chapter 33 peds physical assessment

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chapter 33 peds physical assessment
2013-01-25 14:57:14

peds physical assessment
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  1. 2 ways to reduce anxiety in peds pt?
    Involve parents and allow pt to handle safe equipment
  2. Systematic approach to physical assessment?
    Head to toe
  3. 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

  4. When should uncomfortable procedures be done when examining an infant birth to 6 months?
  5. What should an infant birth to 6months be wearing during physical exam ?
    • Males - diaper
    • Females - nothing
  6. How do I rants over 6 months differ from birth to 6 months?
    They feel stranger anxiety
  7. Why are toddlers the most difficult to examine?
    They do not cooperate
  8. 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
  9. Who is the most important in gaining the cooperation of a toddler and why?
    Parent because their soothing techniques are familiar
  10. What is the best approach when examining a preschooler? Why?
    • Allow them to participate
    • Because they like showing what thy can do
  11. How does the nurse establish a trusting relationship with a school age child ?
    Ask them questions they can answer
  12. What should a schoolage child wear during exam?
    Drape over underpants or a colorful exam gown
  13. At what ate should the nurse start to consider a child's modesty?
    School agr
  14. How is exam of school aged child conducted?
    Head to toe
  15. What should the nurse teach about while performing a physical exam on a school aged child?
    The body and personal care
  16. What approach works best with adolescents?
    Straightforward and not condescending
  17. Should parents be present during the exam of an adolescent?

    Who decides?
    Not usually

    Ask the pt
  18. Order of exam for an adolescent?
    Head to toe
  19. When should the genital exam of an adolescent be done?
    In the middle of the exam
  20. What type of teaching should the nurse give an adolescent during their exam?
    Puberty, normal development, and answer questions
  21. What should an adolescent wear during exam?
  22. Four basic techniques of exams in order?
    Inspection, palpation, percussion, auscultation
  23. Direct inspection?
    Nurse uses their own sight and hearing
  24. Indirect inspection
    Nurse uses tools to see and hear

    Like otoscope
  25. What is the purpose of palpation?
    Locating structures and masses
  26. What 5 things can be determined by palpation?
    Warmth, texture, size, tenderness, mobility
  27. What part of the hands is used to palpate breasts?
    Pads of fingers
  28. What part of the hand is used to palpate lymph. Odes and pulses?
    Finger tips
  29. What part of the hand is used to palpate temp?
    Back of the hand
  30. What part of the hand is used to palpate vibrations?
  31. Procedure for performing light palpation?
    Apply pressure with fingertips and depress skin 1/2 to 3/5" and move fingers in a circular motion
  32. Procedure for deep palpation?

    When should it be done?
    • Surface depressed 1&1/2 to 2 "
    • After light palpation
  33. What is the purpose of deep palpation
    Identifying abdominal structures and masses
  34. Bimanual palpation?
    It's purpose?
    Use 2 hands to trap a mass or organ between them
  35. Percussion?
    It's purpose?
    Quick tapping of fingers or hands to produce sounds

    To locate the position, size, and density of underlying structures
  36. 3 types of percussion?
    • Mediate/indirect
    • Immediate
    • Fist percussion
  37. Mediate/indirect percussion?
    Finger of one hand placed against the body and finger of other hand acts as a hammer
  38. Immediate percussion?
    Strike finger of one hand directly against the body?
  39. Fist percussion?
    Ulnar aspect of the fist is used to deliver firm blow directly to are
  40. What part of the stethoscope is better for high- pitched sounds?

    2 examples of high pitched sounds?

    Heart and breath sounds
  41. What part of the stethoscope is best for low pitched sounds?

    What makes low pitched sounds?

    Vascular sounds and BP
  42. 4 characteristics used to describe auscultation sounds?
    Pitch, intensity, duration, and quality
  43. What can be determined by smell during exam?
    Hygiene, infection, some conditions
  44. What is the first step of the exam?

    What is done?
    General survey

    Get general info through observation about child's behavior, sex, race, physical appearance
  45. How is the parent included in the general survey?
    Observe their interactions with child
  46. What is the most important component of the physical exam?
    Taking an accurate history
  47. 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
  48. What is included in a complete history?
    • Statistical info
    • Patient profile- regular habits
    • Health history
    • Family history
    • Lifestyle and patterns - interactions with environment and social
    • Review of systems
  49. Normal temp, pulse, RR, and BP of a newborn?
    • 97.7 - 99.1 axillary
    • 120-160 BPM
    • 30-60 breaths/ minute
    • 65/30 - 95/60
  50. Normal vital signs for 4 year old?
    • Temp- 97.5 to 98.6 axillary
    • Pulse - 80-125
    • RR- 20-30
    • BP- 91/52 - 104/66
  51. Normal VS for 10 year old?
    • Temp - 97.5- 98.6 oral
    • Pulse - 70-110
    • RR 16- 22
    • BP- 102/60 - 115/74
    • BP-
  52. Normal VS for 16 year old?
    Like adults
  53. 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
  54. 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
  55. What should be noted when taking a tympanic temp?
    What side it is taken from
  56. When can oral temp be taken?
    Children around age 5 and up
  57. In what children are apical pulse rates measured?
    Children younger than 2 years and those with irregular heart beat or known heart prob
  58. At what ate do you start taking radial pulse rates?
  59. How long should pulse be counted?
    • One minute
    • To compensate for normal irregularities
  60. How does the nurse determine the position of the heart in children you get than 6?
    Palpating the apical pulse
  61. In what situation is the apical
    Pulse and location always noted?

