physical assessment handout color 3 per pg

S.T.A.B.L.E. - Physical Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for eduational purposes. 1 © K. Karlsen 2006 Kristine A. Karlsen MSN, RNC, NNP Author National Program Director, Founder The S.T.A.B.L.E. Program Park City, Utah stable@stableprogram.org Kristine A. Karlsen Kristine A. Karlsen MSN, RNC, NNP MSN, RNC, NNP Author Author National Program Director, Founder National Program Director, Founder The S.T.A.B.L.E. Program The S.T.A.B.L.E. Program Park City, Utah Park City, Utah stable@stableprogram.org stable@stableprogram.org PowerPoint ® Design Mary Puchalski MS, RNC, APN/CNS Lombard, Illinois mary@stableprogram.org Medical Illustrations Marilou Kundmueller RN, BSN, MA PowerPoint PowerPoint ® ® Design Design Mary Puchalski Mary Puchalski MS, RNC, APN/CNS MS, RNC, APN/CNS Lombard, Illinois Lombard, Illinois mary@stableprogram.org mary@stableprogram.org Medical Illustrations Medical Illustrations Marilou Kundmueller Marilou Kundmueller RN, BSN, MA RN, BSN, MA Physical and Gestational Age Assessment of the Newborn Physical and Gestational Age Physical and Gestational Age Assessment of the Newborn Assessment of the Newborn © K. Karlsen 2006 Principles of Physical Exam Principles of Physical Exam Review history Review history Prenatal Prenatal Labor/delivery Labor/delivery Presentation of illness Presentation of illness Use Use Consistent Consistent Organized Organized Gentle approach Gentle approach © K. Karlsen 2006 Wash hands, wear gloves Wash hands, wear gloves Use clean equipment Use clean equipment Keep infant warm Keep infant warm Perform while infant in quiet Perform while infant in quiet state whenever possible state whenever possible Shield infant Shield infant ’ ’ s eyes from s eyes from exam light exam light Comfort infant during and Comfort infant during and after exam after exam Change soiled diapers / redress following exam Change soiled diapers / redress following exam Principles of Physical Exam Principles of Physical Exam S.T.A.B.L.E. - Physical Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for eduational purposes. 2 © K. Karlsen 2006 Principles of Physical Exam Principles of Physical Exam Observe before touching Observe before touching Auscultation before Auscultation before palpation palpation – – in quiet in quiet environment environment Gentle palpation Gentle palpation Avoid if acute abdomen Avoid if acute abdomen Extra care with Extra care with premature infants premature infants © K. Karlsen 2006 Infant Size Infant Size Measurement Measurement Weight Weight Length Length Head circumference Head circumference Appropriate size for age (AGA) Appropriate size for age (AGA) Well Well - - nourished appearance nourished appearance © K. Karlsen 2006 Infant Size Infant Size Small for gestational age (SGA) Small for gestational age (SGA) Weight less than10 Weight less than10 th th percentile for gestational age percentile for gestational age Symmetric Symmetric Asymmetric Asymmetric Appropriate size for age (AGA) Appropriate size for age (AGA) Large for gestational age (LGA) Large for gestational age (LGA) Weight greater than 90 Weight greater than 90 th th percentile for gestational age percentile for gestational age S.T.A.B.L.E. - Physical Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for eduational purposes. 3 © K. Karlsen 2006 Infant Size Infant Size Use Ballard exam to Use Ballard exam to assess gestational age assess gestational age Gestational age assessment Gestational Gestational age assessment age assessment © K. Karlsen 2006 Infant Size Infant Size © © David A. Clark MD David A. Clark MD Discordant twins Discordant twins Discordant twins © K. Karlsen 2006 Neurological Status Neurological Status Normal Normal Active, alert, good tone, moderate Active, alert, good tone, moderate flexion, symmetric strength flexion, symmetric strength and movement and movement Strong, symmetric cry Strong, symmetric cry S.T.A.B.L.E. - Physical Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for eduational purposes. 