PEDIATRIC NURSING EXAM 1 STUDY GUIDE
CHAPTER 4_ASSESSMENT OF CHILD & FAMILY
• Communicating with parents/guardians:
o Encouragement/direction:
▪ Use careful phrasing with broad, open-ended questions
▪ Often all that is required to keep parents talking is a nod or saying “yes” or “uh-huh.”
o Cultural awareness
o Listening/using silence:
▪ Silence permits the interviewee to sort out thoughts and feelings and search for responses to
questions.
o Empathy
o Providing anticipatory guidance- focuses on providing families information on normal growth and
development and nurturing childrearing practices but should extend beyond giving general information to
empowering families to use the information as a means of building competence in their parenting abilities
o Avoid information overload
o Using an interpreter:
▪ Introduce the interpreter to family
▪ Communicate directly with family members when asking questions to reinforce interest in them
and to observe nonverbal expressions
▪ Be aware that some medical words, such as allergy, may have no similar word in another
language; avoid medical jargon whenever possible.
• Communicating with children:
o Don’t be in a hurry
o Allow children time to feel comfortable
o Avoid sudden or rapid advances, broad smiles, extended eye contact, or other gestures that may be seen as
threatening.
o Talk to the parent if child is initially shy.
o Play/use toys- Communicate through transition objects (such as dolls, puppets, and stuffed animals)
before questioning a young child directly
o Get at their eye-level
o Simple words and short sentences
o Be honest- don’t offer choices if there isn’t one
o Consider their development:
▪ Infant-stranger anxiety
• Infants smile and coo when content and cry when distressed.
• Crying is provoked by unpleasant stimuli from inside or outside, such as hunger, pain,
body restraint, or loneliness
▪ Toddler-separation anxiety
▪ Pre-school- concrete
• Therefore use simple, direct language rather than phrases that might be misinterpreted by
a small child
• they attach literal meaning to such common phrases as “two-faced,” “sticky fingers,” or
“coughing your head off”
▪ School age- explanation and reasons
• are interested in the functional aspect of all procedures, objects, and activities
• for example, for taking a blood pressure: Let the child operate the bulb. An explanation
for the procedure might be as simple as, “I want to see how far the arrow moves when the
cuff squeezes your arm.”
▪ Adolescents- privacy
• For adolescents and their parents: provide both parties an opportunity to discuss their
perceptions in an open and unbiased atmosphere can, by itself, be therapeutic
• General approach to assessing children:
Fall 2023
, ▪ Chief complaint- To establish the major specific reason for the child's and parents' seeking of
health care
▪ Present illness- To obtain all details related to the chief complaint
• history of the present illness is a narrative of the chief complaint from its earliest onset
through its progression to the present.
o Learn about details of onset, complete interval history, present status, and the
reason for seeking help now
▪ History
• Birth history- pregnancy, labor and delivery, perinatal history
• Dietary history
• Illness, injuries, hospitalizations, surgeries:
o ask specifically about colds, earaches, and childhood diseases such as measles,
rubella (German measles), chickenpox, mumps, pertussis (whooping cough),
diphtheria, tuberculosis, scarlet fever, strep throat, recurrent ear infections,
gastroesophageal reflux, tonsillitis, or allergic manifestations.
• Allergies (medicine, environmental)
• Medications and immunizations:
o vitamins, antipyretics (especially aspirin), antibiotics, antihistamines,
decongestants, nutritional supplements, or herbs, essential oils, and homeopathic
medications.
• Growth and development:
o Growth-increase in size
▪ Weight:
• At 6 months= double birth weight
• At 1 year= triple birth weight
▪ Length/Height:
• Average birth length is 20”
o Recumbent height up to 24 months
▪ But 2-3 years use recumbent or standing
• Grow 10” first year
• 5 inches second year
• 2.5 inches/year till puberty
▪ Head circumference:
• Measure the largest part of head
• Head and chest circumference will be about equal at about 1-2
years of age
▪ Arm circumference= indirect measure of muscle mass
o Development-maturation in structure, includes growth
o Red Flags for falling off growth curve: BMI >85% and HT < 5%
• Sexual history for adolescents
• Psychosocial and personal status
▪ Vital Signs Measurements: for best results take respirations first and then take temperature last
• Respirations- count for a full minute because newborns have normal periods of apnea up
to 20 seconds
• Apical Pulse- should be quick, listen at apical pulse for full minute
o Apical pulse for infants and young children
o Radial pulse for children older than 2 years old
o Is most accurate when the child is asleep
• Blood pressure
o Take on the leg for infants and young children
o Use correct size cuff:
▪ Bladder width should be 40% of arm circumference
Fall 2023
, ▪ Bladder length should cover 80-100% of the arm circumference
▪ If cuff size is too small= device is falsely high
▪ If cuff size is too large= cuff size is falsely low
o Annually after age 3 using auscultation
• Axillary temperature:
o Children= 98.6-99.5
o Newborns= 97.7-99.7
▪ Review of systems:
• Skin:
o General appearance= notice facies, observe the posture, position, and types of
body movement, hygiene, behavior
o Assess kin for color, texture, temperature, moisture, turgor, lesions, and rashes
o PIV sites are monitored every hour- check fluids, rate, tubing
o Most pressure ulcers in children are caused by taped on medical devices and
check for diaper rash
o Lymph nodes: In children, small, nontender, movable nodes are usually normal.
