pale and boggy
With infectious diseases the nasal mucosa Appears ______& ______ and the drainage is _____ or ____ in color.
Erythematous and swollen
Yellow or green
The ______ and _____ sinuses are inspected and palpate during a nasal exam.
They are examined for ______& _____.
Frontal and maxillary
Swelling and color
Puffiness and redness over sinuses and dark circles under eyes may indicate____.
How are frontal sinuses palpated?
Press over sinus under eyebrow
How are the maxillary sinuses palpated?
Pressing upward with thumbs under the maxillary bones
When should exam of mouth in a young child be done?
How should the exam proceed?
At the end because it may stress them
From anterior structures to interior
Notch b/t nose and
PPE during oral exam?
Tools neededfor oral exam?
Tongue blade and pen light
3 exam techniques used for oral
Inspection, palpation, and sense of smell
5 characteristics of lips to examine?
Symmetry, color, moisture, cracking, and lesions
Attaches lips to gums
How is the buccal mucosa examined?
Observe for ____, _____, &_____.
Hold cheeks open with tongue blade
Color, nodules, and lesions
Where is the parotid gland opening?
Buccal mucosa opposite the upper second molar
4 char of teeth to examine?
Number, cavities, formation, and occlusion
When does eruption of deciduous teeth begin?
When are all present?
What may cause mottling of the permanent teeth?
Excessive ingestion of fluoride
Gums are inspected and palpated for ______ &_____.
Color and swelling
3 things to examine in the floor of the mouth?
Sublingual frenulum, sublingual ridge, & wharton's ducts
How to prevent being bitten during oral exam?
Hold child's cheeks
Cranial nerve XII and it's function?
How is it assessed?
Hypoglossal nerve- to the movement
Stick out tongue as though licking a lollipop and observe for sideways movement
How to test strength of to the?
Put finger on cheek and have them press tongue against it
Should be equally strong on both sides
How to test strength of infant sucking reflex?
Allow infant to suck on gloved finger while palpating hard palate
Cranial nerve IX and it's function?
Glossopharyngeal nerve- swallowing, taste on back of to gue
Cranial nerve X and it's function?
Vagus nerve- breathing, speech, gag reflex
How are cranial nerves XI and X tested?
Ask child to say ah
Soft palate and uvula should rise symmetrically & phonation of ah is understood
How is the oropharynx observed?
Depress tongue with blade
How to use tongue blade to observe oropharynx?
Slide along side of to tongue until reach soft palate then compress tongue to elicit gag reflex and observe back of throat
What may cause a child to snore
How are the eyes examined?
Inspection, palpation, visual accuity, extraocular muscle function
How to test vision of 1-2 mo old?
Black and white images, contrasting figures, or faces
At what age will an infant fixate on a bright object and follow with eyes?
Visual accuity testing for all children shinning no later than age ____ years is recommended.
3 vision tests that work for
Lea chart, tumbling E, HOTV matching test
All children should be screened for visual impairment between ages ____ to test for _____ or it's risk factors.
Loss of one eye's ability to see details
" lazy eye"
How to test preschool vision?
Use HOTV matching- stand 10 feet back, give child cards and have them match them to the chart
Screening is started at the _____ line on the chart for < 4 years and _____ line for older kids.
Correctly ID 4 of 5 letters
How to test older children's vision?
Snellen chart- 20 feet away, both eyes, then one at a time, begin at the line for 40 feet unless child is known to have vision problems
How to do vision test if child has glasses?
Do test without them then with
Go to what line of snellen chart?
Until child misses half plus one of the letters
What does 20/20 mean?
Correctly ID letters for 20 feet at a distance of 20 feet
What does 20/40 mean?
Can see at 20 feet what the avg child sees at 40 ft
At what age should vision be 20/20?
Why do more boys have it?
Recessive x-linked trait
Only one x chromosome
How is color vision evaluated?
