ADDITIONAL ASSESSMENT CONDERATIONS

CLASS #2

Review

The topics discussed in this session are intended to serve as a general review, and a reminder that each of
these components are significant aspects of the assessment. The notes included in the pediatric growth &
development handout will be referenced for dealing with assessment across the lifespan and for a
developmental approach to family dynamics.

Topical Outline

Assessment across the lifespan

Family Assessment
Cultural Assessment
Nutritional Assessment
Sleep Assessment
Sexual Assessment
Vital Signs & Lab Values

Assessment Across the Lifespan

Erikson’s psychosocial theory of development serves an excellent basic framework.

General Guidelines for Dealing with Children

Meet children at their own developmental level

Consider the total family unit and it’s dynamics
Use an eye level position
Avoid threatening gestures or loud sounds
Use a quite, unhurried, confident voice
Talk to the parent if the child is shy
Use transitional objects, such as toys, books, and equipment
Allow young children to stay close to parents
Allow older children to talk without parents
Be specific with questions, requests or instructions
State directions positively
Offer choices when possible, but only choices that exist
Use a variety of techniques, such as storytelling, drawing, writing, and play…

Infants

Use comfort measures, sensory stimulation & nonverbal communication with younger infants.
Use play techniques to slowly warm up to older infants:
(Separation & stranger anxiety responses are to be expected)
Provide comfort after any uncomfortable procedure.
(They may remember or anticipate unpleasant experiences)
Assure safety measures.
(Increasing mobility & curiosity)

Young Child

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Use language & play that is consistent with development
Be direct & concrete
Give only one direction at a time
Consider that they are still egocentric & understand things in terms of “self”
Magical, illogical thinking may be part of anxiety or fear

School-Age Child

Individualize more in terms of personality & what interests them

Consider that mastery, self-esteem, following the rules & fear of failure are important issues
Offer explanations & reasons
They have concern about their bodies & their possessions

Adolescent

Are usually self-conscious & are struggling with independence-dependence issues, as well as body changes
Show genuine interest & respect
Confidentiality, privacy & modesty are important
Be direct about confidentiality & possible concerns what might require sharing of information
Offer the opportunity for examination alone, without parent present
If adolescent is reluctant to talk:
Use of transitions may be helpful
Use of silence may not be helpful

Adult

Young adults may be dealing with establishing families & careers, may be energetic & optimistic or
fatigues & stressed.

Middle adults may be dealing with re-evaluation issues, caring for children & older parents (“sandwich
generation”) & possible changes in their lives. Ill health of elderly parents, adolescent children in difficult
transitions, job or marriage changes may be especially stressful.

Aging Adult

May be comfortable &dealing with a sense of life satisfaction.

May be dissatisfied with life choices
May be dealing with various types of loss
May have vision or hearing deficits or chronic illness
May have many medications that need to be evaluated
Provide more time for interview, or space interview into several visits
Speak slowly, clearly & avoid noise distractions
Provide good lighting & facial orientation

Family Assessment
A variety of definitions & theories can be applied to family assessment.
The family can be assessed in a variety of areas:
Biologic

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 Economic
Educational
Psychological
Sociocultural

Family: Definition

A family is any group of people related biologically, emotionally or legally.

Its function is to help its family members satisfy their needs for physical & emotional survival.

The Family Ideally Provides for Its Members:

• Esteem for the unique worth of its individuals

• Relief from depersonalization, job & society stress
• Buffering & mediation on behalf of individuals
• Emotional life & bonding force (“glue”)
• Support system for meeting basic needs
• Raising of children, for survival &adequate function in the adult world

Family Function & Coping

There probably isn’t a family without problems.

How the family copes may be the more significant aspect of difficulties.
It is within the family that people may be most vulnerable to pain

Family Coping Index:

Adapted from The John’s Hopkins School of Hygiene & Public Health &
The Richmond Virginia, Visiting Nurse Association

A way of looking at the interaction of three areas of family function:

1. Family Strengths: Commitment

Respect
Mutual support
Responsibility to need & welfare of others
Positive interpersonal interactions

2. Family Coping Success: Communication

Interaction
Problem-soling
Power

3. Meeting Developmental
Tasks: Family as well as individual development

Basic Areas of Family Assessment

• Family Structure: composition & significant influences

• Family Function: how families interact

Family Composition:
who lives in home, significant extended family & changes (marriage, separation, divorce, death)

• Nuclear: traditional, biological parents & children

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 • Nuclear Dyad: two adults, without children
• Kin Network (Extended Family)
• Single Parent
• Blended (Reconstituted)
• Binuclear: joint custody of children
• Homosexual
• 3-Generation
• Co- Habitating couples
• Single adult, living alone

Significant Influences

• Home Conditions & Community Environment: type of dwelling, accessibility,

utilities, safety

• Occupation & Education of Family Members: types of employment, work

schedules/satisfactions/hazards,
income adequacy, education levels &
financial status

• Cultural & Religious Traditions: cultural/ethnic beliefs & values,

Religious/cultural practices effecting health
care, country of origin, language spoken,
preferred health care – support,
cultural/religious healers/remedies.

Family Functional Assessment Areas

• Family Interactions & Roles: intimacy & closeness among members,

behaviors of individuals in their status or
position, leadership Vs submission, support
to each other

• Power, Decision Making & Problem Solving: clarity of boundaries of power between
parents & children, who makes decisions or
enforces rules & how are decisions
changed?

• Communication: how members listen to & speak to each

other

• Expression of Feelings & Individuality: person space to grow within structure,

expression of feelings & acceptance,
comfort offered

Theoretical Frameworks for Evaluating Families

Although there are many, four family theories will be briefly addressed:

• Systems Theory
• Developmental Theory
• Structural-Functional
• Interactional

Family Theory: Systems

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The family is viewed social system that continually interacts within itself & the environment.
Change in any one part of a family system affects all other parts of the family system. (circular causality).
Change can occur at any time & at any point in the family system.
An important process is maintaining equilibrium.

Family Theory: Developmental

The family addresses change over time, based on predictable change in the structure, function & roles of
the family, with the oldest child as the marker for stage transition.
The family passes through phases of growth & in every phase the family is faced with developmental tasks.
Duvall’s developmental theory is summarized in the pediatric growth & development notes.

Family Theory: Structural-Functional

The family is viewed as a system that performs social functions (such as working, raising children),
maintains internal equilibrium, interacts with other societal groups & has a strong emphasis on stability.

Family Theory: Interactional

The family if viewed as a unit of interacting personalities, with an emphasis on internal dynamics of the
family, communication, decision-making & problem solving.

