Assessment test 3
Patellar reflex
"knee jerk" reflex. innervation is at the 2nd & 4th lumbar segments; tap patellar tendon while examiner hand supports the knee in flexed position. normal response is extension at the knee & visible contraction of the quadriceps
Older Adults
# of cerebral neurons decreases with age (not necessarily dec. mental fx); velocity of nerve impulse conduction declines; responses to stimuli may take longer.
The CRIES Scale
(crying, requires O2 to keep sats >95, increased vital signs, expression, and sleeplessness) used to evaluate procedure and surgical pain in newborns and infants. Infant behaviors and physiological signs are scored
Infant Physical Exam: Cardiac focus
* tiring/sweating with feeds; heavy or fast breathing with feeds/defecation; cyanosis with feeds or crying; excessive wt gain non-proportional to feeds; maternal health during pregnancy (meds, GD, fever, illicit drugs)
lateral curvature of spine
* usually secondary to in utero position
Gait
*1.* observe pt. walk without shoes noting simultaneous arm movements & upright posture. Should be smooth, regular rhythm & symmetric stride length. *2.* observe Heel-toe walking in a straight line forward & backward. Note extension of arms for balance, shuffling, scissoring, etc. (table 22-4 has all abnormal gait patterns listed)
Equilibrium
*1.* the Romberg test- pt. stands, feet together & arms at sides (with eyes open & then closed). Slight swaying is expected. Loss of balance is a + Romberg sign, indicating cerebellar ataxia, vestibular dysfunction, or sensory loss. *2.* having pt. stand with feet slightly apart & then push their shoulder just enough to throw off balance- recovery should be quick. 3. have pt. hop in place on one foot & then the other for 5 sec. without losing balance.
Cranial Nerve XI
*Accessory*: control of the sternocleidomastoid & trapezius muscles. Paralysis of the sternocleidomastoid muscle is suggested by difficulty in turning the head to the affected side. Observe shoulder height for trapezius muscle function (paralysis of affected shoulder will be lower).
CN VIII
*Acoustic*: use audiometer. Vestibular fx is tested by the Romberg test
Inspection
*Apical Pulse norm (PMI): Midclavicular line @ 5th intercostal space. Possibly seen @ 4th intercostal space... but ONLY in one or the other if heart is healthy. *apical pulse seen easier when sitting up b/c brings heart closer to anterior chest wall. *easily palpable & seen apical pulse when supine suggests intensity related to a problem. *absence of apical pulse with faint heart sounds (esp. in (L) lateral recumbant position) = extracardiac problem (pleural or pericardial fuid).
Cranial Nerve VIII
*Auditory*: can be assessed by response to loud noise (blink or startle). If infant does not respond, more accurate hearing tests should be done.
Severe encephalopathy timing
*Birth-12 hrs*: stupor, coma, periodic breathing, minimal movement, seizures, pupillary/oculomotor responses intact *12-24 hrs*: improved LOC, apneic spells, weakness, jitteriness, severe seizures *24-72 hrs*: LOC deteriorates, stupor & coma with respiratory arrest, pupils fixed & dilated, lost "dolls eye" response
Nervous system overview
*CNS*: brain, spinal cord- coordination & control *PNS*: cranial & spinal nerves, ascending & descending pathways- carries info. to and from the CNS *ANS*: sympathetic/parasympathetic- coordinates & regulates the internal organs
Posturing
*Decorticate or flexor posturing = injury to the corticospinal tracts above brainstem. *Decerebrate or extensor posturing = injury to the brainstem
Cranial Nerve VII
*Facial*: controls facial expression. Evaluate facial symmetry in the non-crying, undisturbed & crying neonate. Injury= marked facial weakness. If entire nerve is damaged, infant cannot wrinkle brow or close his eyes well without crying, & nasolabial creases will be asymmetric.
CN VII
*Facial*: observe a series of expressions: raise eyebrows, squeeze eyes shut, wrinkle forehead, frown, smile, show teeth, purse lips, puff out cheeks. Look for tics, unusual movements, asymmetry, drooping, sagging eye lids. Taste can be evaluated with 4 solutions (bitter, sour, salty, sweet) placed on the lateral side of the tongue. offer a sip of water after each solution. *note that bitter & sour are CN IX, salty & sweet are CN VII
Cranial Nerve IX
*Glossopharyngeal*: controls tongue movement. Inspect tongue movement, gag reflex, & position of uvula. Weakness= uvula deviates to one side
CN IX
*Glossopharyngeal*: taste over posterior third of the tongue. Bitter & sour.
Pregnancy: Cardiac focus
*Hx of cardiac disease or surgery; dizziness or syncope; *indications of heart disease: progressive/severe dyspnea/orthopnea; paroxysmal nocturnal dyspnea; hemoptysis; syncope with exertion; chest pain related to effort or emotion
CN XII
*Hypoglossal*: inspect tongue while at rest on the floor of mouth & while protruding from mouth. Have pt. move tongue side to side, in & out, curled upward & downward. Test tongue strength by having them push tongue against inside of cheek while you put pressure on outside of cheek. Listen for problems making lingual speech sounds (l, t, d, n)
Cranial Nerve XII
*Hypoglossal*: supplies the muscles of the tongue. Assess for atrophy or abnormal movements of the tongue, as well as gag, suck, & swallow reflexes. Damage= a weak suck & delayed swallowing.
Systolic Ejection Murmur
*Most common* innocent murmur (56% of newborns) usually grade I-II vibratory heard on the left sternal border. may last as long as a week
CN III, IV, VI
*Occulomotor, Trochlear, & Abducens*: movement of the eyes through the 6 cardinal points of gaze, pupil size, shape, response to light & accommodation, & opening of the upper eyelids. CN VI is commonly the first to lose fx in the presence of increased ICP
Cranial Nerves III, IV, VI
*Oculomotor, Trochlear, & Abducens*: these nerves supply the pupil and extraocular muscles. Pupillary response should be present at 28-30 wks. Note ptosis, proptosis, sustained nystagmus, or stabismus. *"Doll's eye" maneuver*: gently rotate head from side to side & evaluate for deviation of eyes away from direction of rotation (head turned right= eyes deviate left). If eyes remain in a fixed position, suspect brainstem dysfunction. If eyes move in the same direction as the head is rotated, suspect brainstem or oculomotor dysfunction.
Cranial Nerve I
*Olfactory*: smell, rarely tested, sense of smell is present (infant can discriminate between mothers milk & another womans)
CN I (cranial nerves are also covered in tappero but are assessed a little differently in an adult- sorry for repetition)
*Olfactory*: tested when a concern exists. Have 2-3 vials of aromatic odors. Use least irritating odor first. Have pt. close their eyes, occlude 1 nare at a time, have pt. breath in & out with the vial under the nose, identify the odor. Use a different odor for the other side. They should be able to perceive an odor on each side & identify it.
CN II
*Optic*: visual acuity & visual field tests
Cranial Nerve II
*Optic*: visual acuity, visual fields, & funduscopic exam provides info. for this nerve. Ability to fix eyes on an object & follow it over a 60° arc. Nystagmus (involuntary rapid movement of eye) may be seen. When light is introduced in periphery, head should turn toward light source. Evaluate pupil size & constriction in response to light.
CN XI
*Spinal Accessory*: evaluate size, shape, & strength of trapezius & sternocleidomastoid muscles
Position of heart can vary depending on stature
*Tall, slender person: hangs vertically & centrally positioned. *Short person: more to the left & more horizontal
CN V
*Trigeminal*: motor function by observing the face for muscle atrophy, deviation of the jaw to one side, & fasciculations (twitches). Have pt. clench teeth as you palpate muscles over jaw. The 3 divisions of the trigeminal nerve are then tested for sharp, dull, & light touch sensations. With eyes closed, touch the 6 areas of the face in an unpredictable pattern with a broken tongue blade or paper clip, & then a cotton wisp. If impairment is found, use test tubes filled with hot & cold water to evaluate temp. sensation. Corneal reflex can be assessed by lightly touching the corneal with a cotton wisp- symmetric blink reflex expected.
Cranial Nerve V
*Trigeminal*: supplies the jaw muscles, responsible for the sensory innervation of the face. 3 divisions: mandibular, maxillary, & opthalmic. In unilateral facial paralysis, jaw may deviate to paralyzed side when mouth is open. Strength of the masseter muscle is judged by placing gloved finger in mouth & evaluating strength of the biting portion of the suck. The sensory component is estimated by response to rooting reflex or response to gentle touching of the eyelashes with a piece of cotton. Can test corneal reflex by blowing air into eye to ilicit blinking or by touching the cornea with a small piece of cotton.
CN X
*Vagus*: nasopharyngeal sensation- gag reflex. Touch the posterior wall of pharynx with an applicator & observe for upward movement of the palate & contraction of the pharyngeal muscles. Uvula should remain midline. Have pt. say "ah" & observe for movement of the soft palate & uvula for asymmetry. Have pt. sip & swallow water. Listen to speech for hoarseness, nasal quality, or difficulty with guttural sounds.
Cranial Nerve X
*Vagus*: supplies soft palate, pharynx, & larynx. Bilateral lesions of this nerve impair swallowing. Function is evaluated by listening to cry for abnormalities (hoarseness, stridor, aphonia). Ability to swallow= functioning nerve.
What does a "Heave or Lift" indicate?
*a more forceful and widely distributed apical pulse = increased CO or (L) ventricular hypertrophy
S4 = 4th heart sound
*atrial contraction to eject any remaining blood, can sometimes produce S4
Pregnancy
*blood volume increases 40-50% over the prepregnancy level, primarily due to increase in plasma volume. Begins in 1st trimester & reaches max @ 30 weeks. *blood volume returns to prepregnancy within 3-4 weeks after delivery. *on avg, plasma volume increases 50% with singleton & 70% with twins. *heart works harder d/t increased rate & stroke volume -> increase (L) ventricle wall thickness & mass. *cardiac output (CO) increases ~ 30-40% & reaches max @ ~ 25-32 weeks gestation. CO returns to prepregnancy @ ~2 weeks after delivery *uterus enlargement -> movement of diaphragm upwards -> heart shifts more horizontal w/ slight axis rotation.
S2 = 2nd heart sound = "dub"
*closure of Aortic (slightly before) & Pulmonic valves. *composed of 1st) A2 = aortic valve closure & 2nd) P2 = pulmonic valve closure. *often heard as two distinct components = split S2
Cardiac cycle
*electrical stim starts the cycle & precedes the mechanical response by a brief moment. *myocardial depolarization is the cause of events on the (L) side of the heart which occurs slightly before (R) side events. *when heart rate is ~ 68-72 bpm, ventricular systole is shorter than diastole. As rate increases to ~ 120 bpm, the two phases of cardiac cycle approximate each other.
ECG (electrocardiogram)
*graphic recording of electrical activity during cardiac cycle. * records electrical current generated by movement of ions: depolarization & repolarization. *depolarization: spread of stimulus through heart muscle *repolarization: return of stimulated heart muscle to resting state
Heart sounds
*heard best in an area away from the anatomic site b/c the sound is transmitted in the direction of blood flow
S1
*hold breath on expiration; marks beginningof systole; coincides with rise of Carotid pulse. * listen for S1 while you palpate the carotid
Location of heart
*in mediastinum, left of ML, above diaphragm, between medial & lower borders of lungs, behind the sternum. *essentially turned ventrally on its axis, putting the right (R) side more forward.
Valves that connect the four chambers of the heart
*in the fully formed, defect free heart these are the only intracardiac pathways & permit blood flow in only one direction. 1) Atrioventricular valves: between atria & ventricles. Tricuspid & Mitral. Open with atria contraction (diastole) allowing blood to enter ventricles. Close with ventricular contraction (systole) to prevent blood backflow. 2) Semilunar valves: two valves, each has three cusps. Pulmonic & Aortic. Valves open with Systole -> blood rushes into pulmonary artery & aorta. Valves close with Diastole -> prevent blood backflow.
Ventricles
*large, thick walled chambers that pump blood to lungs & body. form the muscle mass of heart. * adult heart: (L) ventricle mass is > than (R) ventricle mass b/c the higher pressure in systemic circulation requires greater contraction. ~ 12cm long, 8cm wide & 6cm AP diameter
Aortic Valve
*lies between the (L) ventricle & the aorta
Position of heart in Infants & Children
*lies more horizontally compared to adults. * apex rides higher, 4th (L) intercostal space. *adult heart position is reached at 7yo
Cardiac disease risk factors
*male, hyperlipidemia, ↑ homocysteine level, HTN, smoking, diabetes, obesity, stress, fatigue *associated s/s: dyspnea, chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea, anorexia, N/V
S2
*marks initiation of diastole; inhale deeply and listen for S2 @ pulmonic auscultatory area
Electrical Impulses control sequence of muscular contarctions
*myocardial contraction originates & is paced by sinoatrial node (SA node) located in wall of (R) atrium then travels through both atria -> atrioventricular node (AV node) located in atrial septum, impulse is delayed then -> bundle of His -> Purkinje fibers located in ventricular myocardium. *ventricular contraction is initiated @ the apex then -> the base of the heart
Fetal circulation
*nonfunctional fetal lungs: blood flows from (R) atrium -> (L) atrium via Foramen Ovale (FO). (R) ventricle pumps blood through patent ductus arteriosus (PDA) rather than to the lungs. *(R) & (L) ventricles are equal in wt & muscle mass b/c they both pump to systemic circulation. (L) ventricle mass increases after birth in response to assuming total responsibility for systemic circulation. *birth changes: closure of ductus arteriosus (~24-48 hrs) & functional closure of interatrial FO as pressure rises in (L) atrium. **@ 1yo = relative sizes of the (L) & (R) ventricles approximate the adult ratio of 2:1
Physical Exam
*perform sitting, supine & (L) lateral recumbent position in order to compare findings. **have the pt lean forward while seated to bring the heart closer to the chest wall to accentuate findings.
Apical pulse
*result of the (L) ventricle's contraction & thrust. *felt in the 5th left intercostal space @ the midclavicular line
Pulmonic Valve
*separates the (R) ventricle from the pulmonary artery
U wave
*small deflection rarely seen just after the T wave, possibly r/t repolarization of Purkinje fibers. ** seen with electrolyte abnormalities
Atria
*small, thin walled reservoirs fro blood returning to the heart from the veins
Ascultation
*sound is transmitted in the direction of blood flow. *heart sounds are relatively low frequency. *diaphragm (firm pressure) then bell (light pressure)
QT interval
*the time elapsed from onset of ventricular depolarization until completion of ventricular repolarization. *varies with cardiac rate.
Tricuspid Valve
*three cusps; separates (R) atrium from (R) ventricle
PR interval
*time from initial stim of atria to initial stim of ventricles . *usually 0.12 - 0.20 secs
Children: Cardiac focus
*tiring during play; lengthy naps; knee-chest or squatting after SOB; HA; nosebleeds; joint pain; expected ht, wt, & physical & cognitive development. *PMI @ 4th intercostal medial to nipple
Pericardium
*tough, double-walled, fibrous sac encasing & protecting the heart. *several mls of fluid are between the inner & outer layers to provide for low friction movements.
Mitral Valves
*two cusps; separates (L) atrium from (L) ventricle
Four Chambers
*two upper = (R) & (L) atria (aka auricles d/t ear like shape. *two lower = (R) & (L) ventricles. *Left-heart: (L) artium & (L) ventricle *Right-heart: (R) atrium & (R) ventricle
Systole
*ventricles contract. * Tricuspid & Mitral valve closure = S1 = 1st heart sound "lub"
Diastole
*ventricles dilate. *relatively passive interval until ventricular filing is almost complete which sometimes produces a 3rd heart sound = S3.
QRS complex
*ventricular depolarization; < 0.10 secs
ST segment & T wave
*ventricular repolarization
2. Lower Lesion Injury - Klumpke's Palsy
- "good shoulder, bad hand" - involves cranial nerve 8 and thoracic nerve 1, with complete or partial paralysis of the forearm and hand muscles - this lower arm paralysis is rare - when lower plexus is involved, the shoulder is in relatively normal position with the wrist and hand flaccid, having little or no control
in a term newborn, ratio of upper body length to the length of the lower body segment should not exceed
- 1.7:1 - this ratio is most useful to determine whether a small newborn is proportionate or has congenitally shortened lower extremities, as in achondroplasia
femoral stretch
- AKA hip extension test - used to detect inflammation of the nerve root at the L1, L2, L3, and sometimes L4 level - have patient lie prone and extend the hip - no pain is expected - presence of pain on extension is a positive sign of nerve root irritation
osgood-schlatter disease
- a traction apophysitis (inflammation of a bony outgrowth)of the anterior aspect of the tibial tubercule - develops in association with inflammation of the anterior patellar tendon - self-limiting disorder is most common in boys between 9-15 - subjective: child is walking with a limp, often describes knee pain - objective: knee swelling that is aggravated by strenuous activity, pain especially prominent with activity involving the quad muscle, pain with palpation over the tibial tuberisity
macrodactyly
- abnormal enlargement of the finger or toe due to osseous or soft-tissue enlargement - may be normal - may be due to neurofibromatosis, lymphadema, hemangioma, arterial vascular fistulas, or lipomas
Sprengel's Deformity (Congenital Elevated Scapula)
- abnormally small, elevated scapula; can be unilateral or bilateral - on exam the scapula is noted to be hypoplastic, elevated, and malrotated; when palpated the vertebral border lies superiorly and more horizontally than normal - angle of scapula may give the appearance of webbed neck or a fullness at base of neck - limitation of shoulder motion, especially in abduction and forward flexion - familial predisposition - frequently associated with congenital spinal problems, renal anomalies, Klippel-Feil syndrome
absolute exclusion criteria for an ankle radiograph series
- age less than 18 years - intoxication - multiple painful (distracting) injuries - pregnancy - head injury - neurological defect
infant feet
- all infants are flat footed - many have a slight varus curvature of the tibias (tibial torsion) or forefoot adduction (metatarsus aductus) from fetal positioning - the midline of the foot may bisect the 3rd and 4th toes, rather than the 2nd and 3rd toes - forefoot should be flexible, straightening with abduction
temporomandibular joint
- an audible or palpable snapping or clicking is not unusual - pain, crepitus, locking, or popping may indicate dysfunction
observe lower leg alignment
- angle between the femur and tibia is expected to be less than 15 degrees - variations of the lower leg alignment are genu valgum (knock knees) and genu varum (bowlegs)
Carrying angle of arm
- angle between the humerus and radius while arm is passively extended, palm forward - angle is usually 5-15 degrees laterally - variations include cubitus valgus (lateral angle exceeding 15 degrees) and cubitus varus (medial carrying angle)
Tibiotalar joint
- ankle - articulation of the tibia, fibula, and talus - protected by ligaments on the medial and lateral surfaces - hinge joint that permits dorsiflexion and plantar flexion - additional ankle joints that permit to pivot or rotate (pronation and supination) are the talocalcaneal (subtalar) joint and transverse tarsal joint - articulations between the tarsals and metatarsals, the metatarsals and proximal phalanges, and the middle and distal phalanges allow flexion and extension
ankles and feet
- ankle and forefoot adduction (positional deformity) can be differentiated form congenital equinovarus (clubfoot) by passively positioning the foot in the midline and dorsiflexing it - a clubfoot or other structurally abnormal foot and ankle will not have ROM and will resist dorsiflexion
convex curvature of the lumbar and thoracic spine
- apparent when infant in sitting position - the lumbar and sacral curves that are seen in adults develop later, when infant sits up and begins to stand
To test hip flexion strength
- apply resistance while the patient maintains flexion of the hip when the knee is flexed and then extended - muscle strength can also be evaluated during abduction and adduction, as well as by resistance to uncrossing legs while seated
Hip joint
- articulation between the acetabulum and the femur - the depth of the acetabulum in the pelvic bone (as well as the joint which is stabilized by three strong ligaments) helps stabilize and protect the head of the femur in the joint capsule - 3 bursae reduce friction in the hip - a ball and socket joint, permitting movement of many axes
Knee
- articulation of femur, tibia, and patella - fibrocartilaginous disks (medial and lateral menisci) which cushion the tibia and femur, are attached to the tibia and the joint capsule - collateral ligaments give medial and lateral stability to knee - 2 cruciate ligaments cross obliquely within the knee, adding anterior and posterior stability - anterior cruciate ligament protects the knee from hyperextension - suprapatellar bursa separates the patella, quadriceps tendon, and muscle from the femur - knee is a hinge joint, permitting flexion and extension between the femur and tibia on one plane
Elbow joints
- articulation of the humerus, radius, and ulna - its 3 contiguous surfaces are enclosed in a single synovial cavity, with the ligaments of the radius and ulna protecting the joint - a bursa lies between the olecranon and the skin - the elbow is a hinge joint, permitting movement of the humerus and the ulna in one plane (flexion and extension)
Forearm joints
- articulations between the radius and ulna at both the proximal and distal locations - important for pronation and supination
scoliosis
- ask patient to bend slowly forward and touch toes - a lateral curvature or rib hump should make you suspect scoliosis - most commonly affects girls and progresses during early adolescence - no known cause - associated with leg length discrepancy - may have crease on one side of waist
strength of temporalis and masseter muscles
- ask patient to clench teeth while you palpate the contracted muscles and apply opposing force - simultaneously tests cranial nerve V
phalen test
- ask patient to hold both wrists in a fully palmar flexed position with dorsal surfaces pressed together for 1 minute - numbness and parathesia in the distribution of the median nerve are suggestive of carpal tunnel - reverse phalen test is performed by placing the palms and fingers together with full wrist extension
Muscle strength
- ask the pt to first contract the muscle you indicate by extending or flexing the joint and then to resist as you apply force against that muscle contraction - alternatively, tell the patient to push against your hand to feel the resistance
lumbosacral hyperextension
- ask woman to bend forward at the waist toward her toes, palpate the distance between L4 and S1 spinal processes, as she rises to standing note when the distance between the two becomes fixed before the spine is fully extended - she may be hyperextended when walking, possibly resulting in lower back pain - most back pain resolves within 6 months after delivery
thumb abduction test
- assess median nerve - weakness associated with carpal tunnel
neurovascular assessment
- assess when an extremity is injured, assess distal to the injury - unexpected findings: pallor or cyanosis, cool or cold, cap refill > 4 sec, significantly swollen, presence of moderate to severe pain, numbness, tingling, pins and needles sensation, decreased or no movement - needs emergency intervention
upper extremity
- assymmetry in ROM may indicate weakness, paralysis, fractures, or infection - failure to move an extremity can indicate a spinal cord injury or BPP
legg-calve-perthes disease
- avascular necrosis of the femoral head - results from a decreased blood supply to the femoral head - subjective: most common in boys between 3-11; pain often referred to the medial thigh, knee, or groin; bilateral involvement may occur in 10% of cases - objective: children may have a limp that is painless or antalgic (painful limp with shorted time on extremity); loss of internal rotation; abduction and decreased ROM on affected side; muscle weakness of the upper leg may be present if symptoms have been present for a prolonged period
Knee ROM
- bend each knee, expect 130 degrees of flexion - straighten leg and stretch it, expect full extension and up to 15 degrees of hyperextension
ROM of hand and wrist
- bend fingers forward at metacarpophalangeal joint, then strethc the fingers up and back at the knuckle - flexion of 90 degrees is expected - hyperextension of 30 degrees is expected - Fig A
ROM of thoracic and lumbar spine
- bend forward at the waist and try to touch toes without bending knees, expect flexion of 75 to 90 degrees - bend back at waist as far as possible, expect hyperextension of 30 degrees - bend to each side as far as possible, expect lateral bending of 35 degrees - swing upper trunk from waist in a circular motion from to side and back to side while you stabilize pelvis, expect rotation of the upper trunk 30 degrees forward and backward
cervical spine ROM
- bend head forward chin to chest, expect flexion of 45 degrees - bend head backward, chin to ceiling, expect extension of 45 degrees - bend head side to side, ear to each shoulder, expect lateral bending degree of 40 degrees - turn head side to side, chin to shoulder, expect rotation of 70 degrees
ROM of hand and wrist
- bend the hand at the wrist up and down - flexion of 90 degrees - hyperextension of 70 degrees - Fig C
Osteoarthritis
- bony overgrowths in the distal interphalengeal joints, which can be felt as hard, nontender nodules usually 2-3 mm in diamter but sometimes encompassing the entire joint are associated with osteoarthritis
chest circumference
- can be useful when compared to FOC if the examiner suspects a problem with head or chest size - measure at the nipple line during expiration - term infants: average chest circumference is approx 2cm smaller than the FOC - average is 30.5-33cm (12-13in) - FOC may exceed the chest circumference for the first 5 months of life - from 5 months to 2 years, FOC and chest can be about the same
radial head subluxation (nursemaid's elbow)
- caused by jerking the arm upward while the elbow is extended, the jerking pulls apart the elbow joint and tears the margin of the annular ligament around the radial head into the joint - subjective: common in children 1-4 years old; child complains of pain in the elbow and wrist and refuses to move the arm - objective: holds arms slightly flexed and pronated; supination motion is resisted
spindle shaped fingers
- caused by painful swelling of the proximal interphalangeal joints - associated with acute stage of rheumatoid arthritis
rheumatoid arthritis
- chronic systemic inflammatory disorder of the synovial tissue surrounding the joints - cause is unknown; within the inflamed synovial tissue and fluid polymorphonuclear leukocytes aggregate; multiple inflammatory cytokines and enzymes are released that can result in subsequent damage to bone, cartilage, and other tissues - subjective: joint pain and stiffness, especially in the morning or after periods of inactivity; constitutional symptoms of fatigue, myalgias, weight loss, and low grade fever are common - objective: involved joints include the hands, wrists, feet, ankles as well as hips, knees, and cervical spine; synovitis with soft tissue swelling and effusions is present on exam; nodules and characteristic deformities can develop
internal tibial torsion
- common of almost all newborns - usual cause of in-toeing from birth to 2 years - spontaneous recovery is expected
dislocation
- complete separation of the contact between 2 bones in a joint - often caused by pressure or force pushing the bone out of the joint, usually occurs in trauma - subjective: can occur more easily in patients with hyperextensibility conditions (Marfan, Ehlers-Danlos) - objective: deformity and inability to use the extremity or joint as usual
Spine
