-
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
No
-
When should uncomfortable procedures be done when examining an infant birth to 6 months?
Last
-
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?
School agr
-
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?
Who decides?
Not usually
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?
Gown
-
Four basic techniques of exams in order?
Inspection, palpation, percussion, auscultation
-
Direct inspection?
Nurse uses their own sight and hearing
-
Indirect inspection
Nurse uses tools to see and hear
Like otoscope
-
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?
Finger tips
-
What part of the hand is used to palpate temp?
Back of the hand
-
What part of the hand is used to palpate vibrations?
Palm
-
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
-
Bimanual palpation?
It's purpose?
Use 2 hands to trap a mass or organ between them
-
Percussion?
It's purpose?
Quick tapping of fingers or hands to produce sounds
To locate the position, size, and density of underlying structures
-
3 types of percussion?
- Mediate/indirect
- Immediate
- Fist percussion
-
Mediate/indirect percussion?
Finger of one hand placed against the body and finger of other hand acts as a hammer
-
Immediate percussion?
Strike finger of one hand directly against the body?
-
Fist percussion?
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?
Diaphragm
Heart and breath sounds
-
What part of the stethoscope is best for low pitched sounds?
What makes low pitched sounds?
Bell
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?
General survey
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?
- Statistical info
- Patient profile- regular habits
- Health history
- Family history
- 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
- 120-160 BPM
- 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
- RR- 20-30
- 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
- BP-
-
Normal VS for 16 year old?
Like adults
-
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?
Why?
Axillary
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?
3
-
How long should pulse be counted?
Why?
- One minute
- 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
- All ages
-
What pulses are compared in children of any age?
Femoral, radial, and carotid
-
What pulse do infants have that others don't
Anterior fontanel.
-
What does an irregular pulse in an infant usually indicate?
- Not abnormal
- 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
One minute
-
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?
> 120/80
-
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
- More accurate
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.
1.2
-
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.
Chest
-
When do head and chest circumference become nearly equal?
1 year
-
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
Calipers
-
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 _______.
Why?
- 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?
Overweight/ obesity
-
What 3 things are plotted on CDC chart and what ages are included?
Height, weight, and BMI
2-20
-
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.
95th
-
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
- Black
- Diffusely darker
-
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?
Acanthosis nigricans
-
What is acanthosis nigricans?
Darker, thicker skin in folds (posterior neck, behind knees and elbows, and in armpits )
-
Vitiligo?
Areas of depigmentation
-
Nevi?
Areas of increased pigmentation
-
Jaundice?
Where is it best seen?
- Yellow skin
- Sclera/ whites of eyes
-
Cyanosis?
Where is it best seen?
- Blue skin
- Mucous membranes of the mouth especially under tongue
-
Carotenemia?
Where is it best seen?
- Orange skin
- Palms and soles of feet
-
Pallor?
Loss of skin color?
-
-
Mottling?
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.
-
Hirsutism?
Excessive hair growth
-
Alopecia?
Unusual hair loss
-
Why are most cases of head lice discovered?
Scratching
-
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
160
-
Cap refill should be less than ____ seconds. Longer cap refill may indicate what 4 conditions?
- < 2 seconds
- Anemia
- Peripheral edema
- Vasoconstriction
- 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?
- Sentinel node
- 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?
Palpate
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?
Several seconds
Weak neck muscles
-
When is head lag an indication muscles may.not be dev properly?
6 mo
-
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?
2-3 mo
-
The anterior fontanel should be < ____ cm inlength and width after 12 mo, and should be completely closed by age ____ to _____ mo.
5
12-24
-
A sunken fontanel may indicate_____.
Dehydration
-
Bulging fontanel can indicate _______.
Increased intracranial pressure.
-
Craniosynostosis?
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?
Why?
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 __________?
2 examples?
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
Dysmorphic features
-
The eyes are examined for _____,______,&______.
Size, position, and configuration
-
Hypertelorism?
Eyes are wide spaced
-
Hypotelorism?
Eyes close together
-
Hypoplastic philtrum?
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.
10
-
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?
Gloves
-
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?
Allergies
-
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____.
Inflammatory response
-
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
-
-
PPE during oral exam?
Gloves
-
Tools neededfor oral exam?
