physical assessment handout color 6 per pg

Karlsen 2006 Neurological Status Normal reflexes in term infant Root and suck © K.. Karlsen 2006 Neurological Status Normal reflexes in term infant Root and suckMoroarms extend, abduct,

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©K Karlsen 2006

Kristine A KarlsenMSN, RNC, NNP

Author

National Program Director, Founder

The S.T.A.B.L.E Program

Park City, Utah

stable@stableprogram.org

Author

National Program Director, Founder

The S.T.A.B.L.E Program

Park City, Utah

stable@stableprogram.org

PowerPoint ® Design Mary Puchalski MS, RNC, APN/CNS

Lombard, Illinois

mary@stableprogram.org

Medical Illustrations Marilou Kundmueller RN, BSN, MA

ConsistentOrganizedGentle approach

©K Karlsen 2006

Wash hands, wear gloves

Use clean equipment

Keep infant warm

Perform while infant in quiet

state whenever possible

Shield infant’s eyes from

exam light

Comfort infant during and

after exam

Change soiled diapers / redress following exam

Principles of Physical Exam

Observe before touching

Auscultation beforepalpation–in quietenvironmentGentle palpationAvoid if acute abdomenExtra care withpremature infants

Infant Size

MeasurementWeightLengthHead circumference

Appropriate size for age (AGA)Well-nourished appearance

percentile for gestational age

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©K Karlsen 2006

Infant Size

Use Ballard exam to

assess gestational age

Gestational age assessment

Active, alert, good tone, moderate

flexion, symmetric strength

and movement

Strong, symmetric cry

Neurological Status

Normal reflexes in term infant

Root and suck

Root and suckMoroarms extend, abduct, hands open, followed byflexion of arms and closing of hands

Palmar and plantar grasp

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©K Karlsen 2006

Root and suck

Moroarms extend, abduct, hands open, followed by

flexion of arms and closing of hands

Babinskiextension or flexion of toes after stimulating

sole of foot

©K Karlsen 2006

Root and suck

Moroarms extend, abduct, hands open, followed by

flexion of arms and closing of hands

Babinskiextension or flexion of toes after stimulating

sole of foot

Tonic neck (fencing position)

Truncal incurvation (Galant reflex)pelvis moves toward

Varies with molding andscalp swelling

Head

Sutures

ApproximatedOverlappingWide-spacedMobility

Occipital bone

Sagittal suture

Posterior fontanel

Lambdoidal suture Lambdoidal suture

Frontal bone

Frontal bone Coronal suture Coronal suture

Anterior

Parietal bone

Metopic suture Metopic suture

Squamosal suture Squamosal suture

Head

Shape

MoldingSymmetricAsymmetric

Size of fontanels

AnteriorPosterior

Scalp swellings

LocationCharacteristics

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Superior sagittal sinus – drains blood from scalp back to heart

Head

©K Karlsen 2006

Caput Succedaneum Cephalohematoma Subgaleal Hemorrhage

Head   Scalp Swellings Scalp Swellings

©K Karlsen 2006

Emissary vein

Superior sagittal sinus

Duration Blood loss

Palpation Location

Resolves in

48 – 72 hours Minimal

Soft and spongy Edema of presenting

part of scalp – usually

shifts with positioning

Accumulation of serosanguineous fluid in subcutaneous tissues of scalp

Head   Caput Succedaneum Caput Succedaneum

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

Blood accumulation between skull bone and periosteum

Emissary vein

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©K Karlsen 2006

Duration Blood loss

Resolves over

2 – 3 wks High morbidity

& mortality

May lead to severe anemia and hypovolemic shock

Rupture of emissary veinssubtle but massive hemorrhage!

Subgaleal space – holds up to 240 ml

of blood – potentially entire blood volume

Subgaleal space – holds up to 240 ml

of blood – potentially entire blood volume

Resolves over

2 – 3 wks High morbidity

& mortality

May lead to severe anemia and hypovolemic shock

Video courtesy of Swiss Society of Neonatology

Infant with subgaleal hemorrhage

Note area of hemorrhage

Anterior

Note fluid waves, tachypnea and retractions Note fluid waves, tachypnea and retractions

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Abnormally placed whorl

Hair  Abnormal Findings

Low hairline ©David A Clark MD

Trisomy 21

Congenital absence of hair growth – bald patch Congenital absence of hair growth – bald patch

Hair  Abnormal Findings

Cornelia de Lange syndrome

Face

SymmetryFeatures

Symmetric facies

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Broad nasal bridge

Short, up-turned nose

Smooth, long philtrum

Thin upper lip

Pinched appearance of noseLow-set, malformed earsMicrognathia

Central facial anomalies, midface hypoplasiaAnophthalmia, microphthalmia,

hypotelorismCataracts, coloboma of irisBroad, bulbous noseCleft lip, palateLow-set, malformed earsScalp defects

cutis aplasia

Face   Abnormal Findings Abnormal Findings

Microphthalmia Anophthalmia,

holoprosencephaly Anophthalmia, holoprosencephaly

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Assess for symmetry when crying

