nur 202 (4-6)

• The vital signs include


  temperature, pulse, respirations, blood pressure
• what is the normal oral temperature

  36.4-37.4 degree Celsius, 97.6- 99.3 degree Fahrenheit
• where can temperature be measured

  oral, axillary, rectal, lymphatic
• what pulse is taken on older child

  radial pulse
• this pulse must be counted before the child is disturbed for other procedures


  apical pulse
• how should an unusual in quality, rate, rhythm should be counted

  counted for full minute and compared to the opposite site
• how many bpm for neonate

  100-180 bpm
• how many bpm for 14-18 year olds

  50-95 bpm
• how do infants breathe

  abdominal breathers
• how to count for respirations on infants

  observing the movement of the infants abdomen
• how can a blood pressure be taken

  auscultation, palpitation, doppler, electronic
• The common sites to obtain bp from a child


  upper arm, lower arm, forearm, thigh, calf, ankle
• how to make the child to not be afraid with bp taking

  take blood pressure to stuff animals or dolls
• examining the body system of the child

  physical examination
• physical examination include

  examination in head, neck, chest, lungs, heart, abdomen, genitalia, rectum, back and extremities.
• symmetry in features of the face and head

  head and neck
• head and neck includes the following assessment

  assessment in range of motion, fontanels, eyes, ears, nose mouth, throat
• it observe the childs ability to control head and range of motion and in infants to observed for any stiffness in the neck

  assess the range of motion
• the nurse feels the skull to determine if the fontanels are open/close and check for swelling or depression


  assess fontanels
• note for any redness in the eye, asking the child to follow a light to observe pupils

  assess the eyes
• this is done to determine infants and childrens normal growth rate

  chest and lungs
• where to measure chest

  measure at the nipple level with a tape measure
• what to use to assess and listen to breath sounds of each lobes of the lungs and heart

  stethoscope
• In some infant and children a pulsation can be seen in the chest that indicate the heart beat

  point of maximum impulse
• How long does the nurse listen to heart sounds and count the rate

  1 minute
• How to assess the hearts function's effectiveness

  assess pulses in various parts of the body
• how does the abdomen of infants and small children looks

  slightly protruded
• what are the 4 sections of the abdomen

  left upper quadrant, right upper quadrant, left lower quadrant, right lower quadrant
• it observes the back for symmetry and curvature of the spine

  assess the back
• the infants spine is

  rounded and flexible
• this is the most complex aspect of the physical exam of the infant and child

  assessing neurologic status
• This exam includes detailed examination of the reflex responses

  neurologic exam
• the use of standard scale for monitoring permits the comparison of results from one time to another; the nurse monitors various aspects of the childs neurologic functioning


  neurologic assessment tool
• a systematic, comprehensive examination of individuals, family, group, community regarding health related cultural beliefs, values and practices

  Cultural assessment
• the increased challenges of providing health care to patient with health care beliefs and practices and needs different from health care provider

  global migration
• the system of shared ideas, rules, meaning that influence how we view the world, experience it emotionally, and behave in relation to other people

  culture
• the ethnic group composed of individuals who self-identify membership with or belongs to a group with shared values, ancestry, experiences


  ethnicity
• socially constructed concept of dividing people into populations or groups on the basis of various sets physical characteristics

  race
• it recognize the need for a set of skills necessary to care for people of different culture

  cultural competence
• the motivation the nurse needs to "want to" and not "need to" become culturally aware


  cultural desire