    For what age?
    • Acute care settings
    • All ages
  62. What pulses are compared in children of any age?
    Femoral, radial, and carotid
  63. What pulse do infants have that others don't
    Anterior fontanel.
  64. What does an irregular pulse in an infant usually indicate?
    • Not abnormal
    • Usually response to changes in respiration
  65. 3 things to observe in respiration?
    Rate, depth, ease of respirations
  66. What is the difference in observing RR of infants and toddler and up children?
    • Infant- ABD excursion
    • Toddler and up- thoracic excursion
  67. How long should RR be observed
    One minute
  68. 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
  69. What does inspiratory strider indicate?
    Partial Obstruction of airway
  70. Continuous inspiratory and expiratory stridot indicates _____.
    Delayed dev of cartilage in trachea or small larynx
  71. when is it recommended that all children have BP Becker regularly?
    Beginning at age 3
  72. How often should BP be taken in acute care setting?
    At least every day
  73. If a child's BP indicates hypertensive what must be done before it is recorded?
    Must be confirmed
  74. When does a child's BP require further evaluation
    Avg of 3 abnormal BP taken at Esperanto occasions
  75. Adolescent prehypertensive point?
    > 120/80
  76. What will too small/ too large BP CUFF CAUSE?
    Elevated/ low BP reading
  77. What should the nurse tell the child before getting BP?
    The cuff will squeeze/ give the arm a hug
  78. What is important when evaluating pain?
    Using dev appropriate pain assessment tool
  79. What is anthropometrics?
    Measuring human body and assessing nutrition, growth, and dev
  80. What anthropometric measures are always taken in children
    Head circumference, height, and weight
  81. How to calculate BMI?
    Weight(lb) x 703 / height in inches squared.
  82. What provides info about SQ tissue, muscle, and fat in body?
    Mid arm muscle circumference, ski fold thickness, weight
  83. What do the serial physical measurements show?
    Rate of growth
  84. 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
  85. 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
  86. 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
    • More accurate

    Lay on paper and mark where heels and top of head are and measure with measuring tape
  87. How is a standing child measured?

    How might his measurement compare to the lying measurement?
    Same as adult

    May be slightly differnet
  88. What should be done to all scales before measuring the child?
    Zeroed or balanced
  89. How are infants measured?
    Naked on a baby scale
  90. How are children who can stand weighed?
    Like adults in nothing but underwear
  91. What children have their head circumference measured?
    All age birth to 36 months and all above 3 with questionable head size macrocephaly or microcephaly
  92. How is head circumference measured?
    No stretch measuring tape around largest part of head/ forehead
  93. During the first year of life the head circumference usually increases by _____ cm.
  94. What can hear circumference indicate?
    Rate of dev, nutritional status, hydrocephalus
  95. What is hydrocephalus?
    Abnormal accumulation of CSF
  96. Circumference of _____ is routinely measured only in newborns and is usually smaller than head circumference.
  97. When do head and chest circumference become nearly equal?
    1 year
  98. How to measure chest circumference?
    Tape measure around chest at nipple line and measurement taken b/t inspiration and expiration
  99. What does triceps skin fold indicate?

    How is it obtained?
    Total body fat

  100. Mid arm circumference indicates ______& ______.
    Muscle and fat
  101. How to measure midarm circumference?
    Measure midpoint between acromion and olecranon and record in cm
  102. 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
  103. 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
  104. 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
  105. There are separate growth charts for ______ & ______.
    Girls and boys
  106. What 4 things are potted on WHO birth chart for age 0-2 years?
    Length, weight, head circumference, and length to weight relationship
  107. What. An length to weight relationship indicate?
    Overweight/ obesity
  108. What 3 things are plotted on CDC chart and what ages are included?
    Height, weight, and BMI