Ishihara charts- have patterns that cannot be seen by color blind
Cranial nerve II and it's function?
How is it tested?
Optic nerve- vision
Cover one eye and bring an object from behind until child is able to see it in peripheral vision
What 3 tests are used to test extraocular muscle function?
Why is it tested?
Corneal light reflex/hirschberg
Test binocular vision and presence of strabismus
Corneal light reflex test?
Shine light directly onto irises from 16 in away, reflection of light should appear in same spot on both eyes
If light reflects off center in one eye during corneal light reflex test what does it mean?
Eyes are malaligned
How can epicanthial folds affect corneal
Light reflex test?
May give false malalignment
What is end-stage-nystagmus?
Oscillation of eye
Prob with children < 2-3 years with field of vision test?
May not cooperate
When is testing of extraocular eye movement critical?
Kids < 5
What 3 nerves are tested when assessing extraocular muscle function?
III, IV, & VI
Cranial nerve VI and its function?
Abducent nerve- abducts eye
Cranial nerve IV and it's function?
Downward and inward movement of the eye
Cranial nerve III and it's function?
Oculomotor nerve- most eye movements, pupil construction, keeping eyelid open
What indicates muscle weakness with the cover/ uncover test?
Movement of the eye
What conditions can be discovered with the random dot E test?
Amblyopia & strabismus
What children may have epicanthial folds?
How to examine lacrimal apparatus?
Have child look down, palpate outer part of upper lid along bony prominence for swelling or redness
Punctum? Who should this be palpated in?
Should eye be palpated in young children
Not unless there is a problem
How to highlight any abnormalities in the cornea?
Shine a light across them
How to highlight anterior chamber?
Shine a light across the eye from temporal side,
The irises contain muscle fibers that ______ in response to light.
Contract or expand
In most ppl unequal pupils indicates______.
What should be done to prepare for ophthalmoscope exam?
Dim the lights
3 parts of an ear assessment?
Hearing, external exam, otoscope exam
When is a newborn's hearing / acoustic nerve tested?
At time of birth & before discharge
How is hearing of an older infant tested?
Have parent stand behind them and speak and observe their response
An infant < ______ mo may have a startle reflex to sounds.
Tests hearing with beeping noise
Sweep test tests for ______& the pure tone test tests for _________.
Extent of loss
In what age group is Audiometry used?
Preschool and school age
The whisper test?
Used for what age?
Stand 2 ft behind child & whisper numbers/ letters (or a sentence for preschoolers) and have them repeat it
Tuning fork test
Air conduction of sound is > bone normally?
Rinne hearing test?
Determines whether air conduction is greater than bone conduction
Weber hearing test?
Determines ability to hear by bone conduction
How to examine external ear?
Inspect for abnormalities, note any discharge, pull auricle to see any discomfort, palpate mastoid process
______ is examined with an otoscope.
How to choose speculum size for
Largest that will comfortably fit
In a child < 3 years how is ear canal straightened to use otoscope?
> 3 years?
Pinna down and back
Pinna up and back
What exam techniques are used for thorax and lungs?
What is included in inspection of the chest?
Abnormal breath sounds, sputum, RR & pattern,
How is the thoracic area of infants and young kids different from adults?
2 common alterations of the anterior chest?
Pectus carinatum/ pigeon Chest
Pectus ecavatum / funnel chest
Common alteration of the posterior chest?
Scoliosis- s curve of thoracic and lumbar vertebrae
Where does palpation of the chest begin?
How can you lower stress for the pt during this time?
Stay in view
Posterior chest is assessed for what 3 things?
Tenderness, tactile fremitus, and chest excursion
The presence of tactile fremitus when palpating the posterior chest of a child may indicate ________.
Breath sounds are characterized by what 4 factors?
Intensity, pitch, quality, & duration
What is preferable position when listening to breath sounds?
Where should nurse be?
To the side of pt
Position of child for auscultating posterior thorax?