Attributes of or Strategies for Building Strong Families

• Sense of Commitment
• Help each other feel good about themselves
• Protect & support each other
• Provide for basic needs

• Sharing Traditions
• Brings individuals together: provides for “emotional glue”
• Special occasions to look forward to
• Participation & contribution by all family members

• Active Expression of appreciation

• Give compliments: Be specific
• Encourage: Focus on assets & improvement

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 • Be sincere: Avoid use of superficial flattery
• Give “warm fuzzies”: Written, spoken, non-verbal

• Effective Communication
• Listening to each other
• Sharing concerns & feelings
• Cooperating with each other
• Negotiating situations

• Spending Time Together

• Make plans for family activities or spending time together
• “Dates” & scheduled appointments, one on one
• Repeat enjoyable activities
• Minimize stressful activities
• Special time with children: Young children (once a day)
Older children (once a week)

• Shared Values
• Common beliefs
• Spiritual beliefs
• Religious practices
• “Together” participation by family members

• Solving Problems & Coping

• Deal with issues in a positive way
• Share ideas
• Look at change as an opportunity to grow
• Be willing to accept support from others

• Sense of Humor
• Avoid living in the past or worrying about the future
• Take one day at a time

Issues Presenting Difficulties in Families

(Brian Romalis, MD)

• Support & satisfaction of needs from outside the family may not compensate for what is
missing inside the family, especially from a spouse
• In general, the less family support, the more morbidity & mortality
• Excessive involvement (enmeshment) can be as much of a problem as disengagement
• Families, connected by emotion, resist change in roles & behaviors of individual members.
• Change is disequalibrating & disquieting
• If attention is paid to how the changed behavior will affect the family, the change is better
tolerated. A desirable ripple effect throughout the family may follow.
• Emotions bind families
• Conflict arises when emotions & attitudes between 2 or more members are too far out of
synchrony
• Needs are then not met & dissatisfactions arise
• The interview is the tool to try & discern dissatisfactions, the stresses they cause, symptoms
that result & how they are handled

• It can be helpful for the patient to clarify the nature of the conflict--to name a few:

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 • Dominance vs submission
• Closeness vs autonomy
• Emotion vs rationality
• Overinvolvement Vs distancing
• Health Vs disease
• Adequacy Vs mismanagement
• Responsibility Vs irresponsibility
• Sharing Vs nonsharing

COMMON PSYCHOSOCIAL PROBLEMS ENCOUNTERED IN FAMILY PRACTICE

(Brian Romalis, MD)

• Domestic conflict & sexual difficulties

• Substance abuse & dependence
• Domestic violence
• Physical or emotional abuse of women & children
• Sexual abuse of women & children
• Divorce: disruption of the home, changes in roles, reactions to loss
• Financial: management/mismanagement

Cultural Assessment
Cultural beliefs & personal characteristics determine health behavior in individuals & families. The
following web sites may be of interest:

http://www.hslib.washington.edu/clinical/ethnomed/index.html
http://raceandhealth.hhs.gov/
http://www.dml.georgetown.edu/depts/pediatrics/gucdc/nccc6.html
http://www.diversityrx.org/

Definitions

• Culture: knowledge, beliefs, skills, art, morals, law & acquired habits of a group of people
• Subculture: smaller group within a larger culture, with shared characteristics
• Race: classification of humans on basis of physical characteristics that are transmitted from
biological ancestors (The three recognized races are Caucasian, Negroid & Mongoloid)
• Ethnic Group: members share common national or regional origin & social, linguistic,
cultural & physical heritage (ethnic identity). Common ethnic groups in the US include:
White, Black, Hispanic, Asian, Native American Indian, European & Middle Eastern.

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 • Minority Group: individuals or groups considered different or receive unequal treatment
due to racial, cultural, ethnic, sexual orientation, socioeconomic status or other associations
• Customs & Rituals: learned behaviors shared by a cultural group
• Values & Cultural Norms: principles that provide the foundation for beliefs, attitudes &
behaviors. Beliefs & behaviors affect attitudes toward illness causation, preferred method of
treatment or folk remedies & expected outcomes of health contacts.

Values That May Affect Health Care Interactions

• Time Orientation
• Present: accepts each day, little regard for past, future unpredictable
• Past: past traditions are meaningful
• Future: anticipate future, high value on change

• Activity Orientation
• Doing: emphasizes accomplishments, external standards
• Being: spontaneous self expression
• Becoming: self-development

• Human Nature Orientations

• Human being basically evil, but can be corrected with self-control & discipline
• Human being neutral, neither good nor evil

• Human-Nature Orientations

• Very little control over destiny

• Harmony with nature
• Master over nature

• Relational Orientations

• Individualistic: individual focus, more impersonal relationships with outsiders

• Lineal: group goals & family lineage position dominant
• Collateral: group goals dominant, m ore emphasis on relationship with
others at own level

Beliefs & Practices That May Affect Health Care Practices

• Folk Illness:
• Naturalistic Illness:
Patient may seek care from a folk practitioner, such as a
spiritualist, voodoo priest, curandero, herbalist, medicine man
or other
Usually involve the concept of equalibrium, the most common
being imbalances between “cold (yin) & hot (yan);” most
common in Hispanic, Chinese, Filipino & Arab culture.
Treatment usually involves restoring balance by applying
opposite forces (a “hot” treatment for a “cold” condition), &
the “hot-cold” conditions & treatments are culturally
determined (not related to actual temperature).

• Personalistic Illness: Illness results from aggression directed at, or punishment of,
the individual (the “evil eye” or witchcraft), & folk healers are
more often involved in care.

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 • The “evil eye” concept is more common in Mediterranean
& Spanish cultures & involves looking at a person or a
child, & unintentionally casting evil upon the child.
Many children may wear protective items, such as
crosses, beads or amulets for protection.
• Witchcraft as a cause of illness, may be more common
In Puerto Ricans, Haitians & Black Americans.

• Other Issues:
• “coining” or “moxa” involve applying heat to the
relieve illness, & may leave marks on the skin
• some culture prefer distant space & others prefer close
space
• some cultures prefer direct eye contact, while others
avoid direct eye contact
• family authority, such as matriarchal or patriarchal
dominance may be important
• dietary customs may be important in selected health care
problems, such as obesity or hypertension

Nutritional Assessment
Nutrition web sites of interest:

National Institutes of Health:

http://www.nih.gov/

Mayo Clinic Nutrition Center

http://www.mayohealth.org
http://www.mayohealth.org/mayo/common/htm/dietpage.htm

American Dietetic Association

http://www.eatright.org

Food and Nutrition Information Center

http://www.nal.usda.gov/fnic/

National Health Information Center

http://nhic-nt.health.org/

NIH Office of Dietary Supplements

http://odp.od.nih.gov/ods/

Tufts University Nutrition Navigator

http://www.navigator.tufts.edu/

U.S. Food and Drug Administration

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http://www.fda.gov/

American Heart Association

http://www.americanheart.org

Southwestern Michigan Dietetic Association

http://www.semda.org/info/ and http://www.semda.org/sitemap.html

Assessment

• Nutrition is a major component of health maintenance.