Tongue blade and pen light
-
3 exam techniques used for oral
Exam?
Inspection, palpation, and sense of smell
-
5 characteristics of lips to examine?
Symmetry, color, moisture, cracking, and lesions
-
Alveolar frenulum?
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?
6 mo
30 mo
-
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?
Normal?
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
Enlarged tonsils
-
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?
4 weeks
-
Visual accuity testing for all children shinning no later than age ____ years is recommended.
3
-
3 vision tests that work for
Preschoolers?
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.
3-5
Amblyopia
-
Amblyopia?
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.
-
Successful HOTV?
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?
5
-
Color blindness?
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
Field-of-vision test
Cover/uncover test
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?
-
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?
Trochlear nerve
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?
Asian
-
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?
Tear duct
Infants
-
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______.
CNS injury
-
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.
4
-
Audiometry?
Tests hearing with beeping noise
-
Sweep test tests for ______& the pure tone test tests for _________.
- Hearing losses
- 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
Preschool- adolescents
-
Conduction tests?
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.
Tympanic membrane
-
How to choose speculum size for
Otoscope?
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?
All 4
-
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?
Rounder
-
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?
Posterior chest
Stay in view
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Posterior chest is assessed for what 3 things?
Tenderness, tactile fremitus, and chest excursion
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The presence of tactile fremitus when palpating the posterior chest of a child may indicate ________.
Airway alterations
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Breath sounds are characterized by what 4 factors?
Intensity, pitch, quality, & duration
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What is preferable position when listening to breath sounds?
Where should nurse be?
Upright
To the side of pt
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Position of child for auscultating posterior thorax?
Head bent forward and hands folded in front
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What should child do during posterior thorax auscultation?
Open mouth and breathe in and out, blow bubbles, pretend to blow out candles
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Crackles?
AKA?
Fluid in airways, discontinuous, crackling heard during inspiration and not cleared with coughing
Rales, crepitation
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Pleural friction rub?
Where is it best heard?
Like rubbing leather together.
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High pitched wheeze?
Cause?
Musical squeaking mostly on expiration , coughing may change the sound
Narrowing of air passages for fluid, swelling, spasm, or tumors
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Low-pitched wheeze?
AKA?
Musical snoring moaning sounds
More predominant on expiration
May clear some with coughing
Sonorous wheeze
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3 techniques for inspecting the heart?
Inspection, palpation, and auscultation
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5 areas of the anterior chest that should be closely examined?
Aortic area, pulmonic area, right ventricular area, apex, and epigastric area
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Where is the aortic area?
Right second IC space
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Where is the pulmonic area?
Left second intercostal space
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Where is the right ventricular. Area?
Left sternal boarder
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Where is the apex?
Fifth left IC space in midclavicular line
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Where is the epigastric area?
below the xiphoid process
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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
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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
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Precordium?
What things is it inspected for?
anterior chest overlying the heart and great vessels
bulges, lifts, heaves, and apical impulse
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By age _____years the apical impulse will be at the fifth IC space.
7
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Why is the precordium palpated?
presence of pulsations at each area
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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
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The examiner should use the ______ aspect of the hand to feel for thrills.
What are thrills?
palmar
palpable vibrations of the heart
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3 positions a child should be in during auscultation of both heart and chest?
supine, lateral recumbent, and sitting up
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Where is S1 sound heard best?
at the apex of the heart in the tricuspid and mitral area
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Where is S2 heard the best?
at the base in the aortic and pulmonic area
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What produces the S1 sound?
closing of the mitril and tricuspid valves
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What produces S2 sound?
closing of the aortic and pulmonic valves
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What is indicated by a pause heard during S2?
Where can this best be heard?
considered normal in children
pulmonic area
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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
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Children's heart rates often increase with _______ and decrease with ______.
(inspiration or expiration)
inspiration
expiration
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How can the examiner decrease irregular heart rhythm associated with respirations?
have the pt hold breath during heart auscultation if possible
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4 types of extra heart sounds?
opening snaps, ejection clicks, midsystolic to systolic clicks, and murmurs
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What are heart snaps and clicks?
short, high-pitched sounds heard with valve disorders that are not affected by respirations
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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
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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
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What is noted when palpating arterial pulses?
rate, rhythm, elasticity of vessel wall, & equal force of bilateral pulses
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It is necessary to compare _____pulses in children.
opposite side to side and lower extremity to upper
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Hearts of infants and children should be auscultated in a ____shape.