Asymmetrynerve injury

Eyes  Position and Size

Normal eye spacinginner canthal distance

= palpebral fissure length

Outer canthal distance

Palpebral fissure length (size of eye) Interpupillary distance

Inner canthal distance

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Area of obstruction

Nose

Choanal Atresia

One or both nares obstructedCyanotic at rest but

‘pinks up’with crying

If bilateral, may needoral airway orendotracheal intubationOral airway sizes

00–small infants

0–term or largeinfants

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Treacher Collins syndrome

and Chin  Abnormal Findings Mouth

©K Karlsen 2006

Pierre-Robin Sequence

Very small jaw

Tongue obstructs airway

May have cleft palate

©Jack Dolcourt MD

Neck  Abnormal Findings

Cystic hygroma  soft, fluctuant, transilluminates Cystic hygromasoft, fluctuant, transilluminates

Chest  Abnormal Findings

Broad chest and wide spaced nipples

Turner syndrome

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Chest  Abnormal Findings

Accessory nipple

Broad chest and wide spaced nipples Broad chest and wide spaced nipples

Respiratoryrate > 60‘tachypnea’

Respiratory rate < 30 plus laboredbreathingsign of exhaustion

!Gaspingsign of impendingcardiorespiratory arrestGrunting

FlaringRetractions

©K Karlsen 2006

Retractions

Intercostal–between the ribs

Substernal–under the sternum

Chest and Airway

Diaphragmatic hernia

Bowel in chestUAC tipaortashifted to rightGastric tube tipstomach in chest

Chest and Airway

CDH Stabilization

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Type B 1%

Type C 86%

Type C 86% Type D Type D 1% 1% Type E Type E 4% 4%

Chest and Airway

TE fistulaRenalRadialLimb

Chest and Airway

Active bowel sounds

Soft and non-tender to palpation

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©K Karlsen 2006

Abdomen

©David A Clark MD

Eagle-Barrett syndrome (Prune belly syndrome)

Appearancescaphoid, distended, visible loops

Colorerythema, bluish discoloration

Bowel soundshypo or hyperactive

Palpationfirm, tender, masses

Abdomen   Abnormal Findings Abnormal Findings

Two vessel cord

Note herniation of abdominal contents through base of umbilical cord

High incidence (30 – 50%) of significant chromosomal, cardiac, gastrointestinal, genitourinary, musculoskeletal, central nervous system anomalies

High incidence (30 – 50%) of significant chromosomal, cardiac, gastrointestinal, genitourinary, musculoskeletal, central nervous system anomalies Omphalocele

Stabilization guidelines

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Gastroschisis

Defect in abdominal wall

to RIGHT of umbilical cord

No peritoneal sac protects the herniated organs

Defect in abdominal wall

to RIGHT of umbilical cord

No peritoneal sac protects the herniated organs

Normal Intestinal Development

Between 6 and 12 weeks gestation

bowel enters abdomen

Cecum rotates counterclockwise

to right lower quadrant

Intestine fixed to posterior abdominal

wall by wide fan of mesentery

Note points of fixationMesenteric artery suppliesblood to intestine

Midgut volvulus (twisting)

Clockwise rotation withstrangulationblood supply

to small intestine cut off

Heart in left sideusually indicates complex CHD

Abdomen   Liver Abnormal Findings Liver Abnormal Findings

Liver

on left

Heart on right

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Abdomen   Liver Abnormal Findings Liver Abnormal Findings

Cytomegalovirus – hepatosplenomegaly Cytomegalovirus – hepatosplenomegaly

Biliary atresia with liver

enlargement and acholic stool

Biliary atresia with liver

enlargement and acholic stool

Abnormal curvaturescoliosis, lordosis, kyphosisVertebral alignment

Myeloschisis

Myelocystocele Myelomeningocele

Skin Color  Normal Findings

Acrocyanosis–bluish discoloration of hands and feetOften resolves by 48 hours of age

Rule out hypothermia

Twin-to-twin transfusion Twin-to-twin transfusion

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Caused by desaturation of arterial blood

Indicates cardiac / respiratory dysfunction

Hemoglobincarrying no O2appears

purple“reduced hemoglobin”

until skin refills Count seconds until skin refills Compare upper

to lower body Compare upper

Persistent cutismarmoratawith some trisomies

or syndromes

Skin Perfusion   Abnormal Findings Abnormal Findings

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Skin   Non-pathologic Findings Non-pathologic Findings

Erythema toxicum

Common benign rashsmall white

or yellow papules or vesicles with

erythematous base

Most common on face, trunk, extremities

Smear reveals numerous eosinophils

Skin   Non-pathologic Findings Non-pathologic Findings

Transient neonatal pustular melanosis

Superficial vesiculopustular lesions

Usually rupture within 12 to 48 hours after birth

After rupture, pigmented

macules are seen

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Arthrogryposis multiplex congenita Arthrogryposis multiplex congenita Erb’s palsy

Erb’s palsy

Extremities   Abnormal Findings Abnormal Findings

Thanotrophic dwarf Achondroplasia

Amniotic band constriction Amniotic band constriction

Amniotic band amputation

Cornelia de Lange – phocomelic Cornelia de Lange – phocomelic

Rubinstein-Taybi – broad thumb Rubinstein-Taybi – broad thumb Triploidy

Zellweger syndrome – ulnar deviation Zellweger syndrome – ulnar deviation

Zellweger syndrome – prominent knees Zellweger syndrome – prominent knees

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Simian crease

Short, broad hands and feet Short, broad hands and feet

Wide space between

great and second toe

Wide space between

great and second toe

Polydactyly Tapered, thin fingers

Hypospadias chordee – bifid scrotum

Genitalia   Male Male

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Genitalia   Female Female

Bruising from breech

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