• The purpose of nutritional screening is to identify risk for malnutrition:
• Over nutrition (most common)
• Undernutrition
• Identifying nutritional risk is important in terns of reducing the severity of disease or
shortening recovery time

Types of Nutritional Assessment

• Nutritional screening
• Comprehensive assessment
Nutritional Screening

• Health history for conditions that might interfere with food intake
• Lifestyle habits, such as food choices & exercise patterns
• Medication history, including prescription, OTC, alcohol, tobacco, other drugs, vitamins,
minerals & supplements
• Diet History
• Diet recall (24 hour recall most commonly used)
• Food records (food record for several days, usually 3-4 days)
• Food frequency questionnaire (type & frequency of foods over past 6 months)

More Comprehensive Nutritional Screening

• If weight is below 80% or 120% or greater of ideal weight

• If there is an unintentional weight loss of greater then 4.5 kg
• Serum albumin level below 3.5 g/dl (normal range 3.5 – 5.5 g/dl)
• Total lymphocyte count below 1500 cells/mm3 (range 1500 – 3000 cells/mm)
• History or physical exam indications

Subjective History Information

• Usual weight & weight changes

• Changes in appetite, taste, smell, dentition, chewing & swallowing
• Recent illness, surgery, trauma, burns, infection, chronic illness
• Vomiting, diarrhea, constipation
• Food allergies or intolerance

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Compare Diet with Food Pyramid:
Six Food Groups & Guideline of 5 servings of fruits or vegetables per day
http://www.nal.usda.gov/fnic

• Bread, cereal, rice & paste: 6-11 servings/day

• Fruit Group: 2-4 servings/day
• Vegetable: 3-5 servings/day
• Meat, poultry, fish, dry beans,
Eggs & nuts: 2-3 servings/day
• Milk, yogurt & cheese: 2-3 servings/day
• Fate, oils & sweets sparingly

Age Related Considerations

• Infants

Maternal nutrition during pregnancy

Feeding methods (breast or bottle)
Supplements (fluoride, vitamins, iron)
Introduction of solid food at 6 months
Finger foods & baby’s feeding preferences

• Young Children

Sporadic or picky eaters

Food choices over time? (sufficient variety?)
Battles over food intake should be avoided

• Adolescent

Present weight, body image & desired weight

Selection of snacks or fast foods
Age of menarche, delays, cessation, and athletic activities

• Pregnancy & Breast Feeding Female

Weight gain
Food preferences
Dietary problems, nausea or vomiting (“morning sickness”)
Edema, fluid retention
Need for caloric increase
Prenatal vitamins & folic acid supplement

• Older Adult

• Changes in taste, diet or dentition

• Inappropriate food intake (due to poverty, isolation, disability, illness, age greater
than 80)

Objective Date: Clinical Assessment Observations)

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 • Skin for poor turgor, color changes, dryness, roughness, lesions
• Hair for depigmentation, courseness, dryness, dullness, increased friability
• Mouth for fissures, stomatitis, mottling or pitting teeth
• Musckuloskeletal system for bony deformities, muscle twitching, wasting or weakness
• Cardiovascular system for arrhythmias or BP changes
• Gastrointestinal system for distended, weak abdomen, diarrhea or constipation
• Neurological system for listlessness, irritability, motor clumsiness, diminished reflexes

Objective Data: Body Anthropometric Measurements

Height
Weight
Body Mass Index (BMI)
Skin Fold Thickness (TSF) Triceps Skin Fold
Mid-upper arm circumference
Waist-to-hip-ratio

Weight

• Weight loss between 5% & 10% is potentially significant for undernutrition

• Weight loss greater then 10% over 5 to 6 months is significant for undernutrition

Body Mass Index (BMI)

• This is a numeric value, indicating body weight & risk for health problems.
• The BMI can be calculated mathematically (weight in kilograms divided by height in meters
squared,
• or by use of a graphic Nomogram, which compares height & weight to arrive at a BMI & also
a “weight goal”:

Degree of % higher than BMI Weight goal Degree of

Obesity ideal body weight rating medical risk

None <20 20-24 1 = goal/ideal None

Mild 20-40 25-29 2 = 20% over Low
Moderate 40-100 30-39 3 = 40% over Moderate to high
Severe >100 or >45 kg higher >40 Very high
than ideal body weight

Skin Fold Thickness (TSF): Triceps Skin Fold

Assesses body composition
Most commonly used for screening & assessment for malnutrition

• Measure with a calibrated skinfold caliper, on non-dominant upper arm, halfway between
shoulder & elbow, with arm hanging loosely.

• Measure a cross section if skin, pulled away from underlying muscle

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 • Measure 3 times & take average

Average (50% ile) Skinfold Thickness Measurements (mm)

Males: Age 18 – 74 8.5 – 11.0

Females: Age 18-74 17.5 – 23.0

Waist/Hip Ratio
Assesses Body Proportion

• Measure waist: Smallest circumference

• Measure hip: Level of maximum extension of buttocks posteriorly
• Divide: Waist circumference by hip circumference
• Waist/hip ratio: 1 or lower for men or 0.8 or lower for women is acceptable
Higher ratios indicate increased health risk

Lab Studies

• Hemoglobin & Hemotocrit:

indicators of anemia & in severe cases, protein malnutrition

• Hematocrit:
• Low: deficient iron, vitamin B12, B6, folate; blood loss or overhydration
• High: dehydration, chronic anoxia or polycythemia

• Total lymphocyte count (TLC):

• Low: nutrition deficiencies, depressed immune system, certain viral infections,
medications
• High: bacterial infection, sepsis, TB, chronic leukemia

• Serum albumin:
• Low: inadequate protein intake, poor wound healing, impaired function of immune
system

• Fasting Blood Sugar:

• Used to screen for diabetes or glucose intolerance

• Serum Lipid Levels:

• Used to determine risk for coronary heart disease
• TCHOL: Total cholesterol Elevations increase risk
• TG: Triglycerides Elevations increase risk
• LDL: Low density lipoprotein Elevations increase risk
• HDL: High density lipoprotein Elevations decrease risk

Hemoglobin
• Infants: 14.5-22.5 g/dl or 9.0-14.0 g/dl
• Children: 11.5-15.5 G/DL
• Adults: Males 14-18 g/dl Females 12-16 g/dl
•

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Hematocrit
• Infants: 44-72% or 28-42%
• Children: 35-45%
• Adults: Males 37-49% Females 36-46%