What 4 areas are auscultated?
Z
aortic, pulmonic, tricuspid, mitral
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Why may infants of both sexes have engorged breasts?
estrogen crossing placenta
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thelarche?
What does it indicate?
When may it occur?
breast development
beginning of puberty in girls
as early as age 7
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When is an inverted nipple significant?
if it has just occurred
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When should girls be taught how to do breast self-examination?
once they have reached menarche
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When should breast self-exam be done?
3 to 4 days after menses because less tender
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gynecomastia?
Who may this affect?
enlargement of breast tissue
adolescent boys during puberty
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3 ways to relax the abdomen of a child for abd exam?
empty bladder, warm hands, and supine position with knees flexed
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Sequence of techniques during the abd exam?
inspection, auscultation, percussion, palpation
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What is included in an abdominal inspection?
contour, symmetry, umbilicus & skin condition, pulsations or movement, and hair distribution
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What is contour and how is it assessed?
profile of the abd from rib margin to the pubic bone
looking across the abdomen
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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
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What type of contour is typical for toddler's abd?
protruberant
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Is it normal to see peristalsis of the abd in infants and children?
no
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What part of the stethoscope is used for auscultation of abdomen?
diaphragm
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Auscultation of the abd begins in what quadrant?
lower right
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Where should bruits be auscultated? With what part of the stethoscope?
aortic, renal, iliac, and femoral arteries
bell
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Where should examiner listen for a venous hum?
epigastric region and around the umbilicus
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What is abd palpation used for?
ID mass or tenderness & determine size, consistency, and location of organs
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How to relax a child who is afraid/ticklish during abd palpation?
Have them help with the palpations, have them breathe deeply
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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
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How can you determine if tenseness is voluntary?
Wait for the child to breathe and should go away if voluntary
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What does rigidity of the abd indicate?
acute inflammation of the peritoneum
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What should also be checked during abd palpation?
skin turgor, femoral pulses, and inguinal lymph nodes
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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
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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,
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Should the physical exam end with the genital exam?
no, need further oppurtunities for communication
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PPE for genital exam?
gloves
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By the time a male is age _____ years, the foreskin may be easily retractable.
5 to 6
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Difference between the scrotum of infant or young boy and adolescent boy?
infant/young - proximal is wider and distal narrower
adolescent is opposite
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How to prevent the cremasteric reflex?
What is it?
have the boy sit cross legged
testes withdrow into the inguinal canal
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What type of teaching should be done with genital exam of adolescent boy?
testicular self examination
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Exam of female genitalia?
drape pt, gloves, visual inspection and gentle palpation
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5 components of the musculoskeletal system?
bones, muscles, joints, ligaments, cartilage
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How is the musculoskeletal system examined in children?
observe them playing and doing physical activities and ROM
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What test is used to assess fine and gross motor ability of child younger than 5?
Denver Developmental Screening Test II (DDST - II)
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cephalocaudal?
head to toe
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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
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What causes most injuries to extremities of children and adolescents?
- overuse injuries like sprains
- sports requiring repetitive motions - swimming, gymnastics, skating, and running
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What areas are palpated for tenderness, sweeling, deformity, and crepitus if injuries or abuse are suspected?
skull, extremities, and ribs
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3 deformities of the spine?
scoliosis, kyphosis, and lordosis
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By age _____ mo infant can lift head while prone.
2 mo
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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
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What spine abnormality is common in young children?
lordosis
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______ of the foot is common b/t ages 12 and 30 months b/c young children have a broad based stance
pronation
-
Adduction / toeing in?
How is this treated?
child walks on the lateral side of the foot
usually corrects itself by age 3 years
-
genu varum?
bowleg - space of more than 2.5 c is measured b/t knees as the ankles are held together
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Genu varu is normal after the child has begun to ______ & may persist until the child is ____years old.
-
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
-
What should happen to the iliac crest if a child stands on one leg and then the other
should stay level
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Adolescent examination is the same as school age except special attention should be paid to the _____ because adolescents frequently have _____.