4 © K. Karlsen 2006 Neurological Status Neurological Status Normal reflexes in term infant Normal reflexes in term infant Root and suck Root and suck © K. Karlsen 2006 Neurological Status Neurological Status Normal reflexes in term infant Normal reflexes in term infant Root and suck Root and suck Moro Moro   arms extend, abduct, hands open arms extend, abduct, hands open , followed by , followed by flexion of arms and closing of hands flexion of arms and closing of hands © K. Karlsen 2006 Neurological Status Neurological Status Normal reflexes in term infant Normal reflexes in term infant Root and suck Root and suck Moro Moro   arms extend, abduct, hands open arms extend, abduct, hands open , followed by , followed by flexion of arms and closing of hands flexion of arms and closing of hands Palmar and plantar grasp Palmar and plantar grasp S.T.A.B.L.E. - Physical Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for eduational purposes. 5 © K. Karlsen 2006 Neurological Status Neurological Status Normal reflexes in term infant Normal reflexes in term infant Root and suck Root and suck Moro Moro   arms extend, abduct, hands open arms extend, abduct, hands open , followed by , followed by flexion of arms and closing of hands flexion of arms and closing of hands Palmar and plantar grasp Palmar and plantar grasp Babinski Babinski   extension or flexion of toes after stimulating extension or flexion of toes after stimulating sole of foot sole of foot © K. Karlsen 2006 Neurological Status Neurological Status Normal reflexes in term infant Normal reflexes in term infant Root and suck Root and suck Moro Moro   arms extend, abduct, hands open arms extend, abduct, hands open , followed by , followed by flexion of arms and closing of hands flexion of arms and closing of hands Palmar and plantar grasp Palmar and plantar grasp Babinski Babinski   extension or flexion of toes after stimulating extension or flexion of toes after stimulating sole of foot sole of foot Tonic neck (fencing position) Tonic neck (fencing position) Truncal incurvation (Galant reflex) Truncal incurvation (Galant reflex)   pelvis moves toward pelvis moves toward side of stimulus side of stimulus © K. Karlsen 2006 Neurological Status Neurological Status Abnormal Abnormal Weak suck or poor feeding Weak suck or poor feeding pattern pattern Weak cry Weak cry Distressed facies Distressed facies Lethargy / hypotonia Lethargy / hypotonia Hyperreflexia Hyperreflexia / hypertonia / hypertonia Decreased or absent reflexes Decreased or absent reflexes Irritability Irritability Seizures Seizures Coma Coma S.T.A.B.L.E. - Physical Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for eduational purposes. 6 © K. Karlsen 2006 Head Head Size Size Indication of normal brain growth Indication of normal brain growth Record largest measurement Record largest measurement Above ear and eyebrow ridges Above ear and eyebrow ridges Occipitofrontal circumference Occipitofrontal circumference (OFC) (OFC) Varies with molding and Varies with molding and scalp swelling scalp swelling © K. Karlsen 2006 Head Head Sutures Sutures Approximated Approximated Overlapping Overlapping Wide Wide - - spaced spaced Mobility Mobility Occipital bone Occipital Occipital bone bone Sagittal suture Sagittal Sagittal suture suture Posterior Posterior fontanel fontanel Lambdoidal suture Lambdoidal Lambdoidal suture suture Frontal bone Frontal Frontal bone bone Coronal suture Coronal Coronal suture suture Anterior fontanel Anterior Anterior fontanel fontanel Parietal bone Parietal Parietal bone bone Metopic suture Metopic Metopic suture suture Squamosal suture Squamosal Squamosal suture suture © K. Karlsen 2006 Head Head Shape Shape Molding Molding Symmetric Symmetric Asymmetric Asymmetric Size of fontanels Size of fontanels Anterior Anterior Posterior Posterior Scalp swellings Scalp swellings Location Location Characteristics Characteristics © © David A. Clark MD David A. Clark MD S.T.A.B.L.E. - Physical Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for eduational purposes. 