Serum Albumin: 3.5-5.5 g/dl

Total lymphocyte count

• 1500-1800 mild depletion
• 900-1500 moderate depletion
• <900 severe depletion

Serum Lipids: Optimum Levels

Measured in mg/dl

Adults Children
TCHOL <200 <170
Triglycerides <200 <150
LDL <130 <110
HDL >35 >35

Sleep Assessment
Sleep

• Sleep has restorative function (physically & psychologically)

• Prolonged sleep deprivation may cause changes in mood & performance, which may include
Fatigue, irritability anxiety, depression, feelings of persecution, poor concentration,
feelings of depersonalization & increased aggression

Purposes of Sleep Assessment

• Identify sleep problems

• Evaluate quantity & quality of sleep from individual’s perspectaive
• Identify circumstances that promote or inhibit sleep
• Identify psychological or physiological factors affecting sleep

Two Categories of Sleep

Both types of sleep occur during the 4 to 6 cycles of sleep occurring during 8-hour sleep periods

• Non- REM: Non rapid eye movement sleep, consisting of four stages, during which no
dreaming occurs
• REM: Rapid eye movement sleep, during which dreaming occurs

Stages of Non-REM Sleep

Stage 1: Occurs when falling asleep, last 5 minutes, drowsy feeling, awakes easily
Stage 2: Lasts 10 to 15 minutes, deeper sleep, more difficult
Stage3: Deeper, more restful, activity decreased

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 Stage 4: Deepest & most restorative sleep, begins 15 to 20 minutes after falling asleep

Sleep Patterns Change with Age

• Sleep time, patterns & REM sleep vary with age:

• Infants: Sleep 14 – 18 hours per day
• Young children: Sleep 10 – 14 hours per day
• Older children: Sleep 8-10 hours per day
• Adolescents: May increase sleep time
• Adults: Sleep 7 – 9 hours per day (some may require less)
• Older Adults: Have a decrease in stage 4 sleep & may awaken frequently

Common Sleep Problems

• Sleep apnea: cessation of air flow at mouth & nose for at least 10 seconds at a time
• Insomnia: inbility to fall asleep or stay asleep
• Sleepwalking: occurs most often in children, is usually not remembered, may be
related to other predisposing factors
• Sleep terrors: occur more often in children, a few hours after sleep, are intense &
Usually not remembered
• Nocturnal enuresis: (bed-wetting), more common in boys, may be primary or secondary

Vital Signs
• Most frequent measurements:
temperature, pulse,
respiration and blood pressure

Temperature

• General over-all range:

97 – 99.6° F (36.1 – 37.6° C)

Conversions:
Fahrenheight to Celsius: (F – 32) X 5/9 =C
Celsius to Fahrenheight: 9/5 X (C + 32) = F

• Regulation for heat loss-conservation occurs in the hypothalamus

Heat loss: occurs via

• Conduction: direct contact with object of higher temperature
to object of lower temperature
• Convection: loss of heat molecules to the air, such as
with increased air flow
• Radiation: loss of heat to cooler objects in the environment,
that are not in direct contact
• Evaporation: loss of moisture to gaseous form

Heat conservation: occurs via

• Reduced peripheral circulation: capillary constriction &
reduced refill, blanching or pallor
• Nonshivering thermogenesis: vasoconstriction
• Voluntary muscle contraction & shivering

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• Influences

• Age: Temp. control is not well developed in

infants and young children, & temperatures may
vary considerably. Temperature declines with age:
Young child: 37.2° C (99° F)
Adult: 37° C (98.6° F)
Older Adult: 36° C (96.8° F)

• Biological rhythms: Diurnal variations up to 1.0° C,

with lowest in point between 1-4 AM & highest peak
between 4-6 PM

• Hormone regulation: Thyroid & progesterone

increase temperature (example, temperature increase
with ovulation)

• Eating, exercise, stress, crying, environment & clothing:

temporary elevations, especially in children

• Pharmacologic agents: According to specific drug action

• Methods

Oral: Adult Average: 37° C (98.6° F):

for alert, cooperative adult or older child
(over age 5-6 years)
Rectal: Adult Average: 37.5° C (99.5° F):
for confused, comatose, uncooperative,
unable to close mouth or if receiving O2
Axillary: Adult Average: 36.5° C (97.5° F):
for infants & young children
Tympanic: Infrared sensor to detect temperature of
tympanic blood flow, correlates with core
temperature, variable accuracy, not
recommended with otitis media/externa

Respiration

• General Observations: Symmetry, rate, rhythm, depth,

tachypnea, bradypnea, abnormal patterns or dyspnea: count for
full minute in infants & young children, due to irregularity of
respirations

• Hypoxia:

Peripheral cyanosis: evident in nailbeds & peripheral

extremities, usually caused by vasoconstriction &
common in young infants
Central cyanosis: evident in lips, buccal mucosa
& trunk (infants & young children), indicating significant

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 decrease in oxygen carrying capacity or O2 saturation
Anxiety, restlessness, air-hunger or decreasing levels
or consciousness: may be related to hypoxia

• Influences:

• Age: Rate decreases with age: tends to

increase easily in infants & young children, with
anxiety, crying, fever or disease: irregular rhythm
& apneic spells of less than 15-20 seconds occur
frequently in young infants (apneic spells longer
than 20 seconds are considered pathological)

• Fever, increased activity or fear: increase

rate & depth

• Pain, pathological conditions & medications:

may cause respiratory increase or decrease

• Average Respiratory Rates:

Age Rate/Minute
Premature 40-90
Neonate 30-80
1 yr 20-40 (30)
2-4 yrs 20-30 (25)
5-10 yrs 17-22 (20)
10-15 yrs 15-22 (18)
Adult 12-20 (16)

Pulse

• General Assessment:Usually includes peripheral

and apical for:
rate: adult range: 60 -100 beats/minute (bpm):
diurnal pattern of lowest rate between 1-4 AM
& highest rate between 4-6 PM: conditioned
athletes may have lower than usual rates
bradycardia: rate below 60 bpm
tachycardia: rate above 100 bpm
rhythm: even tempo
sinus arrhythmia: pulse rate increases during
inspiration, decreases during expiration
(a normal variation, especially in children &
young adults)
volume: (amplitude or force): shows strength of left
ventricular contraction, or stroke volume:

3 point scale 4 point scale

4+ = bounding
3+ = full, bounding 3+ = increased
2+ = normal 2+ = normal

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 1+ = weak, thready 1+ = diminished
0 = absent 0 = absent

• Peripheral Pulses: Provides additional indications

cardiac function & peripheral profusion: may include:
brachial, radial, ulnar, temporal, carotid, femoral,
popliteal, posterior tibial and doralis pedis arteries
Decreased femoral pulses: are associated with
aortic stenosis

• Influences:

