Jezel P.

Ronquillo

ASSESSING THE OLDER ADULT

1. Identify three factors that may confuse symptoms reported by older adults?

Confusion
Decreased pain sensation
Atypical symptoms

2. What might you do differently when obtaining history from an older client?

Three strategies to assess for atypical presentation of illness include: (1) Vague Presentation of
Illness; (2) Altered Presentation of Illness; and (3) Non-presentation (under-reporting) of Illness.

3. The developmental task for an older client is integrity versus despair. What type of behavior
might you see if your client has been successful at this stage? What type of behavior might you
see if he or she has been unsuccessful at this stage?

Successfully resolving the crisis at this stage leads to the development of what Erikson referred
to as ego integrity. People are able to look back at their life with a sense of contentment and face
the end of life with a sense of wisdom and no regrets.2 Erikson defined this wisdom as an "in-
formed and detached concern with life itself even in the face of death itself."

Those who feel proud of their accomplishments will feel a sense of integrity. Successfully com-
pleting this phase means looking back with few regrets and a general feeling of satisfaction.
These individuals will attain wisdom, even when confronting death.2

Those who are unsuccessful during this phase will feel that their life has been wasted and will
experience many regrets. The individual will be left with feelings of bitterness and despair.

4. List factors that you should consider when performing a physical assessment on an older
client?
The history may take more time because of sensory or cognitive impairment or simply because
an older patient has had time to accrue numerous details. Several sessions may be required.
The patient should be recognized as the primary source of information. If doubts arise about ac-
curacy, other sources should be contacted with due respect paid to the sensitivities and confiden-
tiality of the patient. When interviewing the patient and caregiver together, ask questions first to
the patient, then to the caregiver.
If the patient's responses to initial questions are clearly inappropriate, turn to the mental status
exam immediately.
The patient should be dressed and seated. The physician should also be seated and facing the pa-
tient at eye level, speaking clearly with good lip movement. If the patient is severely hearing im-
paired and an amplifier is not available, write questions in large print.

Use honorifics (i.e., Mr., Mrs., Miss, or Ms.) unless the patient specifically requests you to do
otherwise.

5. When performing an assessment on an older client, what changes might you see from head to
toe?

With age, the skin wrinkles, becomes lax, and loses turgor. The vascularity of the dermis de-
creases, causing lighter skin to look paler and more opaque. Skin on the backs of the hands and
forearms appears thin, fragile, loose, and transparent. There may be purple patches or macules,
termed actinic purpura, that fade over time. These spots and patches come from blood that has
leaked through poorly supported capillaries and spread within the dermis.

6. Types of incontinence answers:

Stress - B
Urge - C
Overflow - D
Functional - A

ASSESSING THE SCHOOL AGE CHILD AND ADOLESCENT

1. The developmental task for the school age child is industry versus inferiority. What type of
behavior might you see if your client has been successful at this stage? What type of behav-
ior might you see if your client has been unsuccessful at this stage?

At earlier stages of development, children were largely able to engage in activities for fun and to
receive praise and attention. Once school begins, actual performance and skill are evaluated.
Grades and feedback from educators encourage kids to pay more attention to the actual quality of
their work.

During the industry versus inferiority stage, children become capable of performing increasingly
complex tasks. As a result, they strive to master new skills. Children who are encouraged and
commended by parents and teachers develop a feeling of competence and belief in their abilities.
Those who receive little or no encouragement from parents, teachers, or peers will doubt their
ability to be successful.
Children who struggle to develop this sense of competence may emerge from this stage with
feelings of failure and inferiority. This can set the stage for later problems in development. Peo-
ple who don't feel competent in their ability to succeed may be less likely to try new things and
more likely to assume that their efforts will not measure up under scrutiny.
2. The developmental task for the adolescent is identity versus role confusion. What type of be-
havior might you see if your client has been successful at this stage? What type of behavior
might you see if your client has been unsuccessful at this stage?

Those who are successful develop fidelity, a psychological virtue characterized by the ability to
relate to others and form genuine relationships.1 This ability plays an important role in the up-
coming stage known as intimacy versus isolation.

So, what happens to those who do not end up successfully forming an identity at this point in de-
velopment? Kids who are not allowed to explore and test out different identities might be left
with what Erikson referred to as role confusion. These individuals are not sure who they are or
what they like. They tend to drift from one job or relationship to another, never really sure what
they want to do with their lives. Instead of feeling a sense of personal cohesiveness, they are left
feeling disappointed and confused about their place in life.