- composed of cervical, thoracic, lumbar, and sacral vertebrae - all but the sacral vertebrae are separated from each other by fibrocartilaginous disks - each disk has a nucleus of fibrogelatinous material that cushions the vertebral bodies - vertebrae form a series of joints that glide slightly over eachother's surfaces, permitting movement on several axes
carpal tunnel syndrome
- compression of median nerve - due to microtrauma, local edema, repetitive motion, or vibration of hands - associated with rheumatoid arthritis, gout, acromegaly, hypothyroidism, and hormonal changes of pregnancy - subjective: numbness, burning, or tingling in the hands often occur at night; can also be elicited by rotational movements; pain may radiate to arms - objective: weakness of the thumb and flattening of the thenar eminence of palm
Rotator cuff
- comprised of 4 muscles (supraspinatus, infraspinatus, teres minor, subcapularis) and their tendons - reinforces the glenohumeral joint to stabilize the shoulder and the position of the humeral head within the joint - shoulder is a ball and socket joint that permits movement of the shoulder in many axes
syndactyly
- congenital webbing of fingers or toes, most common deformity of upper extremities - caused by failure, during 6th to 8th week of gestation, of the usual necrosis of skin that normally separates the fingers - appears sporadic in most cases, some is familial - can occur with other congenital anomalies such as Apert's and Streeter's dysplasia - severity ranges from minimal "bridging" between adjacent fingers/toes to complete webbing of hand or foot - syndactyly of toes does not interfere with function - treatment of syndactyly of fingers depends on severity of webbing - when multiple fingers involved, function may deteriorate as the fingers grow - early correction, especially if the fingers affected are of unequal length - ortho consult
dupuytren contracture
- contractures involving the flexor hand tendons - cause is unknown, although there may be a hereditary component - subjective: flexion contractures develop insidiously; incidence increases after the age of 40, occuring more frequently in men - objective: flexor tendons generally of the 4th and 5th digits contract, causing fingers to curl with impaired extension; these tendons are easily palpable
clavicles
- crepitus (grating that can be felt or heard on movement of ends of a broken bone) - suspect a fractured clavicle when there is history of difficult delivery, irregularity in contour, shortening, tenderness, crepitus, asymmetric Moro - most common birth injury: broken clavicle
osteoporosis
- decrease in bone mass because bone resorption is more rapid than bone deposition - become fragile and susceptible to spontaneous fractures - most commonly seen in postmenopausal women - glucocorticoid excess and hypogonadism are also risk factors - subjective: presenting symptom is usually loss of height or and acute painful fracture; most common fracture sites are hip, vertebrae, and wrist - objective: affected persons lose height and have decreased abdominothoracic space; in the spine vertebral compression fractures lead to kyphosis or scoliosis
Klippel-Feil Syndrome
- defect of cervical vertebrae: both decrease in # of vertebrae and fusion of 2 or more vertebrae - those diagnosed in newborn period have upper spine involvement as opposed to lower cervical involvement - varies in severity depending on # of vertebrae that are fused - unknown cause; theories say fetal insult, in utero vascular insult, or neural tube anomalies; sometimes familial indicating a genetic transmission - neck appears shorter than normal, decreased ROM is most frequent clinical finding - rotational loss more pronounced than loss of flexion/extension - classic signs seen in less than 50% of neonates with syndrome: short neck, low posterior hairline, limitation of neck motion - confirm with x-ray of neck - other bone abnormalities associated with this: sprengel's deformity, congenital scoliosis, congenital limb deficiencies
osteoarthritis
- deterioration of the articular cartilage covering the ends of the bone in synovial joints - as a result of cartilage abrasion, pitting, and thinning, the bone surfaces are eventually exposed with bone rubbing against bone - separately there can be remodeling of the bone surface and formation of bone spurs - subjective: pain in hands/feet/hips/knees/cervical and lumbar spine (most commonly); onset usually begins after 40 and develops slowly over many years with nearly 100% of people older than 75 being affected - objective: the joints may be enlarged due to bone growths (osteophytes); may have crepitus and limited, painful ROM
barlow maneuver
- determines whether the femoral head can be dislocated from the acetabulum - hand position is same as for ortoloni, with hip and leg flexed - as knee is brought to center (adducted) from the abducted position, the practitioner's thumb pushes laterally on the upper inner thigh - a "clunk" indicates that the femoral head has slipped over the lateral edge of the acetabulum, hip joint is unstable and dislocatable - a variation of barlow is to stabilize pelvis with one hand while using the other to try to move the thigh anteriorly and posteriorly without flexing the hip
rheumatoid arthritis
- deviation of fingers to the ulnar side - swan neck deformities - boutonniere deformity
elbow, forearm, wrist
- difficult to evaluate the elbow in infants because the normal neonate has a mild flexion contracture that does not disappear until a few weeks after birth - greater wrist flexion in term than preterm neonates
When muscle strength is grade 3 or less
- disability is present; activity cannot be accomplished in a gravity field; external support is necessary to perform movements - weakness may result from disuse, atrophy, pain, fatigue, or overstretching
gout
- disorder of purine metabolism that results in elevated serum uric acid level - monosodium urate crystal deposition in joints and surrounding tissues results in acute inflammatory attacks - subjective: sudden onset of hot, swollen joint; exquisite pain; limited ROM; primarily affects men older than 40 and postmenopausal women; usually affects the proximal phalanx of the great toe, although the wrists, hands, ankles, and knees may be involved - objective: the skin over the affected joint may be shiny and red or purple; uric acid crystals may form as tophi under the skin with chronic gout
tibial torsion
- draw imaginary line connecting the anterior-superior iliac spine with the mid-patella, and continue down the foot - external tibial torsion: if line falls medial to big toe - internal tibial torsion: if line falls lateral to second toe
Infants and Children Considerations
- during fetal development, skeletal system emerges from embryologic connective tissues to form cartilage that calcifies and eventually becomes bone - long bones increase in diameter by the growth of the new bone tissue around the bone shaft - increased length of bones results from proliferation of cartilage at the growth plates (epiphyses) - in smaller bones (such as carpals) ossification centers form in calcified cartilage - specific sequence and timing of bone growth and ossification during childhood - ligaments are stronger than bone until adolescence, therefor injuries to long bones and joints are more likely to result in fractures than in sprains
DDH - treatment/diagnosis
- easiest and most effective if started in first 6 months of life - 60-80% resolve with no intervention - most effective diagnostic tool during 1st month of life: ultrasound (completed on infants with high risk factors such as females in breech position or those with positive ortoloni or barlow tests) - radiographs of newborns with suspected DDH of limited value: because femoral heads do not ossify until 4-6 months of age - early treatment with Pavlik harness and von Rosen splint shows 95% success rate
Older Adults Considerations
- equilibrium between bone deposition and bone resorption changes, and resorption dominates - for menopausal women, decreased estrogen increases bone resorption and decreases calcium deposition, resulting in bone loss and decreased bone density - woman can lose up to 30% of bone mass by age 80 - long bones and vertebrae particularly vulnerable to loss of bone density - weight bearing bones may become predisposed to fractures - bony prominences become more apparent with the loss of subcutaneous fat - cartilage around joints deteriorates - muscle mass undergoes alterations as increased amounts of collagen collect in the tissues initially, followed by fibrosis of connective tissue - tendons become less elastic, resulting in reduction of total muscle mass, tone, and strength - progressive decrease in reaction time, speed of movement, agility, and endurance
lachman test
- evaluate anterior cruciate ligament integrity - with patient supine, flex the knee 10-15 degrees with the heel on the table, place one hand above knee to stabilize the femur and place the other hand around the proximal tibia, while stabilizing the femur pull the tibia anteriorly, attempt to have the patient relax the hamstring muscles for an optimal test - increased laxity greater than 5mm compared to the other uninjured side, indicates injury to the ligament
assessment for carpal tunnel syndrome
- evaluate integrity of median nerve, which innervates the palm of the hand and the palmar surface of the thumb, index and middle fingers, and half of the ring finger - ask patient to mark the specific locations of pain, numbness, and tingling on the Katz hand diagram
Range of motion and muscle tone
- evaluated simultaneously - pain, limitation of motion, spastic movement, joint instability, deformity, and contracture suggest a problem with the joint, related muscle group, or nerve supply - during examination of passive ROM do not force the joint if there is pain or muscle spasm - muscle tone may be assessed by feeling the resistance to passive stretch - during passive ROM, the muscles should have slight tension - passive ROM often exceeds active ROM by 5 degrees - discrepancies between active and passive ROM may indicate a true muscle weakness or a joint disorder - spastic muscles are harder to put through ROM
Neck ROM
- examine for rotation and for anterior and lateral flexion - rotation of 80 degrees and lateral flexion of 40 degrees to both right and left sides is normal - in anterior flexion the chin should touch or almost touch chest - in extension, the occipital part of head should touch or almost touch back of the neck
muscle strain
- excessive stretching or forceful contraction beyond the muscles functional capacity, often associated with improper warm up, fatigue, or previous injury - subjective: muscle pain, severity ranges from mild intrafibrous tear to total rupture of single muscle - objective: temporary muscle weakness or spasm, pain, contusion
temporomandibular joint
- expect 3-6cm between upper and lower teeth when jaw is open - expect lateral movement of 1-2cm in each direction - should be able to protrude and retract chin
polydactyly
- extra digits - postaxial (small finger, small toe) polydactyly has a variable racial incidence - more common with african american infants, less common in caucasian - more frequent in infants with positive family history - can be isolated or an autosomal dominant trait - can be a manifestation of a multiple malformation syndrom such as trisomy 13 or Meckel-Gruber syndrome - postaxial polydactyly in african american infants almost always an isolated finding - postaxial polydactyly in caucasians without a family history is associated with chromosomal abnormalities or other malformations - most common type is a floppy digit or skin tah on either side of the radial or ulnar side of the hand - may also involve duplication of a normal looking digit, giving the infant a functional 6 fingered hand or foot with 6 toes
toddler feet
- fat pad obscures longitudinal arch of foot until age 3 - after that time the arch should be apparent when the foot is not bearing weight - metatarsal adductus should be resolved - feet will pronate slightly inward until after about 30 months, after that weight bearing should shift to the midline of the feet
ganglion
- firm mass over the dorsum of the wrist - cystic, round, nontender swellings along tendon sheaths or joint capsules that are more prominent with flexion
clubfoot (talipes equinovarus)
- fixed congenital defect of the ankle and foot - causes include genetic factors and external influences in the final trimester such as intrauterine compression - subjective: diagnosis is usually obvious at birth - objective: most common combination of position deformities includes inversion of the foot at ankle and plantar flexion, with the toes lower than the heel
hand - trisomy 18
- flexed fingers with the index finger overlapping the third finger
paget disease of the bone - osteitis deformans
- focal metabolic disorder of the bone - appears in persons older than 45; excessive bone resorption and bone formation produce a mosaic pattern of lamellar bone - subjective: bones of skull are often affected, which can produce symptoms of vertigo and headache; progressive deafness from involvement of the ossicles or neural elements may develop - objective: bowed tibias, misshapen pelvis, or prominent skull forehead may be evident; frequent fractures may occur
Neer test
- forward flex the patients arm up to 150 degrees while depressing the scapula - this depresses the greater tuberosity and supraspinatus muscle against the anteroinferior acromion - increased shoulder pain is associated with rotator cuff inflammation or a tear
examine spine
- from base of skull to coccyx, noting any skin disruption, tufts of hair, soft or cystic masses, hemangiomas, a pilondial dimple, cysts, or sinus tracts: these may be signs of congenital spinal or neurologic anomaly
palpate popliteal space
- fullness in popliteal space may indicate a popliteal (Baker) cyst
Sacral vertebrae
- fused - form the posterior portion of the pelvis with the coccyx
hips of newborn
- generally have a flexion contracture - when pelvis is stabilized and the lumbar spin is flattened out by extending one leg flat and flexing the other knee to the chest, a flexion contracture of the hip can be detected in the extended leg - the degree of flexion contracture on the extended leg is the angle that is measured between the thigh and the horizontal plane of the bed or exam table - normal newborns have a 20-30 degree contracture that resolves by 4-6 months of age - newborn hip can externally rotate 80-90 degrees, and internal rotation 0-10 degrees
excessive hyperextension of the knee with weight bearing
- genu recurvatum - may indicate weakness of the quadriceps muscle
muscular dystrophy
- group of genetic disorders involving gradual degeneration of the muscle fibers - progressive symmetric weakness and muscle atrophy or pseudohypertrophy from fatty muscle infiltrates - skeletal muscles and the heart may be involved - some forms result in only mild disability, and these patients can expect a normal life span - other types produce severe disability, deformity, and death - subjective: early signs include clumsiness, difficulty climbing stairs, and frequent falls - objective: muscle atrophy and weakness with a waddling gait; positive gower sign; progressive loss of function, including inabilty to walk
pregnancy
- growing fetus shift center of gravity forward, leading to increased lordosis and a compensatory forward cervical flexion - stopped shoulders and large breasts exaggerate spinal curvature - increased mobility and instability of the sacroiliac joints and symphasis pubis as the ligaments become less tense contribute to the "waddling" gait of pregnancy - carpal tunnel syndrome experienced by some women during the last trimester because of the associated fluid retention, but should resolve several weeks after delivery
Congenital Absence of the Radius (Radial Dysplasia)
- hand and wrist deviated to 90 degrees or more - forearm shortened with bowing of the ulna - thumb usually absent or hypoplastic - marked limited movement of the hand, wrist, forearm - males more than females - may be inherited sporadically, must further evaluate for VACTERL (vertebral anomalies, anal anomalies, atresia, cardiac anomalies, tracheoesophageal abnormalities, renal abnormalities, and limb anomalies); Fanconi anemia; and Holt-Oram syndrome - treatment: both operative and nonoperative options, for cosmetic and functional reasons; consult pedi hand surgeon
bowleg (genu varum)
- have child stand facing you, knees at eye level, measure distance between the knees when medial malleolus of ankles are together - genu varum if space is 2.5cm (1in) between knees - common finding in toddlers until 18 months
evaluate strength of sternecleoidmastoid muscle and trapezius muscle
- have patient maintain each of the above positions while applying opposing force - with rotation, cranial nerve XI is tested
evaluate strength of shoulder
- have patient shrug shoulders while you apply opposing force - measures strength of shoulder girdle muscles - cranial nerve XI is simultaneously evaluated
Evaluate hand strength
- have pt tightly grip 2 of your fingers - to avoid painful compression from an overzealous squeeze, offer your 2 fingers of one hand side by side in a handshake position
ankylosing spondylitis
- hereditary, chronic inflammatory disease, may affect cervical, thoracic, and lumbar spine and will also involve the sacroiliac joints - inflamed intervertebral disks and longitudinal ligaments ossify; leads to eventual fusion and severe deformity of the vertebral column - Subjective: men between 20-40, begins with low back and buttock pain also involving hips and shoulders; buttock pain can fluctuate from one side to other - Objective: restriction in lumbar flexion of patient; limited ROM of shoulders, chest wall, hips, knees; uveitis may be present (swelling and irritation of middle part of eye)
lumbosacral radiculopathy (herniated lumbar disk)
- herniation of lumbar disk that irritates the corresponding spinal nerve root - generally caused by degenerative changes of the disk; most commonly at L4, L5, and S1 nerve roots; greatest incidence between 31 and 50 years of age - Subjective: associated with lifting heavy objects, common symptoms include low back pain with radiation to the buttocks and posterior thigh or down the leg in the distribution of the dermatome of the nerve root, pain relief is achieved by lying down - Objective: spasm or tenderness over the paraspinal musculature may be present, potentially difficulty with heel walking (L4 or L5) or toe walking (S1), numbness, tingling, or weakness in the involved extremity
clubfoot (talipes equinovarus)
- high incidence in caucasians - highest incidence in polynesians - lowest incidence in asians - males twice as often as females - likely cause is combo of genetic and environmental factors - neural, muscular, as osseous factors are also possible - within families, the probability is 3% for siblings and 20-30% for the offspring of affected parents - clinical presentation characterized by 3 primary components: adduction of the forefoot (points medially), prnounced varus of the heel, and downward pointing of the foot and toes (equinus positioning) - may be unilateral, bilateral in 50% - some relativleey flexible and correctable with exercises and serial casting - surgery required when this fails - can be started in nursery - consult ortho on day of birth
to evaluate general muscle strength of infant
- hold infant in vertical suspension with your hands under the axillae - adequate shoulder muscle strength is present if infant maintains the upright position - if infant starts to slip through your fingers, proximal muscle weakness is present
anterior and posterior drawer test
- identifies instability of the anterior and posterior cruciate ligaments - patient lie supine and flex the knee 45 to 90 degrees, placing foot flat on table, place both hands on the lower leg with the thumbs on the ridge of the anterior tibia just distal to the tibial tuberosity, draw the tibia forward, forcing the tibia to slide forward of the femur, then push the tibia backward - anterior or posterior movement of the knee greater than 5mm in either direction is an unexpected finding
initial treatment of BPP
- in cases where nerve roots are not disrupted, infants regain neurologic function within several days as the hemorrhage and edema in area resolve - gentle handling and protection of the arm 1st few days of life will avoid any additional injury to plexus - initial treatment: aimed at preventing contractures of the shoulder, elbow, forearm, and hand during observational recovery phase - most infants gain significant functional improvement by 3 months, close exam reveals tightness of shoulder on internal rotation, difficulties of supination of forearm, and abduction of shoulder
Brachial Plexus Palsy (BPP)
- incidence of lower plexus lesions has decreased significantly with decline in vaginal breech births - result of prolonged and difficult labor involving traction and lateral flexion of neck - also attributed to abnormal in utero forces on the posterior shoulder of the fetus as it passes over maternal bony prominences such as the sacral promontory - increased in utero pressure and traction also proposed as the cause in an abnormal uterus (bicornuate or fibroid uterus) - other perinatal factors: LGA, breech presentation, shoulder dystocia in vertex deliveries, difficult head or arm extraction in breech deliveries - 3 types of BPP
older adults
- increased dorsal kyphosis, accompanied by flexion of the hips and knees - head may tilt backward to compensate for the increased thoracic curvature - extremities may appear long if the trunk has diminished in length due to vertebral collapse - base of support may be broader with the feet more widely spaced, and patient may hold arms away from body to aid balancing - reduction in total muscle mass: related to atrophy (due to disease such as arthritis) or loss of nerve innervation (diabetic neuropathy)
Pregnant Women Considerations
- increased hormonal levels contribute to elasticity of ligaments and softening of cartilage in the pelvis at about 12 to 20 weeks gestation - increased mobility of the sacroiliac, sacrococcygeal, and symphysis pubis joints results - as fetus grows, lordosis (inward curvature of lower spine) occurs in effort to shift the center of gravity back over the lower extremities - ligaments and muscles of the lower spine may become stressed, leading to lower back pain
osteomyelitis
- infection in the bone - usually results from an open wound or systemic infection; purulent matter spreads through the cortex of the bone and into the soft tissue; decreased blood flow to the affected bone may lead to necrosis - subjective: dull pain usually develops insidiously at the involved site and progresses over days to weeks; limp or decreased movement in infants and children - objective: signs of infection include edema, erythema, and warmth of the site; tenderness to palpation, pain with movement, and signs of inflammation such as fever
bursitis
- inflammation of the bursa - due to repetitive movement and excessive pressure on the bursa, can also be due to infection or gout - subjective: common sites are the shoulder, elbow, hip, knee; with pain and stiffness surrounding the joint around the inflamed bursa; pain usually worse during activity - objective: limitation of motion caused by swelling, pain on movement, point tenderness, and erythematous warm site; soreness may radiate to tendons at site
tenosynovitis (tendonitis)
- inflammation of the synovium lined sheath around tendon - seen with repetitive actions associated with occupational or sports activities, can occur with inflammatory conditions like rheumatoid arthritis - subjective: pain with movement of common sites such as shoulder, knee, heel, wrist - objective: point tenderness over the involved tendon; pain with active movement and some limitation of movement in the affected joint
3. Complete Paralysis of Arm
- injury to plexus at all levels - paralysis of wrist and hand, shoulder and elbow dysfunction - skeletal injury may coexist and should be ruled out radiographically
Inspection
- inspect the anterior, posterior, and lateral aspects of the patient's posture; ability to stand erect; symmetry of body parts; alignment of the extremities
Fasciculation
- involuntary twitching of the muscle - occurs after injury to a muscle's motor neuron
secondary treatment of BPP
- involves nerve repair to restore neurologic function that hasn't occurred spontaneously - infants with total plexus involvement: need brachial plexus exploration and reconstruction if no return of bicep function at 3 months of age - if arm remains flaccid at 2-3 months for infants with upper BPP, surgery is done at 3-6 months - if peripheral nerve disruption or nerve root disruption, early intervention with microsurgery is recommended - 20% require surgery
term newborn posture
- lie in a symmetric position with limbs flexed and the legs partially abducted at the hips so that the soles of the feet may nearly touch each other - head is slightly flexed and positioned in midline or turned to one side - resting position is often that of the tonic neck reflex - spontaneous motor activity of flexion and extension, alternating between arms and legs, is random and uncoordinated - fingers are usually in a fist, with thumb under the fingers - slight tremors may be seen in the arms and legs with vigorous crying during the first 48 hrs of life - any tremors noted after 4 days of age while the infant is at rest is abnormal and a sign of a neurological problem
carpal tunnel - positive electrodiagnostic study
- likelihood of a positive electrodiagnostic study is increased by the following: weakened thumb abduction, a classic or probable distribution of symptoms on the Katz hand diagram, and hypalgesia (decreased pain sensation along the thumb and median nerve distribution when compared to the little finger on the same hand) - tinel and phelan tests are less accurate
nails
- long in post-term - absent or spoon shaped in some syndromes
Knee effusion
- loss of concavities on the anterior aspect, on each side, of knee and above patella - fluid fills the suprapatellar pouch and the concavity below the patella medially - the usual indentation above and on the medial side of the patella is filled out to be convex rather than concave
Evaluate strength of wrist muscles
- maintain wrist flexion and hyperextension while you apply opposing force
trendelenburg test
- maneuver to detect weak hip abductor muscles - ask patient to stand and balance first on one foot and then the other, observing from behind, note any assymetry or change in the level of the iliac crests - when the iliac crest drops on the side of the lifted leg, the hip abductor muscles on the weight bearing side are weak
puffy hands and feet
- may appear as a result of lymphedema - characteristic finding of Turner and Noonan
congenital absence of tibia or fibula
- may be partial or complete - absence of tibia: mild to marked shortening of lower leg, knee is unstable and has a flexion contracture, foot may be normal or fixed in a mild to severe varus position - absence of fibula: shortening of involved leg, bowing of tibia anteriorly and medially, foot deformity is often severe, with a valgus position - need early intervention with an orthopedist - parents should be offered genetic counseling due to high potential for transmission of disorder and associated disorders
head circumference
- measure around occipital and parietal areas over the frontal prominence, avoiding the ears - intrauterine head growth is 0.5-0.8cm/week and is an indicator of brain growth - average FOC in term newborns is 33-35cm (13-14in) with normal variations of 32.5-37.5cm (12.5-14.5in) - FOC can change markedly in first few days because of head molding of the head during delivery - obtain FOC weekly and plot on GA appropriate grwoth chart - FOC is correlated with neurodevelopment - as a general rule the FOC (in cm) = 1/2 the body length (in cm) + 10
infant length
- measured from heel to crown (top of head) with infant supine, legs extended, head flat - make marks on bed at head and heel, then measure between marks - direct measurement of infant is difficult because of head molding and incomplete extension of knees - length of term newborns at birth is 48-53cm (19-21in) - average linear growth in preterm infants is 0.8-1cm/wk - in term is 0.69-0.75cm/wk
rotator cuff tear