  109. What infants may require special growth charts?
    Premature, down syndrome, other conditions that affect growth
  110. 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_______.
    • Horizontal
    • Vertical
  111. Weight and height measurements above _____ percentile or below ______ percentile indicate a growth disturbance.
    • 97th
    • 3rd
  112. How may brain growth be assessed?
    Serial head circumference measurements
  113. BMI from ______ to _____ percentile indicate risk for obesity.
    85th to below 95th
  114. BMI at or above _____ percentile I children older than 2 indicate overweight.
  115. 2 techniques used in skin assessment?
    Inspection and palpation
  116. 4 characteristics of skin that are assessed?
    Color, texture,turgor, and lesions
  117. In dark- skinned infants erythema appears _______, cyanosis appears_______, and jaundice appears______.
    • dusky red or violet
    • Black
    • Diffusely darker
  118. What is the best way to assess skin color of darker skinned infants?
    Determine normal skin color and compare
  119. What skin alterations may indicate diabetes type 2 mellitus in children?
    Acanthosis nigricans
  120. What is acanthosis nigricans?
    Darker, thicker skin in folds (posterior neck, behind knees and elbows, and in armpits )
  121. Vitiligo?
    Areas of depigmentation
  122. Nevi?
    Areas of increased pigmentation
  123. Jaundice?
    Where is it best seen?
    • Yellow skin
    • Sclera/ whites of eyes
  124. Cyanosis?
    Where is it best seen?
    • Blue skin
    • Mucous membranes of the mouth especially under tongue
  125. Carotenemia?
    Where is it best seen?
    • Orange skin
    • Palms and soles of feet
  126. Pallor?
    Loss of skin color?
  127. Erythema?
    Red skin
  128. Mottling?
    Discolored areas of skin
  129. What 6 characteristics of skin may be assessed using palpation?
    Moisture, temp, texture, turgor, edema, and lesions
  130. Why is the back of the hand used to assess skin temp?
    Because it is more sensitive to temp
  131. What comparison should be used when palpating child's temp?
    Compare 2 sides of the body
  132. Where to test skin turgor in children?
    Abdomen and upper arm
  133. 2 areas to palpate for edema in children?
    Extremities and buttocks
  134. Where is periorbital edema observed?
    On the eyelids
  135. What four characteristics of lesions should be noted?
    Configuration, distribution, color, and size
  136. What are primary and secondary lesions?
    Primary- arise from normal skin ( freckle)

    Secondary - results Tom an alteration in primary lesion (scab)
  137. What does configuration of skin lesion refer to?
    Arrangement/position of several lesions in relation to each other or arrangement of a single lesion
  138. What does distribution of lesions refer to?
    Location on body and symmetry or asymmetry of lesions
  139. Hair usually covers all areas of the body except _____, _____, and some areas of _____.
    Palms, soles of feet, genitalia
  140. 4 characteristics of hair that should be noted?
    Texture, changes in color, unusual distribution, cleanliness
  141. Fine, downy hair in non-infants and brittle hair may indicate ______ and ______ abnormalities.
    • Endocrine
    • Nutrition
  142. Hirsutism?
    Excessive hair growth
  143. Alopecia?
    Unusual hair loss
  144. Why are most cases of head lice discovered?
  145. 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

  146. Cap refill should be less than ____ seconds. Longer cap refill may indicate what 4 conditions?
    • < 2 seconds
    • Anemia
    • Peripheral edema
    • Vasoconstriction
    • Decreased cardiac output
  147. 2 assessment techniques used on lymph nodes?
    Inspection and palpation
  148. What regions of the body should have lymph nodes assessed?
    Head and neck, supraclavicular, axillary, arms, inguinal
  149. Characteristics of lymph nodes that indicate infection?
    Enlarged, warm, firm, and fluctuant
  150. What is an enlarged supraclavicular lymph node on the left side in young children called?

    What may it indicate?
    • Sentinel node
    • Wilms tumor or other neoplasticism disease
  151. What is a neoplastic disease?
    the abnormal proliferation of benign or malignant cells. neoplastic
  152. What 2 assessment techniques are used on the head and neck?
    Inspection and palpation
  153. 4 characteristics of the head to evaluate?
    Symmetry, paralysis, weakness, and movement
  154. How should suture lines in infants be assessed?

    When do they flatten?

    Around 6 mo
  155. Paralysis and weakness of the head are directly related to ________.
    Paralysis and weakness of neck muscles
  156. How is head control of infants observed?
    Infant in supine position

    Pulling infant up by arms
  157. How long should 4 mo old be able to support own head?

    What is indicated if the infant cannot do this?
    Several seconds

    Weak neck muscles
  158. When is head lag an indication muscles may.not be dev properly?
    6 mo
  159. What may be indicated by increased extensor and axial muscle tone in a infant?
    Neuromuscular probs/ cerebral palsy
  160. How to assess head of older child?
    Full ROM - up, down, side to side
  161. Characteristics of fontanel to assess?
    Size, tenseness, and pulsation
  162. When should the posterior fontanel be closed?
    2-3 mo
  163. The anterior fontanel should be < ____ cm inlength and width after 12 mo, and should be completely closed by age ____ to _____ mo.

  164. A sunken fontanel may indicate_____.
  165. Bulging fontanel can indicate _______.
    Increased intracranial pressure.
  166. Craniosynostosis?

    How is it indicated?
    Premature closure of the anterior fontanel

    Cannot palpate it
  167. What normal activities may cause the anterior fontanel to bulge?
    Coughing, crying, vomiting
  168. 2 assessment techniques used in neck?
    Inspection and palpation
  169. Neck is assessed for what 3 characteristics?

    Symmetry, size, and shape

    Related to use/ disuse of neck muscles
  170. Webbing of the neck/ presence of an extra skin fold posteriorly is associated with __________?

    2 examples?
    Some chromosomal disorders

    Down syndrome, trisomy
  171. How to palpate child's thyroid gland?
    Identify the isthmus of the thyroid across the trachea
  172. How to ID enlarged thyroid gland in Child?
    Displace thyroid gland and palpate with other hand
  173. What may make the thyroid gland more palpable?
    Having the child swallow
  174. 2 assessment techniques used on face?