Tender, enlarged, warm, erythematous lymph nodes generally indicate infection
or inflammation close to their location.
• Head and neck:
o Suture lines, fontanels
▪ Posterior fontanelle closes around 8 weeks or 2-3 months
▪ Anterior fontanelle closes between 12-18 months
o After 6 months old, significant head lag strongly indicates cerebral injury and is
referred for further evaluation.
o Note head control in infants and head posture in older children. By 4 months old,
most infants should be able to hold the head erect and in midline when in a
vertical position.
• Eyes:
o Inspect for placement of eyes, symmetry, and lids
o Assess conjunctiva and sclera
o Assess pupils for size, shape, movement, and accommodation
o Check for red reflex bilaterally- A brilliant, uniform red reflex is an important
sign because it rules out many serious defects of the cornea, aqueous chamber,
lens, and vitreous chamber. Any dark shadows or opacities are recorded because
they indicate some abnormality in any of these structures.
o Vision acuity
o Light perception, fix and follow (infants)
o Snellen chart (after 3 years)
o Peripheral vision- have the children fixate on a specific point directly in front of
them while an object, such as a finger or a pencil, is moved from beyond the field
of vision into the range of peripheral vision
o Check ocular alignment (Cover test)
• Ears:
o Inspect external structure
o Alignment
o Pinna- The top of the pinna should meet or cross an imaginary line that runs from
the outer orbit of the eye to the occiput, or most prominent protuberance of the
skull
▪ Low-set ears are commonly associated with renal anomalies or cognitive
impairment
o Pits/openings/ tags or sinuses
o Hygiene
o Inspect internal structure
Fall 2023
, o Assist to provide atraumatic exam- Before beginning the otoscopic examination,
position the child properly and gently restrain him or her (child sits on parent's
lap, and parent holds body and head) if necessary. Older children usually
cooperate and do not need restraint.
▪ A helpful suggestion is to let them observe you examining the parent's
ear.
o Assess tympanic canal
o Tympanic membrane- light reflex and bony landmarks
▪ Tympanic membrane should be translucent, light pearly pink or gray
o Auditory testing
• Nose, Mouth, and throat:
o Placement and alignment- The nose should lie in the middle of the face, with
each side exactly symmetric on both sides of the imaginary line.
o Internal structures
o Mucosal lining- is normally redder than the oral membranes, as well as any
swelling, discharge, dryness, or bleeding.
o Turbinates- They should be the same color as the lining of the vestibule.
o Septum- should divide the vestibules equally
o Lips and mouth- often first place to notice cyanosis in babies
▪ For signs of cyanosis, look around the mouth first
▪ Ask the child to open the mouth wide; to move the tongue in different
directions for full visualization; and to say “ahh,” which depresses the
tongue for full view of the back of the mouth (tonsils, uvula, and
oropharynx
▪ Infants and children- inspecting the mouth is upsetting so can leave it for
the end of the physical examination
▪ Lips should be moist, soft, smooth, and pink
▪ Mucous membranes of the mouth should be pink, smooth, glistening,
uniform, and moist
▪ Hard palate of the mouth should be dome shaped- a narrow, flat roof or a
high, arched palate affects the placement of the tongue and can cause
feeding and speech problems
o Teething- first in by 6 months, first out by 6 years
• Chest/Lungs:
o Inspect size, shape, symmetry, movement
▪ In children younger than 6 or 7 years of age, respiratory movement is
principally abdominal or diaphragmatic
o Breast development (Tanner Staging)- record early (precocious) or delated breast
development.
▪ In adolescent girls with sexual maturity, palpate the breasts for evidence
of any masses or hard nodules, and emphasize the importance of routine
breast self-examination
o Lungs:
▪ Respiratory effort- nasal flaring, retractions, stridor vs wheezing
• Observe respirations for rate, rhythm, depth, quality, and the
character of breath sounds
▪ Breath sounds- anterior and posterior, absent or diminished
▪ Oxygen use?