Fever: Increases rate: in children, pulse rate

increases 10-15 bpm for each °C temperature >

Exercise, apprehension, pain: Increase rate

Increased ICP: Decreases rate

O2, CO2, F & E balance & drugs: also affect

cardiovascular function

• Pulse: Common Definitions & Abnormalities

Pulse Deficit: A difference between the apical &

peripheral pulse.(peripheral pulse rate subtracted from
apical pulse): normally “zero;” or no difference:
a pulse deficit indicates weak pulses/heart beats

Bigeminal Pulse:Normal pulse is followed by premature

contractions, which are weaker than the normal pulse.
Rhythm is irregular. Possible causes: premature ventricular
contraction or atrial contraction

Pulses Alterans: Pulses have large amplitude beats

followed by pulses of low amplitude. Rhythm remains
normal. Possible cause: left sided congestive heart failure

Pulsus Paradoxus: An exaggeration of the normal

paradoxical pulse, defined as a normal fall of approximately
5 mm. Hg. in systolic arterial blood pressure during inspiration,
as compared to expiration. A difference of more than
10 mm. Hg is abnormal pulsus paradoxus. Possible causes:
cardiac tamponade, constrictive pericarditis, obstructive
lung disease. It is tested better by BP evaluation of systolic
pressure than by pulse palpation.

Palpitations: Unpleasant sensations of awareness of

the heartbeat: described as skipped beats, racing, fluttering,
pounding or irregularity: may result from rapid acceleration
or slowing of heart, increased forcefulness of cardiac
contraction: not necessarily associated with heart disease

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• Average Pulse Rates:

Age Rate/Minute

Newborn/neonate70-180
1 yr 80-140
2-4 yrs 80-120
5-10 yrs 70-110
10-15 yrs 70-100
Adult 60-100

Blood Pressure:
interaction of cardiac output and peripheral resistance
Systolic Arterial Pressure:
force exerted by blood against arterial wall when ventricles contract
Diastolic Arterial Pressure:
force exerted by blood against arterial wall when ventricles relax

Pulse Pressure:
difference between systolic & diastolic blood pressures:
• usual adult pulse pressure is between 30 – 40 mm Hg
(even as high as 50 mm Hg): example: pulse pressure
may widen with systolic hypertension, may widen with
increased intracranial pressure
• may be wider in children (between 20 – 50 mm Hg):
examples: pulse pressure more than 50 mm Hg in
children may indicate congestive heart failure:
pulse pressure less than 10 mm Hg may indicate
aortic stenosis

Arm Blood Pressure: May be 5-10 mm Hg higher in

right arm than left arm: greater differences between right &
left arm may be associated with congenital aortic stenosis or
acquired conditions, such as aortic dissection or obstruction
of arteries of the upper arm

Leg Blood Pressure: Arm & leg blood pressures are about
equal during the first year of life & after that time the leg blood
pressure is 15-20 mm Hg higher than arm blood pressure

Orthostatic Hypotension: Decrease in systolic BP of

20-30 mm Hg or more when changing from supine to standing
position, & increase in pulse of 10-20 bpm: sudden drops may
result in fainting. Dizziness & faintness from orthostatic
hypotension may occur when taking antihypertensive
medications, volume depleted, confined to bed or in the elderly

Importance of cuff size: Cuff size too narrow may result in

false high BP & cuff size too wide may result in false low BP;
cuff bladder should be long enough to encircle arm without
overlapping: cuff wide should cover no less than one half or
more than two thirds of the upper arm or thigh

19
• Influences

Age: Increases with age

Conditions: Decreases during hemorrhage or shock:

increases with renal disease, increased intracranial pressure,
coarctation of aorta (> in arms & < in legs), phenochromocytoma,
hyperthyroidism, diabetes mellitus and acute pain

General Variations: Occur with degree of excitement,

smoking habits, pain, bladder distention, dietary pattern &
medications.

Diurnal Variation: Usually higher during morning &

afternoon than during evening & night

• Korotkoff sounds: Turbulent sounds of partial obstruction

of arterial flow
• Phase I: sharp tapping sound (systolic)
• Phase II: change to soft swishing sound
• Phase III: sounds more crisp & intense
• Phase IV: muffled tapping (first diastolic)
closer to true diastolic in children:
record for diastolic in children <13 yrs
• Phase V: cessation of sound (2nd diastolic)
closer to true diastolic in adults:
record for diastolic in children >13 yrs
& adults
American Heart Association recommends
Recording systolic/1st diastolic/2nd diastolic

• Normal (average) Blood Pressures

Age Systolic (SBP) Diastolic (DBP)

Newborn 80 46
1-12 months 90 54
2-4 yrs 92 56
5-10 yrs 96-100 58-62
10-15 yrs 102-112 62-68
Adult 100-139 60-89

• Auscultatory gap:
silence caused by disappearance of Korotkoff sounds after
initial appearance and are then heard 10-15 mm Hg later:
can be mistaken for lower SBP reading (point of reappearance):
can be associated with decreased peripheral flow, such as
hypertension or aortic stenosis

Hypertension Classifications: NIH, 6th Report, 1997

20
 Children:
• Normal: < 90th %ile systolic & diastolic
• High normal: 90-95th %ile systolic & diastolic
• Hypertension: > 95th %ile systolic & diastolic

Adults:

Category Systolic (SBP) Diastolic (DBP)

• Normal <130 <85
• High normal 130-139 85-89
• Hypertension
Stage I (mild) 140-159 90-99
Stage II (moderate) 160-179 100-109
Stage III (severe) 180-209 110-119
Stage IV (very severe) ≥ 210 ≥ 120

SUMMARY OF VITAL SIGNS:

Averages for “easy to remember’ categories

Age Pulse Resp BP

Newborn/Neonate 70-180 (120) 30-80 80/46
1 yr 80-140 (110) 20-40 (30) 90/54
2-4 yrs 80-120 (100) 20-30 (25) 92/56
5-10 yrs 70-110 (90) 17-22 (20) 100/60
10-15 yrs 70-100 (85) 15-22 (18) 108/64
Adult 60-100 (80) 12-20 (16) <130/<85

SUMMARY OF SIGNIFICANT GROWTH MEASURMENTS

IN CHILDREN

WEIGHT: 1 kgm = 2.2 lbs 1 kgm = 1000 Gms

Average birth weight = 7 lbs 5 oz (3.3 kgm or 3300 Gms)

Weight Gains:
Double birth weight in 4-5 months: Triple birth weight by 1 yr
Average wt. Gain from 2-9 yrs is approximately 5 lbs/yr

HEIGHT/LENGTH: 1 INCH = 2.5 cms

Average birth length = 20 inches (50 cms)

Height/length gains:
10-12 inches in 1st yr (25-30 cms)