7 © K. Karlsen 2006 Skull bone S S kin C C onnective tissue (CT) A A poneurosis (galea) L L oose CT (subgaleal) P P eriosteum Superior sagittal sinus – drains blood from scalp back to heart Superior sagittal sinus Superior sagittal sinus – – drains blood from drains blood from scalp back to heart scalp back to heart  Scalp Anatomy  Scalp Anatomy Head Head © K. Karlsen 2006 Caput Succedaneum Caput Succedaneum Subgaleal Hemorrhage Subgaleal Hemorrhage Cephalohematoma Cephalohematoma Head Head  Scalp Swellings  Scalp Swellings © K. Karlsen 2006 Emissary Emissary vein vein Superior Superior sagittal sinus sagittal sinus DurationBlood lossPalpationLocation Resolves in 48 – 72 hours MinimalSoft and spongy Pits on pressure Edema of presenting part of scalp – usually crosses suture lines – shifts with positioning Accumulation of serosanguineous fluid in subcutaneous tissues of scalp Accumulation of Accumulation of serosanguineous serosanguineous fluid in fluid in subcutaneous subcutaneous tissues of scalp tissues of scalp Head Head  Caput Succedaneum  Caput Succedaneum S.T.A.B.L.E. - Physical Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for eduational purposes. 8 © K. Karlsen 2006 Head Head  Caput Succedaneum  Caput Succedaneum Vacuum edema Vacuum edema Vacuum edema © K. Karlsen 2006 DurationBlood lossPalpationLocation Resolves in 2 weeks to 3 months Rarely severe X-ray if skull fracture suspected Initially firm More fluctuant after 48 hrs Stops at sutures Parietal and occipital bones May be bilateral Emissary vein Superior sagittal sinus Blood accumulation between skull bone and periosteum Blood Blood accumulation accumulation between skull bone between skull bone and periosteum and periosteum Emissary Emissary vein vein Superior Superior sagittal sinus sagittal sinus  Cephalohematoma  Cephalohematoma Head Head © K. Karlsen 2006  Cephalohematoma  Cephalohematoma Head Head © © David A. Clark MD David A. Clark MD S.T.A.B.L.E. - Physical Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for eduational purposes. 9 © K. Karlsen 2006 DurationBlood lossPalpationLocation Resolves over 2 – 3 wks High morbidity & mortality May lead to severe anemia and hypovolemic shock Firm to fluctuant – “boggy” Dependent swelling Crosses suture lines – may extend from eyes to nape of neck Rupture of emissary veins  subtle but massive hemorrhage! Rupture of emissary Rupture of emissary veins veins   subtle but subtle but massive hemorrhage! massive hemorrhage! Superior Superior sagittal sinus sagittal sinus Subgaleal space – holds up to 240 ml of blood – potentially entire blood volume Subgaleal space Subgaleal space – – holds up to 240 ml holds up to 240 ml of blood of blood – – potentially entire potentially entire blood volume blood volume  Subgaleal Hemorrhage  Subgaleal Hemorrhage Head Head © K. Karlsen 2006 DurationBlood lossPalpationLocation Resolves over 2 – 3 wks High morbidity & mortality May lead to severe anemia and hypovolemic shock Firm to fluctuant – “boggy” Dependent swelling Crosses suture lines – may extend from eyes to nape of neck  Subgaleal Hemorrhage  Subgaleal Hemorrhage Head Head © K. Karlsen 2006 Video courtesy of Swiss Video courtesy of Swiss Society Society of Neonatology of Neonatology Infant with subgaleal hemorrhage Infant with subgaleal hemorrhage Note area of hemorrhage Note area of hemorrhage Note area of hemorrhage Anterior Note fluid waves, tachypnea and retractions Note fluid waves, Note fluid waves, tachypnea and retractions tachypnea and retractions  Subgaleal Hemorrhage  Subgaleal Hemorrhage Head Head Monitoring guidelines Monitoring guidelines Monitoring guidelines S.T.A.B.L.E. - Physical Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for eduational purposes. 10 © K. Karlsen 2006 Head Head Craniosynostosis Craniosynostosis Craniosynostosis © © David A. Clark MD David A. Clark MD © © David A. Clark MD David A. Clark MD  Abnormal Findings  Abnormal Findings Apert syndrome Apert syndrome Crouzon syndrome Crouzon syndrome © K. Karlsen 2006 Congenital hydrocephalus Congenital Congenital hydrocephalus hydrocephalus © © David A. Clark MD David A. Clark MD Head Head  Abnormal Findings  Abnormal Findings © K. Karlsen 2006 Macrocephaly Macrocephaly Macrocephaly © © Jack Dolcourt MD Jack Dolcourt MD © © Jack Dolcourt MD Jack Dolcourt MD Microcephaly Microcephaly Microcephaly © © David A. Clark MD David A. Clark MD © © David A. Clark MD David A. Clark MD 4 P syndrome 4 P syndrome Head Head  Abnormal Findings  Abnormal Findings Holoprosencephaly Holoprosencephaly [...]