-
lordosis?
excessive inward curvature of the spine
-
kyphosis?
Usually caused by?
- bowing / rounding of spine
- hunchback
poor posture
-
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
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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
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What should the nurse do if atrophy or hypertrophy of a muscle is suspected? How is this performed?
measure the muscle
at greatest circumfernce
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5 things examiner palpates joints for?
temp, tenderness, crepitation, swelling, and masses
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What symptoms in children are associated with joint disorders?
fatigue, stiffness or weakness, heat and redness
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age when infant raises head and holds position
2 wks - 2 months
-
age when infant moves all extremities, kicking arms and legs when prone
2 mo
-
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
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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
12 mo
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By what age should an infant be able to walk alone?
15 mo
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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
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What 3 things need to be determined in cases of neurologic deficit?
degree, type, and location of NS lesions
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For children younger than 5 years neurologic functioning is best evaluate with ______ developmental screeening test.
DDST - II
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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
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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
-
5 LOC's?
alert, lethargic, obtunded, stuporous, or comatose
-
alert?
awake and aware of surroundings
-
lethargic?
sluggish and drowsy and has to work to focus on surroundings
-
obtunded
unconscious and only able to be aroused with strong physical stimuli - loud noises/pain
-
comatose
unconscious and unable to be aroused
-
stuporous
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 ______.
learning disorders
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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
document findings
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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
-
anosmia
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
-
bruit
blowing or swishing sounds = turbulent blood flow through a BV
-
Conjunctiva?
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
-
crepitus?
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
-
friction rub
scratching or squeaking sound during I & E and does not clear with coughing
-
habitus?
posture, position, & build of the body
-
hernia?
portion of an organ protrudes through somewhere it isn't supposed to
-
kyphosis?
convex curvature of the thoracic spine
hunchback
-
lift?
caused by?
AKA?
chest rises with heart beat (systole/contraction)
enlarged heart possible
AKA heave
-
systole = ____
contraction
-
Murmur?
Usually caused by?
heart sound caused by vascular turbulence usually
narrowed or leaking heart valves
-
nasolabial fold?
skin crevice b/t nose and mouth
-
nystagmus?
involuntary rhythmic rapid movement of eyeball
-
palpebral fissure?
opening b/t 2 eyelids
-
precordium?
anterior surface of the body over heart and stomach
(epigastric region + inferior thorax)
-
ptosis?
drooping of the upper eyelid
-
rales?
AKA?
discontinuous, usually inhalation, from fluid in alveoli or collapsed alveoli popping open
fine crackles
-
Valvular regurgitation?
backflow of blood through heart valves due to abnormal closing of the valves
-
rhonchi?
snore in throat or bronchial tubes due to partial obstruction/ secretions
-
scaphoid?
shaped like a boat
-
scoliosis?
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.
sinus dysrhythmia
-
speculum?
enlarges passage in body
-
stenosis?
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.
stridor
-
tandem walking?
walking a straight line
-
tangential lighting?
pointing a light at something from an angle
-
thrill?
vibration felt on palpation
-
torticollis?
contracture of the neck/cervical muscles
-
tympany?
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.
vesicular
-
Primary source of health information for a child?
CG
-
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?
nearest 1/8
-
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
32-38 in
33%
-
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/
1. hypoxia
2. hypothermia
-
The most reliable method of determining infant - 2 year old's pulse?
apical rate
-
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?
2
-
Pulse rate range for children age 2 -10 years?
70 - 110
-
Normal pulse rate for age 10 - adolescent?
55-90
-
Tachypnea is a sign of ______, especially in infants.
pneumonia
-
Fever raises infant RR ____ beats/min for every degree of temp?
10
-
Normal RR for up to 1 year?
35-35
-
Normal RR for children 2 - 5 years
22-25
-
Normal RR for children 5 - 12?
19 - 22
-
At what age is RR similar to adult's?
12
-
How to assess cap refill in infant?
hold arm above level of heart and press nailbed or press on heal
-
mongolian spots?
spots on bottom of dark-skinned infants that are harmless
-
Where to check skin turgor of an infant- school aged child?
abd
-
Suture lines are usually palpable up to age ____.
18 months
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