21
5 inches in 2nd yr
3-4 inches in 3rd yr
Then 2-3 inches/yr until adolescent growth spurt
Birth length: doubles at 4 yrs (40 inches)
Birth length: triples by 12-13 yrs (60 inches)
From 2-5 yrs ht increases more rapidly than wt
School years: steady rate for both ht & wt
Adolescent growth spurt: (Generally)
boys twice as tall in adult life as at 2 yrs
girls average increase after menarche is 5 inches (1-7 inch range)

HEAD CIRCUMFERENCE: Accuracy is important

HC (head circumference)
FOC (frontal-occipital circumference)
Measure largest diameter: frontal to occipital protuberance
When to measure? 1st 2 yrs and later if neurological problems
Average HC at birth: 35 cms (13.8 inches for girls) & 36 cms for boys
Increases: 0-3 months: 5 cms (2 inches) total
or approx. 1.6 cms (0.6 inches) /month
3-8 months: 5 cms (2 inches) total
or approx. 1.6 cms (0.4 inches) /month
8-12 months: 2 cms total, or 0.5 cms (0.2 inches) /month

CHEST CIRCUMFERENCE: Closely parallels HC for 1st 4 yrs.

VISION: Birth Fixates, by 2 months, follows to midline

2 ½-4 months Follows past midline
4 months 20/300 – 20/50
6 months Binocular vision:
intermittent strabismus disappears
1-4 yrs Critical for amblyopia detection
4 yrs 20/40 (refer 20/50 or 2 line difference)
5 yrs 20/30 – 20/20 (refer 20/40 or 2 line difference)

EARLY LANGUAGE DEVELOPMENT:

Birth – 4 months Vocalizations
4-6 months Imitation, turns to sound
6-9 months “MaMa, DaDa,” nonspecific
8-14 months “MaMa, DaDa, ” specific
12-18 months 2-6 words
2 yrs 2 word phrases

SELECTED LAB VALUES:

A summary of some of the more frequently used laboratory tests

CBC: Complete Blood Count (numbers of each type of cell)

RBC: Red Blood Cell:

Number of RBCs per cc of blood (amount circulating is important)

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 • Normal Values:
• Newborn: 4.8-7.1 million/mm3
• 1 month: 4.1-6.4
• 6 months: 3.8-5.5
• 1-10 yrs: 4.5-4.8
• Adult men: 4.6-6.2
• Adult women: 4.2-5.4
• Increase (Erythrocitosis) (Polycythemia) consider:
dehydration, polycythemia vera, high altitude, drugs, hypoxia,
normal in newborn
• Decrease (low RBC) consider
Anemia, blood loss/hemorrhage, leukemia/cancer,
malnutrition, vitamin deficiency

HEMOBLOBIN ( Hbg):
Oxygen carrying protein (gm/dl blood)
• Normal Values:
• Newborn: 14.5-22.5 gm/dl
• Infant: 9-14 (physiologic anemia @ 3-5 months)
• Child: 11.5-15.5
• Adolescent: 13-16 (male) 12-16 (female)
• Adult: 13-17 (male) 12-16 (female)
• Increase: same as RBC
• Decrease: same as RBC

HEMATOCRIT (Hct):
Packed cell volume of RBCs, expressed as percentage of total blood volume
• Nomal Values:
• Newborn: 48-69%
• Infant: 28-48
• Child: 33-47
• Adolescent: 37-54 (male) 36-47 (female)
• Adult: 40-54 (male 38-47 (female)

• Increase: same as RBC & Hbg

• Decrease: same as RBC & Hbg

RED CELL INDICIES: useful in determining anemia

• Mean Corpuscular Volume (MCV): (MCV = Hct/RBC)
A measure of cell size (micrometers or femtoliters: fl)
80-100 fl indicates average cell size
Normocytic (normal size): consider
• Decreased production (chronic disease)
• Increased loss (hemorrhage)
• Increased destruction (intravascular hemolysis)
Microcytic (small size): consider Hbg problem
• Hemoglobinopathy (sickle cell, thalasemia)
• Fe (iron) deficiency

23
 Macrocytic (large size): consider DNA problem
• Folate deficiency
• Vit B12 deficiency
• Mean Cell/Corpuscular Hemoglobin (MCH): (MCH = Hbg/RBC)
A measure of amount of Hbg per cell,
or average weight of Hbg in RBCs (picograms)
Essentially same as MCV (Hbg & Hct are interrelated, ie Hbg X 3 = Hct)
27-32 pg. indicated average cell weight
• Mean Cell/Corpuscular Concentration (MCHC)
(MCHC = Hbg/Hct: grams/100 ml RBCs)
A measure of concentration (chromicity) of Hbg in each RBC
• Normochromic: normal Hbg concentration
• Hypochromic: less than normal Hbg concentration
• Hyperchromic: greater than normal Hbg concentration

WBC: Leukocytes: White Blood Cell Total Count (per cc of blood)

part of body’s primary defense against foreign invaders
• Normal Values:
• Newborn: 9,000-30,000/ul
• Infant: 6,000-17,500
• Child: 4,500-16,300
• Adult: 4,500-11,000
• Increase (Leukocytosis: consider
Infection
Hemoconcentration
Stress
Leukemia
(bacterial infection, leukemia, trauma, stress,
tissue necrosis, inflammation, parasitic infection,
pregnancy dehydration, normal in newborn)
• Decrease (Leukopenia) consider
Viral infection
Drugs
Anemia
AIDS
Hodgkin’s Disease
(Drug toxicity, viral infection, leukemia,
bone marrow failure or infiltration, chemotherapy,
radiation, aplastic anemia, autoimmune disease,
overwhelming infection)

DIFFERENTIAL COUNT: includes RBC, Plt & WBC morphology

WBC (Leukocyte) Differential

WBCs are reported as % of total WBC
• Two basic groups & their sub-groups of WBCs or Leukocytes
• Normal Differential:

• GRANULOCYTES

• Neutrophils
• Band or stab (immature form) 1-5%
• Segmented (Mature form) 50-70%
Also called, poly, seg or PMN—
polymorphonuclear neutrophil
• Eosinophils 1-4%

24
 • Basophils 0.5-1%

• AGRANULOCYTES

• Monocytes 2-8%
• Lymphocytes (Immune System) 20-40%
• T cells (cellular immunity)
• B cells (humoral immunity)

GRANULOCYTES: function & limited, more common reasons for elevated counts

NEUTROPHILS: Phagocytosis & early response (neutrophilia)

Bands or stabs
• A “shift to the left” or increase in immature neutrophils,
is usually associated with bacterial infection.
Segs
• Infection, especially bacterial
• Tissue Necrosis (Myocardial infarction, tumors, burns, gangrene,
Carcinoma or sarcoma)
• Acute hemolysis of RBCs
• Inflammation: Acute & chronic: (Rheumatic fever, acute gout, appendicitis)
• Some viral & rickettsial diseases
• Stress (emotional or physical)