- microtrauma and tearing - usually due to degeneration of the muscle and tendon form repeated overhead lifting and compression of the acromion; an acute tear may also result from a fall on an outstretched arm - subjective: pain in the shoulder and deltoid area is common, can awaken the patient at night - objective: inability to maintain a lateral raised arm against resistance; tenderness over the acromionclavicular joint; grating sound on movement, crepitus, and weakness in external shoulder rotation
lower extremities of infants
- mild bowing and external rotation of the lower leg due to intrauterine environmental conditions and fetal positioning - bowing is combo of rotational deformity caused by external rotation of the hip and internal tibial torsion from in uterine position
metatarsus adductus
- most common foot anomaly - deformity of forefoot in which metatarsal bones are deviated medially - probably result of intrauterine positioning - multiple pregnancies and oligo (both decrease room for fetal movement) - equally in males and females, bilaterally in 50% - can be a positional (flexible) deformity with no bony abnormality involved OR a structural (fixed) - positional: forefoot is very mobile and easily abducted, heel likely in neutral position - structural: arch appears greater than normal, may be a medial crease at its middle portion, cant abduct forefoot beyond midline - severe structural anomaly: the heel (hindfoot) in a valgus position - 85% resolve by 3 years old and develop normal foot position and function with no treatment - positional deformities will resolve spontaneously or can be treated with stretching - in a rigid foot an ortho consult is needed for possible casting - surgery indicated only when casting is unable to produce a flexible foot
1. Upper Lesion Injuries - Erb's Palsy
- most frequent type, involves complete or partial paralysis of the shoulder muscles, result of injury to cranial nerves 5, 6, and occasionally 7 - "bad shoulder, good hand" -holds affected arm adducted and internally rotated, with extension at elbow, pronation of the forearm, and flexion of the wrist - Grasp remains intact, but Moro reflex is absent on affected side
Synovial joints
- most joints are synovial - freely moving articulations containing ligaments and cartilage covering the ends of the opposing bones, which are enclosed by a fibrous capsule - a synovial membrane lines the joint and secretes the serous lubricating synovial fluid - bursae develop in the spaces of connective tissue between tendons, ligaments, and bones to promote ease of motion at points where friction would occur
Cervical vertebrae
- most mobile - flexion and extension occur between the skull and C1 - rotation occurs between C1 and C2
soles of feet
- most newborns are flat footed as the result of a plantar fat pad (in the longitudinal arch) - gradually disappears during first year of life
ortolani and barlow maneuvers
- most reliable screening test for evaluating hip stability - performed together in sequence - infant must be in supine position on a relatively firm surface - should not be forceful - a crying, kicking infant can generate enough muscle strength by tightening the adductors and hamstrings to create a false result
Myelomeningocele
- most severe type of spina bifida - congenital neural tube defect; bones of spine don't completely form - presents as a failure of closure at the caudal (tail) end of the vertebral column, permitting the meninges and sometimes the spinal cord to protrude into a sac-like structure - skin disruption not always present so any soft mass over the spine or just off of midline must be examined closely - functional deficit of lower extremities linked to level of involvement; important to examine muscle function of lower extremities - may also see syringomyelia and hip dislocation
Developmental Dysplasia of the Hip (DDH)
- most significant deformity of newborn period - ranges from mild instability (femoral head remains in acetabulum) to irreducible dislocation (where femoral head loses contact completely with the acetabular capsule and is displaced over the fibrocartilaginous rim) - caused by lack of acetabular depth, ligamentous laxity, abnormal intrauterine positioning (breech) - 30-50% due to breech - african and chinese infants have a low incidence - native american and eastern european infants high incidence - these differences may be due less to genetic predisposition and more to child rearing practices such as swaddling (keeps hips in adduction and extension) - females more than males - left more affected than right - parent with DDH or sibling with DDH increases risk - more common in infants with orthopedic conditions: torticollis, congenital foot deformities (clubfoot, metatarsus adductus)
herniated L5
- motor weakness in dorsi flexion of great toe and foot - screening exam: heel walking - reflexes: none reliable
herniated L4
- motor weakness in extension of quadricep - screening exam: squat and rise - reflexes: knee jerk diminished
herniated S1
- motor weakness in plantar flexion of great toe and foot - screenign exam: walking on toes - reflexes: ankle jerk diminished
lumbar stenosis
- narrowing of spinal canal - canal narrowing from bone and ligament hypertrophy may lead to entrapment of the spinal cord as it traverses the spinal canal - Subjective: pain with walking or standing upright that often seems to originate in the buttocks and may radiate down the legs, pain relief may occur with sitting or bending forward, pain may be worsened by prolonged standing, walking, or hyperextending the back - objective: with progression the neuro exam may show lower extremity weakness and sensory loss
congenital scoliosis
- not chormosomal or inherited; an embryonic defect; but may be familial - failure of vertebral formation, segmentation, or a variety of both; can be in any area of vertebral body - females more affected than males, and their curvature likely to worsen - can hold infant under armpits to assess for - if undetected: severe deformities can develop and affect neurologic function/cosmetic appearance - evaluate for genitourniary tract anomalies (unilateral renal agenesis is most common) - Klippel-Feil and Sprengel's deformity can also be seen
ROM
- note assymmetry, tightness, contractures - ROM of all joints is greatest in infancy, gradually lessening with maturity - varies with GA
Risk factors for osteoarthritis
- obesity - family history of osteoarthritis - hypermobility syndromes - aging (older than 40 years) - injury, high levels of sports activities - occupation requiring over use of joints
general observation
- observation for symmetry of movement, size, shape, general alignment, position, and symmetry of different parts of body - observe soft tissues and muscles for swelling, muscle wasting, symmetry
galeazzi (alli's) sign
- observe femoral length with feet flat on bed and femurs aligned, flex both of the infant's knees, with tips of big toes in same horizontal plane, face the feet and observe the height of the knees - positive sign: one knee higher than other - discrepancy in knee height should lead you to investigate for DDH - 24% of patients with congenital constricting bands have a leg length discrepancy
if a discrepancy is seen in the ratio of extremity length to body length
- obtain a thoracic length and extremity length - the GA of the infant determines the normal values for these measurements
TMJ syndrome
- painful jaw movement - caused by congenital anomalies, malocclusion, trauma, arthritis, and other joint diseases - subjective: unilateral facial pain that usually worsens with joint movement; may be referred to anywhere on face or neck - objective: most patients have a muscle spasm, and many have a clicking, popping, or crepitus in the affected joint
fracture
- partial or complete break in continuity of bone from trauma (indirect ,direct ,twisting, crushing) - subjective: pain, limited movement, cannot bear weight, swelling, felt a pop or snap with injury, can occur more easily in patients with bone disorders (osteogenesis imperfecta, osteoporosis, bone metastasis) - objective: deformity, edema, pain, loss of function, color changes, paresthesia
Hawkins test
- performed by abducting the shoulder to 90 degrees, flexing the elbow to 90 degrees, and then internally rotating the arm to its limit - increased shoulder pain is associated with rotator cuff inflammation or a tear
ROM of foot and ankle
- point toe to ceiling, expect dorsiflexion of 20 degrees - point toes to floor, expect plantar flexion of 45 degrees - bending foot at the ankle, turn sole of the foot toward and then away from the other foot, expect inversion of 3o degrees and eversion of 20 degrees - rotating the ankle, turn foot away from and then toward the other foot while the examiner stabilizes the leg, expect abduction of 10 degrees, and adduction of 20 degrees - bend and straighten the toes, expect flexion and extension, especially of the great toes
barlow ortoloni maneuver
- positive barlow: a clunk or sensation is felt as femoral head exits the acetabulum posteriorly - positive ortoloni: if head of femur slips back into the acetabulum with a palpable clunk when pressure is exerted, suspect hip sublaxation or dislocation - high-pitched click are common and expected - by 3months muscles and ligaments tighten, and limited abduction of the hips becomes the most reliable sign of hip subluxation or dislocation
Obtaining a birth history in infants and children
- presentation, LGA, birth injuries (may result in fractures or nerve damage), type of delivery, use of forceps - low birth weight, premature, resuscitation efforts, intrauterine insult or perinatal asphyxia, fetal stroke, maternal infections leading to muscle tone disorders, required ventilator support (may result in anoxia leading to muscle tone disorders)
congenital constricting bands (amniotic band syndrome, amnion disruption sequence, Streeter dysplasia)
- presents as a band encircling the arms, legs, fingers, or toes - can vary from mild, shallow indentions of the soft tissue to severe constrictions causing partial or complete amputation - occasionally the craniofacial structures are affected - upper extremities more frequently involved than lower - associated with other deformations in 50% of cases, most common is clubfoot - may be a cleft lip and facial deformities as a result of bands - etiology unknown, evidence suggests there is an abnormal attachment of the amnion to the fetus, because the amnion has either lost its integrity or ruptured and adhered to a fetal body part - severe bands need to be treated as an emergency, especially if there is evidence of vascular or lymphatic obstruction; need a surgical consult
Musculoskeletal System
- provides stability to the soft tissues of the body - joints held together by ligaments, attached to muscles by tendons, cushioned by cartilage which facilitates movement - protects vital organs, provides storage space for minerals, and produces blood cells (hematopoiesis)
gower sign
- proximal muscle weakness - child rises from a sitting position by placing hands on the legs and pushing the trunk up
Risk factors for osteoporosis
- race (white, asian, native american/american indian); northwestern european descent - light body frame, thin - family history of osteoporosis, previous fractures - nulliparous - amenorrhea or menopause before 45 years of age, postmenopausal - sedentary lifestyle, lack of aerobic or weight ebaring exercise - constant dieting, inadequate Ca and Vit D intake, excessive carbonated soft drinks per day - scoliosis, rheumatoid arthritis, cancer, multiple sclerosis, chronic illness, previous fractures - metabolic disorders (diabetes, hypercortisolism, hypogonadism, hyperthyroidism) - drugs that decrease bone density (thyroxine, corticosteroids, heparin, lithium, anticonvulsants, antacids with aluminum) - cigarette smoking or heavy alcohol use
Adolescent Considerations
- rapid growth during Tanner stage 3 (stage 3 of sexual maturation stages) results in decreased strength in the epiphyses and overall decreased strength and flexibility, leading to greater potential for injury - bone growth completed by age 20, when the last epiphysis closes and becomes firmly fused to the shaft - once growth stops, bone density and strength continue to increase - peak bone mass not achieved in either gender until age 35
Cleidocranial Dystosis (cleidocranial dysplasia or mutational dystosis)
- rare defect that affects the growth of bones in all parts of body - can occur spontaneously or be inherited as an autosomal dominant trait with no predilection of gender or ethnic group - characterized by complete or partial absence of clavicles - usually caused by mutation of RUNX2 (Core Binding Factor alpha 1), located at chromosome 6p21 - this gene encodes a protein necessary for the correct functioning of osteoblast cells, which regulate bone differentiation - bilateral absence of the clavicles or segmental loss of the lateral or middle portions of clavicles allows for excessive scapulothoracic motion where the newborn's shoulders touch in midline without discomfort - complete absence of clavicle usually accompanied by defective ossification of the cranium, large fontanels, and delayed closure of the sutures - as infant ages, there is a delay in eruption of and/or absence of permanent teeth - not cosmetically pleasing, usually little functional disability - no treatment required BUT genetic counseling recommended for parents
genu recurvatum
- rare, congenital dislocation or hyperextension of the knee - possibly result of frank breech position in utero - can also be result of a prenatal developmental defect, a specific disease of the muscles or nerves of the leg, or a manifestation of generalized joint laxity, as seen in "floppy baby syndrome" - can be associated with oligo, anomalies of elastic tissues, and fibrosis of the quad muscle along with deficient hamstrings - more common in females - usually bilateral - treatment: physical therapy and progressive reduction of the hyperextension by serial splinting; some require serial casting to hold knee in flexion - when associated with dislocation of the knee it requires surgery - early orthopedic consult
tibial torsion in toddlers
- residual effect of fetal positioning - should resolve within several years after weight bearing
bilateral symmetry pearl
- should not be defined as absolute because there is no perfect symmetry - eg: the dominant forearm is expected to be larger in athletes who play racquet sports and in manual labors
Glenohumeral joint
- shoulder - articulation between the humerus and the glenoid fossa of the scapula - the acromion and coracoid processes and the ligament between them form the arch surrounding and protecting the joint
ROM of shoulders
- shrug shoulders - should rise symmetrically - raise both arms forward and straight up over head, expect forward flexion of 180 degrees - extend and stretch both arms behind back, expect hyperextension of 50 degrees - lift arms laterally and over the head, expect shoulder abduction of 180 degrees - swing each arm across the front of the body, expect adduction of 50 degrees - place both arms behind the hips, elbows out, expect internal rotation of 90 degrees - place both arms behind the head, elbows out, expect internal rotation of 90 degrees
heat, redness, swelling, and tenderness of joint
- signs of and inflamed joint - possibly caused by rheumatoid arthritis, gout, septic joint, fracture, or tendonitis
hand - Down syndrome
- single crease (simian crease) across the palm usually associated with Down syndrome, but is often found in normal newborns; found in 4% of the population and seen bilaterally in 1% - investigate a combination of short fingers, an incurved little finger, a low-set thumb, and simian crease for Down syndrome
torticollis (wry neck)
- spasmodic, unilateral contraction of the neck muscles - result of birth trauma, intrauterine malposition, muscle fibrosis, venous abnormality in the muscle - not usually seen in immediate newborn period, but a hematoma may sometimes be palpated, or soft tissue swelling may be noted over the involved sternocleidomastoid (SCM) muscle shortly after birth - usually appears as a firm, fibrous mass in the SCM muscle at approx 2 weeks of age: mass is 1-2cm in diameter, hard, immobile, and felt in midportion of SCM muscle - head is tilted laterally toward the involved side, with chin rotated away from affected shoulder - infants with this should be further evaluated for metatarsus adductus and hip dysplasia - if detected early can be treated with stretching by parents - if mass goes unnoticed, torticollis may not be detected until there is plagiocephaly or asymmetry of the face adn skull development - if persists or goes untreated, there is flattening of the occiput on the opposite side and flattening of the frontal bones on the side of the lesion
major landmarks of the back
- spinal process of the vertebrae (C7 and T1 are usually most prominent), the scapulae, iliac crests, and paravertebral muscles
ROM of hand and wrist
- spread fingers apart and then touch them together - Fig D
Elbows
- subcutaneous nodules along pressure points of the ulnar surface may indicate rheumatoid arthritis or gouty tophi
humerus
- suspect fractured humerus if there is a history of difficult delivery, you feel a mass caused by a hematoma formation, or there are signs of pain during palpation - 2nd most common bone fractured during birth
impingement
- tendonitis or overuse injury form repetitive overhead activities
hand measurements
- term infants: distance from tip of middle finger to base of the palm is 6.75 (+/-) 1.25cm - middle finger length to total hand length is usually 0.38-0.48: 1
ortoloni maneuver
- test of hip reduction: produces the reduction of the dislocated femoral head into the acetabulum by abduction - "O" in ortoloni means OUT and this maneuver is used to put the hip back in normal position - with infant supine, flex the infant's knee and hip, and then grasp the thigh with the thumb positioned along the inner thigh and 3rd or 4th finger placed over the grater trochanter laterally - while you adduct the hip, the finger on the greater trochanter presses up against the head of the femur, and the hand presses the shaft of the femur toward the mattress - positive ortolani is produced when a palpable "clunk" is noted, indicating that the femoral head has slipped from a dislocated position back into the acetabulum - higher pitched clicks and snaps can be heard and felt, but can be normal and associated with movement of tendons, ligaments, for fluid in hip joint
tinel sign
- tested by striking the patients wrist with your index or middle finger where the median nerve passes under the flexor retinaculum and volar carpal ligament - a tingling sensation radiating from the wrist to the hand in the distribution of the median nerve is a positive tinel sign and suggestive of carpal tunnel
ask about child's favorite siting position
- the W or reverse tailor position places stress on joints of hips, knees, and ankles - commonly seen in children with in-toeing associated with femoral anteversion
Temporomandibular joint
- the articulation between the mandible and the temporal bone in the cranium - located in the depression just anterior to the tragus of the ear - hinge action of the joint opens and closes the mouth - gliding action permits lateral movement, protrusion, and retraction of the mandible
slipped capital femoral epiphysis
- the capital femoral epiphysis slips over the neck of the femur - most common between 8-16 years old, although affected girls are younger than affected boys - majority of cases are unilateral, left side involved more often than right side - subjective: the child or adolescent presents with knee pain or limp - objective: the affected child has leg weakness and reduced internal hip rotation; characteristic plain radiograph shows slippage of femoral head
metatarus adductus (metatarus varus)
- the most common congenital foot deformity, can either be fixed or flexible - caused by intrauterine positioning; medial adduction of the toes and forefoot results from angulation of the tarsometatarsal joint - subjective: usually obvious at birth, the heel and ankle are univolved - objective: the lateral border of the foot is convex; a crease is sometimes apparent on the medial border of the foot
Radiocarpal joint
- the wrist - consists of the articulations of the radius and carpal bones, as well as between the proximal and distal rows of carpal bones - an articulating disk separates the ulna and carpal bones, and the joint is protected by ligaments and a fibrous capsule - wrist moves in 2 planes: flexion and extension; radial and ulnar (rotational movement)
thomas test
- to detect flexion contractures of the hip that may be masked by excessive lumbar lordosis - have patient lie supine, fully extend one leg flat on the exam table and flex the other leg with the knee to the chest - observe patient's ability to keep the extended leg flat on the exam table - lifting the extended leg off the exam table also indicates a hip flexion contracture in the extended leg
ROM of hand and wrist
- touch the thumb to each fingertip and to the base of the little finger, make a fist - Fig D and F
acute ankle injury in adults
- use the Ottawa Ankle Rules to help identify the characteristics of patients needing and ankle radiograph series - 98.5% sensitivity for detecting an ankle fracture that is present on radiography - there must be pain in the malleolar zone and one of the following: * bone tenderness along the distal 6cm of the posterior edge of the fibula or tip of the lateral malleolus * bone tenderness along the distal 6cm of the posterior edge of the tibia or tip of the medial malleolus * inability to bear weight for 4 steps both immediately after the injury and when in the ER
McMurray test
- used to detect a torn medial or lateral meniscus - patient lie supine and flex one knee, position your thumb and fingers on either side of the joint space, hold the heel with your other hand, fully extending the knee, and rotate the foot and knee outward (valgus stress) to a lateral position, extend and then flex the patient's knee - any palpable or audible click, grinding, pain, or limited extension of the knee is a positive sign of a torn medial meniscus - repeat the procedure, rotating the foot and knee inward (varus stress) - a palpable or audible click, pain, grinding, or lack of extension is a positive sign of a torn lateral meniscus
allis sign
- used to detect hip dislocation or a shortened femur - with infant supine on the exam table flex both knees, keeping feet flat on table and the femurs aligned with each other, position yourself at child's feet, and observe the height of the knees - positive allis test when one knee is lower than the other
bulge sign
- used to determine the presence of excess fluid in the knee - with patients knee extended, milk the medial aspect of the knee upward two or three times, and then milk the lateral side of the patella - observe for a bulge of returning fluid to the hollow area medial to the patella
ballottement
- used to determine the presence of excess fluid or an effusion in the knee - with the knee extended, apply downward pressure on the suprapatellar pouch with the web or the thumb and forefinger of one hand, and then push the patella sharply downward against the femur with a finger of your other hand, if an effusion is present a tapping or clicking will be sensed - release the pressure against the patella, but keep your finger lightly touching it, if an effusion is present, the patella will float our as if a fluid wave were pushing it
varus (abduction) and valgus (adduction) stress tests
- used to identify instability of the lateral and medial collateral ligaments - have patient lie supine and extend the knee, stabilize the femur with one hand and hold the ankle with your other hand, apply varus force against the ankle and internal rotation, excessive laxity is felt as joint is opening, laxity is indicated injury to the collateral ligament - then apply vagus force against the ankle and external rotation, laxity indicates injury to the medial collateral ligament - repeat the movements with the patient's knee flexed to 30 degrees - no excessive medial or lateral movement of the knee is expected
Goniometer
- used to measure joint range of motion - precisely measures the angle - begin with the joint in the fully extended or neutral position, then flex the joint as far as possible - measure the angles of greatest flexion and extension, comparing these with the expected values
straight leg raising test
- used to test for nerve root irritation or lumbar disk herniation at the L4, L5, and S1 levels - have patient lie supine with the neck slightly flexed, have them raise leg keeping the knee extended - no pain should be felt below the knee with leg raising - radicular pain below the knee may be associated with disk herniation - flexion of the knee often eliminates the pain with leg raising - repeat the procedure on the unaffected leg - crossover pain in the affected leg with this maneuver is more indicative of sciatic nerve impingements
overlapping toes in infancy
- usually hereditary - treatment: stretching or stabilizing the toe by taping it in correct position
infant weight
- weight without clothing/diaper at approx same time each day using an infant scale - weight varies with GA, gender, ethnicity, and socioeconomic status - average weight for a term newborn is 2700-4000g (6-9lbs) - all newborns initially lose weight, 10-20% of birth weight is acceptable - variations in weight are result of body water changes - preterm lose more weight and regain BW slower than term - weight gain usually begins within the first 2 weeks, with an average daily gain of 10-20 g/kg/day - in general, infants double their BW by 4-5 months of age
suspect epicondylitis or tendonitis
- when a boggy, soft, or fluctuant swelling - point tenderness at the lateral epicondyle or along the grooves of the olecranon process and epicondyles - increased pain with pronation and supination of the elbow
Inspect shoulders
- when shoulder contour is asymmetric and one shoulder has hollows in the rounding contour, suspect a shoulder dislocation (see page 516, 21-24 A)
ROM of hips
- while supine raise leg with knee extended above the body, expect 90 degree hip flexion (Fig A) - while standing or prone, swing straightened leg behind body without arching the back, expect hip hyperextension of 30 degrees or less (Fig E) - while supine, raise one knee to the chest while keeping the other leg straight, expect hip flexion of 120 degrees (Fig B) - while supine, swing leg laterally and medially with knee straight, expect 45 degrees of abduction and up to 30 degrees of adduction (Fig D) - while supine, flex the knee keeping foot on table and then rotate the leg with the flexed knee toward the other leg, expect internal rotation of 40 degrees (Fig C) - while supine, place the lateral aspect of the foot on the knee of the other leg, move the flexed knee toward the table (called a Patrick or FABER test - Flex, ABduct, Externally Rotate), expect 45 degress of external rotation
examine elbow's ROM
- with elbow fully extended at 0 degrees, bend and straighten the elbow - expect flexion of 160 degrees and extension returning to 0 degrees or 180 degrees of full extension - left pic
knock knee (genu valgum)
- with knees together, measure distance between the medial malleoli of the ankles - genu valgum if space is 2.5cm (1in) - common finding of children between 2-4 years old
examine elbow's ROM
- with the elbow flexed at a right angle, rotate the hand from palm side down to palm side up - expect pronation of 90 degrees and supination of 90 degrees - right pic
ROM of hand and wrist
- with the palm side down, turn each hand to the right and left - expect a radial motion of 20 degrees and an ulnar motion of 55 degrees - Fig F
Clues to diagnosing abdominal pain
-Not hungry- organic cause like appendicitis, infection -"touch-me-not" reaction- pain -Ask pt to point finger at location of pain- if they point to a fixed spot, greater pathologic importance, closer to umbilicus- more likely to be psychosomatic -nonspecific abdominal pain- pts usually keep eyes closed during palpation, organic disease- usually keep eyes open
Bilious vomiting
-obstruction beyond ampulla of Vater (where bile enters SI) -can be from malrotation with midgut volvulus (urgent surgical emergency to avoid intestinal infarction)
Scoring Deep Tendon Reflexes
0 no response 1+ sluggish or diminished 2+ active or expected 3+ more brisk than expected, slightly hyperactive 4+ brisk, hyperactive, intermittent or transient clonus
Penile Width
0.9-1.3 cm
Nociceptors
1) Pain receptors 2) stimulated by physical/mechanical, chemical, or thermal injury 3) impulses sent to brain for interpretation and reaction to stimuli
What are the 5 auscultatory areas?