    Face is assessed for ______.
    Inspection and palpation

    Dysmorphic features
  175. The eyes are examined for _____,______,&______.
    Size, position, and configuration
  176. Hypertelorism?
    Eyes are wide spaced
  177. Hypotelorism?
    Eyes close together
  178. Hypoplastic philtrum?
    Shallow crease or absence of crease below nose
  179. How are low- set ears ID'd?
    Auricle of the ear does not cross or touch the eye- occupy line
  180. The ear position should have no more than ____ degree posterior angle making the ear nearly vertical.
  181. Which 2 cranial nerve functions are assessed during head exam?
    • V- trigeminal nerve
    • VII- facial nerve
  182. 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
  183. 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
  184. PPE required for all. ASAP exams?
  185. Nurse should describe the _____, _______, &______ of drainage from nose.
    Color, amount, consistency
  186. How to assess latency of nostrils?
    Occlude one side and have them sniff
  187. What is indicated by a transverse crease on a child's nose?
  188. 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
  189. The nasal mucosa is inspected for _____ & _____.

    How should it normally appear?
    Color and moisture

    Smooth, moist, & bright pink
  190. Appearance on nasal mucosa in children with allergies?
    Pale and boggy
  191. With infectious diseases the nasal mucosa Appears ______& ______ and the drainage is _____ or ____ in color.
    Erythematous and swollen

    Yellow or green
  192. The ______ and _____ sinuses are inspected and palpate during a nasal exam.

    They are examined for ______& _____.
    Frontal and maxillary

    Swelling and color
  193. Puffiness and redness over sinuses and dark circles under eyes may indicate____.
    Inflammatory response
  194. How are frontal sinuses palpated?
    Press over sinus under eyebrow
  195. How are the maxillary sinuses palpated?
    Pressing upward with thumbs under the maxillary bones
  196. 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
  197. Philtrum?
    • Notch b/t nose and
    • Mouth
  198. PPE during oral exam?
  199. Tools neededfor oral exam?
    Tongue blade and pen light
  200. 3 exam techniques used for oral
    Inspection, palpation, and sense of smell
  201. 5 characteristics of lips to examine?
    Symmetry, color, moisture, cracking, and lesions
  202. Alveolar frenulum?
    Attaches lips to gums
  203. How is the buccal mucosa examined?

    Observe for ____, _____, &_____.
    Hold cheeks open with tongue blade

    Color, nodules, and lesions
  204. Where is the parotid gland opening?
    Buccal mucosa opposite the upper second molar
  205. 4 char of teeth to examine?
    Number, cavities, formation, and occlusion
  206. When does eruption of deciduous teeth begin?

    When are all present?
    6 mo

    30 mo
  207. What may cause mottling of the permanent teeth?
    Excessive ingestion of fluoride
  208. Gums are inspected and palpated for ______ &_____.
    Color and swelling
  209. 3 things to examine in the floor of the mouth?
    Sublingual frenulum, sublingual ridge, & wharton's ducts
  210. How to prevent being bitten during oral exam?
    Hold child's cheeks
  211. 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
  212. 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
  213. How to test strength of infant sucking reflex?
    Allow infant to suck on gloved finger while palpating hard palate
  214. Cranial nerve IX and it's function?
    Glossopharyngeal nerve- swallowing, taste on back of to gue
  215. Cranial nerve X and it's function?
    Vagus nerve- breathing, speech, gag reflex
  216. 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
  217. How is the oropharynx observed?
    Depress tongue with blade
  218. 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
  219. What may cause a child to snore
    Enlarged tonsils
  220. How are the eyes examined?
    Inspection, palpation, visual accuity, extraocular muscle function
  221. How to test vision of 1-2 mo old?
    Black and white images, contrasting figures, or faces
  222. At what age will an infant fixate on a bright object and follow with eyes?
    4 weeks
  223. Visual accuity testing for all children shinning no later than age ____ years is recommended.
  224. 3 vision tests that work for
    Lea chart, tumbling E, HOTV matching test
  225. All children should be screened for visual impairment between ages ____ to test for _____ or it's risk factors.

  226. Amblyopia?
    Loss of one eye's ability to see details

    " lazy eye"
  227. How to test preschool vision?
    Use HOTV matching- stand 10 feet back, give child cards and have them match them to the chart
  228. Screening is started at the _____ line on the chart for < 4 years and _____ line for older kids.
    • 20/40
    • 20/30
  229. Successful HOTV?
    Correctly ID 4 of 5 letters
  230. 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
  231. How to do vision test if child has glasses?
    Do test without them then with
  232. Go to what line of snellen chart?
    Until child misses half plus one of the letters
  233. What does 20/20 mean?
    Correctly ID letters for 20 feet at a distance of 20 feet
  234. What does 20/40 mean?
    Can see at 20 feet what the avg child sees at 40 ft
  235. At what age should vision be 20/20?
  236. Color blindness?