3. What health concerns should you screen for during your assessment?
CHILDREN:

4. Identify areas of health teaching for school age and adolescent clients.

As sexual adjustment and strong sexual urges characterize this age, the nurse may do significant
teaching about sex education and contraception. In addition to teaching adolescents about why
and how their bodies are changing, the nurse is also in a good position to dispel misconceptions
young patients may have about sexual development or sexual behavior. Teaching adolescents
about sexuality requires a special sensitivity and understanding. Respect for the patient’s mod-
esty, privacy, and opinions are critical to establishing an atmosphere of openness and trust. In ad-
dition to sex education, other important patient teaching areas are alcohol and drug abuse and
general health measures, such as the importance of good nutrition and exercise as the basis for
life-long health. Regardless of the topic, health education for adolescents is more effective when
the nurse establishes trust by respecting the adolescent’s needs, shows empathetic understanding,
and answers questions honestly. Patient teaching for adolescents should take the form of guid-
ance rather than lecturing. Nurses who gain credibility with an adolescent patient establish them-
selves as the teen-ager’s advocate rather than representatives of the parents. The nurse may in-
crease health teaching effectiveness by including the family. The nurse can give guidance and
support to family members that can help them understand and respect adolescent behavior. Par-
ents should be encouraged to set realistic limits for adolescents while still allowing them to be-
come increasingly responsible for their own health care management.

5. How does the physical examination differ from an adult?

• Children are developing - physically, emotionally and psychologically - illness impacts

them differently to adults.
 • Normal variants in development of young children result in changes that can be mistaken
as pathology. 
• Patterns of pathology are different in children (compared to adults) and at different ages
within childhood (e.g., causes of limp). 
• Adolescents appear to be at greater risk of musculoskeletal injury during periods of rapid
growth in early puberty.
• Communication with children takes patience and skill - the parent/caregivers often pro-
vide the history but it is still important to engage with and include the child (as appropri-
ate to age). 

6. When an assessing a school age child or an adolescent, what changes or common findings
might you see from head to toe?

Girls:
• Girls may begin to develop breast buds as early as 8 years old. Breasts develop fully be-
tween ages 12 and 18.
• Pubic hair, armpit and leg hair usually begin to grow at about age 9 or 10, and reach adult
patterns at about 13 to 14 years.
• Menarche (the beginning of menstrual periods) typically occurs about 2 years after early
breast and pubic hair appear. It may occur as early as age 9, or as late as age 16. The aver-
age age of menstruation in the United States is about 12 years.
• Girls growth spurt peaks around age 11.5 and slows around age 16.
Boys:
• Boys may begin to notice that their testicles and scrotum grow as early as age 9. Soon, the
penis begins to lengthen. By age 17 or 18, their genitals are usually at their adult size and
shape.
• Pubic hair growth, as well as armpit, leg, chest, and facial hair, begins in boys at about age
12, and reaches adult patterns at about 17 to 18 years.
• Boys do not start puberty with a sudden incident, like the beginning of menstrual periods
in girls. Having regular nocturnal emissions (wet dreams) marks the beginning of puberty
in boys. Wet dreams typically start between ages 13 and 17. The average age is about 14
and a half years.
• Boys' voices change at the same time as the penis grows. Nocturnal emissions occur with
the peak of the height spurt.
• Boys' growth spurt peaks around age 13 and a half and slows around age 18.

7. Consider your ethnic background. What is your culture’s expectation for adolescents?

In our culture, adolescents are generally expected to be outgoing and social. They are expected to
have problems and issues related to their peers as well as their physical development.
ASSESSING THE TODDLER AND PRESCHOOLER

1. The developmental task for the toddler is autonomy versus shame and doubt. What type of
behaviors might you see? What type of behavior might you see if your client has been suc-
cessful at this stage? What type of behavior might you see if your client has been unsuccess-
ful at this stage?

Gaining a sense of personal control over the world is important at this stage of development.
Children at this age are becoming increasingly independent and want to gain more control over
what they do and how they do it. There are a number of different tasks that are often important
during the autonomy versus shame and doubt stage of development.

