PEDS Chapter 32: Health Assessment of Children Flashcards Preview

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Flashcards in PEDS Chapter 32: Health Assessment of Children Deck (31)
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1

Components of the health assessment:
Health____ and ____
Observation of the _____ interaction
Assessment of the child’s ____, ____, ____, and ____ development
_____ assessment

Health interview and history
Observation of the parent–child interaction
Assessment of the child’s emotional, physiologic, cognitive, and social development
Physical assessment

2

Role of the Nurse When Performing a Physical Assessment of a Child:
Establish ____ and ____
Demonstrate ____ for the child and parent/caregiver
Communicate effectively by ____ ___, demonstrating ___, and providing ____
Observe ___
Obtain accurate data
____ and ___ data accurately

Establish rapport and trust
Demonstrate respect for the child and parent/caregiver
Communicate effectively by listening actively, demonstrating empathy, and providing feedback
Observe systematically
Obtain accurate data
Validate and interpret data accurately

3

Is the following statement true or false?
The nurse is eliciting a health history from an adolescent. It is recommended that the nurse acts like the teenager’s peer in order to gain respect and acceptance.

False. It is not recommended that the nurse acts like the teenager’s peer in order to gain respect and acceptance.
Rationale: The nurse should remain in the role of the health care provider while demonstrating respect and acceptance toward the teen. The nurse should also clarify the meaning of jargon or slang that the teen uses, but not use these words in the interview; the teen will simply not accept the nurse as a peer.

4

Exploring Family Dynamics During the Health History:
Does the parent make ___ ___ with the infant?
Does the parent ____ and ___ to the infant’s needs?
Are the parents ineffective when dealing with a toddler’s ___ ___?

eye contact
anticipate and respond
temper tantrum

5

Exploring Family Dynamics During the Health History:
Do the parents’ comments increase the school-age child’s sense of ___-___?
___ observations are crucial to proper assessment of the family’s needs.

self-worth
Behavior

6

Therapeutic Communication Techniques

Active listening.
Using open-ended questions.
Eliminating barriers to communication.

7

Components of the Health History

Demographics
Chief complaint and history of present illness
Past health history
Review of systems
Family health history
Developmental history
Functional history
Family composition, resources, and home environment

8

The nurse is conducting a physical assessment of a teenager and asks about his daily routine. What aspect of the health history is the nurse assessing?
a. developmental history
b. functional history
c. family health history
d. demographics

b. functional history. The functional history involves asking about the child’s daily routine.
Rationale: The developmental history determines the age when landmarks in gross motor control were achieved. The family health history obtains information about the family’s health, and demographics refers to data such as the child’s name, birth date, gender, race, ethnicity, and language spoken.

9

Determining Characteristics of Chief Complaints:
Onset, duration, characteristics, and course (location, signs, symptoms, exposures, and so on).
Previous ___ in the child or family.
Previous ___ or ____, what makes it better or worse.
What the concern means to the child and family.
Inquiry about any exposure to ___ agents.

episodes
testing or therapies
infectious

10

Aspects of the Past Health History

Prenatal or perinatal history, past illnesses, other developmental problems.
Prior history of illnesses, accidents, or injuries in past.
Any operations or hospitalizations child has had.
Child’s diet and allergies.
Child’s immunization status.
Any medications child is taking.
Menstrual history in adolescent females.

11

Review of Systems—Physical Assessment

Growth and development .
Skin.
Head and neck.
Eyes and vision.
Ears and hearing.
Mouth, teeth, and throat.
Respiratory system and breasts.

12

Review of Systems—Physical Assessment (cont.)

Cardiovascular system
Gastrointestinal system
Genitourinary system
Musculoskeletal system
Neurologic system
Endocrine system
Hematologic system

13

The nurse is performing a physical assessment of a 16-year-old girl. Which of the following is a recommended guideline for interviewing a child at this developmental stage?
a. during the interview ask the caregiver to answer any questions the teen is too embarrassed to answer
b. keep up a running dialogue with the caregiver, explaining each step as it is performed
c. perform the genital exam first, and then use a head-to-toe approach to examine other systems
d. explain to the caregiver that the teen needs privacy and ask him or her to wait outside the room

d. explain to the caregiver that the teen needs privacy and ask the caregiver to wait outside the room during the physical examination.
Rationale: The nurse performing a physical examination of the older teenager should ask the caregiver to wait outside to provide privacy for the teen. The nurse should explain confidentiality to the teen and caregiver and interview each together and separately. The nurse should also use a head-to-toe approach with the genital exam performed last.

14

Steps of the Physical Examination

Observation:
Checking color, warmth, characteristics, and texture visually and smelling for any odor.
Palpation:
Validating observations.
Percussion:
Determining the location, size, and density of organs or masses.
Auscultation:
Listening to heart, lungs, and abdomen with stethoscope.

15

The nurse is performing a physical assessment of a child. Which of the following reflects the order in which the assessment techniques are normally performed?
a. observation, palpation, percussion, auscultation
b. palpation, percussion, auscultation, observation
c. percussion, palpation, observation, auscultation
d. observation, auscultation, palpation, percussion

a. observation, palpation, percussion, auscultation. This describes the order in which the physical assessment is performed.
Rationale: The physical examination of children begins with a systematic inspection, checking color, warmth, characteristics, and texture visually and smelling for any odor. Palpation follows inspection to validate observations. Percussion determines the location, size, and density of organs or masses. The stethoscope is used to auscultate the heart, lungs, and abdomen.

16

Components of a Complete Physical Examination:
Assessment-
Examination-

Assessment :
General appearance, vital signs, body measurements, and pain assessment
Examination:
Head, neck, eyes, ears, nose, mouth and throat, skin, thorax and lungs, breasts, heart and peripheral perfusion, abdomen, genitalia and rectum, musculoskeletal system, and neurologic system

17

Infant:
HR
RR

HR 80-150
RR 25-55

18

Toddler:
HR
RR

HR 70-120
RR 20-30

19

Preschooler:
HR
RR

HR 65-110
RR 20-25

20

School-age:
HR
RR

HR 60-100
RR 14-22

21

Adolescent:
HR
RR

HR 55-95
RR 12-18

22

BMI
English

weight in pounds/ (height in inches) x (height in inches)

x703

23

BMI
Metric

weight in kilograms/ (height in meters) x (height in meters)

x10,000

24

Is the following statement true or false?
The nurse is examining an infant and documents “cyanosis.” This condition is a decreased pinkness in light-skinned children or an ashy-gray color in dark-skinned children caused by anemia, shock, fever, or syncope.

False. Cyanosis is blueness of the lips, tongue, oral mucosa, or trunk caused by hypoxia or circulatory collapse.
Rationale: Pallor is decreased pinkness in light-skinned children or an ashy-gray color in dark-skinned children caused by anemia, shock, fever, or syncope.

25

Eye Assessment (PERRLA)

PERRLA: Pupils are equal, round, reactive to light and accommodation.
The eyes demonstrate accommodation, or focusing at different distances, if the pupil constricts as the object moves closer.
Absence of pupillary reflexive action after age 3 weeks may indicate blindness.

26

Grading Heart Murmurs in Children:
1

Barely audible; sometimes heard, sometimes not. Usually heard only with intense concentration.

27

Grading Heart Murmurs in Children:
2

Quiet, soft; heard each time chest is auscultated.

28

Grading Heart Murmurs in Children:
3

Audible, intermediate intensity.

29

Grading Heart Murmurs in Children:
4

Audible, with palpable thrill.

30

Grading Heart Murmurs in Children:
5

Loud, audible with edge of stethoscope lifted off the chest.