Pediatric Nursing Exam 1
“Health Assessment of Infants and Children”
Health Care for Children
Healthy People 2020
o Framework for identifying essential components for child health promotion programs
o Designed to prevent future health problems in children
o Goal to increase quality and length of healthy life and eliminate health disparities
o Leading Health Indicators (Healthy People 2020)
Physical inactivity – if it’s because of the environment, create a safe environment)
Overweight and obesity
Tobacco use
Substance abuse
Responsible sexual behavior – especially in adolescence
Mental health
Injury and violence
Environmental quality
Immunization
Access to health care – transportation, insurance, geographical location prolong treatment
Communication with patient and/or Parent/Caregiver
History Taking
o Chief Complaint
o Present Illness
o History – can be indirect or direct
Birth history
Dietary history
Illness, injuries, hospitalizations, surgeries – any prior complications
Allergies (medicine, environmental)
Medications and immunizations – include OTC
Growth and development – curve your care to the growth and developmental stage
Sexual history for adolescents
Psychosocial and personal status
Important Considerations
o Appropriate setting – find a setting that establishes confidentiality
o Introduce yourself
o Be respectful
o Distractions for child if applicable
o Opportune time – if patient is distressed, come back
o Encourage parents to speak
o Cultural awareness and sensitivity
o Direct the focus – what exactly are they here for?
o Empathy
o Anticipatory Guidance
o Avoid blocks and information overload – may have to reiterate or reinforce something that was already told
o Listen/using silence
Techniques to Consider with Children
Play
Developmentally appropriate creative techniques
Nonverbal Writing and drawing
Verbal I messages and third person
No English or Other Barriers… What do you do?
Interpreter or Language Line
,Developmental Age and Communication
Developmental processes are unique to each stage of development:
o Infant – Birth to about 1 year
o Toddler – 1 to 3 years
o Preschool – 3 to 5 years
o School Aged – 5 to 12 years
o Adolescence – 12 to 18/20 years
Continuous screening and assessment are essential for early intervention when problems are found.
Developmental Age Will Determine Approach
Erick Erikson’s psychosocial stages of development
Jean Piaget’s cognitive developmental theory
Denver developmental
Infants
Nonverbal
Crying, cooing
Respond to non-verbal behavior
Gentle
Parental presence
Erick Erikson – trust vs. mistrust; make sure their basic needs are met
Piaget – sensory motor; everything is hand to mouth; they’re getting ready to progress to preoperational
Early Childhood/Less than 5 years (Toddlers & Pre-School)
Toddlers – stranger anxiety; shows that they are oriented to person
Egocentric – everything is theirs
Equipment – may feel like it can come to life so it scares them; animism is very important
Drawings
Animism
Very literal; so be very specific
School Age Children – Industry vs. Inferiority
Simple explanations
What they know vs. what they see
Concerns
o Threats to body
o Separation
o Need to express concerns/fears
Less of what they see and more of what they know
Adolescents
Pull away from their caregivers
More independent
Other Important Observation
ASSESS Parent-Child relationship
How does parent console child
Observe touching interactions between both
Do parents have necessities w/ them – ex.: formula, diapers, consoling toys
Always CHART observations
Review of Systems
General Cardiovascular
Skin Gastrointestinal
HEENT GU/GYN
Chest Musculoskeletal
Respiratory Neurologic
, Endocrine
Physical Exam and Child Preparation
Distraction
Demonstrate
Positioning
Alter head-to toe sequence as needed
Nutritional Status Exam
Dietary history – what things are they eating?
24-hour recall
Food Diary
Anthropometric measures
Assess general growth Height, weight, Head Circumference, BMI after age 2
o Body systems Skin and Hair, HEENT, Chest, Abdomen, Neuro
Generally:
Use developmental and chronologic age as main criteria for assessment sequence
Prepare the child to ensure Atraumatic Care
Use guidelines for positioning children of various ages (see Table 4.2 pg. 112)
Key Elements
Weight
Height & Length
Skinfold thickness and arm circumference
Head circumference (HC)
BMI (age > 2 years)
Others (chest circumference or abdominal girth)
Questionable Growth
Large discrepancies between ht & wt percentiles
Velocity – shot up in growth patterns
<5th % or >95%
Patterns
Determine Methods for Measurement
Height -
Weights – same methods, same scale, same time, same clothing; make sure scale is zeroes and patient safety
Skinfold
Waist Circumference
BMI – screening tool; not absolute
o Based on age and sex
o 85th -95th%=overweight
o >95th % obese
Head Circumference
Physiological Measurements
Temperature
o Oral
o Rectal
o Axillary
o Tympanic
o Temporal Artery
o Invasive measurements
o Various devices for measurement
o Measurement based on patient age, development, and illness severity
o Birth to 2 years Axillary and Rectal?
o 2 to 5 years Axillary, Tympanic, Oral-hold under tongue? Rectal?