• Toilet training plays a major role; learning to control one’s body functions leads to a feel-
ing of control and a sense of independence.
• Other important events include gaining more control over food choices, toy preferences,
and clothing selection. 
• Kids in this stage of development often feel the need to do things independently, such as
picking out what they will wear each day, putting on their own clothes, and deciding what
they will eat. While this can often be frustrating for parents and caregivers, it is an impor-
tant part of developing a sense of self-control and personal autonomy.
Children who successfully complete this stage feel secure and confident, while those who do not
are left with a sense of inadequacy and self-doubt. This stage also serves as an important build-
ing block for future development. Kids who have confidence in their skills are more likely to
succeed in subsequent tasks such as mastering social, academic, and other skills.

2. The developmental task for the preschooler is initiative versus guilt. What type of behavior
might you see if your client has been successful at this stage? What type of behavior might you
see if your client has been unsuccessful at this stage?

Success in this stage leads to a sense of purpose, while failure results in a sense of guilt. What
does Erikson mean by guilt? Essentially, kids who fail to develop a sense of initiative at this
stage may emerge with a fear of trying new things. When they do direct efforts toward some-
thing, they may feel that they are doing something wrong. While mistakes are inevitable in life,
kids with initiative will understand that mistakes happen and they just need to try again. Children
who experience guilt will instead interpret mistakes as a sign of personal failure, and may be left
with a sense that they are "bad."

3. What are the major health issues for the toddler and preschooler?

RSV
Respiratory syncytial virus (RSV) is an infection of the airways. It usually isn’t serious, but if
your child is under 2, or has a heart or lung disease or a weak immune system, it can inflame
the lungs and cause pneumonia.
Fifth Disease
Another viral illness, fifth disease is common in kids ages 5 to 15.
"In most children, it's benign," says James Cherry, MD, a specialist in children's infectious dis-
eases.
A child with sicle cell anemia or a weak immune system can become very ill from fifth disease.
It can also be serious in pregnant women.

Croup
Croup targets the windpipe and voice box. It is most often caused by viruses, and lasts for a week
or less.

4. Name six assessment findings that might lead you to suspect child abuse.

• Multiple bruising
• Failure to thrive
• Dental carries
• Fractures
• Patchy hair loss

5. What factors should you consider when performing a physical assessment on a toddler or
preschooler?

Physical Assessment of Toddler

Inspect body areas through play – “count fingers and toes”
Allow toddler to handle equipment during assessment and distract with toys and bubbles
Use minimal physical contact initially
Perform traumatic procedures last
Introduce equipment slowly
Auscultate, percuss, palpate when quiet
Give choices whenever possible

Physical Assessment of Preschooler

If cooperative, proceed with head-to-toe
If uncooperative, proceed as with toddler
Request self undressing and allow to wear underpants
Allow child to handle equipment used in assessment
Don’t forget “magical thinking”
Make up “story” about steps of the procedure
Give choices when possible
If proceed as game, will gain cooperation
Photo Source: Del Mar Image Library; Used with permission
6. How does the physical examination differ from an adult’s examination
The classic systematic approach to the physical examination is to begin at the head and proceed
to the toes. For children, painful or frightening procedures should be left until last. Involving par-
ents by asking them to hold or stand by the child can decrease children’s anxiety and assist them
in relaxing.

7. When performing an assessment on a toddler or preschooler, what changes or common find-

ings might you see from head to toe?

Toddlers and preschoolers are sometimes underweight because of being physically overactive. In
addition, they sometimes forego opportunities to eat because they are quite busy with exploring
their surroundings and playing.

8. Consider your own ethnic background. What are your culture’s expectation for children?

Children are expected to be active physically and mentally. Because of this, they are prone to
physical injuries related to accidents.

ASSESSING THE NEWBORN INFANT

1. The newborn has many findings that are apparent at birth but disappear shortly after birth or
within the first year of life. Match the finding in the first column with the appropriate defini-
tion in the second column.

Acrocyanosis - K
Vernix caseosa - C
Desquamation - A
Cutis marmorata - F
Harlequin sign - D
Lanugo - C
Milia - L
Epstein pearls - B
Craniosynostosis - J
Stork bites - H
Caput succedaneum - I
Cephalhematoma - G

2. What five areas are assessed in the APGAR score?

The Apgar score helps find breathing problems and other health issues. It is part of the special at-
tention given to a baby in the first few minutes after birth. The baby is checked at 1 minute and 5
minutes after birth for heart and respiratory rates, muscle tone, reflexes, and color. A baby who
needs help with any of these issues is getting constant attention during those first 5 to 10 min-
utes. In this case, the actual Apgar score is given after the immediate issues have been taken care
of.
Each area can have a score of 0, 1, or 2, with 10 points as the maximum. Most babies score 8 or
9, with 1 or 2 points taken off for blue hands and feet because of immature circulation. If a baby
has a difficult time during delivery and needs extra help after birth, this will be shown in a lower
Apgar score. Apgar scores of 6 or less usually mean a baby needed immediate attention and care.
Sign Score = 0 Score = 1 Score = 2