    Why do more boys have it?
    Recessive x-linked trait

    Only one x chromosome
  237. How is color vision evaluated?
    Ishihara charts- have patterns that cannot be seen by color blind
  238. 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
  239. What 3 tests are used to test extraocular muscle function?

    Why is it tested?
    Corneal light reflex/hirschberg

    Field-of-vision test

    Cover/uncover test

    Test binocular vision and presence of strabismus
  240. Corneal light reflex test?
    Shine light directly onto irises from 16 in away, reflection of light should appear in same spot on both eyes
  241. If light reflects off center in one eye during corneal light reflex test what does it mean?
    Eyes are malaligned
  242. How can epicanthial folds affect corneal
    Light reflex test?
    May give false malalignment
  243. What is end-stage-nystagmus?
    • Normal
    • Oscillation of eye
  244. Prob with children < 2-3 years with field of vision test?
    May not cooperate
  245. When is testing of extraocular eye movement critical?
    Kids < 5
  246. What 3 nerves are tested when assessing extraocular muscle function?
    III, IV, & VI
  247. Cranial nerve VI and its function?
    Abducent nerve- abducts eye
  248. Cranial nerve IV and it's function?
    Trochlear nerve

    Downward and inward movement of the eye
  249. Cranial nerve III and it's function?
    Oculomotor nerve- most eye movements, pupil construction, keeping eyelid open
  250. What indicates muscle weakness with the cover/ uncover test?
    Movement of the eye
  251. What conditions can be discovered with the random dot E test?
    Amblyopia & strabismus
  252. What children may have epicanthial folds?
  253. How to examine lacrimal apparatus?
    Have child look down, palpate outer part of upper lid along bony prominence for swelling or redness
  254. Punctum? Who should this be palpated in?
    Tear duct

  255. Should eye be palpated in young children
    Not unless there is a problem
  256. How to highlight any abnormalities in the cornea?
    Shine a light across them
  257. How to highlight anterior chamber?
    Shine a light across the eye from temporal side,
  258. The irises contain muscle fibers that ______ in response to light.
    Contract or expand
  259. In most ppl unequal pupils indicates______.
    CNS injury
  260. What should be done to prepare for ophthalmoscope exam?
    Dim the lights
  261. 3 parts of an ear assessment?
    Hearing, external exam, otoscope exam
  262. When is a newborn's hearing / acoustic nerve tested?
    At time of birth & before discharge
  263. How is hearing of an older infant tested?
    Have parent stand behind them and speak and observe their response
  264. An infant < ______ mo may have a startle reflex to sounds.
  265. Audiometry?
    Tests hearing with beeping noise
  266. Sweep test tests for ______& the pure tone test tests for _________.
    • Hearing losses
    • Extent of loss
  267. In what age group is Audiometry used?
    Preschool and school age
  268. 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

    Preschool- adolescents
  269. Conduction tests?
    Tuning fork test
  270. Air conduction of sound is bone normally?
  271. Rinne hearing test?
    Determines whether air conduction is greater than bone conduction
  272. Weber hearing test?
    Determines ability to hear by bone conduction
  273. How to examine external ear?
    Inspect for abnormalities, note any discharge, pull auricle to see any discomfort, palpate mastoid process
  274. ______ is examined with an otoscope.
    Tympanic membrane
  275. How to choose speculum size for
    Largest that will comfortably fit
  276. In a child < 3 years how is ear canal straightened to use otoscope?

    > 3 years?
    • Pinna down and back
    • Pinna up and back
  277. What exam techniques are used for thorax and lungs?
    All 4
  278. What is included in inspection of the chest?
    Abnormal breath sounds, sputum, RR & pattern,
  279. How is the thoracic area of infants and young kids different from adults?
  280. 2 common alterations of the anterior chest?
    Pectus carinatum/ pigeon Chest

    Pectus ecavatum / funnel chest
  281. Common alteration of the posterior chest?
    Scoliosis- s curve of thoracic and lumbar vertebrae
  282. Where does palpation of the chest begin?

    How can you lower stress for the pt during this time?
    Posterior chest

    Stay in view
  283. Posterior chest is assessed for what 3 things?
    Tenderness, tactile fremitus, and chest excursion
  284. The presence of tactile fremitus when palpating the posterior chest of a child may indicate ________.
    Airway alterations
  285. Breath sounds are characterized by what 4 factors?
    Intensity, pitch, quality, & duration
  286. What is preferable position when listening to breath sounds?

    Where should nurse be?

    To the side of pt
  287. Position of child for auscultating posterior thorax?
    Head bent forward and hands folded in front
  288. What should child do during posterior thorax auscultation?
    Open mouth and breathe in and out, blow bubbles, pretend to blow out candles
  289. Crackles?

    Fluid in airways, discontinuous, crackling heard during inspiration and not cleared with coughing

    Rales, crepitation
  290. Pleural friction rub?

    Where is it best heard?
    Like rubbing leather together.
  291. High pitched wheeze?

    Musical squeaking mostly on expiration , coughing may change the sound

    Narrowing of air passages for fluid, swelling, spasm, or tumors
  292. Low-pitched wheeze?

