NURS2250: Test-Out

General Subjective (objective = vitals (temp, pulse, RR, BP, O2, pain)

older child: fevers, chills, night sweats, changes to daily activities/sleep, mood change, anxiety

infant/toddler: mood changes, irritability, lethargy, changes in sleep or activity

Neuro Objective

infant: alertness, measurement of head circumference (<2), palpate fontanelles (<2), muscle tone, Babinski reflex, pupillary size and symmetry

toddler/older child: assess LOC, orientation to person, place, and time, pupillary size and symmetry

CV/PV Objective

auscultation of heart sounds using bell and diaphragm, check for edema in all extremities, check pulses (radial, brachial, dorsalis pedis) simultaneously and bilaterally, cap refill <2 secs, mottling

Respiratory Objective

inspection (size, shape, symmetry, deformities) and auscultation of anterior and posterior breath sounds, cough (sputum consistency, color, quantity), assess for retractions, nasal flaring, increased abdominal muscle use, head bobbing, tripod positioning

GI Objective

inspection (symmetry, flat, soft, pulsations, peristaltic waves or bulges, striae, rashes, lesions, veins, ecchymosis in skin, no bulging/inverted umbilicus), auscultation, palpation, questions about bowel function

GU objective

examination of indwelling catheter insertion site and presence of stabilization device (quantity and quality of output) OR questions about output (quantity and quality) with education about I&O —> peds output = 1-2ml/kg/hr; adolescent output = 0.5-1ml/kg/hr

Musculoskeletal Objective

upper/lower ROM and strength in all four extremities on a 0-5 scale

Skin Objective

examine skin for breakdown (occiput, scapula, elbows, sacrum, heels), assess color, temperature, texture, moisture, turgor, lesions, rashes; follow all lines, tubes, and drains from insertion to end point and check current IVF hanging, dates, and times on dressings/tubing; assess IV insertion for phlebitis, swelling, bleeding, infiltration