▪ Mechanical ventilation
• Cardiovascular:
o Auscultate HR:
▪ Regular rate
▪ Murmur: abnormal, S3 sound is normally heard in some children
Fall 2023
CHAPTER 4_ASSESSMENT OF CHILD & FAMILY
• Communicating with parents/guardians:
o Encouragement/direction:
▪ Use careful phrasing with broad, open-ended questions
▪ Often all that is required to keep parents talking is a nod or saying “yes” or “uh-huh.”
o Cultural awareness
o Listening/using silence:
▪ Silence permits the interviewee to sort out thoughts and feelings and search for responses to
questions.
o Empathy
o Providing anticipatory guidance- focuses on providing families information on normal growth and
development and nurturing childrearing practices but should extend beyond giving general information to
empowering families to use the information as a means of building competence in their parenting abilities
o Avoid information overload
o Using an interpreter:
▪ Introduce the interpreter to family
▪ Communicate directly with family members when asking questions to reinforce interest in them
and to observe nonverbal expressions
▪ Be aware that some medical words, such as allergy, may have no similar word in another
language; avoid medical jargon whenever possible.
• Communicating with children:
o Don’t be in a hurry
o Allow children time to feel comfortable
o Avoid sudden or rapid advances, broad smiles, extended eye contact, or other gestures that may be seen as
threatening.
o Talk to the parent if child is initially shy.
o Play/use toys- Communicate through transition objects (such as dolls, puppets, and stuffed animals)
before questioning a young child directly
o Get at their eye-level
o Simple words and short sentences
o Be honest- don’t offer choices if there isn’t one
o Consider their development:
▪ Infant-stranger anxiety
• Infants smile and coo when content and cry when distressed.
• Crying is provoked by unpleasant stimuli from inside or outside, such as hunger, pain,
body restraint, or loneliness
▪ Toddler-separation anxiety
▪ Pre-school- concrete
• Therefore use simple, direct language rather than phrases that might be misinterpreted by
a small child
• they attach literal meaning to such common phrases as “two-faced,” “sticky fingers,” or
“coughing your head off”
▪ School age- explanation and reasons
• are interested in the functional aspect of all procedures, objects, and activities
• for example, for taking a blood pressure: Let the child operate the bulb. An explanation
for the procedure might be as simple as, “I want to see how far the arrow moves when the
cuff squeezes your arm.”
▪ Adolescents- privacy
• For adolescents and their parents: provide both parties an opportunity to discuss their
perceptions in an open and unbiased atmosphere can, by itself, be therapeutic
• General approach to assessing children:
Fall 2023
, ▪ Chief complaint- To establish the major specific reason for the child's and parents' seeking of
health care
▪ Present illness- To obtain all details related to the chief complaint
• history of the present illness is a narrative of the chief complaint from its earliest onset
through its progression to the present.
o Learn about details of onset, complete interval history, present status, and the
reason for seeking help now
▪ History
• Birth history- pregnancy, labor and delivery, perinatal history
• Dietary history
• Illness, injuries, hospitalizations, surgeries:
o ask specifically about colds, earaches, and childhood diseases such as measles,
rubella (German measles), chickenpox, mumps, pertussis (whooping cough),
diphtheria, tuberculosis, scarlet fever, strep throat, recurrent ear infections,
gastroesophageal reflux, tonsillitis, or allergic manifestations.
• Allergies (medicine, environmental)
• Medications and immunizations:
o vitamins, antipyretics (especially aspirin), antibiotics, antihistamines,
decongestants, nutritional supplements, or herbs, essential oils, and homeopathic
medications.
• Growth and development:
o Growth-increase in size
▪ Weight:
• At 6 months= double birth weight
• At 1 year= triple birth weight
▪ Length/Height:
• Average birth length is 20”
o Recumbent height up to 24 months
▪ But 2-3 years use recumbent or standing
• Grow 10” first year
• 5 inches second year
• 2.5 inches/year till puberty
▪ Head circumference:
• Measure the largest part of head
• Head and chest circumference will be about equal at about 1-2
years of age
▪ Arm circumference= indirect measure of muscle mass
o Development-maturation in structure, includes growth
o Red Flags for falling off growth curve: BMI >85% and HT < 5%
• Sexual history for adolescents
• Psychosocial and personal status
▪ Vital Signs Measurements: for best results take respirations first and then take temperature last
• Respirations- count for a full minute because newborns have normal periods of apnea up
to 20 seconds
• Apical Pulse- should be quick, listen at apical pulse for full minute
o Apical pulse for infants and young children
o Radial pulse for children older than 2 years old
o Is most accurate when the child is asleep
• Blood pressure
o Take on the leg for infants and young children
o Use correct size cuff:
▪ Bladder width should be 40% of arm circumference
Fall 2023
, ▪ Bladder length should cover 80-100% of the arm circumference
▪ If cuff size is too small= device is falsely high
▪ If cuff size is too large= cuff size is falsely low
o Annually after age 3 using auscultation
• Axillary temperature:
o Children= 98.6-99.5
o Newborns= 97.7-99.7
▪ Review of systems:
• Skin:
o General appearance= notice facies, observe the posture, position, and types of
body movement, hygiene, behavior
o Assess kin for color, texture, temperature, moisture, turgor, lesions, and rashes
o PIV sites are monitored every hour- check fluids, rate, tubing
o Most pressure ulcers in children are caused by taped on medical devices and
check for diaper rash
o Lymph nodes: In children, small, nontender, movable nodes are usually normal.