    Musical snoring moaning sounds

    More predominant on expiration

    May clear some with coughing

    Sonorous wheeze
  293. 3 techniques for inspecting the heart?
    Inspection, palpation, and auscultation
  294. 5 areas of the anterior chest that should be closely examined?
    Aortic area, pulmonic area, right ventricular area, apex, and epigastric area
  295. Where is the aortic area?
    Right second IC space
  296. Where is the pulmonic area?
    Left second intercostal space
  297. Where is the right ventricular. Area?
    Left sternal boarder
  298. Where is the apex?
    Fifth left IC space in midclavicular line
  299. Where is the epigastric area?
    below the xiphoid process
  300. 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
  301. 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
  302. Precordium?

    What things is it inspected for?
    anterior chest overlying the heart and great vessels

    bulges, lifts, heaves, and apical impulse
  303. By age _____years the apical impulse will be at the fifth IC space.
  304. Why is the precordium palpated?
    presence of pulsations at each area
  305. PMI?

    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
  306. The examiner should use the ______ aspect of the hand to feel for thrills.

    What are thrills?

    palpable vibrations of the heart
  307. 3 positions a child should be in during auscultation of both heart and chest?
    supine, lateral recumbent, and sitting up
  308. Where is S1 sound heard best?
    at the apex of the heart in the tricuspid and mitral area
  309. Where is S2 heard the best?
    at the base in the aortic and pulmonic area
  310. What produces the S1 sound?
    closing of the mitril and tricuspid valves
  311. What produces S2 sound?
    closing of the aortic and pulmonic valves
  312. What is indicated by a pause heard during S2?

    Where can this best be heard?
    considered normal in children

    pulmonic area
  313. 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
  314. Children's heart rates often increase with _______ and decrease with ______.

    (inspiration or expiration)

  315. How can the examiner decrease irregular heart rhythm associated with respirations?
    have the pt hold breath during heart auscultation if possible
  316. 4 types of extra heart sounds?
    opening snaps, ejection clicks, midsystolic to systolic clicks, and murmurs
  317. What are heart snaps and clicks?
    short, high-pitched sounds heard with valve disorders that are not affected by respirations
  318. 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
  319. What type of heart murmurs are frequently heard in children?

    Where are they best heard?

    Describe them.
    innocent or functional heart murmurs

    along the left sternal boarder

    do not radiate, & change with position
  320. What is noted when palpating arterial pulses?
    rate, rhythm, elasticity of vessel wall, & equal force of bilateral pulses
  321. It is necessary to compare _____pulses in children.
    opposite side to side and lower extremity to upper
  322. Hearts of infants and children should be auscultated in a ____shape.

    What 4 areas are auscultated?

    aortic, pulmonic, tricuspid, mitral
  323. Why may infants of both sexes have engorged breasts?
    estrogen crossing placenta
  324. thelarche?

    What does it indicate?

    When may it occur?
    breast development

    beginning of puberty in girls

    as early as age 7
  325. When is an inverted nipple significant?
    if it has just occurred
  326. When should girls be taught how to do breast self-examination?
    once they have reached menarche
  327. When should breast self-exam be done?
    3 to 4 days after menses because less tender
  328. gynecomastia?

    Who may this affect?
    enlargement of breast tissue

    adolescent boys during puberty
  329. 3 ways to relax the abdomen of a child for abd exam?
    empty bladder, warm hands, and supine position with knees flexed
  330. Sequence of techniques during the abd exam?
    inspection, auscultation, percussion, palpation
  331. What is included in an abdominal inspection?
    contour, symmetry, umbilicus & skin condition, pulsations or movement, and hair distribution
  332. What is contour and how is it assessed?
    profile of the abd from rib margin to the pubic bone

    looking across the abdomen
  333. 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
  334. What type of contour is typical for toddler's abd?
  335. Is it normal to see peristalsis of the abd in infants and children?
  336. What part of the stethoscope is used for auscultation of abdomen?
  337. Auscultation of the abd begins in what quadrant?
    lower right
  338. Where should bruits be auscultated? With what part of the stethoscope?
    aortic, renal, iliac, and femoral arteries

  339. Where should examiner listen for a venous hum?
    epigastric region and around the umbilicus
  340. What is abd palpation used for?
    ID mass or tenderness & determine size, consistency, and location of organs
  341. How to relax a child who is afraid/ticklish during abd palpation?
    Have them help with the palpations, have them breathe deeply
  342. 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
  343. How can you determine if tenseness is voluntary?
    Wait for the child to breathe and should go away if voluntary
  344. What does rigidity of the abd indicate?
    acute inflammation of the peritoneum
  345. What should also be checked during abd palpation?
    skin turgor, femoral pulses, and inguinal lymph nodes
  346. 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
  347. 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,
  348. Should the physical exam end with the genital exam?
    no, need further oppurtunities for communication
  349. PPE for genital exam?
  350. By the time a male is age _____ years, the foreskin may be easily retractable.
    5 to 6
  351. Difference between the scrotum of infant or young boy and adolescent boy?
    infant/young - proximal is wider and distal narrower

    adolescent is opposite
  352. How to prevent the cremasteric reflex?