EOSINOPHILS: Suppress inflammatory reaction (eosinophilia)

• Allergy
• Parasitic infections
• Dermatitis

BASOPHILS: Enhance immunoinflammatory reaction (basophilia)

• Prolonged inflammation
• Allergy
• Infections (smallpox, chickenpox, influenza, TB)

AGRANULOCYTES: function & limited, more common reasons for elevated counts

MONOCYTES: Phagocytosis, later response (longer cell life) (monocytosis)

• Chronic inflammation or recovery stage of acute bacterial infection
• Pre-leukemia, Monocytic Leukemias, Hodgkins Disease
• TB
• Lipid Storage Disorders

LYMPHOCYTES: (lymphocytosis)
Combat acute viral infections,
Some chronic bacterial infections
Pertussis
Epstein-Bar (infectious mononucleosis)
CMV (cytomegalic inclusion disease)
Other viral illnesses

25
 • T Lymphocytes: Cellular type immune response
Act directly, migrate to site of infection
Direct B cells to start/stop antibody production
Mediate multiple immune functions

• B Lymphocytes: Humoral or antibody mediated immune response

Mediates antibody production:
• IgA: Antiviral, in all body secretions
• IgE: Allergy, parasitic: Stimulate basophils
• IgG: Smallest, crosses placenta, antibacterial
• IgM: Largest, antibacterial, ABO antibodies

PLATELET ( THROMBOCYTE) COUNT (Plt):

number or thrombocytes per cc of blood
• Normal Value:
• Newborn: 84-478,000
• Thereafter 150,000-400,000

• Increase (Thrombocytosis) Spleenectomy, some chromic leukemias,

Polycythemia vera, hemolytic anemia, essential thrombocythemia, chronic hypoxia
• Decrease (thrombocytopenia)Acute leukemia, aplastic anemia, ITP & TTP, DIC,
Viral infection, platelet antibody, drugs, hyperspleenism, sepsis
• Platelet Function Disorders: Inherited bleeding disorder, such as
Von Willebrand Disease, or acquired, such as liver/kidney disease

SELECTED COAGULATION TESTS: and some limited, common uses

Used to determine adequacy of blood coagulation (intrinsic & extrinsic clotting factors:
May be abnormal in liver disease, DIC (disseminated intravascular coagulation),
or specific congenital conditions, such as hemophilia or von Willebrand Disease.

Bleeding Time: reflects ability of platelets to function normally & capillaries to constrict
their walls: used as a primary screening test for
coagulation disorders & platelet function
Normal Value: 4-7 minutes

• Prothrombin Time (Protime) (PT): Measures function of second

stage clotting factors.
(Prothrombin, protein produced by the liver for clotting, depends on
vitamin K intake & absorption: is reduced in liver disease)
Primarily used for three purposes:
Monitoring oral anticoagulation/coumadin therapy
Evaluation of coagulation disorders (abnormality of extrinsic pathway)
Evaluation of liver function
Normal Value: 11.0-13.0 seconds

• Partial Thromboplastin Time (PTT): Determines overall ability

blood to clot: useful for screening for coagulation disorders of both intrinsic
& extrinsic pathways, monitoring heparin anticoagulation therapy,
liver disease & vitamin K deficiency
Normal Value: 30-45 seconds

• Activated PTT (APPT): Used for the same purpose as PTT, but is a more
sensitive test.

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BLOOD CHEMISTRIES

• GLUCOSE: simple sugar formed from carbohydrate digestion &

conversion of glycogen to glucose by the liver
• Normal Values: Fasting Blood Glucose Random Blood Glucose
Newborn 40-80mg/dl 40-80 mg/dl
Child 60-100 60-100
Adult 70-100 70-105
• Glycosylated hemoglobin (HbA1C)
Indicates average blood glucose levels for 2-3 month period:
helpful in evaluating treatment of diabetes & over-all
blood sugar control
• Increases (hyperglycemia): diabetes mellitus, acute emotional-physical
Stress, Cushing’s disease, phenochromocytoma, pituitary adenoma,
Pancreatitis, brain trauma, chronic liver or renal disease, pregnancy
• Decreases (hypoglycemia): insulin overdose, adrenal insufficiency,
hypopituitarism, starvation, liver damage, alcoholism, premature
infant, enzyme deficiency diseases

SERUM ELECTROLYTES

• SODIUM (Na +): greatest extracellular cation: ECF (extracellular fluid)

Maintains osmotic pressure, acid-base balance, helps transmit nerve impulses:
Reflects changes in water & salt balance
• Normal Values:
Newborn 133-146 mEq/L
Infant 139-146
Child 138-145
Adult 136-145

• Increases (hypernatremia): Dehydration, primary aldosteronism,

Cushing’s disease, diabetes insipidus
• Decreases (hyponatremia:: Burns, CHF, fluid loss (diarrhea, vomiting,
sweating, excess IV fluids, Addison’s disease, nephritis, malabsorption,
DKA, diuretics, excessive oral water intake, hypothyroidism

• CHLORIDE (Cl  ): In extracellular space primarily as sodium chloride or hydrochloric

acid. Maintains cellular integrity, osmotic pressure & acid-base balance
Changes reflected primarily in Na changes
• Normal Values:
• Newborn 98-113 mEq/L
• Infant 95-110
• Child 98-105
• Adult 89-107
• Increases (Hyperchloremia): Dehydration, Cushing’s disease,
hyperventilation (respiratory alkalosis), metabolic acidosis with prolonged
diarrhea, hyperparathyroidism, renal tubular disease, diabetes insipidus,
salicylatae intoxication

• Decreases (hypochloremia): Most losses are through GI tract:

Severe vomiting, gastric suction, chronic respiratory acidosis, burns,

27
 Metabolic alkalosis, CHF, Addison’s disease, salt-losing diseases
(inappropriate antidiuretic hormone: SIADA), overhydration

• POTASSIUM (K +): Major intracellular cation:

Damaged tissue releases K+ into blood:
Influences on ECF & ICF K+ include insulin (promotes cell uptake),
aldosterone (causes kidney excretion), epinephrine (moves K+ into cells)
& acid-base balance (acidosis > serum K+ & alkalosis > serum K+.
Plays major role in nerve conduction, muscle function, acid-base balance, osmotic
Pressure & rate & force of heart contraction.
• Normal Values:
Newborn 3.7-5.9 mEq/L
Infant: 4.1-5.3
Child 3.4-4.7
Adult 3.5-5.1
• Critical values: <2.5 mEq/L causes ventricular fibrillation, or
> 7.0 mEq/L (>6.6 or 8.0 mEq/L
causes myocardial muscle irritability
Increases (hyperkalemia): K+ shifts out of cells (acidosis, decreased
insulin, cell damage as in burns, DIC, accidents), inadequate renal excretion (renal
failure, other kidney disease, Addison’s disease, aldacterone deficiency
• Decreases (hypokalemia): K+ shifts into cells )alkalosis, excess glucose), loss of
K+ from GI tract & biliary tracts (diarrhea, vomiting, excessive sweating,
malabsorption), increased renal excretion (aldosteronism, diuretics), & reduced K+
Intake (starvation).