Head bent forward and hands folded in front
What should child do during posterior thorax auscultation?
Open mouth and breathe in and out, blow bubbles, pretend to blow out candles
Fluid in airways, discontinuous, crackling heard during inspiration and not cleared with coughing
Pleural friction rub?
Where is it best heard?
Like rubbing leather together.
High pitched wheeze?
Musical squeaking mostly on expiration , coughing may change the sound
Narrowing of air passages for fluid, swelling, spasm, or tumors
Musical snoring moaning sounds
More predominant on expiration
May clear some with coughing
3 techniques for inspecting the heart?
Inspection, palpation, and auscultation
5 areas of the anterior chest that should be closely examined?
Aortic area, pulmonic area, right ventricular area, apex, and epigastric area
Where is the aortic area?
Right second IC space
Where is the pulmonic area?
Left second intercostal space
Where is the right ventricular. Area?
Left sternal boarder
Where is the apex?
Fifth left IC space in midclavicular line
Where is the epigastric area?
below the xiphoid process
Differences in heart location in infants?
more horizontal in thorax, apex is 1 - 2 IC spaces above the 5th IC space and lateral to the midclavicular line
How to locate the 2nd intercostal space?
second rib is attached to sternum just below or at the sternal angle so locate the sternal angle
What things is it inspected for?
anterior chest overlying the heart and great vessels
bulges, lifts, heaves, and apical impulse
By age _____years the apical impulse will be at the fifth IC space.
Why is the precordium palpated?
presence of pulsations at each area
Where is it located in a child < 7 years old?
point of maximal impulse / apical pulse
at the 4th IC space lateral to the midclavicular line
The examiner should use the ______ aspect of the hand to feel for thrills.
What are thrills?
palpable vibrations of the heart
3 positions a child should be in during auscultation of both heart and chest?
supine, lateral recumbent, and sitting up
Where is S1 sound heard best?
at the apex of the heart in the tricuspid and mitral area
Where is S2 heard the best?
at the base in the aortic and pulmonic area
What produces the S1 sound?
closing of the mitril and tricuspid valves
What produces S2 sound?
closing of the aortic and pulmonic valves
What is indicated by a pause heard during S2?
Where can this best be heard?
considered normal in children
Sequence of assessing heart sounds?
1. rate and rhythm
2. ID S1 and S2
3. Assess S1 & S2 separately & determine
where they are best heard
4. Listen for extra sounds
5. ID murmurs
Children's heart rates often increase with _______ and decrease with ______.
(inspiration or expiration)
How can the examiner decrease irregular heart rhythm associated with respirations?
have the pt hold breath during heart auscultation if possible
4 types of extra heart sounds?
opening snaps, ejection clicks, midsystolic to systolic clicks, and murmurs
What are heart snaps and clicks?
short, high-pitched sounds heard with valve disorders that are not affected by respirations
What are murmurs?
How are they best heard?
lowing, swooshing sounds that occur because of turbulence of the blood flow in the heart
bell of stethoscope
What type of heart murmurs are frequently heard in children?
Where are they best heard?
innocent or functional heart murmurs
along the left sternal boarder
do not radiate, & change with position
What is noted when palpating arterial pulses?
rate, rhythm, elasticity of vessel wall, & equal force of bilateral pulses
It is necessary to compare _____pulses in children.
opposite side to side and lower extremity to upper
Hearts of infants and children should be auscultated in a ____shape.
What 4 areas are auscultated?
aortic, pulmonic, tricuspid, mitral
Why may infants of both sexes have engorged breasts?
estrogen crossing placenta
What does it indicate?
When may it occur?
beginning of puberty in girls
as early as age 7
When is an inverted nipple significant?
if it has just occurred
When should girls be taught how to do breast self-examination?
once they have reached menarche
When should breast self-exam be done?