    What is it?
    have the boy sit cross legged

    testes withdrow into the inguinal canal
  353. What type of teaching should be done with genital exam of adolescent boy?
     testicular self examination
  354. Exam of female genitalia?
    drape pt, gloves, visual inspection and gentle palpation
  355. 5 components of the musculoskeletal system?
    bones, muscles, joints, ligaments, cartilage
  356. How is the musculoskeletal system examined in children?
    observe them playing and doing physical activities and ROM
  357. What test is used to assess fine and gross motor ability of child younger than 5?
    Denver Developmental Screening Test II (DDST - II)
  358. cephalocaudal?
    head to toe
  359. 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
  360. What causes most injuries to extremities of children and adolescents?
    • overuse injuries like sprains
    • sports requiring repetitive motions - swimming, gymnastics, skating, and running
  361. What areas are palpated for tenderness, sweeling, deformity, and crepitus if injuries or abuse are suspected?
    skull, extremities, and ribs
  362. 3 deformities of the spine?
    scoliosis, kyphosis, and lordosis
  363. By age _____ mo infant can lift head while prone.
    2 mo
  364. 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
  365. What spine abnormality is common in young children?
  366. ______ of the foot is common b/t ages 12 and 30 months b/c young children have a broad based stance
  367. Adduction / toeing in?

    How is this treated?
    child walks on the lateral side of the foot

    usually corrects itself by age 3 years
  368. genu varum?
    bowleg - space of more than 2.5 c is measured b/t knees as the ankles are held together
  369. Genu varu is normal after the child has begun to ______ & may persist until the child is ____years old.
    • walk
    • 3
  370. gunu valgum?

    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
  371. What should happen to the iliac crest if a child stands on one leg and then the other
    should stay level
  372. Adolescent examination is the same as school age except special attention should be paid to the _____ because adolescents frequently have _____.
    • spine
    • kyphosis
  373. lordosis?
    excessive inward curvature of the spine
  374. kyphosis?

    Usually caused by?
    • bowing / rounding of spine
    • hunchback

    poor posture
  375. 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
  376. 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?
  377. How is the motor segment of the trigeminal/cranial nerve V evaluated?
    apply pressure to temporalis muscle while child clenches the teeth
  378. 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
  379. What should the nurse do if atrophy or hypertrophy of a muscle is suspected?  How is this performed?
    measure the muscle

    at greatest circumfernce
  380. 5 things examiner palpates joints for?
    temp, tenderness, crepitation, swelling, and masses
  381. What symptoms in children are associated with joint disorders?
    fatigue, stiffness or weakness, heat and redness
  382. age when infant raises head and holds position
    2 wks - 2 months
  383. age when infant moves all extremities, kicking arms and legs when prone
    2 mo
  384. age when infant draws up knees and raises abdomen off table
    3 - 6 mo
  385. age when infant rocks back and forth while up on hands and knees
    3 - 6 mo
  386. age when infant rolls over
    3 - 6 mo
  387. age when infant sits alone, using hands for support (tripod fashion)
    by 7 months
  388. age when infant moves like inch worm forward or backward by pulling legs to chest
    by 9 mo
  389. When does crawling start
    6 to 9 mo
  390. age when infant begins to pull up
    by 11 mo
  391. age when infant cruises?

    What is cruising?
    by 12 mo

    walks holding onto something or supported by something
  392. what age will infant sit from a standing position
    12 mo
  393. By what age should an infant be able to walk alone?
    15 mo
  394. 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
  395. What 3 things need to be determined in cases of neurologic deficit?
    degree, type, and location of NS lesions
  396. For children younger than 5 years neurologic functioning is best evaluate with ______ developmental screeening test.
    DDST - II
  397. 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
  398. Testing _____, ______, & ______ gives a picture of NS functioning above the spinal cord.
    cerebral function, cranial nerves, and cerebellar functioning
  399. What is involved in the evluation of cerebral function?
    cognitive function - appearnce, behavior, orientation, speech patterns, memory, logic, and affect
  400. How is cerebral functioning assessed?
    history of behavior etc from caregiver

    evaluation of older child/ adolescent LOC, thought, and communication
  401. 5 LOC's?
    alert, lethargic, obtunded, stuporous, or comatose
  402. alert?
    awake and aware of surroundings
  403. lethargic?
    sluggish and drowsy and has to work to focus on surroundings
  404. obtunded
    unconscious and only able to be aroused with strong physical stimuli - loud noises/pain
  405. comatose
    unconscious and unable to be aroused
  406. stuporous
    sleep-like state and cannot be aroused
  407. 4 factors that may influence thought processes?
    attention span, communication, perceptual problems, and emotional withdrawal and depression
  408. What is involved in cerebellar function?

