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NURSING CARE (Pediatric Care and Assessments)

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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 Chi...

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  • February 7, 2024
  • 6
  • 2023/2024
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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

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