3 to 4 days after menses because less tender
Who may this affect?
enlargement of breast tissue
adolescent boys during puberty
3 ways to relax the abdomen of a child for abd exam?
empty bladder, warm hands, and supine position with knees flexed
Sequence of techniques during the abd exam?
inspection, auscultation, percussion, palpation
What is included in an abdominal inspection?
contour, symmetry, umbilicus & skin condition, pulsations or movement, and hair distribution
What is contour and how is it assessed?
profile of the abd from rib margin to the pubic bone
looking across the abdomen
4 ways to describe the abd?
scaphoid - emaciated or malnourished
flat - thin
rounded - normal appearance of abd in young child
protuberant - distention with flatus, obesity, pregnancy if old enough
What type of contour is typical for toddler's abd?
Is it normal to see peristalsis of the abd in infants and children?
What part of the stethoscope is used for auscultation of abdomen?
Auscultation of the abd begins in what quadrant?
Where should bruits be auscultated? With what part of the stethoscope?
aortic, renal, iliac, and femoral arteries
Where should examiner listen for a venous hum?
epigastric region and around the umbilicus
What is abd palpation used for?
ID mass or tenderness & determine size, consistency, and location of organs
How to relax a child who is afraid/ticklish during abd palpation?
Have them help with the palpations, have them breathe deeply
Process of abd palpation?
1. lightly palpate abd no more than 1 cm deep
2. Repeat with deep palpation 5 - 8 cm beginning in right lower quadrant
How can you determine if tenseness is voluntary?
Wait for the child to breathe and should go away if voluntary
What does rigidity of the abd indicate?
acute inflammation of the peritoneum
What should also be checked during abd palpation?
skin turgor, femoral pulses, and inguinal lymph nodes
What is done if an area of tenderness is ID'd in abd?
How is this performed?
rebound tenderness test
place hand perpendicular to the abd away from tender area, push down deeply and lift quickly
will cause severe pain with peritoneal inflammation
Examination of male genitalia of infant, toddler, or young child?
tell child what you are going to do, get parent's permission, inspect peniscompress glans between thumb and forefinger and evaluate meatus, inpect scrotum, palpate scrotum,
Should the physical exam end with the genital exam?
no, need further oppurtunities for communication
PPE for genital exam?
By the time a male is age _____ years, the foreskin may be easily retractable.
5 to 6
Difference between the scrotum of infant or young boy and adolescent boy?
infant/young - proximal is wider and distal narrower
adolescent is opposite
How to prevent the cremasteric reflex?
What is it?
have the boy sit cross legged
testes withdrow into the inguinal canal
What type of teaching should be done with genital exam of adolescent boy?
testicular self examination
Exam of female genitalia?
drape pt, gloves, visual inspection and gentle palpation
5 components of the musculoskeletal system?
bones, muscles, joints, ligaments, cartilage
How is the musculoskeletal system examined in children?
observe them playing and doing physical activities and ROM
What test is used to assess fine and gross motor ability of child younger than 5?
Denver Developmental Screening Test II (DDST - II)
head to toe
2 common deformities of the extremities of children?
What are they?
varus deformity - medial adduction or turning inward
valgus deformity - medial abduction or turning outward
What causes most injuries to extremities of children and adolescents?
overuse injuries like sprains
sports requiring repetitive motions - swimming, gymnastics, skating, and running
What areas are palpated for tenderness, sweeling, deformity, and crepitus if injuries or abuse are suspected?
skull, extremities, and ribs
3 deformities of the spine?
scoliosis, kyphosis, and lordosis
By age _____ mo infant can lift head while prone.
How to check hips for congenital dislocation?
How is this done?
compare leg lengths
baby's feet placed flat on table and knees flexed up - top of knees should be same height
What spine abnormality is common in young children?
______ of the foot is common b/t ages 12 and 30 months b/c young children have a broad based stance
Adduction / toeing in?