1) aortic valve: 2nd (R) intercostal @ (L) sternal border; 2) Pulmonic valve: (L) intercostal space @ (L) sternal border; 3) 2nd pulmonic area: 3rd (L) intercostal space @ (L) sternal border; 4) Tricuspid area: 4th (L) intercostal space along the lower (L) sternal border; 5) Mitral (or apical) area: 5th (L) intercostal space @ midclavicular line.
What combination of symptoms are signs of heart failure?
1) lung crackles; 2) palpable enlarged liver; 3) peripheral edema.
Full-term neonates void ___ to ___ times during the first 48 hours of life.
1-4
Extracranial Hemorrhage
1. Cephalhematoma: forceps. located below the periosteum & confined by the cranial sutures. May contribute to jaundice. 2. Subgaleal Hemorrhage: vacuum extraction. located between the scalp & cranial periosteum. Potential space extends from the orbital ridges to the nape of the neck. Can lead to severe hypovolemic shock & anemia. Signs: boggy scalp, pallor, prolonged cap refill, tachycardia, decreased responsiveness, falling hct, shock. seizure is a late sign.
Auscultation assesses what 3 things in the cardiovascular assessment?
1. Heart Rate. 2. Rhythm Regularity. 3. Heart Sounds (Murmurs, Rubs etc.)
Timeline for cardiovascular assessment
1. Initially 6-12 hours of age. 2. Another 1-3 days of age. 3. Regular intervals thereafter.
4 parts of a Neurologic exam
1. cranial nerves (CN) 2. proprioception & cerebellar function 3. sensory function 4. deep tendon refelexes
Why is assessment of this system important?
1. it is vital to the confirmation of abnormalities detected on ultrasound 2. info recorded on first exam forms the database for all future exams
What could cause an asymmetric Moro reflex?
1. pain from broken bone 2. muscle injury 3. neurologic defect
When assessing the musculoskeletal system, appraise the following:
1. posture, position, & gross anomalies 2. discomfort from movement 3. range of joint motion 4. muscle size, symmetry, & strength 5. configuration & motility of the back
Adult resting resp rate
12-20 breaths pm, ratio of RR to HR is approx 1:4.
Continuous systolic (crescendo) murmur
15% of newborns Grade I-II represent left to right flow when the PDA is not yet closed. First 8 hours of life.
Cerebrum
2 hemispheres divided into lobes; responsible for movement, visceral fxs, perception, behavior. Lobes: 1. *frontal*: voluntary skeletal movement, fine motor skills, eye movement 2. *parietal*: processes sensory data (taste, smell, pain, texture, hearing, etc.) 3. *occipital*: primary vision center 4. *temporal*: interprets sounds, taste, smell, balance
syndactyly
2 or more digits fused together
A critical window of incredible brain growth and differentiation happens between_________
24 and 40 weeks postmenstrual age. How the caregiver interacts with the infant during this time influences brain development and function.
The NBAS assesses the newborns responses to
28 behavioral items, each scored on a 9 pt scale, and 18 elicited responses, each scored on a 4 pt continuum. These items provide information about the infants ability to respond and adapt to his environment.
Colorectal cancer
2nd most common cancer in US S/S- depend on location, size, mets. Abd pain, blood in stool, recent change in stool frequency/character. Occult blood earliest sign. Palpable mass if progressed, anemia from bleeding. May be preventable with detection and early removal of polyps (occult blood testing, scoping)
Get the Family History!!!
3-5% risk of recurrence if another sibling or parent have a CHD.
The pupillary reflex develops at approx________
30 weeks gestational age.
Spinal nerves
31 pairs that arise from the spinal cord & exit at each intervertebral foramen. the anterior branches of several spinal nerves combine to form a *nerve plexus*. The spinal afferent & efferent neurons initiate a reflex response.
Rugae starts to form at
36 weeks gestation (wrinkles on the scrotum)
Gallbladder
4" sac that concentrates and stores bile which is released into duodenum via cystic duct then common bile duct. Bile maintains alkaline pH of SI and helps emulsify fats
Spinal cord & Spinal tracts
40-50cm long, begins at the foramen magnum & stops at L1-L2. Made up of ascending and descending spinal tracts, & upper and lower motor neurons
Newborn infant catheter size
5 french 8French at one year of life.
polydactyly
6 or more digits on an extremity
Average pulse rates for an adults
60-100 bpm, athletes or person taking beta blockers resting=50-60 bpm, Tachycardia is over 100 bpm and bradycardia is less than 60 bpm
newborns normal BP
60-96 mm Hg systolic and 30-62 mm Hg diastolic
Blood pressure commonly decreases in pregnant women beginning at about what week gestation?
8 weeks, gradually falling until a low point is reached at mid-pregnancy, the diastolic BP gradually rises to pre-preg levels by term.
Clitoromegaly
8-10 fold increase in the clitoral index
Physical examination
:-)
Testicular position
<28 weeks - in the abdomen. 20-30 weeks - descends to inguinal canal. Term - testes should be in the scrotal sac.
Colon cancer risk factors
>50 yo, family history, personal history of cancer, polyps, Crohns, or ulcerative colitis, ovarian or endometrial cancer, race/ethnicity: African descent, Jewish, or Eastern European (Ashkenazi) Diet: low fiber, high processed/red meats, low fruit/vegetable Obesity Smoking Low physical activity Heavy EtOH Type 2 DM
What symptom alerts a patient he has peripheral artery disease in the femoral artery? (Select all that apply.) A. Calf pain that is relieved by rest B. Pitting edema in the affected leg C. Pain in the buttocks that radiates down the leg D. Calf pain that occurs during sustained exercise E. Muscle cramping that awakens a person from sleep
A & D Peripheral artery disease of the femoral artery causes muscle ischemia that occurs with sustained exercise and is relieved by rest. Pitting edema is not associated with peripheral artery disease. Pain in the buttocks radiating down the leg suggests sciatic nerve irritation. Muscle cramping awakening a person often results from overuse.
Pseudotumor Cerebri
A clinical syndrome of intracranial hypertension that mimics brain tumors; most common in obese women ages 20-44, may have pain behind eye, episodes of blurred vision, whooshing sound in ears
Sinus Tachycardia
A heart rate greater than the normal for age. 180-200. Most common form of rapid heart rate in the neonate. Usually occurs with a stimulus and resolves when the stimulus is removed or alleviated.
What equipment is used for auscultation?
A pediatric or neonatal stethoscope with a diaphragm and a bell.
Dextrocardia
A rare defect produced when the heart develops in a mirror image of the normal position.
Peritoneum
A serous membrane that forms a protective cover over the abdominal organs, double folds around stomach (greater and lesser omentum), and fan shaped fold covers small intestines (mesentery)
Why is neuro evaluation critical?
A single exam may verify the presence of normal or abnormal neuro responses. Serial followups can validate anomalies identified on the 1st exam & follow their changes or disappearance over time. Improvement/disappearance = better prognosis than Static abnormal responses
A ventricular heave is detected by which assessment technique? A. Palpation B. Inspection C. Auscultation with bell of stethoscope D. Auscultation with diaphragm of stethoscope
A. A ventricular heave caused by ventricular enlargement is best detected by palpation. The heave may not be apparent visually in an obese patient. Auscultation does not detect heaves.
What assessment finding is related to an abdominal aortic aneurysm? A. Audible bruit B. Shiny abdominal skin C. Hyperactive bowel sounds D. Tenderness around umbilicus
A. An audible bruit associated with an abdominal aortic aneurysm may be heard in the area to the left of the umbilicus. Shiny abdominal skin, hyperactive bowel sounds, and tenderness around the umbilicus are not associated with an abdominal aortic aneurysm.
How does a nurse assess for pain related to peritonitis? A. Assess for rebound tenderness. B. Assess for the presence of a fluid wave. C. Perform light palpation in the four quadrants. D. Perform indirect percussion in the costovertebral angle.
A. Rebound tenderness is a sign of peritonitis, acute inflammation of the peritoneum. The nurse pushes slowly and deeply on a site away from the area of pain. Upon quick release, the patient has pain over the area of tenderness. Light palpation or indirect percussion of the costovertebral angle is not specific to peritonitis. Ascites is not associated with peritonitis.
Select the correct description of S2, the second heart sound. A. Corresponds to the "dubb" sound B. Is pathological if heard as a split sound C. Occurs when the mitral and tricuspid valves close D. Is low pitched and best heard with the bell of a stethoscope
A. The second heart sound, S2, corresponds to the "dubb" sound of the heartbeat: lubb-dubb. It is heard as a split sound during inspiration because of the closure of the aortic and pulmonic valves. It is a high-pitched sound best heard with the diaphragm of the stethoscope.
3. In which patient would a positive Babinski sign be considered a normal finding? A. 14-month-old boy B. 7-year-old adolescent C. Woman who is 5 months' pregnant D. Elderly man who exercises three times weekly
A. 14-month-old boy
10.Identify the physiological components that comprise the systolic blood pressure. (Select all that apply.) A. Cardiac output B. Lung capacity C. Serum glucose level D. Compliance of arteries E. Circulating blood volume F. Peripheral vascular resistance
A. Cardiac output D. Compliance of arteries E. Circulating blood volume
9.Select the reasons why elderly persons may be reluctant to report pain. (Select all that apply.) A. Elderly persons do not want to bother others. B. Elderly persons lose the ability to perceive pain. C. Elderly persons are reluctant to take pain medications. D. Elderly persons believe pain is part of the aging process. E. Elderly persons may fear being hospitalized because of the pain.
A. Elderly persons do not want to bother others C. Elderly persons are reluctant to take pain medications. D. Elderly persons believe pain is part of the aging process. E. Elderly persons may fear being hospitalized because of the pain.
1. A patient states that he has severe foot pain that started hours earlier. The area of pain is the metatarsophalangeal joint of the first toe. The skin over the joint is red, warm, and swollen. This is consistent with what condition? A. Gout B. Tophi C. Fracture D. Osteoarthritis
A. Gout
10.Select a risk factor for osteoarthritis. (Select all that apply.) A. Obesity B. Low-calcium diet C. Sedentary lifestyle D. Age older than 40 years E. Family history of osteoarthritis
A. Obesity D. Age older than 40 years E. Family history of osteoarthritis
2.Which component of the vital signs of this adult patient is within the normal range? A. Pulse: 88 beats/min B. Respirations: 24 breaths/min C. Temperature: 38º C D. Blood pressure: 164/90 mm Hg
A. Pulse: 88 beats/min
4. The nurse observes the gait of a client as he enters the room. He uses short steps, keeps his knees in contact, and walks with considerable effort. What term is used to describe this gait? A. Scissors gait B. Steppage gait C. Parkinsonian gait D. Cerebellar ataxic gait
A. Scissors gait
10. Which assessment finding is suggestive of shaken baby syndrome in a 3-month-old infant? (Select all that apply.) A. Seizures B. Decreased alertness C. Bruising on the head D. Bilateral retinal detachments E. Bilateral retinal hemorrhages F. Social smile
A. Seizures B. Decreased alertness D. Bilateral retinal detachments E. Bilateral retinal hemorrhages
9. Watch the video. What is the purpose of having the patient clasp his fingers together and try to pull them apart while the patellar reflexes are being assessed? A. To ensure accuracy of the reflex B. To eliminate the essential tremor C. To enhance the strength of the reflex D. To diminish the strength of the reflex
A. To ensure accuracy of the reflex
9.Which assessment finding is consistent with carpal tunnel syndrome? (Select all that apply.) A. Weakness in the hand B. Clubbing of the fingernails C. Color changes in fingers with pain D. Heberden nodules on finger joints E. Awakened by hand numbness and burning
A. Weakness in the hand E. Awakened by hand numbness and burning
What factors in the immediate newborn period are important to note prior to neuro exam?
APGARs, cord blood pH, presence of perinatal depression, difficulty transitioning, feeding ability, *accurate GA* (essential for interpretation of posture, tone, & reflexes)
Gastroschisis
Abdominal wall defect, discrete from umbilical cord, usually right of midline. Lower incidence of associated anomalies, except for atresias and enteritis from blood flow interruptions
Hirschsprung disease
Absence of parasympathetic ganglionic cells in a segment of colon, interrupts motility- lead to accumulation of stool proximal of defect, obstruction S/S: fail to pass mec in 24-48h, failure to thrive, constipation, abd distention, bilious vomiting, diarrhea
Acute Pancreatitis
Acute inflammation- pancreatic enzymes autodigest pancreas More common in biliary disease and chronic alcohol use S/S: Epigastric pain, radiate to back, constant and dull. N/v, distention, fever, anorexia. Diffuse abd tenderness. Decreased BS. Grey Turner sign positive. Fever, tachycardia, dyspnea due to diaphragmatic irritation. Pancreatic enzymes elevated.
Older Adults
Age associated changes include: decrease heart size; HTN &/or heart disease may -> enlargement; thickened (L) ventricle wall & endocardium; valves fibrose & calcify; decrease stroke volume; CO during exercise decreases by 30-40%; less elastic & more rigid myocardium -> delayed myocardial contractility; less efficient response to stress with increased O2 demand; tachycardia poorly tolerated;
HPI
All factors relating to: abdominal pain (PQRST), medications, indigestion, nausea, vomiting, diarrhea, constipation, incontinence, jaundice
What important information can you get from the mother's pregnancy history?
Antenatal U/S findings like enlarged kidneys. Polyhydramnios (20-30% of infants with poly have major structural malformations such as esophageal atresia and duodenal atresia- and with a >16 cm pocket of amniotic fluid, the chance of anomaly is 90%). Copious oral secretions can indicate TE fistula, biliary gastric secretions can indicate intestinal obstruction.
What are the four traditional auscultory areas of the heart
Aortic, pulmonic, tricuspid, mitral you should at the very least, auscultate these areas. Other areas recommended are R and L infrclavicular areas, both sides of the back, both axillae, the anterior fontanel, R anterior chest, and liver.
Pain in RLQ
Appendicitis, Meckel diverticulitis, salpingitis, ovarian cyst, ruptured ectopic pregnancy, tuboovarian abscess, renal/ureteral stone, strangulated hernia, regional ileitis, perforated colon
McBurney sign
Appendicitis: Rebound tenderness and sharp pain when McBurney's point is palpated (RLQ)
Iliopsoas muscle test
Appendicitis: pt lies supine, place your hand over lower right thigh, ask pt to raise R leg while you push down. Pain indicates irritation as psoas muscle rubs near appendix area
Aaron's sign
Appendicits. pain in area of heart or stomach on palpation of mcburney's point
Stomach Cancer
Arises from epithelial cells of mucous membrane, more in lower half of stomach, early growth is mucosa/submucosa, progresses to muscular layer, mets common. S/S: Vague/nonspecific symptoms- loss of appetite, fullness, weight loss, dysphagia, epigastric pain, epigastric mass
Primary hepatocellular carcinoma
Arises with cirrhosis, 20-30 yrs after liver injury/disease onset. Most pts die from tumor progression (survival 6 mos after diagnosis). Mets to lungs, portal vein, periportal nodes, bones, brain. (Vaccinations reduce overall incidence) S/S: jaundice, anorexia, fatigue, fullness, clay-colored stools, tea-colored urine, hepatomegaly, irregular liver border, nodules
Ascites asst
Ascites fluid settles with gravity- dullness in dependent parts, tympany in upper parts (have pt lie on side, switch sides). May require xray to confirm Fluid wave assessment: (requires 3 hands) have pt or assistant press hand firmly in midline of abdomen while supine. Place 1 hand on either side of abdomen, strike one side sharply with fingertips. Feel for impulse of fluid wave on other hand. Ascites fluid wave will transmit across to other hand, adopose tissue will not.
For children, how would you ask them about pain and document in HPI?
Ask parent what word the child uses for pain (owie, etc...), ask child what he/she tells mommy when he hurts, what made hurt feel better, and pain behaviors such as; facial expressions, grimacing, and protective posture.
Palpation (adult asst)
Assess for muscle spasm, mass, fluid, tenderness, mobility, consistency, muscular resistance (guarding). Light palpation: with palm of 1 hand, depress no more than 1 cm, all 4 quadrants Moderate palpation: may use 1 or 2 hands, all 4 quadrants, between depth of light and deep (duh) Deep palpation: 2 hands on top of each other to press deeply, feel for aorta, pain, spleen, liver, kidneys (1 hand on top, 1 on bottom of flank- easier to feel R than L)
________ is the main focus of the cardiovascular examination.
Auscultation
The nurse assesses hypoactive and absent bowel sounds in the four quadrants of the abdomen in a female patient. Which finding from the patient history is likely the cause? (Select all that apply.) A. Has stress incontinence B. Takes diuretic medication daily C. History of essential hypertension D. Abdominal hysterectomy 3 years ago E. Takes narcotic analgesics for recent shoulder injury
B & E. Taking a diuretic predisposes the patient to hypokalemia, a cause of decreased peristalsis. Taking narcotics also decreases peristaltic activity. The history of stress incontinence, essential hypertension, and past abdominal hysterectomy are not significant to decreased peristalsis.
How should the nurse assess for a carotid bruit? A. Palpate firmly over the carotid artery with fingertips. B. Ask the patient not to breathe during auscultation over the carotid artery. C. Auscultate over the carotid artery with the diaphragm of the stethoscope. D. Auscultate over the carotid artery while palpating the pulse in the jugular vein.
B. A carotid bruit is best heard during auscultation with the bell over the carotid artery while the patient holds his or her breath. The carotid artery is palpated lightly with the fingerpads. There is no pulse in the jugular vein.
Under which circumstance is it appropriate to use direct or indirect percussion with a closed fist during assessment? A. To locate the border of the spleen B. To test for tenderness of the kidney C. To determine the lower border of the liver D. To locate areas of tympany in the abdominal cavity
B. Direct or indirect percussion with a closed fist is used to elicit areas of tenderness of the kidney. Tenderness is noted in the costovertebral angle. A spleen that is palpable in the left upper quadrant is usually enlarged. Percussing with fingers is the technique used to detect the lower border of the liver and areas of tympany in the abdomen.
When does the nurse expect to hear an S4 heart sound? A. Just after S2 B. Just before S1 C. Between S1 and S2 D. Only when S3 is present
B. S4 is a late diastolic sound that is heard just before S1. It does not occur just after S2 or between S1 and S2. It may be present with S3 or heard without S3.
During which segment of the electrical conduction of a heartbeat does ventricular systole occur? A. P-R B. QRS C. ST D. T
B. The QRS corresponds to the heart's mechanical action of ventricular systole. The P-R interval corresponds to atrial systole. The ST segment and T waves correspond to ventricular diastole.
An infant develops severe abdominal pain, keeps his legs pulled to his abdomen, and has light red mucous stools. What condition do these symptoms suggest? A. Pyloric stenosis B. Intussusception C. Nephroblastoma D. Hirschsprung disease
B. The clinical picture suggests intussusception, a condition in which a segment of bowel telescopes into another causing obstruction. Pyloric stenosis is hypertrophy of the pyloric sphincter causing projectile vomiting in the neonate. Nephroblastoma is a malignancy of the kidney causing an abdominal mass in children 2 to 3 years old. Hirschsprung disease is a congenital absence of innervation of the colon causing constipation and requiring surgery.
A pregnant woman in the third trimester becomes weak and faint when lying down on her back. What is the cause of this symptom? (Select all that apply.) A. Likelihood of varicose veins B. Decreased venous blood return C. Increased circulating blood volume D. Pressure of the fetus on major blood vessels
B. & D. Pressure of the fetus on major blood vessels and decreased return of venous blood cause the woman to experience faintness and weakness. The woman has increased circulating blood volume and likely varicose veins, but these are not causing the symptoms.
5. A patient states he injured his right ankle while walking the previous day. How should the nurse assess the ankle initially? A. Ask the patient to take a few steps. B. Observe and compare the right with the left ankle. C. Perform passive range of motion on the right ankle. D. Palpate the ankle area gently and observe for areas of pain.
B. Observe and compare the right with the left ankle.
4. While palpating the patient's knee, the nurse finds effusion in the joint. What further assessment will support this finding? A. Phalen test B. Testing for ballottement C. Measuring range of motion D. Measuring leg length bilaterally
B. Testing for ballottement
1. How does the nurse test cerebellar function? A. Eliciting the corneal reflex B. Testing rapid alternating movements C. Pushing the patient's neck toward the chest D. Asking the patient to identify an unseen object in his or her hand
B. Testing rapid alternating movements
Hypertension
BP consistently at 140/90 or >. Essential hypertension pathology is poorly understood. for secondary hypertension, potential causes include; renal disease,renal artery stenosis, aldosteronism, thyroid disorders, coarctation of the aorta, or phenchromocytoma. subjective data: essential hypertension id asymptomatic, in malignant severe hypertension, headache, blurred vision, dyspnea, or encephalopathy may be present. Objective data: Mult confirmed BP at or above 140/90 or in children greater than 95th percentile for age, gender, and height percentile. End organ damage may be present with long-standing hypertension
Infant: auscultation/percussion
BS q 10-30 sec by 1-2h after birth, should have no bruits or hums.
Auscultation: infant
BS start by about 15 minutes of age. Listen in all 4 quadrants, but sounds transmit throughout abdomen readily. Normal BS- tinkling q15-20 sec (full 5 minutes before diagnosing them as absent). Hyperactive BS may be normal or r/t obsturction (esp if infant ill/distended abdomen) Hypoactive bs may be related to maternal sedation Bruits can indicate malformation of hepatic or renal vessels or hemangiomas
GERD
Backward flow of gastric contents Patho: relaxation or incompetence of LES, delayed gastric emptying, common in elderly and pregnant S/S: heartburn, bitter/sour taste, hoarseness, possible red throat, infants: arching, fussiness with feeding, regurgitation. May exacerbate asthma attack
Maternal History must be obtained and is the first step! Why????
Because several maternal factors affect neonatal cardiovascular system.
Chordee
Bend in the shaft of the penis ventral chordee almost always comes with hypospadias
Palpate the Peripheral Pulses (Next 2 Slides)
Best done with infant quiet Asses rate, rhythm, volume, and character. Allow you to approximate the cardiac output absent doral pedalis pulses are normal in newborns.
Central Cyanosis
Bluish color of the skin, lips, tongue, earlobes, scrotum and nailbeds. (this visibility occurs when 5g Hgb is not bound to oxygen /100mL. Central (requires intervention) can be differentiated from peripheral (normal for about 2 days of life) cyanosis by determining an arterial saturation. <80-85% in an infant with a normal Hbg. If an infant is centrally cyanotic, apply 100% oxygen. If cyanosis does not improve or worsens with crying, you should highly suspect cardiac
Which method should the nurse use to determine if a patient has ascites? (Select all that apply.) A. Perform the iliopsoas muscle test. B. Observe a bulge at the umbilicus. C. Test for a fluid wave in the abdomen. D. Test for shifting dullness in the abdomen. E. Perform light palpation for right upper quadrant tenderness.
C & D. The nurse notes a fluid wave by striking the side of the abdomen with the patient supine and feeling the fluid wave impulse on the opposite side. Shifting dullness is detected by percussing dullness with the patient supine and noting a shift in the dullness when the patient turns on his side. The iliopsoas muscle test is used to assess pain related to appendicitis. A bulge at the umbilicus may be present with ascites but is actually caused by a hernia. Tenderness in the right upper quadrant may be associated with cholelithiasis.