• CALCIUM (C2+): Helps with blood coagulation, neuromuscular

conduction, intracellular regulation, glandular secretion, control of skeletal
& cardiac muscle contractility (only ionized form used: 50% is protein bound)
Most is stored in skeleton & teeth:
Regulated by thyroid & parathyroid gland
Monitored for diagnosis of parathyroid dysfunction, hypercalcemia of malignancy
• Normal Values:
Newborn 7.6-10.4 mg/dl
Infant 9.0-11.0
Child 8.8-10.8
Adult 8.8-10.2
• Increases (hypercalcemia): Hyperparathyroidism, cancer, thyroid
toxicosis, Paget’s disease, idiopathic in infancy, increased
Vitamin D/milk/antacid intake, bone destruction & immobilization
• Decreases (hypocalcemia): Hypoparathyroidism, malabsorption,
acute pancreatitis, alkalosis, renal failure, Vitamin D Deficiency, malnutrition,
alcoholism, hepatic cirrhosis: cow’s milk induced hypocalcemia in neonates
(neonatal tetany)

• PHOSPHOROUS: Has inverse relationship with Ca+:

Helps regulate Ca+ levels & mineralizaton of bones & teeth:

28
 monitor in renal & GI disorders
• Normal Values:
Newborn 4.5-9.0 mg/dl
Infant 4.5-6.7
Child 4.5-5.5
Adult 2.7-4.5
Older adult 2.3-3.7
• Increases (hyperphosphatemia): alcoholism, vomiting & diarrhea, Vitamin D deficiency
• Decreases (hypophosphatemia): DKA, renal failure, hypothyroidism

• MAGNESIUM (Mg): Abundant in RBCs: essential for bone & muscle:

helps control Na, K, Ca, phosphorous: monitor in renal & GI disorders
• Normal Values:
Newborn 1.4-2.9mg/dl
Child 1.6-2.6 mg/dl
Adult 1.5-2.5 mg/dl
Increases (hypermagnesemia): Dehydration, renal failure, hypothyroidism,
Addison’s Disease, Adrenalectomy (adrenocortical insufficiency), use of antacids
Containing magnesium (milk of magnesia)
Decreases (hypomagnesemia): hypercalcemia of any cause, DKA, hemodialysis,
chronic renal disease, chronic pancreatitis, hypoparathyroidism, malabsorption syndromes,
chronic

• BICARBONATE (HCO3): major extracellular buffer: reflects CO2 content of blood,

Changes in acid-base balance & measure of serum alkalinity or acidity
• Normal Values
Arterial 21-28 mEq/L
Venous 22-29 mEq/L
Increased (metabolic alkalosis): severe vomiting (loss of HCl),
Emphysema (chronic compensation for respiratory acidosis), hyperaldosterism
Decreased (metabolic acidosis): sever diarrhea (loss of alkali from colon),
Starvation, acute renal failure, salicylate toxicity, diabetic ketoacidosis

URINALYSIS

Physical Dipstick (chemical) Micoscopic

Color: pale, amber, yellow, Glucose: neg Casts: neg,

Clear to slightly hazy (occasional hyaline)
Specific gravity: 1.015-1.025 Ketones: neg RBC: rare or neg
pH 4.5-8.0 Blood: neg Crystals: neg
Protein: neg WBC: neg or rare
Bilirubin: neg Epithelial cells: few
Urobilinogen: neg
Nitrate for bacteria: neg
Leukocyte esterase: neg

URINALYSIS: ABNORMAL FINDINGS

29
Change in color, cloudy
Foul, sweet or fruity, ammonia odor
Specific gravity <1.005 or >1.026
Protein >8 mg/dL
Glucose >15 mg/dL
Ketones +1 or +3
RBCs > 2
WBCs >4
Casts

RENAL FUNCTION STUDIES

• BLOOD UREA NITROGEN (BUN): end product of protein metabolism

• Normal Values:
Newborn: 4-18 mg/dl
Child 5-18 mg.dl
Adult 5-20 mg/dl
Older adult 8-20 mg/dl
Increased (azotemia): impaired renal function, CHF
(Decreased renal perfusion), salt & water depletion, shock, GI hemorrhage
(protein catabolism), acute MI, stress, excessive protein intake
Decreased: liver failure, acromegaly, malnutrition, use of anabolic steroids,
Overhydration, malabsorption

CREATININE (CR) CLEARANCE: a more precise indicator of renal status:

A byproduct of muscle energy metabolism, produced at a constant rate &
removed by the kidneys
• Normal Values:
Newborn: 0.8-1.4 mg/dl
Infant 0.7-1.7
Child <6 0.3-0.6
Child >6 0.4-1.2
Adult men 0.6-1.3
Adult women 0.5-1.0
Increased: impaired renal function, urinary tract obstruction, muscle
disease (acromegaly, myasthenia gravis, muscular dystrophy, polio), CHF,
shock, dehydration, rhabdomyolysis
Decreased: small stature, decreased muscle mass, severe liver disease,
Inadequate dietary protein intake:
Generally, decreases in Cr are not clinically significant

REFERENCES:

Barkauskas, V., Stoltenberg-Allen, K., Baumann, L., & Darling-Fisher, C. (1998) Health &
PhysicalAssessment, 2nd Edition, St. Louis: Mosby.

Bickley, L.S. & Hoekelman, R.A. (1999) Bates’ Guide to Physical Exmination and History
Taking , 7th Edition, Philadelphia: Lippincott.

30
Engel, Joyce (1997). Pocket Guide: Pediatric Assessment, 3rd Edition. St. Louis Mosby.

Fischbach, Francis (2000) A Manual of Laboratory and Diagnostic Tests, 6th Edition,
Philadelphia: Lippincott.

Steinke, Elaine, PhD, RN, Associate Professor, School of Nursing, Wichita State Univeristy.

Swartz, Mark H. (1998). The Textbook of Physical Diagnosis: History and Physical Examination, 3rd
Edition, Philadelphia: W.B. Saunders.

Wallach, Jacques (1998) Handbook of Interpretation of Diagnostiac Tests, Philadelphia: Lippincott-Raven.

Wong, D., Hockenberry-Eaton, M., Winkelstein, M., Wilson, D., & DiVito-Thomas, P. (1999) Waley &
Wong’s Nursing Care of Infants and Children, 6th Edition, St.Louis: Mosby.

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