Tender, enlarged, warm, erythematous lymph nodes generally indicate infection
or inflammation close to their location.
• Head and neck:
o Suture lines, fontanels
▪ Posterior fontanelle closes around 8 weeks or 2-3 months
▪ Anterior fontanelle closes between 12-18 months
o After 6 months old, significant head lag strongly indicates cerebral injury and is
referred for further evaluation.
o Note head control in infants and head posture in older children. By 4 months old,
most infants should be able to hold the head erect and in midline when in a
vertical position.
• Eyes:
o Inspect for placement of eyes, symmetry, and lids
o Assess conjunctiva and sclera
o Assess pupils for size, shape, movement, and accommodation
o Check for red reflex bilaterally- A brilliant, uniform red reflex is an important
sign because it rules out many serious defects of the cornea, aqueous chamber,
lens, and vitreous chamber. Any dark shadows or opacities are recorded because
they indicate some abnormality in any of these structures.
o Vision acuity
o Light perception, fix and follow (infants)
o Snellen chart (after 3 years)
o Peripheral vision- have the children fixate on a specific point directly in front of
them while an object, such as a finger or a pencil, is moved from beyond the field
of vision into the range of peripheral vision
o Check ocular alignment (Cover test)
• Ears:
o Inspect external structure
o Alignment
o Pinna- The top of the pinna should meet or cross an imaginary line that runs from
the outer orbit of the eye to the occiput, or most prominent protuberance of the
skull
▪ Low-set ears are commonly associated with renal anomalies or cognitive
impairment
o Pits/openings/ tags or sinuses
o Hygiene
o Inspect internal structure
Fall 2023
, o Assist to provide atraumatic exam- Before beginning the otoscopic examination,
position the child properly and gently restrain him or her (child sits on parent's
lap, and parent holds body and head) if necessary. Older children usually
cooperate and do not need restraint.
▪ A helpful suggestion is to let them observe you examining the parent's
ear.
o Assess tympanic canal
o Tympanic membrane- light reflex and bony landmarks
▪ Tympanic membrane should be translucent, light pearly pink or gray
o Auditory testing
• Nose, Mouth, and throat:
o Placement and alignment- The nose should lie in the middle of the face, with
each side exactly symmetric on both sides of the imaginary line.
o Internal structures
o Mucosal lining- is normally redder than the oral membranes, as well as any
swelling, discharge, dryness, or bleeding.
o Turbinates- They should be the same color as the lining of the vestibule.
o Septum- should divide the vestibules equally
o Lips and mouth- often first place to notice cyanosis in babies
▪ For signs of cyanosis, look around the mouth first
▪ Ask the child to open the mouth wide; to move the tongue in different
directions for full visualization; and to say “ahh,” which depresses the
tongue for full view of the back of the mouth (tonsils, uvula, and
oropharynx
▪ Infants and children- inspecting the mouth is upsetting so can leave it for
the end of the physical examination
▪ Lips should be moist, soft, smooth, and pink
▪ Mucous membranes of the mouth should be pink, smooth, glistening,
uniform, and moist
▪ Hard palate of the mouth should be dome shaped- a narrow, flat roof or a
high, arched palate affects the placement of the tongue and can cause
feeding and speech problems
o Teething- first in by 6 months, first out by 6 years
• Chest/Lungs:
o Inspect size, shape, symmetry, movement
▪ In children younger than 6 or 7 years of age, respiratory movement is
principally abdominal or diaphragmatic
o Breast development (Tanner Staging)- record early (precocious) or delated breast
development.
▪ In adolescent girls with sexual maturity, palpate the breasts for evidence
of any masses or hard nodules, and emphasize the importance of routine
breast self-examination
o Lungs:
▪ Respiratory effort- nasal flaring, retractions, stridor vs wheezing
• Observe respirations for rate, rhythm, depth, quality, and the
character of breath sounds
▪ Breath sounds- anterior and posterior, absent or diminished
▪ Oxygen use?
▪ Mechanical ventilation
• Cardiovascular:
o Auscultate HR:
▪ Regular rate
▪ Murmur: abnormal, S3 sound is normally heard in some children
Fall 2023