How is this treated?
child walks on the lateral side of the foot
usually corrects itself by age 3 years
bowleg - space of more than 2.5 c is measured b/t knees as the ankles are held together
Genu varu is normal after the child has begun to ______ & may persist until the child is ____years old.
When does it occur?
more than 2.5 cm remains b/t medial maleoli (ankles) when knees are held together
between ages 2 and 3 1/2
What should happen to the iliac crest if a child stands on one leg and then the other
should stay level
Adolescent examination is the same as school age except special attention should be paid to the _____ because adolescents frequently have _____.
excessive inward curvature of the spine
Usually caused by?
bowing / rounding of spine
What age children may be screened for scoliosis?
How is this screening performed?
9 - 15
child bends forwrd with shoulders dropping and arms hanging and nurse looks for unilateral elevation of the lower thoracic ribs and flank
How is ROM in children assessed?
observe them moving, do passive ROM if problem is observed, How is the motor segment of cranial nerve V / trigeminal nerve evaluated?
How is the motor segment of the trigeminal/cranial nerve V evaluated?
apply pressure to temporalis muscle while child clenches the teeth
How is cranial nerve XI / accessory nerve tested?
assessing the strength of the sternocleidomastoid and trapezius muscles during rotation of the head from side to side and chin to shoulder
What should the nurse do if atrophy or hypertrophy of a muscle is suspected? How is this performed?
measure the muscle
at greatest circumfernce
5 things examiner palpates joints for?
temp, tenderness, crepitation, swelling, and masses
What symptoms in children are associated with joint disorders?
fatigue, stiffness or weakness, heat and redness
age when infant raises head and holds position
2 wks - 2 months
age when infant moves all extremities, kicking arms and legs when prone
age when infant draws up knees and raises abdomen off table
3 - 6 mo
age when infant rocks back and forth while up on hands and knees
3 - 6 mo
age when infant rolls over
3 - 6 mo
age when infant sits alone, using hands for support (tripod fashion)
by 7 months
age when infant moves like inch worm forward or backward by pulling legs to chest
by 9 mo
When does crawling start
6 to 9 mo
age when infant begins to pull up
by 11 mo
age when infant cruises?
What is cruising?
by 12 mo
walks holding onto something or supported by something
what age will infant sit from a standing position
By what age should an infant be able to walk alone?
2 phases in which gate is assessed?
What are they?
stance - heel strikes the floor, weight is transferred to the ball of the foot, and toes push off the floor
swing- foot is off the floor
What 3 things need to be determined in cases of neurologic deficit?
degree, type, and location of NS lesions
For children younger than 5 years neurologic functioning is best evaluate with ______ developmental screeening test.
DDST - II
3 ways brain dysfunction in infants and young children may be manifested?
Very young children?
apnea, loss of consciousness, and seizures
very young children may have nonspecific symptoms - irritability, recurrent vomiting, fever, and loss of appetite
Testing _____, ______, & ______ gives a picture of NS functioning above the spinal cord.
cerebral function, cranial nerves, and cerebellar functioning
What is involved in the evluation of cerebral function?
cognitive function - appearnce, behavior, orientation, speech patterns, memory, logic, and affect
How is cerebral functioning assessed?
history of behavior etc from caregiver
evaluation of older child/ adolescent LOC, thought, and communication
alert, lethargic, obtunded, stuporous, or comatose
awake and aware of surroundings
sluggish and drowsy and has to work to focus on surroundings
unconscious and only able to be aroused with strong physical stimuli - loud noises/pain
unconscious and unable to be aroused
sleep-like state and cannot be aroused
4 factors that may influence thought processes?
attention span, communication, perceptual problems, and emotional withdrawal and depression
What is involved in cerebellar function?
How is it tested?
proprioception, balance, and coordination
have child perform specific movements
How is muscle strength tested?
first without resistance then with
corresponding muscles on 2 sides are compared
Most brain growth occurs when?
in the first year of life
What are neurologic "soft" signs?
findings that indicate child is unable to perform activities r/t its age
Children with multiple soft signs are often found to have ______.
