NURSING CARE
(Pediatric Care and Assessments)
Variation in Normal
• Newborn: 36.8C axillary
• 1-3 years: 37.7C rectal
• 6-8 years: 37C oral
• 10 years: 37C oral
• Teen years: 37C oral
• °F to °C: Deduct 32, then multiply by 5, then divide by 9
• °C to °F: Multiply by 9, then divide by 5, then add 32
Examining Children
• With children, always proceed from least invasive or uncomfortable
to most invasive. Head, neck, heart, lungs, and range of motion.
• Assess ears, mouth, abdomen, and genitals last.
Physical Assessment of Children
• General assessment: Interaction with family
• Skin assessment:
• Color, turgor, lesions; color reflects ethnicity, diet, disease, and
injury
• Pallor: Anemia, cyanosis (compromised cardiorespiratory state)
• Yellow skin and sclera: Liver dysfunction
• Petechial lesions: Infectious process or blood disorder
• Echymotic lesions: Blood disorder, injury
• Dehydration: Skin tents
Skin (Continued):
, • Rash: Determine if skin blanches or turns pale; petechial lesions do
not blanch
• Check hair, scalp, nail beds, palms of hands
Eyes:
• White children: Sclera is white
• Dark skinned children: Sclera can be slightly yellow with small black
marks.
• Conjunctivitis, styes, erythema, swelling, discharge
• Visual acuity
Lung assessment:
• Best to auscultate with child in sitting position
• Auscultate 5 lobes (posterior and anterior)
• Do early in assessment with infant
• Very slow respirations may mean lack of energy
• Alteration in depth: Hypercapnia or too deep associated with fever
• Hypopnea (to shallow) associate with central nervous system
depression
Cardiac assessment:
• Point of Maximal Impulse (PMI): Area of most intense pulsation and
points of apical impulse, or impulse corresponding to the apex of
the heart usually located in same area of chest.
• Apical impulse found lateral of the left midclavicular line and 4 th
intercostal space in children younger than 7 years.
Murmurs:
Attributed to turbulent blood flow within the vessels; assess for intensity,
location, quality, timing, and radiation.
Abdominal:
• To minimize sensation of tickling, palpate abdomen through a layer
of light clothing or place the child’s hand on top of the nurses’ hand
(Pediatric Care and Assessments)
Variation in Normal
• Newborn: 36.8C axillary
• 1-3 years: 37.7C rectal
• 6-8 years: 37C oral
• 10 years: 37C oral
• Teen years: 37C oral
• °F to °C: Deduct 32, then multiply by 5, then divide by 9
• °C to °F: Multiply by 9, then divide by 5, then add 32
Examining Children
• With children, always proceed from least invasive or uncomfortable
to most invasive. Head, neck, heart, lungs, and range of motion.
• Assess ears, mouth, abdomen, and genitals last.
Physical Assessment of Children
• General assessment: Interaction with family
• Skin assessment:
• Color, turgor, lesions; color reflects ethnicity, diet, disease, and
injury
• Pallor: Anemia, cyanosis (compromised cardiorespiratory state)
• Yellow skin and sclera: Liver dysfunction
• Petechial lesions: Infectious process or blood disorder
• Echymotic lesions: Blood disorder, injury
• Dehydration: Skin tents
Skin (Continued):
, • Rash: Determine if skin blanches or turns pale; petechial lesions do
not blanch
• Check hair, scalp, nail beds, palms of hands
Eyes:
• White children: Sclera is white
• Dark skinned children: Sclera can be slightly yellow with small black
marks.
• Conjunctivitis, styes, erythema, swelling, discharge
• Visual acuity
Lung assessment:
• Best to auscultate with child in sitting position
• Auscultate 5 lobes (posterior and anterior)
• Do early in assessment with infant
• Very slow respirations may mean lack of energy
• Alteration in depth: Hypercapnia or too deep associated with fever
• Hypopnea (to shallow) associate with central nervous system
depression
Cardiac assessment:
• Point of Maximal Impulse (PMI): Area of most intense pulsation and
points of apical impulse, or impulse corresponding to the apex of
the heart usually located in same area of chest.
• Apical impulse found lateral of the left midclavicular line and 4 th
intercostal space in children younger than 7 years.
Murmurs:
Attributed to turbulent blood flow within the vessels; assess for intensity,
location, quality, timing, and radiation.
Abdominal:
• To minimize sensation of tickling, palpate abdomen through a layer
of light clothing or place the child’s hand on top of the nurses’ hand