, o >5 years Oral, Axillary, Tympanic
Pulse
o <2 years, measure APICAL for 1 full minute
o Grade pulses – 0 to +4
o Compare radial and femoral pulses
Respirations
o Breathing is diaphragmatic and irregular
o Look for retractions, nasal flaring, etc.
Blood Pressure
o USE CORRECT CUFF SIZE (2/3 of the arm)
o Annually after age 3 years using auscultation
o Automated devices in newborns and infants
o Cuff size should be inner inflatable bladder should be 40% of diameter or 2/3 length of the arm
o Too small cuff reads abnormally high
o Too big reads abnormally lower (bigger cuff is preferable if that’s all is available)
o Place on extremity to fit.
o Note differences
Vital Signs
HR RR BP SYSTOLIC BP DIASTOLIC
BEATS/MIN BREATHS/MIN mmHg mmHg
Newborn 100 – 180 30 – 60 60 – 90 20 – 60
0 – 1 mo.
Infant 100 – 160 30 – 60 87 – 105 53 – 66
1 – 12 mos.
Toddler 80 – 110 24 – 40 95 – 105 53 – 66
1 – 3 yrs.
Preschool age 70 – 110 22 – 34 95 – 110 56 – 70
3 – 5 yrs.
School Age 65 – 110 18 – 30 97 – 112 57 – 71
6 – 11 yrs.
Pre-adolescent 70 – 110 18 – 22 105 – 124 60 – 80
11 – 13 yrs.
Adolescent 60 – 90 12 – 16 112 – 128 66 – 80
13 – 18 yrs.
Adult 50 – 90 12 – 20 113 - 136 65 – 84
18+ years
Consider – Count respirations FIRST (before disturbing the child), Count apical heart rate SECOND, Measure blood pressure (if
applicable) THIRD, Measure temperature LAST
General Appearance
Expression & Appearance
Posture, movement
Body language
Hygiene – are they clean and do they have an odor
Behavior
Emotions, interactions
Mental acuity
Motor development
Things to Note Concerning Skin
Color – red, pale, cyanotic
Texture – smooth, bumpy, etc
Temperature
Moisture
Turgor
“Health Assessment of Infants and Children”
Health Care for Children
Healthy People 2020
o Framework for identifying essential components for child health promotion programs
o Designed to prevent future health problems in children
o Goal to increase quality and length of healthy life and eliminate health disparities
o Leading Health Indicators (Healthy People 2020)
Physical inactivity – if it’s because of the environment, create a safe environment)
Overweight and obesity
Tobacco use
Substance abuse
Responsible sexual behavior – especially in adolescence
Mental health
Injury and violence
Environmental quality
Immunization
Access to health care – transportation, insurance, geographical location prolong treatment
Communication with patient and/or Parent/Caregiver
History Taking
o Chief Complaint
o Present Illness
o History – can be indirect or direct
Birth history
Dietary history
Illness, injuries, hospitalizations, surgeries – any prior complications
Allergies (medicine, environmental)
Medications and immunizations – include OTC
Growth and development – curve your care to the growth and developmental stage
Sexual history for adolescents
Psychosocial and personal status
Important Considerations
o Appropriate setting – find a setting that establishes confidentiality
o Introduce yourself
o Be respectful
o Distractions for child if applicable
o Opportune time – if patient is distressed, come back
o Encourage parents to speak
o Cultural awareness and sensitivity
o Direct the focus – what exactly are they here for?
o Empathy
o Anticipatory Guidance
o Avoid blocks and information overload – may have to reiterate or reinforce something that was already told
o Listen/using silence
Techniques to Consider with Children
Play
Developmentally appropriate creative techniques
Nonverbal Writing and drawing
Verbal I messages and third person
No English or Other Barriers… What do you do?
Interpreter or Language Line
,Developmental Age and Communication
Developmental processes are unique to each stage of development:
o Infant – Birth to about 1 year
o Toddler – 1 to 3 years
o Preschool – 3 to 5 years
o School Aged – 5 to 12 years
o Adolescence – 12 to 18/20 years
Continuous screening and assessment are essential for early intervention when problems are found.