Why do children with neurologic "soft" signs need evaluation and monitoring?
because children with med, mental, or emotional probs may have same signs
What should the examiner do after the exam is completed?
ask parent/child if there are any questions
short att span
poor motor coordination
uneven perceptual development
no dominant side
movements involving more muscles than intended
absence of the sense of smell
bronchial breath sounds
loud, high-pitched sounds normally heard over trachea and large bronchi
bronchovesicular breath sounds
medium - pitched and quieter sounds heard over the main-stem bronchi
blowing or swishing sounds = turbulent blood flow through a BV
membrane of the eylids and sclera of the eye
2 parts of the conjunctiva?
1. bulbar - covers cornea and front part of sclera
2. palpebral - lines eyelids and appears red b/c of vascularity
dry, crackling or grating sound
3 causes of crepitus?
1. fluid in the alveoli of the lungs
2. bone rubbing against bone
3. air in SQ tissue
scratching or squeaking sound during I & E and does not clear with coughing
posture, position, & build of the body
portion of an organ protrudes through somewhere it isn't supposed to
convex curvature of the thoracic spine
chest rises with heart beat (systole/contraction)
enlarged heart possible
systole = ____
Usually caused by?
heart sound caused by vascular turbulence usually
narrowed or leaking heart valves
skin crevice b/t nose and mouth
involuntary rhythmic rapid movement of eyeball
opening b/t 2 eyelids
anterior surface of the body over heart and stomach
(epigastric region + inferior thorax)
drooping of the upper eyelid
discontinuous, usually inhalation, from fluid in alveoli or collapsed alveoli popping open
backflow of blood through heart valves due to abnormal closing of the valves
snore in throat or bronchial tubes due to partial obstruction/ secretions
shaped like a boat
lateral deviation of the spine
_____ ______ is the slowing or speeding up of the heart rate in response to breathing that may be a normal finding in children.
enlarges passage in body
abnormal narrowing of a body passage or BV
_____ is a harsh, high-pitched breath sound such as that heard on inhalation with an acute laryngeal obstruction.
walking a straight line
pointing a light at something from an angle
vibration felt on palpation
contracture of the neck/cervical muscles
bell-like sound heard during percussion of an area that contains air or gas such as stomach or intestines
______ breath sounds are soft, fine, low-pitched sounds heard over the peripheral lung tissue.
Primary source of health information for a child?
How should infant weights be rounded?
to the nearest half ounce
How should the weight of toddlers, pre-schoolers, and school age children be rounded?
to the nearest 1/4
What is a concern for weight of adolescent girls?
body image and eating disorders
How should height of toddler and up be rounded?
When is head circumference included in physical exam?
infants up to 36 months old and beyond if there is a reason
Normal newborn head circumference is ____ and it increases about _____ % by age 1 year
What changes occur in body temp from infant - adolescent?
body temp is usually higher in infants and slowly lowers with age
2 major causes of bradycardia in infants and children/
The most reliable method of determining infant - 2 year old's pulse?
Normal heart rate at 2 mo, 6 mo, and 12 mo?
2 mo 90-100
6 mo 80-180
1 year - 75-155
At what age is it ok to do radial pulse?
Pulse rate range for children age 2 -10 years?
70 - 110
Normal pulse rate for age 10 - adolescent?
Tachypnea is a sign of ______, especially in infants.
Fever raises infant RR ____ beats/min for every degree of temp?
Normal RR for up to 1 year?
Normal RR for children 2 - 5 years
Normal RR for children 5 - 12?
19 - 22
At what age is RR similar to adult's?
How to assess cap refill in infant?
hold arm above level of heart and press nailbed or press on heal
spots on bottom of dark-skinned infants that are harmless
Where to check skin turgor of an infant- school aged child?
Suture lines are usually palpable up to age ____.