Heart rate Absent Below 100 per Above 100 per minute
minute

Breathing ef- Absent Weak, irregular, or Good, crying

fort gasping

Muscle tone Flaccid Some flexing of Well-flexed, or active move-

arms and legs ments of arms and legs

Reflex or irri- No response Grimace or weak cry Good cry

tability

Color Blue all over, Body pink, hands Pink all ov

or pale and feet blue

3. What areas do you need to include in the newborn’s health history?

A. Maternal health during pregnancy: bleeding, trauma, hypertension, fevers, infectious illnesses,
medications, drugs, alcohol, smoking, rupture of membranes
B. Gestational age at delivery
C. Labor and delivery - length of labor, fetal distress, type of delivery (vaginal, cesarean section),
use of forceps, anesthesia, breech delivery
D. Neonatal period - Apgar scores, breathing problems, use of oxygen, need for intensive care,
hyperbilirubinemia, birth injuries, feeding problems, length of stay, birth weight

4. What measurements should you include in your assessment of the newborn infant?
The physical maturity part of the Dubowitz/Ballard exam looks at physical features that look dif-
ferent at different stages of a baby's gestational age. Babies who are physically mature usually
have higher scores than premature babies.
Points are given for each area of assessment. A low of -1 or -2 means that the baby is very imma-
ture. A score of 4 or 5 means that the baby is very mature (postmature). These are the areas
looked at:
• Skin textures. Is the skin sticky, smooth, or peeling?

• Soft, downy hair on the baby’s body (lanugo). This hair is not found on imma-
ture babies. It shows up on a mature infant, but goes away for a postmature infant.

• Plantar creases. These are creases on the soles of the feet. They can be absent or
range up to covering the entire foot.

• Breast. The provider looks at the thickness and size of breast tissue and the
darker ring around each nipple (areola).

• Eyes and ears. The provider checks to see if the eyes are fused or open. He or she
also checks the amount of cartilage and stiffness of the ears.

• Genitals, male. The provider checks for the testes and how the scrotum looks. It
may be smooth or wrinkled.

• Genitals, female. The provider checks the size of the clitoris and the labia and
how they look.

5. Match the reflex in the first column to the proper technique in the second column.

Moro - D
Startle - G
Tonic Neck - L
Palmar - B
Plantar - E/F
Babinski - E/F
Stepping - H
Crawling - P
Magnet - J
Pull-to-sit - M
Crossed extension -
Trunk incurvation
Rooting - C
Sucking - N
Extrusion - O
Glabellar - A
6. When performing an assessment on a newborn infant, what changes or common findings
might you see from head-to-toe?
Harlequin color change is a rare, peculiar discrepancy in color between the longitudinal halves
of the body, extending from the forehead to the symphysis pubis. A curiosity of no known patho-
logic significance, the phenomenon is elicited by placing the infant on his side for several min-
utes. The dependent half of the body turns deep pink, while the upper half is pale. The colors are
reversed when the infant is turned onto the opposite side. The color change often spontaneously
occurs in the supine position.
Lanugo is fine hair, which is barely visible and characteristic of the newborn period. It is more
obvious in premature and postmature infants and most easily seen over the shoulder, back, fore-
head, and cheeks.
Milia are minute, white papules on the chin, nose, cheeks, and forehead. They are distended se-
baceous glands that disappear spontaneously in several days or weeks. Sudamina are tiny vesi-
cles over the face and neck that are formed by distention of sweat glands.
Erythema toxicum is a pink papular rash on which vesicles are often superimposed. The vesicles
may appear purulent and are thus confused with staphylococcal pyoderma. They appear any-
where over the body within 24–48 hours after birth and resolve spontaneously after several days.
The vesicles contain eosinophils that are demonstrable on a smear prepared with Wright's stain.
The rash is innocuous and its etiology is unknown.

7. Consider your ethnic background. What, if any, cultural practices are associated with care of
the newborn?

Pagbibigkis - Tying a piece of cloth around the baby’s abdomen to cover the umbilical stump
Delivery by traditional birth attendant