The nurse hears a pericardial friction rub while listening to heart sounds. Which characteristic is correct about this sound? A. Is louder during inspiration B. Is best heard with the patient supine C. Occurs throughout the heart sound cycle D. Will not be heard if the patient holds their breath
C. A pericardial friction rub is a scratchy sound heard throughout the heart cycle in patients with pericarditis. The sound is enhanced when the patient holds their breath on expiration while sitting up and leaning forward.
At what angle would the nurse expect jugular venous distension to disappear in a normal patient? A. 10 degrees B. 25 degrees C. 45 degrees D. 90 degrees
C. Jugular venous distention disappears normally around 45 degrees. It is normally present at 10 and 25 degrees and should not be present at 90 degrees.
How is the diagnosis of deep venous thrombosis in the leg confirmed? A. Positive Homan sign B. Presence of unilateral edema C. Clot on venous ultrasound examination D. Audible venous hum over the thrombus
C. Presence of deep venous thrombosis is confirmed by presence of a clot in the vein on ultrasound testing. A positive Homan sign neither confirms nor rules out deep venous thrombosis. Unilateral edema occurs frequently with deep venous thrombosis but needs further testing for confirmation. A venous hum is not heard over the thrombus.
Why is the Allen test performed? A. Determine if valves in vein of hand are competent B. Test whether the patient has coarctation of the aorta C. Determine whether the ulnar artery provides adequate circulation D. Determine whether the patient likely has a deep venous thrombosis
C. The Allen test is done before radial artery puncture for arterial blood gas sampling or insertion of an arterial line. It demonstrates that adequate circulation is provided by the ulnar artery. It does not determine condition of veins in the hand, presence of deep venous thrombosis, or coarctation of the aorta.
Which intervention should the nurse do first in assessing the abdomen? A. Perform light palpation. B. Auscultate before palpation. C. Ask the patient to empty the bladder. D. Observe for scars from previous surgeries.
C. The nurse should first ask the patient to empty the bladder because a full bladder will interfere with the assessment findings. Observing for scars and performing auscultation before light palpation are done after the patient is prepared for the assessment.
What is likely the cause of a pulsating mass palpated behind the knee? A. Varicose vein B. Popliteal hernia C Popliteal aneurysm D. Femoral venous thrombosis
C. A pulsating mass behind the knee is likely a popliteal aneurysm. Veins or thrombosed veins do not have pulsations. Hernias occur in the abdominal area.
1. Select the best method to determine the respiratory rate A. Count the number of times the patient inhales in 10 seconds and multiply by 6. B. Place the hand in front of the patient's nose and count respirations for 1 minute. C. After counting the pulse, proceed to counting breaths for 30 seconds and multiply by 2. D. Ask the patient to start breathing normally and count the rising and falling of the chest for 1 minute.
C. After counting the pulse, proceed to counting breaths for 30 seconds and multiply by 2.
5. A nurse observes very fine, rapid, continuous twitching of a patient's finger while at rest. How should the nurse document this finding? A. Paralysis B. Spasticity C. Fasciculation D. Intention tremor
C. Fasciculation
3.Damage to which part of the brain may result in pyrexia? A. Cerebrum B. Cerebellum C. Hypothalamus D. Anterior pituitary
C. Hypothalamus
3. Which change is most commonly observed in aging patients? A. Lordosis B. Scoliosis C. Kyphosis D. Ankylosis
C. Kyphosis
6. Which assessment finding is associated with lumbar stenosis? A. S-shaped curvature of the spine B. Flattening of the thenar eminence C. Pain associated with prolonged standing D. Pain that occurs with bending over at the waist
C. Pain associated with prolonged standing
6.The nurse has difficulty taking a blood pressure because the patient's upper arm is too large for the blood cuff. What should the nurse do? A. Do not monitor the blood pressure until the correct sized cuff is available. B. Place the cuff on the forearm and palpate the systolic blood pressure at the brachial pulse. C. Place the cuff on the forearm and palpate the radial pulse to obtain the systolic blood pressure. D. Take the blood pressure with the present cuff while holding it together and add 10 to the systolic pressure.
C. Place the cuff on the forearm and palpate the radial pulse to obtain the systolic blood pressure
7.Which technique is the correct manner to locate the radial pulse rate? A. Place the thumb over the bone at the wrist distal to the thumb. B. Place the fingertips against the bone at the wrist distal to the thumb. C. Place the fingerpads of the second and third fingers over the wrist bone below the thumb. D. Place the fingerpads of the second and third fingers over the wrist bone below the little finger.
C. Place the fingerpads of the second and third fingers over the wrist bone below the thumb
8.The nurse applies a blood pressure cuff to a patient's arm and finds the radial pulse. The blood pressure cuff is pumped up 20 mm Hg higher than the point when the pulse was obliterated. The air is let out, and the pulse is felt again at 110 mm Hg. What is the significance of the 110? A. Pulse rate B. Pulse pressure C. Systolic blood pressure D. Diastolic blood pressure
C. Systolic blood pressure
6. Under what conditions should a patient be tested for clonus? A. When the patient has nuchal rigidity B. When deep tendon reflexes are absent C. When deep tendon reflexes are hyperactive D. When the patient is showing decorticate posturing
C. When deep tendon reflexes are hyperactive
No anal wink
CNS disorder
L&D History is important because:
Causal factors such as perinatal hypoxia, maternal infection, or drugs during labor will help the examiner determine whether CHD is a likely explanation for abnormal physical findings. Birth weight, gestational age, and sex all must be taken into consideration.
Murmurs
Caused by turbulent blood flow. 2 kinds of murmurs... innocent and pathologic.
Murphy sign
Cholecystitis: Abrupt cessation of inspiration on palpation of gallbladder area
Duodenal ulcer
Chronic break in duodenal mucosa (scars with healing) Patho: may be from H. pylori and increased gastric acid (Zollinger-Ellison S.), men more than women S/S: Epigastric pain when stomach is empty, relieved by food/antacids, may have hematemesis. Tenderness with palpation. Can cause significant bleeding- hypotension/tachycardia, can perforate duodenum
Neuropathic pain
Chronic form of pain caused by a primary lesion or dysfunction of the CNS that persists beyond expected after healing. Potential causes; postherpetic neuralgia, diabetic peripheral neuropathy, trigeminal neuropathy, or radiculopathy. Subjective data: burning intense tightness, shooting, stabbing, shocklike sensations, may worsen at night, exaggerated response to painful stimuli, pain response to stimuli that is not painful, sleep disturbance, interference with ADL's. Objective data: confirmed self-report of pain for all painful body regions. Distribution of pain sensation, light touch, pin prick, vibration sense, and proprioception may be diminished in affected area, numbness weakness, and loss of deep tendon reflexes in affected area.
Ulcerative colitis
Chronic inflammatory disorder of colon/rectum that produces mucosal friability/ulceration. Cause unknown- immunologic/genetic factors, high risk of colon cancer. S/S: Frequent bloody/watery diarrhea (20-30/day), weight loss, debilitation, fatigue, may have remission, may have jaundice (scarring of bile ducts). Contrast radiograph- loss of normal mucosal pattern. Sclerosing cholangitis. Endoscope- ulceration/bleeding, mucosal edema
Crohn disease
Chronic inflammatory disorder of part of GI tract- causes ulcerations, fibrosis, malabsorption. Most common in termal ileum/colon, cause unknown (may be imbalance of inflammatory mediators) S/S: Chronic diarrhea with compromised nutrition, systemic: arthritis, iritis, erythema nodosum. Flares and remissions, RLQ tenderness, may have masses due to inflamed bowel, perianal tags/fistulae/abscesses. Cobblestone mucosa in colonoscopy
A systolic that is significantly higher in the upper extremities than the lower, especially in combination with absent or weak femoral pulses, should raise suspicion to
Coarctation of the Aorta
Important aspects of family history
Colorectal cancer, polyposis, gallbladder disease, malabsorption syndromes (celiac, cystic fibrosis), Hirschsprungs, familial Mediterranean fever
Loops of bowel
Concerning if loop is fixed rather than transient
Biliary atresia
Congenital obstruction/absence of some/all of bile duct system. Postnatal onset result from perinatal insult like viral infection. Embryonic onset assoc with other congenital anomalies S/S: jaundice, light clay colored stools, dark urine, failure to gain weight, splenomegaly, hepatomegaly, portal htn. Need surgical correction
Genitourinary Assessment
Consists of the kidneys, urinary tract, and the reproductive tract.
The nurse observes a bluish discoloration around the umbilicus in a patient (Cullen sign). What is this sign associated with? A. Appendicitis B. Umbilical hernia C. Liver enlargement D. Intraabdominal bleeding
D. A bluish discoloration around the umbilicus is a sign of bleeding within the abdomen. An umbilical hernia causes a bulge at the umbilicus. Liver enlargement is detected by percussing the borders of the liver. Rebound tenderness in the right lower quadrant is associated with appendicitis.
Which type of incontinence is caused by dementia in patients? A. Urge B. Stress C. Overflow D. Functional
D. Functional incontinence occurs in persons with dementia because decreased mental capacity limits the ability to attend to the urge to void. The urge type is the uncontrollable constant need to urinate. Stress type is small volume incontinence that occurs with coughing or sneezing. Overflow type is dribbling in small amounts while the bladder remains full and overdistended.
What is the cause of a varicose vein? A. Smoking cigarettes B. Sclerosis in the vein C. Embolism from the heart D. Incompetent valves in the vein
D. Incompetent valves are the cause of varicose veins. This is often caused by heredity, obesity, or standing in one place. Sclerosis is a treatment used in treating small varicose veins. Smoking is not associated with varicose veins. An embolism from the heart would affect the arterial system.
Which condition is associated with episodes of bloating, abdominal pain, and constipation alternating with diarrhea? A. Diverticulitis B. Ulcerative colitis C. Colorectal cancer D. Inflammatory bowel disease
D. Inflammatory bowel disease is a chronic condition with episodes of constipation and diarrhea. Diverticulitis is a condition in which outpouchings of the colon become inflamed and cause pain. Ulcerative colitis is a condition of chronic inflammation of the colon resulting in frequent bloody diarrhea. Colorectal cancer is a malignant condition causing bleeding and eventually obstruction if treated.
What is the purpose of the liver scratch test? A. Assess for the presence of bruit B. Determine whether the patient has ascites C. Differentiate between cirrhosis and hepatitis D. Determine liver span when abdomen is distended
D. The liver scratch test is used to define liver borders in a patient with abdominal distention. Changes in sound while scratching the abdomen are heard with the stethoscope over the liver. The scratch test is not used to identify bruit or ascites or differentiate types of liver disease.
A patient has a holosystolic murmur. Which statement is correct about this murmur? A. The sound is very loud. B. The sound is a summation gallop C. The sound is heard between S2 and S1. D. The sound is heard with mitral regurgitation.
D. The murmur is associated with mitral regurgitation when the mitral valve does not fully close with systole. The loudness depends on many factors and is described in grades. A summation gallop is a combination of all four heart sounds (S1, S2, S3, S4). A systolic murmur is heard during systole (between S1 and S2).
How does the nurse, assessing a patient with lower leg pain, distinguish Achilles tendonitis from deep venous thrombosis? A. Check the Homan sign. B. Inspect for pitting edema. C. Auscultate for a venous hum. D. Palpate for tenderness over the Achilles tendon.
D. The nurse palpates over the Achilles tendon to determine whether lower leg pain is caused by tendonitis. The Homan sign may or may not be present with deep venous thrombosis. Pitting edema and presence of a venous hum are not used to differentiate the conditions.
Where is the point of maximum impact heard in most normal adult patients? A. Lower left sternal border B. Left second intercostal space C. Right second intercostal space D. Fifth intercostal space midclavicular line
D. The point of maximum impact is heard or palpated most commonly in the fifth intercostal space midclavicular line, the mitral valve area. The point of maximal impulse is not located along the left sternal border or in the left or right second intercostal spaces.
What effect on the radial pulse is a usual finding for a client with atrial fibrillation? A. The rhythm is a regular irregularity. B. The pulse rate is over 100 beats/min. C. The radial pulse rate is greater than the apical pulse rate. D. There is a fluctuation in strength and quality of the pulse.
D. The pulse is inconsistent in quality because different amounts of blood are expelled with ventricular contraction because of the inconsistent filling of the ventricles. The radial pulse is irregular because there is no consistency in the rhythm. The rate of atrial fibrillation may be slower or faster than 100 beats/min. The apical pulse should be greater than the radial because all of the beats heard at the heart may not be perfused peripherally.
4.Which is the best intervention to assess a patient's level of pain? A. Ask the patient to describe the pain regarding location and quality. B. Observe the patient's facial expressions while he says he has pain. C. Observe the activities the patient is doing when he says he has pain. D. Ask the patient to compare present pain to past pain and rate it on a pain scale.
D. Ask the patient to compare present pain to past pain and rate it on a pain scale.
5.Which characteristic is correct in describing pain related to nerve damage? A. Spasmodic B. Deep and aching C. Heavy and throbbing D. Burning and shocklike
D. Burning and shocklike
7. What patient activity is included in assessment of the temporomandibular joint? A. Puff the cheeks B. Swallow water C. Touch the chin to the chest D. Open the mouth widely
D. Open the mouth widely
2. The nurse notices the patient has a slow tremor of her thumb and opposing fingers that stopped when she picked up her purse. This tremor is commonly associated with which condition? A. Meningitis B. Multiple sclerosis C. Myasthenia gravis D. Parkinson disease
D. Parkinson disease
2. Which finding is consistent with the assessment of a patient's left leg that was injured several months earlier and has significantly limited the patient's ability to walk because of pain since the injury? A. Palpable crepitus in the knee joint B. Full range of motion of the knee joint C. Callus on the great toe of the left foot D. Slight atrophy of the left gastrocnemius muscle
D. Slight atrophy of the left gastrocnemius muscle
7. The abdominal reflexes are tested to assess functioning of the nerves in which location of the spine? A. Sacral B. Lumbar C. Cervical D. Thoracic
D. Thoracic
8. A patient tells the nurse he has back pain. The nurse later asks the patient to walk on his heels and then his toes. What is the significance of this test? A. To assess the patient's coordination B. To determine spinal range of motion C. To determine if sciatic nerve irritation is present D. To determine the specific spinal nerve involved
D. To determine the specific spinal nerve involved
8. A patient tells the nurse she has been noticing her sense of touch has become weaker. Which test specifically evaluates touch? A. Romberg test B. Heel-to-shin test C. Brachioradialis reflex D. Two-point discrimination
D. Two-point discrimination
must assess stability of hip to rule out _______
DDH developmental dyaplasia of the hip
Orthostatic hypotension
Decrease in blood pressure related to positional or postural changes from lying to sitting or standing positions, patients with GI bleed have dramatic changes in BP with postural change.
Geriatric GI
Decreased motility, reduced circulation, decreased mucus and enzyme secretion, decreased hepatic size and blood flow, obesity, type II DM, gallstones
Sunken/scaphoid abdomen
Diaphragmatic hernia
Pulse deficit
Difference between the apical and peripheral pulses. Is seen with ectopic rhythms
Hydronephrosis
Dilation of renal pelvis and calyces due to obstruction of urine flow S/S: Intermittant, severe pain with n/v, hematuria, flank pain, fever, CVA tenderness (severe), Distended bladder
Irritable bowel syndrome
Disorder of intestinal motility 1 in 5 Americans, greater in women, appears in early adulthood S/S- cluster of symptoms- abd pain, bloating, constipation, diarrhea (alternate diarrhea and constipation), mucousy stool, bouts during emotional stress, unremarkable exam (R/o other causes). 3 days/month for last 3 months, relieved by defecation
Diverticular Disease
Diverticula are saclike mucosal outpouchings through colonic muscle. May be caused by dysmotility, defective muscle structure, defect in collagen, aging S/S: May be asymptomatic. When inflamed, LLQ pain, anorexia, n/v, constipation, pain at site of inflammation, distention, tympany on percussion, decreased bs, bleeding
Pulse rate/rhythm
Document rate. Note irregularities or skipped beats.
Timing
Does it occur in systole (after S1) or diastole (after S2)? Does it occur early, mid, or late in systole or diastole? Is it occur throughout systole or during midsystolic ejection? Is it continuous? (is it heard during the whole heart beat?)
Percussion: spleen
Dullness on left side, 6th to 9th rib. If suspicion is high of splenomegaly, confirm with xray as other things can produce dullness too
Pain in RUQ
Duodenal ulcer, hepatitis, hepatomegaly, lower lobe pneumonia, cholecystitis
Premature Ventricular beats
Early beat arising from an irritable ventricular focus. presents as a wide and bizarre QRS complex. Could be from hypoxia, CHD, irritation caused by *invasive catheter*, or as a result of a surgical procedure. MOst often benign if infrequent.
Edema
Edema is rarely associated with CHD... *EXCEPT* Infants with Turner's Syndrome will have *isolated peripheral edema*. These infants show a high incidence of *Coarctation of the Aorta*.
What substances in the body can change or inhibit the pain perceived?
Endorphins (exogenous opioids), serotonin, and norepinephrine
What makes the cardiovascular assessment difficult in the neonate?
Examination findings change constantly over the first few hours, days and weeks of life. This is due to the transition from fetal to newborn circulation.
EBS Eagle-Barrett Syndrome
Exclusively in males. Present with a prune belly, undescended testes and various GU malformation. occasionally have imperforate anus, malrotation and other GI anomalies
T OR F The PMI and the Apical impulse are always in the same spot
False Although they are usually the same. Within the first few hours of life the PMI will be in the 5th intercostal space at the lower sternal border. This will resolve after transition when the RV predominance has been corrected.
T OR F During the first few hours of life a bounding precordium is indicative of cardiac disease
False. This can be a normal finding when seen on the left sternal border. This is due to the RV predominance in transitional circulation.. Should resolve within a few hours.
Elderly: Fecal incontinence
Fecal leakage, assoc. with fecal impaction, underlying disease, and neurogenic disorders. Impaction assoc with immobilization, poor fluid and dietary intake, laxative overuse.
Groin/femoral area
Feel for femoral pulse, compare bilat. and compare to brachial pulses (sign of pda, interrupted aortic arch or coarc) (check limb blood pressures if pulse differences present) Assess for inguinal hernias Assess for bulges near femoral artery
Abdominal venous pattern
Fig 17-6
Duodenum
Forms a C-shaped curve around the head of the pancreas, common bile duct and pancreatic duct opens into duodenum 3" below pylorus
Single umbilical artery
Found in 0.3% of neonates Associated with renal anomalies in 7% of infants presenting with SUA
Abdominal distention
Frequent finding in the neonate. due to lack of abd muscle development. Masses or ascites are uncommon findings for abdominal distention.
Acute diarrhea
Frequent, < 4 weeks. Patho: usu viral, self limited, special situations- int'l travel, camping, contaminated water, undercooked poultry/beef/unpasteurized milk, raw shellfish, other food poisoning S/S: pain/n/v, fever, possible bloody diarrhea (shigella/campylobacter), vomiting within several hours of questionable food, abdominal tenderness, RLQ pain, dehydration (severe- shocky)
Assessing Muscle Strength
Grade = Muscle Functional Level 0 = No evidence of movement 1 = Trace of movement 2 = Full ROM, but not against gravity (Passive movement) 3 = Full ROM against gravity but not against resistance 4 = Full ROM against gravity and some resistance, but weak 5 = Full ROM against gravity, full resistance
Deep Tendon Reflexes
Have pt. sit or lie down. Position limb with slight tension on the tendon & briskly tap the tendon with a flick of the wrist. May include biceps (strike your thumb rather than the tendon directly), brachioradial (1-2 in above wrist), triceps, patellar, achilles, clonus
Osteoarthritis
Heberden nodes: located along the distal interphalangeal joints Bouchard nodes: along the proximal interphalangeal joints
Cullen sign
Hemoperitoneum/pancreatitis/ectopic pregnancy: ecchymosis around umbilicus
Grey Turner sign
Hemoperitoneum/pancreatitis: flank ecchymosis
Omphalocele
Herniation of abdominal contents into umbilical cord (sac may be ruptured so examine carefully to differentiate from gastroschisis). 67% chance of other defects such as cardiac, neurologic, GU, skeletal, and chromosomal. Associated with Beckwith-Wiedemann syndrome, trisomies 13, 18, and 21
Palpation: liver
Hook hand under right ribs, have pt take deep breath, feel for liver as diaphragm lowers, feel for nodules, contour. May be able to feel enlarged gallbladder (painful- cholecystitis, nontender- common bile duct obstruction)
Palpation: infant
Hypertonic muscles- pain or peritoneal irritation Hypotonic- neuromuscular disease, perinatal dpn, maternal meds Palpate for liver, spleen, kidneys (difficult), masses, bladder (see cards 53, 54)
Pyloric stenosis
Hypertrophy of circular muscle of pylorus leading to obstruction of pyloric sphincter. S/S: projectile vomiting, then feeds eagerly, fail to gain weight, may have visible peristalsis wave, olive-shaped mass in RUQ
Loudness
I: barely audible II: Soft, but audible immediately III: Moderate intensity (no thrill) IV: Louder (may have a thrill) V: Very Loud (can be heard with the stethoscope rim barely on chest VI: Extremely loud (can be heard without touching the scope to the chest.
Older adults, what questions would you ask to assess pain level and document in HPI?
Identify what word they use for pain, achy, sore, discomfort, and use this word with them, if older adult is cognitively impaired as family for ques to how they describe pain.
Systemic Lupus
Increased incidence of congenital complete AV block in the neonate. *Infant will present with low resting heart rate, can happen in utero.*
Maternal Diabetes
Increases the risk of neonatal CHD by 3-4 times that of the general population.
Inspect the infant's skin and Mucous Membranes. (Next 4 Slides)
Infant should be centrally pink in a well-lit room. Lips, tongue, earlobes, and scrotum are part of being "centrally pink" If the tongue is not pink, then your baby is centrally cyanotic.
Pyelonephritis
Infection of kidney and renal pelvis (can be caused by catheter, DM, sexual activity, UTIs, vesicouretural reflux, urinary incontinence S/S- Fever, dysuria, flank pain, rigors, polyuria, frequency, urgency, hematuria, ill-appearing, significant pain, CVA tenderness. Pyuria and bacturia
Acute glomerulonephritis
Inflammation of capillary loops of the renal glomeruli, results from immune complex deposition, causes include infection, IgA nephropathy S/S: nonspecific nause, malaise, flank pain, h/a due to htn, tea colored urine or hematuria, peripheral and periorbital edema. Casts in urine
Necrotizing enterocolitis
Inflammatory disease of GI mucosa, assoc with prematurity and gut immaturity. Multifactorial cause. S/S: feeding intolerance, distention, vomiting, bloody stools, systemic instability, apnea, pneumatosis
Hepatitis
Inflammatory process characterized by diffuse/patchy hepatocellular necrosis. Patho: usu viral (Hep A-E: D only occurs with B, E is self-limited with fecal contaminated water/food) S/S: Can be asymptomatic. Jaundice, anorexia, abd pain, clay-colored stools, tea-colored urine, fatigue, prominent abd. vasculature, cutaneous spider angiomas, hematemesis, abd fullness. Palpation: initially enlarged, then reduced. Hepatic encephalopathy, portal htn, ascites, muscle wasting, nutritional deficiencies, abnormal LFT/coags
Cholecystitis
Inflammatory process of gallbladder, usu due to cystic duct obstruction from stones. Patho: Cystic duct obstruction- gallbladder distended, blood flow is compromised, ischemia/inflammation Without stones- from surgery, trauma, sepsis, or long-term TPN Chronic cholecystitis causes a scarred/contracted gallbladder S/S- RUQ pain, radiates around torso, R scapula, abrupt, 2-4hrs. May have fever, jaundice, anorexia. Chronic- fat intolerance, flatulence, nausea, anorexia, nonspecific abd pain.
Male Genitalia
Inspect in the supine position. Palpate the scrotal sac and inguinal canal to assess for presence of testes and masses.