Developmental Age Will Determine Approach
Erick Erikson’s psychosocial stages of development
Jean Piaget’s cognitive developmental theory
Denver developmental
Infants
Nonverbal
Crying, cooing
Respond to non-verbal behavior
Gentle
Parental presence
Erick Erikson – trust vs. mistrust; make sure their basic needs are met
Piaget – sensory motor; everything is hand to mouth; they’re getting ready to progress to preoperational
Early Childhood/Less than 5 years (Toddlers & Pre-School)
Toddlers – stranger anxiety; shows that they are oriented to person
Egocentric – everything is theirs
Equipment – may feel like it can come to life so it scares them; animism is very important
Drawings
Animism
Very literal; so be very specific
School Age Children – Industry vs. Inferiority
Simple explanations
What they know vs. what they see
Concerns
o Threats to body
o Separation
o Need to express concerns/fears
Less of what they see and more of what they know
Adolescents
Pull away from their caregivers
More independent
Other Important Observation
ASSESS Parent-Child relationship
How does parent console child
Observe touching interactions between both
Do parents have necessities w/ them – ex.: formula, diapers, consoling toys
Always CHART observations
Review of Systems
General Cardiovascular
Skin Gastrointestinal
HEENT GU/GYN
Chest Musculoskeletal
Respiratory Neurologic
, Endocrine
Physical Exam and Child Preparation
Distraction
Demonstrate
Positioning
Alter head-to toe sequence as needed
Nutritional Status Exam
Dietary history – what things are they eating?
24-hour recall
Food Diary
Anthropometric measures
Assess general growth Height, weight, Head Circumference, BMI after age 2
o Body systems Skin and Hair, HEENT, Chest, Abdomen, Neuro
Generally:
Use developmental and chronologic age as main criteria for assessment sequence
Prepare the child to ensure Atraumatic Care
Use guidelines for positioning children of various ages (see Table 4.2 pg. 112)
Key Elements
Weight
Height & Length
Skinfold thickness and arm circumference
Head circumference (HC)
BMI (age > 2 years)
Others (chest circumference or abdominal girth)
Questionable Growth
Large discrepancies between ht & wt percentiles
Velocity – shot up in growth patterns
<5th % or >95%
Patterns
Determine Methods for Measurement
Height -
Weights – same methods, same scale, same time, same clothing; make sure scale is zeroes and patient safety
Skinfold
Waist Circumference
BMI – screening tool; not absolute
o Based on age and sex
o 85th -95th%=overweight
o >95th % obese
Head Circumference
Physiological Measurements
Temperature
o Oral
o Rectal
o Axillary
o Tympanic
o Temporal Artery
o Invasive measurements
o Various devices for measurement
o Measurement based on patient age, development, and illness severity
o Birth to 2 years Axillary and Rectal?
o 2 to 5 years Axillary, Tympanic, Oral-hold under tongue? Rectal?
, o >5 years Oral, Axillary, Tympanic
Pulse
o <2 years, measure APICAL for 1 full minute
o Grade pulses – 0 to +4
o Compare radial and femoral pulses
Respirations
o Breathing is diaphragmatic and irregular
o Look for retractions, nasal flaring, etc.
Blood Pressure
o USE CORRECT CUFF SIZE (2/3 of the arm)
o Annually after age 3 years using auscultation
o Automated devices in newborns and infants
o Cuff size should be inner inflatable bladder should be 40% of diameter or 2/3 length of the arm
o Too small cuff reads abnormally high
o Too big reads abnormally lower (bigger cuff is preferable if that’s all is available)
o Place on extremity to fit.
o Note differences
Vital Signs
HR RR BP SYSTOLIC BP DIASTOLIC
BEATS/MIN BREATHS/MIN mmHg mmHg
Newborn 100 – 180 30 – 60 60 – 90 20 – 60
0 – 1 mo.
Infant 100 – 160 30 – 60 87 – 105 53 – 66
1 – 12 mos.
Toddler 80 – 110 24 – 40 95 – 105 53 – 66
1 – 3 yrs.
Preschool age 70 – 110 22 – 34 95 – 110 56 – 70
3 – 5 yrs.
School Age 65 – 110 18 – 30 97 – 112 57 – 71
6 – 11 yrs.
Pre-adolescent 70 – 110 18 – 22 105 – 124 60 – 80
11 – 13 yrs.
Adolescent 60 – 90 12 – 16 112 – 128 66 – 80
13 – 18 yrs.
Adult 50 – 90 12 – 20 113 - 136 65 – 84
18+ years
Consider – Count respirations FIRST (before disturbing the child), Count apical heart rate SECOND, Measure blood pressure (if
applicable) THIRD, Measure temperature LAST
General Appearance
Expression & Appearance
Posture, movement
Body language
Hygiene – are they clean and do they have an odor
Behavior
Emotions, interactions
Mental acuity
Motor development
Things to Note Concerning Skin
Color – red, pale, cyanotic
Texture – smooth, bumpy, etc
Temperature
Moisture
Turgor