    How is it tested?
    proprioception, balance, and coordination

    have child perform specific movements
  409. How is muscle strength tested?
    first without resistance then with

    corresponding muscles on 2 sides are compared
  410. Most brain growth occurs when?
    in the first year of life
  411. What are neurologic "soft" signs?
    findings that indicate child is unable to perform activities r/t its age
  412. Children with multiple soft signs are often found to have ______.
    learning disorders
  413. Why do children with neurologic "soft" signs need evaluation and monitoring?
    because children with med, mental, or emotional probs may have same signs
  414. What should the examiner do after the exam is completed?
    ask parent/child if there are any questions

    document findings
  415. Neurologic "soft"signs?
    • short att span
    • poor motor coordination
    • clumsiness
    • frequent falling
    • hyperkinesis
    • uneven perceptual development
    • no dominant side
    • language disturbances
    • movements involving more muscles than intended
  416. anosmia
    absence of the sense of smell
  417. bronchial breath sounds
    loud, high-pitched sounds normally heard over trachea and large bronchi
  418. bronchovesicular breath sounds
    medium - pitched and quieter sounds heard over the main-stem bronchi
  419. bruit
    blowing or swishing sounds = turbulent blood flow through a BV
  420. Conjunctiva?
    membrane of the eylids and sclera of the eye
  421. 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
  422. crepitus?
    dry, crackling or grating sound
  423. 3 causes of crepitus?
    • 1. fluid in the alveoli of the lungs
    • 2. bone rubbing against bone
    • 3. air in SQ tissue
  424. friction rub
    scratching or squeaking sound during I & E and does not clear with coughing
  425. habitus?
    posture, position, & build of the body
  426. hernia?
    portion of an organ protrudes through somewhere it isn't supposed to
  427. kyphosis?
    convex curvature of the thoracic spine

  428. lift?

    caused by?

    chest rises with heart beat (systole/contraction)

    enlarged heart possible

    AKA heave
  429. systole = ____
  430. Murmur?

    Usually caused by?
    heart sound caused by vascular turbulence usually

    narrowed or leaking heart valves
  431. nasolabial fold?
    skin crevice b/t nose and mouth
  432. nystagmus?
    involuntary rhythmic rapid movement of eyeball
  433. palpebral fissure?
    opening b/t 2 eyelids
  434. precordium?
    anterior surface of the body over heart and stomach

    (epigastric region + inferior thorax)
  435. ptosis?
    drooping of the upper eyelid
  436. rales?

    discontinuous, usually inhalation, from fluid in alveoli or collapsed alveoli popping open

    fine crackles
  437. Valvular regurgitation?
    backflow of blood through heart valves due to abnormal closing of the valves
  438. rhonchi?
    snore in throat or bronchial tubes due to partial obstruction/ secretions
  439. scaphoid?
    shaped like a boat
  440. scoliosis?
    lateral deviation of the spine
  441. _____ ______ is the slowing or speeding up of the heart rate in response to breathing that may be a normal finding in children.
    sinus dysrhythmia
  442. speculum?
    enlarges passage in body
  443. stenosis?
    abnormal narrowing of a body passage or BV
  444. _____ is a harsh, high-pitched breath sound such as that heard on inhalation with an acute laryngeal obstruction.
  445. tandem walking?
    walking a straight line
  446. tangential lighting?
    pointing a light at something from an angle
  447. thrill?
    vibration felt on palpation
  448. torticollis?
    contracture of the neck/cervical muscles
  449. tympany?
    bell-like sound heard during percussion of an area that contains air or gas such as stomach or intestines
  450. ______ breath sounds are soft, fine, low-pitched sounds heard over the peripheral lung tissue.
  451. Primary source of health information for a child?
  452. How should infant weights be rounded?
    to the nearest half ounce
  453. How should the weight of toddlers, pre-schoolers, and school age children be rounded?
    to the nearest 1/4
  454. What is a concern for weight of adolescent girls?
    body image and eating disorders
  455. How should height of toddler and up be rounded?
    nearest 1/8
  456. When is head circumference included in physical exam?
    infants up to 36 months old and beyond if there is a reason
  457. Normal newborn head circumference is ____ and it increases about _____ % by age 1 year
    32-38 in

  458. What changes occur in body temp from infant - adolescent?
    body temp is usually higher in infants and slowly lowers with age
  459. 2 major causes of bradycardia in infants and children/
    1. hypoxia

    2. hypothermia
  460. The most reliable method of determining infant - 2 year old's pulse?
    apical rate
  461. Normal heart rate at 2 mo, 6 mo, and 12 mo?
    • 2 mo 90-100
    • 6 mo 80-180
    • 1 year - 75-155
  462. At what age is it ok to do radial pulse?
  463. Pulse rate range for children age 2 -10 years?
    70 - 110
  464. Normal pulse rate for age 10 - adolescent?
  465. Tachypnea is a sign of ______, especially in infants.
  466. Fever raises infant RR ____ beats/min for every degree of temp?
  467. Normal RR for up to 1 year?
  468. Normal RR for children 2 - 5 years
  469. Normal RR for children 5 - 12?
    19 - 22
  470. At what age is RR similar to adult's?
  471. How to assess cap refill in infant?
    hold arm above level of heart and press nailbed or press on heal
  472. mongolian spots?
    spots on bottom of dark-skinned infants that are harmless
  473. Where to check skin turgor of an infant- school aged child?
  474. Suture lines are usually palpable up to age ____.
    18 months