Umbilical cord
Inspect umbilical cord, count vessels, (single UA- look for other anomalies, stump separates around 2 weeks of age. Serous/serosang discharge may indicate granuloma, consider patent urachal cyst. Look for hernia. Thick cord = well nourished fetus, thin may indicate placental insufficiency Red encircling cord and on abdomen- omphalitis, requires prompt treatment Umbilical polyp: red/raw granuloma at site of separation
Periumbical pain
Intestinal obstruction, acute pancreatitis, early appendicitis, mesenteric thrombosis, aortic aneurysm, diverticulitis
Dance sign
Intussusception: Absent BS in RLQ
extrophy-epispadias complex (EEC)
Involves defects of the urinary and genital tracts, musculoskeletal system, and sometimes the intestinal tract.
Chronic pancreatitis
Irreversible morphologic changes resulting in atrophy, fibrosis, and calcification. Common in chronic alcohol use, congenital pancreatic abnormalities, CF, autoimmune, and medication induced disease S/S: Constant, unremitting abd pain, wt loss, steatorrhea, s/s similar to acute pancreatitis, malnutrition, elevated pancreatic enzymes
The next 9 cards are behaviors that define variations in temperment.
Is it over yet????
Spleen
LUQ. Consists of white pulp (lymphoid tissue- filters blood and manufactures lymphocytes and monocytes) and red pulp (capillaries- storage and release of blood)
A-delta fibers
Large fibers that transmit acute, sharp, well-localized pain
Renal abscess
Localized infection in the medulla or cortex of the kidney S/S: same as pyelo, beyond 72 hrs of appropriate antibiotic therapy. Renal u/s, CT, or MRI can diagnose
Location
Location of the murmur is usually described in reference to the interspace and the midsternal, midclavicular, or anterior axillary lines. NOted where the murmur is at maximum intensity
Cloacal extrophy
More severe May include an omphalocele containing intestines, liver, and spleen. Penis is small and divided in half. females present with a bifid clitoris
Wilms tumor (nephroblastoma)
Most common intraabdominal tumor in children, 2-3 y/o, family history factor, assoc with other syndromes S/S: painless enlargement of abd, mass, sometimes pain/vomiting/hematuria. Htn
Spleen lac/rupture
Most commonly injured organ in abd trauma S/S- pain in LUQ, ratiation to left shoulder (Kehr sign), hypovolemia/syncope. Dx by paracentesis or CT.
congenital hypoplasia of the depressor anguli oris muscle
Most evident when the infant is crying; failure of one corner of the mouth to move down & out; may be associated with congenital cardiovascular anomalies, & neuroblastoma
Examination equipment and preparation (adult asst)
Need: stethoscope, measuring tape, pen, good light source, short fingernails, have pt empty bladder, pt sitting, then supine, draped, relaxed
The tool used for behavioral assessment in the term (36-44 wk) newborn is__________
Neonatal Behavioral Assessment Scale (NBAS).
Abdominal masses in infants and children
Neonates: hydronephrosis, multicystic dysplastic kidney, renal vein thrombosis, wilms tumor, ovarian cyst, hydrocolpos, hydrometrocolpos, GI duplication Infants/children: Feces (constipation), pyloric stenosis, GI duplication, meckel diverticulum, neuroblastoma, wilms tumor, lymphoma, hepatoblastoma, embryonal sarcoma, ovarian cyst, teratoma
Do older adults have a diminished perception of pain?
No, they usually have chronic pain related to disease processes. (arthritis etc..) They often don't report pain because of personal beliefs, they don't want to be a nuisance, afraid it will lead to costly tests, etc...
Proprioception & Cerebellar Function: Coordination and Fine Motor Skills
Observe for involuntary movements (tremors, tics, fasciculations). Note part of the body affected, quality, rate, & rhythm. •*Rapid Rhythmic Alternating Movements*: seated pt. pats his knees with both hands, alternating turning the hands up & down & gradually increasing speed OR pt. touch the thumb to each finger on the same hand looking for smooth rhythmic movements. •*Accuracy of Movements*: finger-to-nose test, heel-to-shin test (see pic)
Continuous Murmur
Occurs in 33% of premature infants with a PDA. May also be associated with an AV Fistula
Loud systolic ejection murmur
Occurs in the immediate neonatal period. Usually Grade II-V. Is almost always the result of pulmonary stenosis or coarctation of the aorta.
Meconium ilius
Only obstruction that presents with abdominal distention at birth Distal intestinal obstruction cause by thick inspissated impacted meconium in LI. May be first manifestation of cystic fibrosis. Some with volvulus, atresia, mec peritonitis S/S: Failure to pass meconium by 24 hours old, vomiting and abd distention, may be shocky. Uncomplicated cases can be treated with hyperosmoloar enema
Meckel diverticulum
Outpouching of ileum, occurs in 2% of population S/S: may be asymptomatic, found during unrelated xray/surgery. Children- red rectal bleeding with little, if any, abd pain. Some have pain, sim to appendicitis with bilious emesis, may have intestinal obstruction
Wide pulse pressures are seen in premature infants with a
PDA
Infant: palpation
Palpate with knees elevated to promote relaxation. Spleen may be 1-2 cm below costal margin (enlarged may be hemolytic disease or sepsis). Liver: lower edge 1-3 cm below costal margin at mid clavicular line, upper edge at 6th ICS. Hepatomegaly >3cm below costal margin) suspect infection, cardiac failure, or liver disease. Olive-shaped mass- pyloric stenosis
Hiatal hernia with esophagitis
Part of stomach passes through diaphragm Very common, more in women/elderly, assoc with pregnancy, obesity, ascites, tight-fitting clothes S/S- epigastric pain/heartburn worsens lying down, relieved sitting/antacids. Mouth fills with fluid from esophagus, dysphagia, sudden vomiting/pain
Pathologic Murmurs
Pathologic murmurs present at varying times. Immediately following birth - pathologic murmurs are almost always caused by stenosis or regurgitation. 3days to 4-6 weeks of age - murmurs present due to the closing of the PDA and the resolution of PVR. ASD can be undetected until up to 2 years of life. The absence of a murmur may be an ominous sign. The pda is most often the cause of a murmur in the immediate neonatal period. An infant with a CHD that is ductal dependent will die without a PDA and a MURMUR. ANY MURMUR THAT OCCURS AFTER 48 HOURS OF LIFE, IS GRADED HIGHER THAN A II, OR IS PRESENT IN A SYMPTOMATIC INFANT REQUIRES FURTHER EVALUATION
Percussion: liver span
Percuss to find top and bottom of liver over mid clavicular line to detect enlargement or atrophy. Upper border should be around 5th intercostal space- too high indicates upward displacement- abdominal fluid/mass. Normal liver span is 6-12 cm. Abnormal of lower border is 2-3 cm below costal margin (may be related to pulmonary disease like emphysema)
Blumberg sign
Peritoneal irritation or appendicitis: Rebound tenderness
Markle sign
Peritoneal irritation/appendicitis: Pt stands with straight knees, raises up on toes, then relaxes and allows heels to hit floor- will cause abd pain
Rovsing sign
Peritoneal irritation/appendicitis: RLQ pain worse if LLQ palpated
Ballance sign
Peritoneal irritations: Fixed dullness to percussion of left flank and dullness in right flank disappears with position change
Environmental Factors
Pg 94 Table 7-1 Lists the common environmental factors.
Quality and pitch
Pitch - high, medium or low? Quality - harsh rumbling or musical
pg. 300
Please review: *Figure 14-11 for fetal Circulation *Table 14-1 for Changes during Prgenancy
Infants: intussusception
Prolopsing/telescoping of intestine into another causing obstruction. Commonly occurs at 3-12 months old, may resolve but sometimes results in infarction, perforation and peritonitis. S/S: acute intermittent pain, distention, vomiting, inconsolable knees flexed, may have red-currant jelly like stools (blood and mucus). Sausage shaped mass in abd, Require contrast enema for diagnosis
If problems are detected during routine examination, what other procedures can be done?
Protective sensation, Meningeal Signs, Jolt Accentuation of Headache, Posturing
Exstrophy of bladder
Rare- Posterior wall of bladder is exposed and urine drains into abdomen
Catheter
Real-time measurement of BP and mean. Measures HR. INVASIVE.
Muscles and connective tissue of abdomen
Rectus abdominis, internal and external obliques linea alba (midline tendonous band from xiphoid to symphysis pubis), inguinal ligament (ilium to each side of the pubis)
Auscultation (adult asst)
Regular BS: gurgles/clicks 5-35/minute. Auscultate with diaphragm, all 4 quadrants Increased frequency: gastroenteritis, early bowel obstruction, or hunger High pitched tinkling: intestinal fluid/air under pressure (early obstruction) Decreased BS: peritonitis, paralytic ileus Absent BS (none in 5 minutes) with rigidity and pain = surgical emergency Friction rubs over liver/spleen: inflammation from tumor/infection/inflammation Bruit: vascular disease (listen with bell over epigastric region, aortic/renal/iliac/femoral arteries) Venous hum over umbilicus: increased collateral circulation between portal and systemic venous systems
Please review pg. 301-303 for:
Review of related Hx, HPI, PMH, Family Hx, Personal?Social Hx
Infant: inspection
Rounded/dome shaped abd. is normal. Distention can be due to mass, feces, organ enlargement. Scaphoid can be CDH. Diastasis rectus 1-4 cm normal unless organ herniation occurs (rare)
Obturator muscle test
Ruptured appendix or pelvic abscess: pt supine, R leg flexed at knee and hip 90 degrees, hold ankle and above knee, rotate leg lateraly and medially, will cause R hypogastric pain
Pain in LUQ
Ruptured spleen, gastric ulcer, aortic aneurysm, perforated colon, lower lobe pneumonia
Which heart sound is the carotid artery synchronous with?
S1
Heart Sounds
S1 and S2 - traditional heart beat
S3
S3 best heard at the apex of the heart during early diastole. can be difficult to auscultate in the newborn and most commonly is related to premature infants with PDA's
orthopnea
SOB when lying flat
Evaluating Blood Pressure
Should be done with the infant quiet. Should be left to the end of the exam. Should be measured in all infants suspected of CHD, renal disease, or with signs of hypotension.
Assess the direction and force of the urine stream
Should be forceful straight and continuous.
Foreskin
Should cover the glans completely. should be tight witha tiny opening to allow urination.
Pain in LLQ
Sigmoid diverticulitis, salpingitis, ovarian cyst, ruptured ectopic pregnancy, tuboovarian abscess, renal/ureteral stone, strangulated hernia, regional ileitis, perforated colon, ulcerative colitis
Abdominal distention pearl- sign of hypokalemia as a cause for paralytic ileus
Significant distention with hypoactive BS, no pain or masses, diminished DTRs, pt on diuretics. Check potassium
Observing Breathing Patterns
Signs of respiratory distress may be a signs of congestive heart failure. An infant that is cyanotic and has unlabored respiratory effort may be cardiac. Nonlabored tachypnea with central cyanosis is a result of hypoxic respiratory drive.
Inspection
Skin color and characteristics, contour, visible veins (assess which way blood flows), scars Abnormal: jaundice, cyanosis, red/inflamed, blue periumbilical discoloration (Cullen sign), new onset straie not r/t pregnancy/obesity may indicate tumor, ascites, or Cushing disease (purplish), lesions- esp pearl-like nodules in umbilicus (Sister Mary Joseph nodules- sometimes first sign of malignancy), swelling/hernia
Inspection: infant
Skin- color, rash, bruising, veins Shape/movement- chest and abdomen should move parallel to each other during respiration, asynchronous movement indicates resp distress. Shape can be flat to slightly distended if just fed Measure abdomen at umbilicus, should be less than FOC <32weeks, greater than FOC >36 weeks.
Children: neuroblastoma
Solid malignancy of embryonal orgin of peripheral SNS A spectrum of tumors of varying degrees of neural differentiation S/S: asymptomatic abd mass, maliase, loss of appetite, weight loss, protrusion of one or both eyes, mets. Fixed/firm, nontender irregular, nodular abd. mass that crosses midline, mets to periorbital region. Horner syndrome, ataxia, opsomyoclonus (dancing eyes, dancing feet). Xray- calcified mass with hemorrhage
Nonalcoholic fatty liver disease
Spectrum of hepatic disorders, not assoc with excessive EtOH intake, ranging from steatosis to cirrhosis to hepatocellular carcinoma. Patho: Hepatic cell inflammation from accumulation of triglycerides in liver. Genetic and environmental factors, and insulin resistance. Higher prev. in Hispanics. S/S: Asymptomatic, or RUQ pain, fatigue, malaise, jaundice, abnormal LFTs, may have hepatomegaly.
Kehr sign
Spleen rupture/renal calculi/ectopic pregnancy: Abd pain radiating to L shoulder
Splitting
Splitting is when you hear two distinct components of a heart sound. Usually never heard with S1, but should be present in the S2 sound after 1-2 days of life. Wide splitting of the S2 is abnormal and is associated with ASD, Pulmonary stenosis, Ebstein's anomaly, PAPVR, mitral regurgitation, or right bundle branch block.
Cholelithiasis
Stone formation in gallbladder (crystalizing from high concentration) Patho: crystals mix with mucus, form gallbladder sludge, then stones. High in cholesterol and calcium bilirubinate. Chronic disease results in fibrosis and gallbladder dysfunction and cancer. S/S- asymptomatic, or indigestion, colic, mild transient jaundice, episodes of acute cholecystitis
Renal calculi
Stones formed in pelvis of kidney. Composed of Ca salts, uric acid, cystine, and struvite. Alkaline urine situations cause stones. S/S: fever, dysuria, hematuria, flank pain, renal colic, severe cramping, flank pain, n/v when passing through ureter. elevated ca to cr ratio in urine, hematuria
Romberg-howship sign
Strangulated obturator hernia: pain down medial aspect of thigh to knees
Acute renal failure
Sudden impairment of renal funcion, acute uremic episode. Serum Cr 0.5-1.0 mg/dL. Retention of notrogenous and metabolic waste products and ECF from decreased GFR. S/S: U/O can be normal, decreased, or absent. Prerenal due to decreased kidney perfusion, postrenal due to obstruction.
Acute pain
Sudden, short duration / surgery, injury, acute illness
Primary Sensory Function
Superficial touch (cotton wisp), superficial pain (paper clip), temperature & deep pressure (only done if superficial pain sensation not intact), vibration (tuning fork), position of joints (ex. which way am i moving your toe?)
Innocent Murmurs
Systolic Ejection murmur Continuous systolic murmur (crescendo) Early midsystolic ejection murmur
Palapation
Systolic pressure can be determined by noting the pressure that the pulses can once again be palpated during deflation of the cuff.
* THE CARDIOVASCULAR EXAMINATION*
THE NEXT (#) SLIDES...
Heart Rate
Term neonates heart rate at rest is 120-140 bpm
Abdomen
Term: Round and symmetric, smooth opaque skin Preterm: abdomen is protrubed. skin is thinner and may be prominent blood vessels. Inspect for masses in all quadrants.
Cryptochordism
Testes that assume an extrascrotal location. Tested fail to descend into the scrotal sac 3.4% of term males. 30% of preterm males
A few pages at the end of this chapter are case assessments of a healthy preterm infant and two immature preterm infants, it pulls the behavior assessment together based on these infants. I didn't know how to put them in here and make sense so you might want to read pages 211-214 to understand what I am talking about. lol
Th-Th-That's all folks!
S1
The first hear sound Thought to be produced by the closure of the Mitral and tricuspid valves after atrial contraction. Best heard at the apex of the heart. Factors that increase cardiac output will increase the amplitude of the S1... So it should be no surprise that the S1 will be really loud in the newborn in the first few hours of life. WHY?? because of the RV predominance that occurs in the transition period.
Pulse volume / character
The most important determinations in neonatal pulse evaluation. Pulses are classified numerically 3+ -- Full or bounding 2+ -- Normally palpated 1+ -- Thready or weak 0 -- Absent
FYI
The next 10 slides are a very general overview of A & P so if you want to review in more detail you can.
S2
The second heart sound. Thought to be produced by the closure of the aortic and pulmonic valves. Should be heard most loudly at the base of the heart.
By three months of age
The testes should be in the right place. Spontaneous decent rarely occurs after nine months of age.
Get a 4 point blood pressure when...
There is any question of a CHD. If there is difficulty obtaining pressures. If a murmur is heard. If there is an absence of femoral pulses.
Purkinje fibers
These fast-conducting heart muscle cells spread the electrical signal throughout the ventricular wall.
Polycythemia
These infants may appear cyanotic, but usually are not. These infants have an increased amount of hemoglobin, a lot of them being unsaturated with O2, leading to a buish purple tone.
Mothers with CHD
These women pass along a 15% chance of CHD in their babies.
Evaluating a murmur
Timing Loudness Location
Past Medical History
Trauma, meningitis, encephalitis, lead poisoning, poliomyelitis, deformities, congenital anomalies, genetic syndromes, cardiovascular, circulatory problems, neuro disorder, brain surgery, headaches
Hemolytic uremic syndrome
Triad of microangiopathic hemolytic anemia, thrombocytopeina, and uremia. Cause of ARF in children under 4 yo, bacterial/viral cause S/S: preceding URI or gastroenteritis with fever/abd pain, vomiting. Bloody diarrhea. GI involvement, perforation, sudden onset of pallor, weakness, lethargy, decreased u/o, petechaie, dehydration, edema, hepatosplenomegaly
"Try Pulling My Arm"
Tricuspid, Pulmonic, Mitral, Aortic **order of the cardiac valves
Alimentary tract (adult)
Tube 27 feet long from mouth to anus -esophagus- 10", small intestine- 21' (duodenum 1', jejunum 8', ilium 12'), large intestine- 5'
Testicular Torsion
Twisting of the testis on its spermatic cord. May occur prenatally and is unilateral. Infant will have a hard, swollen scrotum that is bluish to red in color. Possibly an emergent situation. 4-6 hours of ischemia to testis may result in irreversible damage and loss of gonad.
Infant hernias
Umbilical hernia- usually close spontaneously by 2 years old Epigastric hernia- firm palpable nodule between umbilicus and xyphoid (usu. requires surgery) Inguinal hernia- intestines in scrotum or soft tissue of labia (requires surgical repair)
Common adult abdominal hernias
Umbilical, incisional (previous surgical sites), midline bulges. Non reducible hernias require immediate surgery
Evaluating muscle strength
Upper extremities: pull-to-sit, grasp reflex Lower extremities: stepping reflex (at 37 wks)
Balanic Hypospadias
Urethral opening is ventrally situated at the base of the glans.
Inspection: contour
Use tangential light, observe for peristalsis, muscular/fatty/scaphoid, symmetry, swelling (hernia), distention, have pt take deep breath and hold- look for new masses/bulges, pulsations, breathing movements (abdominal breathing vs costal)
Wong/Baker FACES Scale and the Oucher Scale
Used for children over 3, each face has a different level of pain, tell child what each face means and ask child what face best matches how he/she feels.
Common defects seen with maternal diabetes
VSD and Transposition of the Great Arteries. Hypertrophic cardiomyopathy is commonly found in infants of diabetic mothers.
Pallor/Mottling/Perfusion
Vasoconstriction and shunting of blood to vital organs due to cardiac insufficiency may present as a pale skin color. *Cardiogenic shock* - *mottled* infant presenting with *hypovolemia* or *decreased cardiac output*. An infant that is hypoxic and anemic may not be blue because of the low HBG levels Check capillary refill time for perfusion
Liver structure and function
Weighs 3 lbs, lobes contain lobules (functional units) made up of liver cells that radiate around a central vein. Functions: secrete bile (and excrete fat soluble substance into bile), metabolism of carbs, fats, and proteins, storage of iron and vitamins, detoxification, antibody production, conjugation/excretion of steroid hormones, production of prothrombin, fibrinogen, and other coagulation substances. Blood flow: some blood directly from aorta via hepatic artery, blood from portal vein carrying blood from digestive tract and spleen, veins empty into inferior vena cava
Levine sign
When the patient places a clenched fist on the sternum as he/she describes their chest pain. May be present with *ischemic* chest pain.
Behavioral states Quiet alert
Wide, bright eyes attention focused on stimulus This state provides the greatest opportunity for infant interactions with caregiver. Preterm infants may have difficulty maintaining a quiet alert state for long or they may become hyperalert with an inability to decrease or end fixation on stimulus.
When is the best time to assess an infant's abdomen?
Within the first few hours of life, when the bowel is not yet filled with air
bunion
a bursa often forms at the pressure point, and if becomes inflamed it becomes a bunion
Seizure Disorder (epilepsy)
a chronic disorder characterized by recurrent, unprovoked seizures secondary to an underlying brain abnormality; can be caused by brain injury, toxins, stroke, brain tumor, & hypoxic syndromes
Peripheral Neuropathy
a disorder of the PNS that results in motor & sensory loss in the distribution of one or more nerves, commonly caused by DM; gradual onset of numbness, tingling, burning, & cramping, mostly in hands & feet
Cerebral Palsy (CP)
a group of permanent disorders of movement & posture development associated with nonprogressive (static) disturbances that occurred in the developing fetal or infant brain
Sinus bradycardia
a heart rate less than normal for age. Caused by parasympathetic predominance. vagal stimulation causes bradycardia.
check infants back for tufts of hair, dimples, discolorations, cysts or masses near the spine
a mass near the spine that transilluminates should cause you to suspect a meningocele or myelomeningocele
Intrapartum Maternal Lumbosacral Plexopathy
a neuropathy that can occur during late pregnancy & delivery that occurs when the lumbosacral trunk (& sometimes the superior gluteal & obturator nerves) is compressed between the maternal pelvic rim & the fetal head leading to motor deficits in a lower extremity; may see a unilateral foot drop & pain that radiates from the buttock into the leg.
Heave
a palpated PMI that is slow rising and diffuse associated with fluid volume overload.
Cortical Thumb
a persistent tightly fisted hand in which the thumb is firmly enclosed by the fingers; may indicate neurologic abnormality
Guillain-Barre Syndrome
a postinfectious disorder following a nonspecific GI or respiratory infection that causes an acute neuromuscular paralysis; increased protein in CSF; progressive weakness (more in legs)
Tuberous sclerosis
a progressive degenerative neurologic disease in which collections of abnormal neurons & glia occur in the subependymal & cortical areas of the brain ❖Significant findings: areas of skin depigmentation. Lesion(s) white, macular, & have leaflike borders
Shaken baby syndrome
a severe form of child abuse resulting from the violent shaking of infants younger than 1
Parkinson Disease
a slowly progressive, degenerative neurologic disorder in which deficiency of the dopamine neurotransmitter results in poor communication between parts of the brain that coordinate & control movement & balance; most often in people over 50; may see tremors, muscular rigidity, stooped posture, slurred monotone speech, impaired cognition
Normal Pressure Hydrocephalus (older adult)
a syndrome simulating degenerative diseases that is caused by noncommunicating hydrocephalus (dilated ventricles with intracranial pressure within expected ranges); may be d/t slightly elevated CSF; gait impairment, wide-based stance, short small steps, & reduced floor clearancce, No tremor, no sensory impairment, impaired memory recall for recent events
Bell Palsy
a temporary acute paralysis or weakness of one side of the face; may be caused by acute inflammation of CN VII; rapidly progressive (over 2-3 days); eyelid won't close on affected side & lower lid sags
terminology
abduction: move limb away from midline of body adduction: move limb toward or past midline of body dorsiflexion: flexing limb toward back, flexing foot so the forefoot is higher than ankle everted: turning limb out and away from midline of body extension: straightening a limb at a joint flexion: bending a limb at a joint inverted: turning limb inward toward midline of body plantar flexion: extending foot so that the forefoot is lower than the ankle pronation: turning the face down rotation (neck): turning face side to side supination: turning face up valgus: bent outward or twisted away from midline of body varus: turned inward
An appropriate behavioral assessment describes the infants_________
abilities to utilize intervention support and delineates the types of facilitation necessary to ensure smooth function
anterior tibial bowing
abnormal and an orthopedic consult should be sought
Hypospadias
abnormal location of the urethral meatus on the ventral surface of the penis. 8.2/1000 births. associated with a hooded or malformed prepuce.
What intrapartum factors can affect a neuro exam?
abnormal presentation, prolonged labor, precipitous delivery, fetal distress, difficult or operative extraction, anesthetic agents/meds used around the time of delivery
Micropenis
abnormally short or thin penis that is more than 2 standard deviations below the mean of length and width for age using standard charts. Endocrinologist and geneticist consult!