... appearance No discoloration Active bowel sounds Soft and non-tender to palpation non- Normal abdomen Normal abdomen © K Karlsen 2006 © Jack Dolcourt MD (c) Kristine A Karlsen 2006 Handout reproducible for eduational purposes 23 S.T.A.B.L.E - Physical Assessment Abdomen  Abnormal Findings Appearance  scaphoid, distended, visible loops Color  erythema, bluish discoloration Bowel sounds  hypo or hyperactive... reproducible for eduational purposes 31 S.T.A.B.L.E - Physical Assessment Skin Perfusion  Normal Findings Perfusion reflects cardiac output Normal capillary refill time (CRT) ≤ 3 seconds Press Press Release Release Count seconds Count seconds until skin refills until skin refills Compare upper Compare upper to lower body to lower body © K Karlsen 2006 Skin Perfusion  Abnormal Findings Prolonged capillary... for eduational purposes 30 S.T.A.B.L.E - Physical Assessment Skin Color  Abnormal Findings Plethora Polycythemia Neonatal polycythemia Neonatal polycythemia © David A Clark MD Twin-to-twin transfusion Twin- toTwin-to-twin transfusion Normal male hand Normal male hand Maternal anemia Maternal anemia © K Karlsen 2006 Skin Color  Abnormal Findings AAP hyperbilirubinemia and AAP hyperbilirubinemia and phototherapy... signs of poor perfusion Skin mottling © K Karlsen 2006 Skin Perfusion  Abnormal Findings Cutis marmorata Bluish marbling / mottling Caused by dilation of capillaries and venules in response to chilling or stress Persistent cutis marmorata with some trisomies or syndromes © K Karlsen 2006 (c) Kristine A Karlsen 2006 Handout reproducible for eduational purposes 32 S.T.A.B.L.E - Physical Assessment Skin... Bilious gastric drainage Bilious gastric drainage © K Karlsen 2006 (c) Kristine A Karlsen 2006 Handout reproducible for eduational purposes 24 S.T.A.B.L.E - Physical Assessment Abdomen  Abnormal Findings Appearance  scaphoid, distended, visible loops Color  erythema, bluish discoloration Bowel sounds  hypo or hyperactive Palpation  firm, tender, masses Eagle-Barrett syndrome Eagle(Prune belly syndrome)... Abnormal Findings Appearance  scaphoid, distended, visible loops Color  erythema, bluish discoloration Bowel sounds  hypo or hyperactive Palpation  firm, tender, masses © Jack Dolcourt MD © K Karlsen 2006 Abdomen  Abnormal Findings Appearance  scaphoid, distended, visible loops Color  erythema, bluish discoloration Bowel sounds  hypo or hyperactive Palpation  firm, tender, masses Visible bowel loops... Skin Color  Abnormal Findings Central cyanosis Bluish discoloration of tongue and mucous membranes Caused by desaturation of arterial blood Indicates cardiac / respiratory dysfunction Hemoglobin carrying no O2 appears purple  “reduced hemoglobin” hemoglobin” Cyanosis visible with 3 – 5 gm/dL reduced hemoglobin © K Karlsen 2006 (c) Kristine A Karlsen 2006 Handout reproducible for eduational purposes 31 ... guidelines Stabilization guidelines © K Karlsen 2006 (c) Kristine A Karlsen 2006 Handout reproducible for eduational purposes 26 S.T.A.B.L.E - Physical Assessment Abdomen  Abnormal Findings Gastroschisis Defect in abdominal wall Defect in abdominal wall to RIGHT of umbilical cord to RIGHT of umbilical cord No peritoneal sac protects No peritoneal sac protects the herniated organs the herniated organs Stabilization... Findings Fetal Alcohol Syndrome Flattened midface Broad nasal bridge Short, up-turned nose upSmooth, long philtrum Thin upper lip Hypoplastic maxilla Philtrum © K Karlsen 2006 (c) Kristine A Karlsen 2006 Handout reproducible for eduational purposes © David A Clark MD 13 S.T.A.B.L.E - Physical Assessment Face  Abnormal Findings Trisomy 21 Short round head Flat facial profile Epicanthal folds Brushfield’s spots... Kristine A Karlsen 2006 Handout reproducible for eduational purposes 35 S.T.A.B.L.E - Physical Assessment Extremities  Fractures © David A Clark MD Clavicle Clavicle © K Karlsen 2006 © David A Clark MD Extremities  Fractures Humerus Humerus Femur Femur © K Karlsen 2006 Extremities  Abnormal Findings Breech presentation Breech presentation © K Karlsen 2006 (c) Kristine A Karlsen 2006 Handout reproducible . Kundmueller RN, BSN, MA RN, BSN, MA Physical and Gestational Age Assessment of the Newborn Physical and Gestational Age Physical and Gestational Age Assessment of the Newborn Assessment of the Newborn ©. exam Change soiled diapers / redress following exam Change soiled diapers / redress following exam Principles of Physical Exam Principles of Physical Exam S.T.A.B.L.E. - Physical Assessment (c) Kristine. 90 th th percentile for gestational age percentile for gestational age S.T.A.B.L.E. - Physical Assessment (c) Kristine A. Karlsen 2006. Handout reproducible for eduational purposes. 3 © K. Karlsen