Aphalia
absence of a penis
anorchia
absence of testicular tissue
Encephalitis
acute inflammation of the brain & spinal cord involving the meninges, often d/t a virus; might have photophobia or stiff neck
Older Adults and compromised cardiac function
affected by: long standing HTN; infarcts; can -> decline in cardiac output. caused by: fibrosis, sclerosis of SA node region & heart valves & increased vagal tone.
Cerebellum
aids the motor cortex of the cerebrum in voluntary movement; processes sensory info.; control of muscle tone, balance, & posture
Penoscrotal hypospadias
aka perineal hypospadias. urethral opening at the penoscrotal junction
Functions of musculoskeletal system
allows movement, provides structure, protects vital organs (brain, spinal cord), stores minerals (calcium, phospohorus), produces RBCs & WBCs
Muscular system
almost completely formed at birth
The interplay of behaviors assessed by the APIB is evaluated ______________
along with the degree of organization rather than maturation of the CNS as the focus because in this model the infant is seen as being in continuous interaction with the environment.
Intracranial Tumor
an abnormal growth within the cranial cavity that may be a primary or metastatic cancer; signs will vary by location of tumor; may have early morning vomiting, persistent HA that awakens them from sleep
Signs of approach indicate the infant is ready to interact with the caregiver or the environment, these behaviors include____________
an alert, focused gaze, reg breathing, and dilated pupils, may also exhibit grasping, sucking, or hand to mouth movements.
Myasthenia Gravis
an autoimmune disorder of neuromuscular junction involved with muscle activation; autoanibodies directed against the acetylcholine receptors in the neuromuscular junction cause destruction & inflammatory changes in the postsynaptic membranes that lead to muscle dysfunction; weakness of skeletal muscles without reflex, sensory, or coordination abnormalities
Premature atrial beats
an early beat arising from the supra ventricular focus. Most often benign, but can be associated with CHD or other problems. If the beat is not tolerated, treat the underlying cause.
A bounding precordium in a normal newborn is indicative of
an infant in transition heart defects that have severe left to right shunting or severe valvular regurgitation
Meningitis
an inflammatory process in the meninges, the membrane around the brain & spinal cord; may see nuchal rigidity, fever, + brudzinski & kerig signs
suspect gouty arthritis
and inflamed metatarsophalangeal joint of the great toe
Ectopic rhythm
any cardiac rhythm arising from a center other than the normal pacemaker, the sinus node
What is the importance of a prenatal history for the musculoskeletal assessment?
any event or condition that changes the intrauterine environment can alter fetal growth, movement, or position (oligo, maternal uterine malformations, abnormal growth patterns, teratogenic agents, breech presentation)
Cardiac Rhythm and regularity.
any suspicion of arrhythmia warrants cardiac monitoring and an ECG.
Bounding to full pulses can be indicative of...
aortic-runoff lesions (PDA, truncus, aortic regurgitation, AV fistula)
Apical Impulse
apical impulse can be seen and palpated in the neonate. It is usually in the 4th intercostal space at or to the left of the midclavicular line.
Initial observation would be general _____ and _____.
appearance and behavior. An infant + CHD may be lethargic or flaccid. Extracardiac anomalies must be noted because they are associated with CHD 25% OF THE TIME. neurologic, GI, TEF, renal and GU, and diaphragmatic hernias are anomalies that often come with a CHD as a bonus.
The preterm or neurologically impaired infant may exhibit sudden changes between states, but abrupt state changes in the healthy term newborn____________
are cause for concern
Precordium
area on the anterior chest under which the heart lies.
Resting posture at 28 weeks
arms and legs extended, little tone
Habituation is best assessed when the infant is
asleep or in a drowsy state
Umbilical cord
assess appearance, length, diameter, vessels, insertion site. Should be gelatinous and bluish. three vessels.
single palmar crease
associated with Down syndrome
Meningitis
associated with gram + and gram - organisms, viruses & fungi. Signs: temp instability, irritability, poor feeding, vomiting, lethargy, poor tone, tremors, seizures, full fontanel, nuchal rigidity
other indicators the hip is abnormal
assymetry of skin folds in the gluteal and femoral regions
P wave
atrial depolarization
Habituation to auditory and tactile stimulus can be done in a similar manner by_________
auditory- using an objest that makes a noise 10-15 inches from infant and follow same sequence as visual. Tactile- pressing the sole of the foot to a smooth object and following same sequence as visual
Neurofibromatosis
autosomal dominant genetic disorder where dysplastic tumors occur along nerves, in the eyes, or in the meninges. ❖Significant findings: cafe au lait spots of 1.5 cm or larger or > 3 in number
Penile length
average is 3.5 cm
Avoidance behaviors (time out signals) include___
averting gaze, frowning, sneezing, yawning, vomiting, and hiccuping, may also include finger splaying, arching, stiffening, or crying. Color changes, apnea, irregular breathing, and decreased O2 sats also indicate the need for time out.
Other influencing factors from other body systems
barrel chest or pectus deformity; Xanthelsma (yellow deposit of fat under skin); funduscopic changes with HTN; ascites or pitting edema; ABD aortic bruit
Why are infants less able to modify pain impulses?
because the descending pathways from the brain to the dorsal horn of the spinal cord are not fully developed at birth.
Identifying conditions of risk, describing behavior patterns, and estimating developmental function are all important aspects of _____________
behavioral assessment.
Palpate bladder
between the umbilicus and the symphysis pubis. Now always palpable and may need to be percussed. tympany refers to a urine filled bladder. Dull sounds represent a mass.
Flush method
blanch hand or foot and inflate cuff... When the pale appendage blanches (refills) the pressure at that point will be your mean.
Primary Subarachnoid Hemorrhage
bleeding occurs from vessels in the subarachnoid space & the blood is usually located over the surface of the cerebral hemispheres. causes: trauma, hypoxia. Minor: may go undetected if asymptomatic. Moderate: seizures. Severe/massive: rapid deterioration, death, hydrocephalus (if they live).
Musculoskeletal System is comprised of
bones, joints, & their supporting connective tissues.
One femoral and the right ____ should be palpated _____.
brachial, simultaneously absent or weak femoral pulses and a strong preductal pulse is often associated with coarctation of the aorta, aortic stenosis, and hypoplastic left syndrome.
Tonic phase: (seizure)
brief flexion & characteristic cry with contraction of abdominal muscles, followed by generalized extension for 10 to 15 min., LOC for 1-2 min, eyes deviate upward, & dilated pupils
When in the alert state newborns will respond to auditory stimulus with___________
brightening of the eyes and face and turning of the head to search for the sound. the preterm infant begin to orient to a soft sound source around 28 weeks gestational age but often can not tolerate loud noxious noise.
Base
broader upper portion
Palpation : Synovial thickening
can be felt in joints that are close to the skin surface when the synovium is edematous or hypertrophied because of inflammation
Palpation: Crepitus
can be felt when two irregular bony surfaces rub together, or with the movement of a tendon inside the tendon sheath when tenosynovitis is present
Transillumination of the skull
can be helpful when a large FOC for GA is found; rubber-cuffed flashlight applied firmly to skull; glow >2cm is abnormal for fluid accumulation
Dandy-Walker syndrome
can cause posterior ballooning of the skull seen in hydrocephalus; consists of congenital agenesis of the foramen of Magendie and Luschka with dilation of the the 4th ventricle
observe wear of child's shoes
can tell you about alignment of legs and feet
Disorders of the lower motor neurons (Werdnig-Hoffmann disease)
cause flaccid weakness of the extremities with initial sparing of the face & cranial nerves; *Fasciculation* may be seen & is best observed in the tongue. Inspection will reveal continuous & rapid twitching movements.
Asymmetric deep-tendon reflexes
central or peripheral nervous system impairment
evidence of birth trauma
cephalhematoma, depressed area of skull, forcep marks, lacerations, abrasions, bruising, petechiae, localized swelling. Evidence of birth trauma to the *face* or *limbs* prompts you to evaluate spontaneous movement & symmetry of movement to identify underlying damage to nerves.
prenatal factors may have a bearing on conditions such as
cerebral palsy, brachial plexus palsy, facial assymetry, and torticollis
Arthrogryposis
characterized by fixed position & limitation of limb movement. This is a major presenting feature in neuromuscular disease. Caused by brain malformations, chromosomal defects, genetic syndromes, & destructive lesions of the CNS
bilateral facial weakness
characterized by generalized hypotonia & weakness at the level of the muscle; seen with congenital myotonic or muscular dystrophy & congenical facial diplegia syndrome (severe). Clinical presentation: tentlike appearance of the upper lip, partly open mouth.
The "slow-to-warm" baby
characterized by mild intensity, positive or negative moods, and slow adaptation to new situations or people. These infants need repeated, slow exposure to a situation before they will respond positively.
ask child to stand, rising from a supine position
child with good muscle strength will rise to a standing position without using the arms for leverage
Function of the heart
circulate blood through two separate circuits: 1) the body; 2) the lungs
Signs of stress or fatigue include__________
color changes, irregular respiration's, apnea, changes in tone, irritability or lethargy, and vomiting.
Postictal state: (seizure)
coma followed by confusion & lethargy
lordosis
common in obesity and pregnancy
Proprioception & Cerebellar Function: Balance
comprised of Equilibrium & Gait
No stool within 24 hours of birth
consider anal atresia, stenosis
brachial plexus injury with respirator distress or sustained tachypnea
consider phrenic nerve damage & resultant diaphragm paralysis; 5% of brachial plexus injuries have phrenic nerve injury
lateral tibial bowing without significant shortening
considered normal
Priapism
continuous, seemingly painless erection. may occur in infants who are polycythemic, or caused by birth trauma.
Clonic phase: (seizure)
contractions alternate with muscle relaxation
Behavioral assessment begins with evaluating the infants ability to____________________
control his state, move smoothly from one state to another, and maintain alertness.
Postural tone
correlates with active tone; long duration, low-amplitude stretch in response to gravity; best tested by the *traction response* (pull-to-sit maneuver) to test ability to resist pull of gravity. Normal: infant contracts shoulder & arm muscles, followed by flexion of the neck with minimal head lag. Hypotonia: seen in the picture- note more than minimal head lag; this may result from disturbances in the CNS, PNS, or skeletal muscles.
Phasic tone
correlates with passive tone & deep tendon reflexes; brief, forceful contraction in response to a short-duration, high-amplitude stretch; resistance to passive movements can be seen with the scarf sign & by arm/leg recoil; can test bicep or patellar reflex
Klumpke's palsy
damage to the lower spinal roots C8 & T1
Erb's Palsy
damage to the upper spinal roots C5 & C6
Periventricular Leukomalacia
decreased arterial blood flow in the premature infant. Damage to the periventricular area results in weakness in the lower extremities.
"easy baby"
demonstrates regularity, positive approaches to new situations, adaptability to change, and overall positive mood.
History for Children
developmental milestones, performance of self-care activities, hyperactive or impulse behavior, health problems
A displaced apical pulse to the (R) is suggestive of?
dextrocardia, diaphragmatic hernia, distended stomach, pulmonary abnormality
Hydrocolpos
distention of the vagina
Hydrometrocolpos
distention of the vagina and uterus
Step 1: Observation
done prior to disturbing the neonate. look for dysmorphic features, evidence of birth trauma, skin lesions, posture and activity
Periph pain receptors transmit sensation to the _______ _______ of the spinal cord thru sensory ________ fibers
dorsal horn / nerve
Exaggerated deep-tendon reflexes
drug withdrawal syndrome, SSRI or nicotine exposure
Oscillometric Measurement
electronic BP cuff that gives Systolic, Diastolic, Mean and HR.
Urachus
embryologic structure that connects the bladder to the umbilical cord. Clear discharge from the umbilical cord may represent a patent urachus. Specific gravity can be used to confirm its urine. Infants with fat cords that do not fall off in the normal amount of time may have a patent urachus.
5 factors affecting perception / interpretation of pain
emotions, culture, sleep, previous pain, age
Personal and Social History
environmental hazards (lead, arsenic, etc.), hand/eye/foot dominance, ability to care for self, sleeping/eating patterns, use of alcohol/illicit drugs
Sensory Function
evaluate both 1. Primary Sensory Function & 2. Cortical Sensory Function by having pt identify sensory stimuli at the hands, lower arms, abdomen, feet & lower legs. You should expect to see minimal differences side to side, correct description of sensations, recognition of the side of the body tested, location of sensation. Loss of sensation can indicate spinal tract, brainstem, or cerebral lesions.
fractured clavicle
evident by a lump on the collarbone caused by the callus that forms on the healing clavicle noted in the first few weeks after birth
Neuro exam on a child
exam of CNs are often elicited by playing a game. Observe child at play, note gait & fine motor coordination, grasping & releasing toys (expect no tremors), heel-to-toe walking, hopping, & jumping
because the lower extremities of the fetus have been folded on the abdomen, the newborns lower extremities often appear_____?
externally rotated and bowed, with everted feet
At a minimum, the ____ and _____ pulses should be palpated bilaterally.
femoral and brachial
thrill
fine, palpable vibration (palpable murmur) often over the base of the heart in the area of the (R) or (L) 2nd intercostal. Turbulent blood flow r/t a defect in aortic or pulmonic valve. ie.: stenosis, pulmonary HTN, ASD.
Testes should be ____ and _____ with equal sizing.
firm and smooth. The testes should be ovoid, mobile and at least 1.4cm.
examination of bony structures is important in a newborn exam because?
first opportunity to assess intrauterine development; deviations from normal may be first indicator of a genetic abnormality or disease
physical signs of intrauterine compression
flattened facies, malformed ears, contraction deformaties of the limbs, pulmonary hypoplasia are all signs... they suggest oligohydramnios .... so you should rule out urogenital anomalies.
Meningeal Signs
flex neck while pt. is supine; looking for nuchal rigidity (stiff neck). Pain & resistance are associated with nuchal rigidity.
mallet toe
flexion deformity of the distal interphalangeal joint
Bruits
flow disturbances from interference with normal laminar flow through vessels may cause vessel wall vibrations heard as systolic murmurs; can be heard with Sturge-Weber, arteriovenous malformations; place bell of stethoscope over temporal, frontal, & occipital areas
pes planus
foot that remains flat even when not weight bearing
discrepancy in circumference and length
for most people should be no more than 1cm
indication of forearm strength in infants
from about 2 months, the infant should be able to lift the head and trunk from the prone position
increased intracranial pressure and hydrocephalus
full or bulging fontanel with widened sutures; head shape is globular
Assessment of the Autonomic Nervous System
functions of the segmental & peripheral centers of the ANS are well established in the term infant. Controls the activity of systems & organs essential for life. Vital signs, skin, & sphincters are areas that can be assessed. Assess for anocutaneous reflex, or "anal wink". Bladder sphincter: constant dribbling of urine or bladder distention may indicate neurogenic bladder. Harlequin sign: when lying on side, dependent area red/upper area pale- normal variant demonstrating autonomic vasomotor instability.
Parts and function of the stomach
fundus, body, pylorus. Secretes HCl, pepsin (digests protein), and gastric lipase (emulsifies fat)
behavior indicating acute pain in adult
guarding, grimace, vocalizations such as groan, crying etc..., rocking, pacing, inability to keep still, changes in VS, pallor, diaphoresis, pupil dilation, dry mouth, decreased attention span, irritability.
The infants ability to decrease his response to a repeated stimulus is referred to as__________
habituation. When a stimulus is repeated the infants initial response to it will gradually disappear.
Stereognosis
hand patient a familiar object (key) & have them identify it
The "difficult baby"
has an irregular schedule, trouble adapting to new situations, a low threshold for stimuli, and intense often negative moods
Hand joints
has articulations between the carpals and metacarpals, metacarpals and proximal phalanges, and middle and distal phalanges
infant delivered in a breech presentation
has flexed, abducted hips and extended knees
S4
heard at the apex of the heart and is a low-pitched sound of *late diastole*. rarely heard in neonates. ALWAYS PATHOLOGIC. Indicative of conditions involved with decreased compliance (CHF or cardiomyopathy)
Situs Inversus
heart & stomach are formed to the (R) & liver to the left (L)
Percussion (adult asst)
helps detect air, fluid (ascites), and masses. Tympanic sound over stomach and intestines, dull over organs/masses.
Family History
hereditary disorders, alcoholism, intellectual disability, epilespy, alzheimer disease or dementia, parkinsons, learning disorders, weakness or gait disorders, cerebral palsy, medical or metabolic disorders (thyroid, htn, DM)
pes cavus
high instep, may be associated with claw toes
Rebound tenderness
hold hand at 90 degrees, press gently but deeply into region remote from area of discomfort. Rapidly withdraw hand. Will cause a sharp, stabbing pain at the site of peritoneal inflammation
Stepping Reflex
hold neonate upright with both feet touching a firm surface, alternating stepping movements should be observed. reflex appears at birth but is most active 72 hrs after birth. An asymmetrical response is seen with CNS or peripheral nerve injury or a fracture of a long bone of the leg.
head >90th% & height <90th% may indicate
hydrocephaly, macrocephaly, or hydranencephaly
claw toes
hyperextension of the metatarsophalangeal joint with flexion of the toe's proximal and distal joints
hammertoe
hyperextension of the metatarsophalangeal joint with flexion of the toe's proximal joint
Growth in the size of the mucle is caused by ___.
hypertrophy of the cells (NOT hyperplasia!)
Pregnant Women
hypothalamic-pituitary neurohormonal changes occur; increased sleep needs in 1st trimester; late pregnancy can affect sleep d/t discomfort, urine fx, leg cramps, etc.
Jolt Accentuation of Headache
if pt. presents with HA & fever; have pt. move head horizontally at a rate of 2-3 rotations/sec.; + sign is increased HA
suspect dislocation or avulsion of the femoral epiphysis
if there is pain on passive movement or little spontaneous movement of leg
Palpate the Kidneys
in the flank area.. not always palpable but if the infant voids, you know they have at least one.
Behavioral assessment is intended to identify______
in what situations and with what supports the infant exhibits organized behavior. It is also the purpose to describe the threshold of disorganization indicated in the infants behaviors of defense and avoidance.
Assessment of Sensory Function
includes touch & pain; the withdrawal reflex is stimulated to evaluate peripheral sensory function; can touch a pen to the sole of the foot to provoke flexion of the limb with extension of the other limb (sometimes flexion of both limbs is seen); can be helpful in an exam of an infant with a myelomeningocele or suspected spinal cord transection to delineate level of abnormality.
Behavioral states Crying
increased motor activity color changes
Behavioral states Active alert
increased motor activity periods of fussiness irregular respiration's The preterm infant will usually become distressed and unable to organize with stimuli.
calluses and corns
indicate chronic pressure or irritation
First 8 weeks of life
infant will have prominent labia, a large clitoris, and a urethral meatus that is difficult to visualize due to maternal estrogen.
Endocardium
innermost layer, lines the chambers of the heart& covers heart valves & small muscles associated with the opening/closing of valves
Biceps reflex
innervated at the 5th & 6th cranial nerve roots; hold arm with elbow in flexion & examiner thumb over the insertion of the biceps tendon. tap examiner thumb with reflex hammer, & flexion of bicep occurs
Inspection of muscles
inspect for gross hypertrophy or atrophy, fasciculations, and spasms
Organization reflects the infants ability to________
integrate physiological and behavioral systems in response to the environment without disruption in state or physiologic functions.
The APIB examines the __________
interplay of behaviors within five behavioral parameters: autonomic (physiological changes), motor, attention/interaction, and self regulatory (ability to maintain state and self-console).
Ascites
intra-abdominal collection of fluid and revealed by percussion.
position and appearance of extremities at birth can reflect____?
intrauterine position
Dyskinetic CP
involuntary slow writhing movements of the extremities; tremors may be present
Sinus Arrythmia
irregularity in the R--R interval. Usually a normal finding and is associated with respirations.
pseudomenses
is a normal finding in the newborn and is due to maternal hormones. may last up to 10 days.
The FLACC scale
is used for infants and children (2 months to 7 years) unable to validate the presence of or quantify the severity of pain and the checklist of nonverbal indicators is appropriate for adults who are unable to validate the presence of or quantify the severity of pain. Assesses Face, legs, activity, cry, and consolability.
An edematous and ecchymotic vagina
is usually due to birth trauma and may last for several days.
assess the curvature of the spine and the strength of the paravertebral muscles with the infant in the sitting position
kyphosis of the thoracic and lumbar spine will be apparent in sitting position until the infant can sit without support
Preterm infants
large clitoris and minora - small majora.
hallux valgus
lateral deviation of the great toe, which may cause overlapping of the second toe
Subdural Hemorrhage
least common intracranial hemorrhage. usually caused by trauma. caused by 1. rupture of the tentorium: rupture of the vein of Galen, straight sinus or transverse sinus; ex. forceps 2. occipital diastasis: separation of the cartilaginous joint between the squamous & lateral portions of the occipital bone. 3. falx lacerations: bleeding from the superior sagittal sinus, hematoma development occurs. 4. rupture of superficial cerebral veins: results in blood collecting over cerebral convexities
"Frog Leg" position
legs are abducted, lateral thigh rests against the bed. This is abnormal in neonates > 36 wks
Hypertonia
less common finding (vs hypotonia); if present, passive manipulation of the limbs increases the tone
Resting Posture for Term neonate
lies with hips abducted & partially flexed with knees flexed. arms adducted & flexed at elbow. hands loosely fisted
signs of hip dislocation
limited abduction and assymetric gluteal folds
Palpating the Liver
liver that protrudes more than 3 cm below the R costal margin is a good indicator of R sided heart failure.
Coronary Sulcus
located on the anterior external surface of the heart & separates the atria from the ventricles
The preterm infant has ____ sleep cycles than the term infant.
longer
differential diagnosis for osteoarthritis versus rhematoid arthritis
look at page 538...i cant figure out how to get the picture in here
Inguinal Hernia
loops of intestine herniate through the patent processus vaginalis. reducible requires surgical intervention
Weak or absent peripheral pulses occur in the presence of ...
low cardiac output. this could be caused by shock or tamponade, but you should also rule out ductal dependent lesions such as hypoplastic left ventricles.
Behavioral states light sleep
low levels of activity rapid eye movement possible may startle or make brief fussing or crying noises
Thrills
low-frequency, palpable murmurs. Feel similar to touching a purring cat. Thrills are not normal in the newborn infant. they are indicative of pulmonary stenosis, Tetralogy of Fallot, PDA(rare).
young children spine
lumbar curvature of spine and protuberant abdomen
Infants and Children
major brain growth occurs in the 1st yr of life along with myelinization of the brain & nervous system. Anything that effects growth during this time= profound effects. At birth, neuro impulses are controlled by the brainstem & spinal cord (sucking, rooting, etc.). Motor maturation occurs in a cephalocaudal direction (control of head/neck 1st, then trunk & extremities).
Opisthotonus
marked extensor hypertonia with arching of the back; seen with bacterial meningitis, severe neonatal encephalopathy, massive IVH, & tetanus
NO urine output after 48 hours of life or if presenting with illness or abnormalities
may be a sign of malformation or obstruction of the urniary tract
Weak reflexes
may be seen < 28 wks, with encephalopathy, sepsis, or with dysfunction of the motor unit
adolescents
may have slight kyphosis and rounded shoulders with an intrascapular space of 5-6in
Lack of movement of one arm
may indicate brachial plexus injury
persistently thickened achilles tendon
may indicate the tendonitis that can develop with spondyloarthritis or from xanthelasma of hyperlipidemia
one of the most important indicator of health in an infant is?
measurement of growth as reflected in increasing body weight and length along expected pathways and within certain limits
Penile Hypospadias
meatus is found between the glans and the scrotum.
landmarks ankle
medial malleolus, lateral malleolus, achilles tendon
Periventricular-Intraventricular Hemorrhage (PV-IVH)
most common cause of intracranial hemorrhage in premature neonates. IVH increases with decreasing GA. The subependymal germinal matrix is a matrix of poorly suported, thin-walled capillaries that is no longer present at term. Hemorrhage can stay localized in this area or rupture into the ventricular system causing distention of the lateral ventricles. Hydrocephalus can occur. Can result after a period of increased or decreased blood flow, increased central venous pressure, or with coagulation abnormalities. Signs: falling hct, hypotension, bradicardia, metabolic acidosis, bulging anterior font.
Seizures
most frequent sign of neonatal neurologic disorders. Once identified, rapid evaluation of the cause & prompt treatment should follow.
Activity level refers to
motor activity such as playing, dressing, crawling, eating, and walking. Sleep-wake cycles and their durations are also used in scoring activity level.
The NBAS focuses on __________
motor responses and maturity, interactive skills, visual and auditory orientation, management of sleep-wake cycles, physiologic integrity, and reflexes.
Assessment of neuro covers:
motor system, reflexes, sensory system, & cranial nerves
term infant
muscular contour is smooth, despite lack of strength the muscles should feel firm and slightly resist pressure
Other causes of generalized facial weakness
myasthenia gravis, infantile botulism, posterior fossa hematoma, cerebral contusion, neonatal encephalopathy
GU is also paired with other anomalies
myelomeningocele, VACTERL
Apex
narrower lower tip
disorders that affect the musculoskeletal system may also originate from the________?
neurologic system
if infant feels limp
never mistake for a condition of immaturity, further assess to rule out a neurologic condition
children HR from newborn - 17 yr old
newborn 120-170 1 yr 80-160 3 yrs 80-120 6 yrs 75-115 10 yrs 70-110 17 yrs 60-100
children RR from newborn to 17 yr old
newborn 30-80 1 yr 20-40 3 yrs 20-30 6 yrs 16-22 10 yrs 16-20 17 yrs 12-20
Behavioral states deep sleep
no eye movements no activity regular breathing delayed response to external stimuli with only brief arousal
Hydrocele
non-tender, fluid filled, scrotal mass overlying the testis and spermatic cord. not reducible usually resolve the first year of life, but if persistent at 2 years, will require intervention.
Most pain impulses in neonates are transmitted along what fibers?
nonmyelinated C fibers. Because myelination of the A-delta fibers continues to develop after birth.
Phimosis
nonretractable foreskin. Normal up to the first few years of life.
variation in heart rate is a ______ finding
normal an infant with no variation in response to stimuli is abnormal and requires observation.
Blood pressure for adults
normal < 120 systolic and < 80 diastolic Prehypertention 120-139 systolic OR 80-89 diastolic High BP stage 1= 140-159 systolic OR 90-99 diastolic stage 2 = 160 or > systolic OR 100 or > diastolic
Lack urine output in the first 48 hours of life
normal finding
Sucking reflex
normally present at birth (even in the premature) but weaker with decreasing GA; introduce gloved finger to evaluate strength & coordination of suck
The behavioral exam relies on describing the infants______
observable behavior. This behavior is thought to be a reflection of the infants underlying neurological status.
functional assessment
observe ability to: rise from lying to sitting position, rising from chair to standing, walking, climbing steps, descending steps, picking item up from floor, tying shoes, putting on and pulling up trousers or stockings, putting on sweater, zipping dress in back, combing hair, pushing chair from table while seated, buttoning button, writing name
Inspect shoulders
observe for a winged scapula, an outward prominence of the scapula, indicating injury to the nerve of the anterior serratus muscle (see page 516, 21-24 B)
State is determined by_________
observing an infants level of arousal and accompanying behaviors or cues.
Muscle wasting
occurs after injury as a result of pain, disease of the muscle, or damage to the motor neuron
Percussion
of minimal use.... duh. change from resonant to dull marks the heart borders
Most palapable abdominal masses are
of renal origin. Think multicystic dysplasic kidneys.
preterm infants may have a visible precordium because
of the lack of subcutaneous tissue.
Early soft midsystolic ejection murmur
often heard in neonates especially premature. Grade I-II. medium to high pitch. Presents in the first week or two of life. Resolves in three to six months of age. result of the acute bifurcation of the pulmonary artery.
resting posture of preterm
one of extension
What would you assess when someone reports pain and document in HPI?
onset, quality, intensity, associated symptoms, what pt thinks is causing pain, effect on ADL's, effect on psyche, pain control measures, and any medications.
What could a loss of apical pulse "thrust" indicate?
overlying fluid or air or displacement beneath the sternum
Percussion: kidneys
palm of R hand over costovertebral angle, strike right hand with left fist, should not produce pain
Embryonic GI development
pancreatic buds, liver, and gallbladder start to form at 4 weeks gestation (intestines already a single tube). Swallowing of amniotic fluid starts at 17 weeks
Extrophy of the bladder
part of the EEC male predominance 1/10000 births embryologic defect causes lack of muscle and connective tissue in the anterior abdominal wall causing the bladder to protrude through the defect.
Interventricular Septum
partition that separates the right-heart from the left-heart
can correct positional deformities with
passive joint manipulation
Brainstem
pathway between cerebral cortex & spinal cord; controls involuntary fxs; includes medulla oblongata, pons, midbrain, & diencephalon; cranial nerves arise from here.
History for Older Adults
pattern of increased stumbling, falls, interference with performance of daily living tasks, hearing loss, visual deficit, transient neurologic deficits
Higher risk for chromosomal disorders and problems with sexual differentiation
penile hypospadias and penoscrotal hypospadias. any hypospadias paired with another genital anomaly...such as cryptochordism or micro penis.
Cranial nerves
peripheral nerves that arise from the brain (not spinal cord)
Chronic pain
persistent / prolonged disease process
circumference in athletes who use the dominant arm almost exclusively in their activites may have some discrapancy
pitchers and tennis players
Tonic Neck Reflex
place infant supine, turn head to one side, infant should extend the upper extremity on the side toward which the head is turned & flex the upper extremity on the other side (aka fencing position)
Review prenatal history
polyhydramnios or oligohydramnios may represent the possibility of GU tract or renal impairment Certain GU anomalies have a genetic disposition, so family history is important. genetic counseling maybe appropriate for some anomalies.
sports injury risk factors
poor physical conditioning, failure to warm up muscles, intensity of competition, collision and contact sports, rapid growth, overuse of joints
Normal variations in shape, size, contour, or movement could be caused by:
position in utero or genetic factors. Must distinguish from congenital anomalies & birth trauma.
History for Infants
prenatal & maternal history, birth history, respiratory status at birth, neonatal health (jaundice, infections, seizures, ototoxic meds, irritability, poor suck), congenital anomalies, heart disease, hypotonia or hypertonia, developmental delay
Ambiguous genitalia
presence of a phallic structure that is not discretely male or female, an abnormally located urethral meatus, and the inability to palpate one or both gonads in males. consult endocrinology, social work, genetics. refer to infant as baby until the appropriate sex of rearing is determined.
Babinski sign
present when there is dorsiflexion of the great toe with or without fanning of the other toes (expected in children <2)
The bladder is higher in ____ infants and is a common cause for abd distention
preterm
Multiple Sclerosis (MS)
progressive autoimmune disorder characterized by a combination & degeneration of the myelin of the brains white matter, leading to decreased brain mass & obstructed transmission of nerve impulses
The checklist for Nonverbal Pain Indicators
provides guidelines to observe and record pain behaviors, but no pain intensity is calculated.
Clonus
rapid movement of a joint brought on by sudden stretching of a tendon; *sustained clonus*: more than 8-10 beats= cerebral irritation
Ossification occurs _____ over the first year of life.
rapidly
Passage of meconium in vagina or urethra
rectovaginal fistula or rectourethral fistula
Trigeminal Neuralgia (tic douloureux)
recurrent paroxysmal sharp pain that radiates into one or more branches of the 5th cranial nerve. usual age of onset 40-60 yrs. old; sharp pain on 1 side of face that lasts sec. to min.; can be brought on by chewing, swallowing, talking, brushing teeth, washing the face, etc.
To test visual response to stimuli_________
response to light, when light directed toward infants eyes an appropriate response is grimace and close eyelids. A second test is to evaluate the infants ability to fixate on an object and track it. Term newborns focus on objects at a distance of about 10-12 inches and improves with maturity. Preterm infants greater than 30 wks demonstrate both of these but may take longer to fixate and have less visual acuity than term.
Babinski Reflex
response to stimulation of the foot is usually flexion but in a neonate babinski is + if extenstion or flexion of the toes occurs. Consistent absence of any response is indicative of CNS depression or abnormal spinal nerve innervation. Extension/ fanning of toes is abnormal > 18 months.
Moro Reflex
response to the sensation of loss of support. Hold neonate in the supine position with the head a few cm off the bed, remove the hand supporting the head & allow the head to fall back into hand or against the bed. expect to see the arms extend & abduct with the hands opened, followed by the inward/ flexion of the arms with closed fists. A cry may accompany this reflex in infants greater than 32 weeks. An incomplete response may be seen in infants less than 32 weeks.
Anencephaly
result of defective closure of the *anterior neural tube*. Defect begins at the vertex & may extend to the foramen magnum. Dermal covering absent. Hemorrhagic & fibrotic cerebral tissue exposed. underdeveloped cranium: shallow orbits, protruding eyes. Most commonly involves forebrain & upper brainstem
Encephalocele
result of defective closure of the *anterior neural tube*. Protrusion of meninges & sometimes cerebral tissue. *cranium bifidum*: defect in the skull that allows protrusion; can be present without protrusion & will appear as a small, tissue covered opening in the skull with tufts of hair surrounding the defect. Transillumination, x-rays, & US can be useful in identifying the extent of brain tissue in sac.
Spina Bifida Occulta
result of defective closure of the *posterior neural tube* of the vertebrae. Occurs in the lower lumbar & lumbosacral area & covered with skin. Tufts of hair, lipomas along the spine may indicate serious underlying issues. Differentiate a dimple (common) from a sinus (may extend into an open spinal cord). Do NOT probe the site with instruments in order to avoid trauma and introducing bacteria. X-ray or US helpful.
Meningocele
result of defective closure of the *posterior neural tube*. lesion associated with spina bifida that usually involve more than 1 vertebrae. Meninges covered by a thin skin, protrude through the bony defect.
Myelomeningocele
result of defective closure of the *posterior neural tube*. lesions associated with spina bifida in which there is bilateral broadening of the vertebrae or absence of the vertebral arches. Meninges, spinal roots, & nerves protrude. Remnants of the spinal cord are fused, neural tube exposed on the dorsal portion of the mass. Hydrocephalus is frequently seen d/t the Arnold-Chiari malformation (blockage of cerebrospinal fluid outflow from the 4th ventricle).
Neonatal Encephalopathy
results from an insult to the fetus causing lack of o2 & perfusion. A result of Asphyxia (acidosis, hypoxia, & hypercapnia). *mild encephalopathy*: irritability, jitteriness, & hyperalterness; *moderate*: lethargy, hypotonia, a decrease in movements, & seizures; *severe*: coma, flaccidity, disturbed brainstem function, & seizures. Risk factors: low cord pH, < 6 Apgar, extended resuscitation.
prenatal history
review for possible birth trauma, neurologic insult; note duration of labor, signs of fetal distress, type of delivery (vag vs cesarean)
What can cause a "lift" along the (L) sternal border?
right ventricular hypertrophy
To slow progression of musculoskeletal changes with aging
routine exercise, well balanced diet at all ages including intake of calcium and vitamin D
Neuro exam on an older adult
same as for adult but allow more time for performing maneuvers that require coordination; be aware of meds they may be taking that can affect CNS; gait may have shorter steps & shuffling; may have less brisk deep tendon reflexes
Doppler Ultrasound
same as palpation but more accurate
gibbus
sharp, angular deformity associated with a collapsed vertebrae from osteoporosis
Tap
sharp, well-localized PMI associated with pressure overload.
To assess visual habituation the examiner_______
shines a light in the infants eyes from 10-12 inches away. Repeat every 5 sec to a max of 10 times or until infant ceases to respond. Note the presence of startles, blinking, facial grimaces and resp changes. If habituation occurs responses will become delayed and eventually disappear. Infants who are able to habituate successfully do so within 5 -9 flashes.
curve of lumbar spine
should be concave
inspect cervical spine
should be concave with head erect, no assymmetric skin folds should be present
curve of thoracic spine
should be convex
Screening for CHD with Pulse Oximetry
should be done on every infant within the first 24 hours of life. positive if any sat is <90% the sat is less than 95% in both extremities on three seperate measurements (in one hour + intervals) There is a >3% difference in sats between the foot and R hand on three occasions seperated by one hour.
joint surfaces
should be smooth and without nodules, swelling, bogginess, or tenderness
palmar surface of each hand
should have a central depression with a prominent, rounded mound (thenar eminence) on the thumb side of the hand and a less prominent hypothenar eminence on the little finger side of the hand
Circumcision
should not be performed on neonates with hypospadias or epispadias.
Maternal and Family History
should precede exam for genetic or neurologic problems of the family, maternal medical difficulties, use of meds, alcohol, or illicit drugs. Note results of chromosome analysis, ultrasounds, & fetal well being tests.
Flaccid, lumpy abdomen
sign of congenital absence of abdominal musculature- Eagle Barrett syndrome (may also have GU abnormalities)
Extinction Phenomenon
simultaneously touch 2 areas on each side of the body with sharp edge of broken tongue blade. ask how many touches are felt & where
unequal length or circumference of extremities has been associated with?
skeletal anomalies, tumors, and intra-abdominal neoplasms
microcephaly
small FOC (< 10th %tile); can be caused by chromosomal abnormality, maternal drug or alcohol use, intrauterine infection, CMV, TORCH
Ejection Clicks
snappy, high-frequency sounds that are best heard just after S1. Normal in the first 24 hours of life. if they remain or are notices later... start thinking aortic or pulmonic stenosis, PPHN, truncus, or TET.
bifid defect of vertebrae
spinal process is split
The disorganized infant will react to the environment with sudden _____________
state changes and will exhibit frantic, jittery movements, color changes, and irregular respiration's, and possible hypotonia.
Exam: cardiac function
stethoscope, marking pencil, cm ruler ***inspection, palpation, percussion, then ascultation. while sitting, leaning forward, lying supine, & (L) lateral recumbant
Decreased compliance
stiff myocardium. decreases the ejection volume of blood from the ventricles.
Palmar grasp
stimulate palmar surface with finger; attempt to withdraw finger to tighten grasp; weak palmar grasp in term infant = cerebral, local nerve, or muscle injury
Rooting Reflex
stroke cheek & corner of mouth. infant head should turn toward stimulus, & mouth should open
paroxysmal nocturnal dyspnea
sudden awakening from sleeping with shortness of breath
SVT
supraventricular tachycardia Usually presents as a heart rate above 200. causes decreased cardiac output due to short diastolic filling time. this can cause congestive heart failure within 48 hours if not corrected. vagal, stimulation, medication or cardioversion.
orchiopexy
surgical correction of cryptochordism
Complex regional pain syndrome
syndrome in which regional pain extends beyond a specific peripheral nerve injury in an extremity with motor, sensory, and autonomic changes. Subjective data: Burning, shooting, aching, sensitivity to cold or sweating changes, pain increases or persists after light pressure, allodynia, numbness may be present. Objective data: Edema, changes in skin blood flow, abnormal skin color, red and hot, cyanotic, temp difference up to 1 degree between the affected and unaffected extremity, increased sweating may be seen.
Quality of movement
term: moves limbs smoothly preterm: tremors & jitteriness can be normal but can also be a sign of hypoglycemia, hypocalcemia, drug withdrawal, & neonatal encephalopathy
Truncal Incurvation (Galant) Reflex
tested with neonate in ventral suspension, with anterior chest wall in the palm of the examiners hand. Firm pressure with the thumb or cotton swab is applied parallel to the spine in the thoracic area. A + response is flexion of the pelvis toward the side of the stimulus
Cortical Sensory Functions
tests cognitive ability to interpret sensations. •Tests: Stereognosis, Two-Point Discrimination, Extinction Phenomenon, Graphesthesia, Point Location
Distractibility refers to
the ability of extraneous stimuli to interfere with the individuals current behavior.
arm length is measured from
the acromion process through the olecranon process to the distal ulnar prominence
Threshold of responsiveness refers to
the amount of stimulation required to generate a response either positive or negative
leg length is measured from
the anterior superior iliac spine to the medial malleolus of the ankle, crossing the knee on the medial side
Acromioclavicular joint
the articulation between the acromion processes and the clavicle
Sternoclavicular joint
the articulation between the manubrium of the sternum and the clavicle
A instrument for assessing preterm infants behavior is__
the assessment of preterm infant behavior (APIB).
Approach or withdrawl refers to
the individuals reaction to a new stimulus such as food, a new toy, or person. Approach responses are positive; withdrawal responses are negative reactions to the new stimulus.
Adaptability refers to
the individuals response to new situations once the initial response has passed.
In evaluating organization of motor behavior, the examiner assesses____________
the infants movement patterns, energy level, and tone.
Attention span or persistence refers to
the length of time an individual will pursue a specific activity especially when obstacles interfere with it.
State refers to___________
the level of consciousness exhibited by the infant. This is determined by the level of arousal and ability to respond to stimuli.
Intensity of reaction refers to
the level of energy in a response, whether positive or negative
Sensory threshold refers to_________
the level of tolerance for stimuli within which the infant can respond appropriately. When the infant reaches or exceeds his threshold , he becomes overstimulated and exhibits signs of stress and fatigue.
Epispadias
the location of the urethral meatus on the dorsal aspect of the penis.
Quality of mood describes
the overall mood of the individual.
the Anderson Behavioral State Scale is specifically designed for____________
the preterm infant. Because it breaks down the typical 5 or 6 states into 12 states making it more sensitive to the preterm infants behavioral states.
Postpolio Syndrome (progressive postpoliomyelitis muscular atrophy)
the reappearance of neurologic signs 10 or more yrs after survival of acute poliomyelitis; history of polio
Rhythmicity refers to
the regularity of functions such as hunger, sleep-wake patterns, and elimination
Why do we palpate the right brachial instead of the left?
the right subclavian vein is always preductal.
Stroke (brain attack or cerebrovascular accident)
the sudden interruption of blood supply to a part of the brain or the rupture of a blood vessel, spilling blood into spaces around brain cells.
Temperament refers to__________
the way an individual interacts with his environment.
Why would you want to note if this is the firstborn child?
there is a higher incidence of developmental dysplasia of the hip (DDH) in firstborn children
why are measurements taken soon after birth important?
they serve as a baseline for subsequent assessments of growth and development; all measurements plotted on a growth chart and correlated with GA
Myocardium
thick muscle middle layer; responsible for pumping action of the heart.
Epicardium
thin outermost muscle layer, covers surface of heart & extends onto the great vessels.
Major landmarks of legs and knees
tibial tuberosity, medial and lateral tibial condyles, medial and lateral epicondyles of the femur, adductor tubercle of the femur, and patella
Premature Infant Pain Scale (PIPP) is used for?
to assess procedural pain in preterm and full term neonates between 28-40 wks gestation. It measures physiologic signs, pain behaviors, gestational age, and behavioral state
Resting posture from 28-40 weeks
tone increases in a caudocephalic direction, with increased tone in flexion observed first in the legs (32-34 wks) and later in the arms (34-36 wks)
Point Location
touch area on pts. skin, remove stimulus (finger), have pt. point to area touched.
Timing of exam
try to examine 30 min - 1 hr prior to feeding to increase chance neonate being in a quiet alert state
The heart forms during the first ____ ____ of pregnancy.
two months. So it is really important to get details about this period, because this is usually when the anomaly/defect occurs.
Diphalia
two penises... Two types: bifid penis - split in half duplicate - actual second whole penis (OH MY)
Effects of pregnancy on GI tract
umbilical protrusion, linea nigra skin discoloration, diastasis recti (separation of abdominal muscles), 2nd trimester: constipation, reflux of duodenal contents into stomach, gastroesophageal reflux, possible gallstones, straie
C-polymodal fibers
unmyelinated, slowly transmitted; Dull burning, aching, diffuse pain
Normal movements in term infant
upper and lower extremities move in an alternating pattern; mass movements occur in response to environmental stimuli & discomfort; coarse tremors or brief trembling of the chin may occur; occasional uncoordinated movements
Protective sensation
use monofilament to test for sensation on several sites of the foot (in all pts. with DM & peripheral neuropathy). Adequate pressure is applied when the filament bends.
Two-Point Discrimination
use the ends of 2 paperclips to touch the patients skin with 1 or both at various places on the body. ask them how many points are felt
The Neonatal Infant Pain Scale
used to assess procedure pain in preterm and full term infants up to 6 wks of age. Facial expression, cry, breathing pattern, arm and leg movements, and state of arousal are scored
inspect hips
using major landmarks of iliac crest and greater trochanter of femur, note any assymmetry in the iliac crest height, size of the buttocks, or number and level of gluteal folds
facial asymmetry or unilateral lack of expression
usually an isolated finding in infants with facial weakness d/t *Bell's Palsy*; may be from intrauterine positioning with pressure on facial nerve or from extraction with forceps. Bruising may be present.
Spinal Cord Injuries
usually seen in deliveries that overstretch the vertebral axis or over-rotate the body in relation to the head. *Transection injuries*: irreversible. Compression or ischemic injuries can have partial or complete recovery. Following injury, shock & difficulty initiating respiration are common. Lesions above C3 or C4 paralyze the diaphragm. Lower lesions result in flaccidity of the legs & portions of the arms. Lack of response to pinprick can be seen below level of injury.
Behavioral states Drowsiness
variable activity levels Dull-heavy lidded eyes that open and close will react to stimuli but response is often delayed, or he may startle easily. from this state infant may return to sleep or move to more alert state
To assess habituation, the stimulus can involve
visual, auditory, or tactile senses.
watching young children play during the history can provide information about the musculoskeletal system
watch them pick up and play with toys, observe ability to sit, creep, and grasp and release objects
History for Pregnant women
weeks gestation, EDD, seizure activity, headache, nutritional status
Strong palmar or digital pulses in the premature infant indicate ....
wide pulse pressures
Graphesthesia
with a blunt pen, draw a letter, #, or shape on the patients hand & have them identify it.
confirm congenital limb deficiency by
xray
Neuro evaluation tools by different developers
•Amiel-Tison: term or corrected term neonates during 1st yr of life for neuromuscular function •Prechtl: term neonate •Lilly and Victor Dubowitz: term and preterm; movement and tone •Brazelton: behavioral items
Quality of cry
•Loud, lusty cry: term neonate •Weaker cry: premature, depressed, or ill neonate •High-pitched cry: neurologic disturbances, metabolic abnormalities, drug withdrawal •High-pitched, incessant crying, hyperirritable: drug withdrawal, excessive nicotine exposure, exposure to SSRIs •Catlike cry: cri du chat syndrome (deletion of the short arm of 5th chromosome) •Stridor: partial vocal cord paralysis r/t cervical nerve damage or to partial webs, stenosis, or malacia of the airway
Reflexes: superficial
•Plantar reflex:use the end of the reflex hammer to stroke foot from heel to ball. Expect flexion of all toes. •Abdominal reflex: stroke each quadrant of the abdomen with the end of a reflex hammer or tongue blade. Stroke away from umbilicus; direction dependent on whether you want to elicit the upper or lower abdomen reflex. •Cremasteric reflex: stroke inner thigh of male pt. Expect the testicle & scrotum to rise on the stroked side.
History of present illness
•Seizures: sequence of events, aura, LOC, automatism, muscle tone, postictal phase (after seizure), relationship of seizure to time of day, meals, stress, etc., frequency, meds •Pain: (refers to headaches, neck pain, sciatica, or trigeminal neuralgia) onset, quality/intensity, location, associated manifestations, efforts to treat, impact on life, meds •Gait coordination: balance, falling, associated problems (arthritis of spine or knees, stroke, seizure, etc.), meds •Weakness or paresthesia: onset, character, associated symptoms (tingling, numbness, confusion, etc.), concurrent chronic illness (HIV, DM), meds •Tremor: onset, character, relieved by ? (rest, activity, alcohol), meds
Assessment
•done within 24 hours •assure you have an accurate GA •perform non-disturbing maneuvers first (palpate head/neck) & distressing maneuvers near the end (hips) •undress infant and position supine initially •head to toe
Jittery or seizure?
•jitteriness: rapid alternating movements of equal amplitude in both directions; noise & touch can elicit jitteriness which can be stopped by flexing or holding the involved extremity. •seizure: have a fast & slow component & are not as rapid; generally not initiated by stimulation, nor can they be stopped by flexing or holding; may see abnormal eye movements.
Newborn bones
•soft bc they are comprised of mostly cartilage, which has only a small amount of calcium •skeleton is flexible & joints are elastic (so infant can pass through birth canal)
Sturge-Weber syndrome with underlying arteriovenous malformations
❖Significant findings: port wine nevi involving both eyelids, with bilateral distribution or those that are unilateral but involve all three branches of the trigeminal nerve (pic of where the 3 branches are)
