Exam 1 Flashcards
What all is part of the Cognitive-Affective Domain?
Level of consciousness Communication Orientation Attention Memory Perception/Judgment Mood and Pain
Alert
Eyes open, interacting with their environment
Lethargic
Drowsy, in and out of consciousness, not attending to tasks
Glasgow Coma Scale
Level of consciousness and severity of injury with trauma to head/brain
Assessed by MD in ER/ICU
What levels of consciousness may PT be done?
Active participation in alert and lethargic states
PROM and positioning if unconscious
Difference between Orientation x3 and Orientation x4
x3: Person, place, and time
x4: Person, place, time, and diagnosis
Aphasia
Inability to comprehend written or spoken language, formulate written or spoken language, or use written or spoken language
Expressive Aphasia
Non-fluent Broca's Aphasia Limited vocabulary Slow, hesitant speech with good auditory/reading comprehension (communication board) May have impaired written skills
Receptive Aphasia
Fluent
Wernicke’s Aphasia
No problem speaking, no comprehension
Global Aphasia
Inability to produce or comprehend language
Dysarthria
Lesion in brain that mediates speech production
Labored speaking skills, but understand communication and can express in written
Aphonia
Inability to produce speech due to paralysis of vocal cords or diaphragm
Broca’s Aphasia Physiology
Lesion of frontal lobe (anterior motor association - inferior frontal gyrus)
Usually seen with CVA/TBI
Refer to SLP for assessment
Wernicke’s Aphasia Physiology
Lesion in posterior portion of temporal lobe and part of parietal lobe
Reading and writing are impaired
Dysarthria Physiology
Acquired
Impairment of speech production from damage to the PNS/CNS causing weakness of the motor/speech system (respiration, phonation, articulation, resonance)
Production is not altered, but melody and rhythm changed
CP, TBI, CVA, MS, PD, ALS
May coexist with aphasia in CVA/TBI
Attention
Ability to select and attend to a specific stimulus while suppressing extraneous stimuli
Ability to remain on task
Amnesia
State of memory dysfunction
Perception
Ability of an individual to recognize and interpret sensory information, high order function as it requires the individual to integrate auditory, sensory, visual, and somatosensory information
Should be screened for any type of brain injury
Clinical indicators of perceptual difficulty
Brain Damage Unable to perform self ADLs/simple tasks Difficulty initiation/completing a task Unable to identify common onbjects Unable to follow simple directions
Unilateral Neglect
Not aware of one half of their body/plate/environment
Typically right-sided brain injury that impairs left side
Brain damage over eye damage
Lesion located in Right parietal lobe (parietal sensory association cortex)
Often right middle cerebral artery CVA
Clinical measures of neglect
Line Bisection: draw horizontal line and ask to draw line bisecting (bisect line to the right of the center in neglect)
Cancellation tests: cross out all objects they see on piece of paper
Hemianopia
Defective vision in half of the visual field
Lesion in optic pathway or tract
Check visual fields
May present with hemianopia and neglect
Apraxia
Movement disorder resulting in inability to perform movements without underlying cause
Cognitive deficit that interferes with motor planning
Lesion in frontal and posterior parietal lobes
i.e. when given scissors, try to use as a comb
Types of Apraxia
Ideomotor
Ideational
Constructional
Childhood apraxia of speech
Ideomotor Apraxia
Disconnect between idea of a movement and the execution
Knows what to do but can’t
Can’t walk on command, but can get up and get a coffee
Lesion in frontal and/or posterior parietal lobe
Ideational Apraxia
Inability to figure out how to perform a task
Given a hairbrush and told brush hair, but doesn’t know how to
Lesion in parietal lobe
Constructional Apraxia
Faulty spatial analysis and conceptualization of task
Unable to understand relationship of parts to whole
Can’t put sandwich together even though they are given the ingredients; all parts of clock are there but not correct
Lesion in posterior parietal lobe
Childhood Apraxia of speech
Developmental challenge in the brain and can’t form speech correctly
2-4 years: issues getting the wrong sounds/words
Won’t just grow out, refer to SLP
Judgment
Part of executive function
Impairments lead to impulsiveness, socially inappropriate behavior
Assess executive function if they can figure out how to fold/open a walker, find number in phone book, differentiate photos
Mood
Affects participation and treatment
What are the emotional states?
Fatigue Anxiety Depression - impacts recovery Delusion Disinhibition - inappropriate expression of emotion Aggressiveness Apathy
Components of Musculoskeletal Domain
Strength: need at least 3/5 for most functional activities
ROM: visual screening followed by goni in limited range (AROM and PROM)
Posture: sitting and standing
Pressure Sores
Most common preventable secondary condition PTs need to assess for in neurologic dysfunction
Bony prominences at risk for pressure ulcers
Calcaneus
External Occipital Meatus
Sacrum
Causes of Ulcer
Immobility Moisture Lack of Sensation Poor Oxygenation Poor Nutrition Shearing Force
Trophic skin exam changes
Skin color: venous stasis (bluish/purple in LE)
Skin texture: smooth and shiny, absence of hair
Skin Temp: cool = impaired; hot=infected
Edema
Calf pain + increased temp + edema may = DVT
Braden scale: administered by nursing to determine risk
Upper Motor Neuron Lesions (cortex, brainstem, corticospinal tracts, spinal cord)
Spasticity/Hypertonia Exaggerated reflexes Babinski and Clonus Synergy Weakness Disuse Atrophy
Lower Motor Neuron Lesions (cranial nerves/nuclei, spinal cord - AHC, spinal root, peripheral nerve)
Flaccidity/Hypotonia Decreased or absent reflexes No primitive reflexes Weakness Atrophy due to lack of innervation (severe wasting)
Reflexes
Muscle
Developmental: ATNR; STNR; postural synergy patterns: observed muscle hypertonicity and gross movement patterns
Primitive Reflexes: babinski, clonus
Cranial Nerve Testing
UE Synergy Patterns
Flexor component: elbow, wrist, and finger
Extensor component: shoulder ADD and IR, and forearm pronation
LE Synergy Patterns
Extensor component: Hip IR and ADD, knee extension, plantarflexion and inversion
Tonal Abnormalities
Flaccidity Hypotonia Normal Spasticity Dystonia Rigidity
Spasticity
Resistance to external stretch increases with increasing speed of stretch and varies with direction of movement
Resistance to external stretch rises above threshold speed
Dystonia
Involuntary sustained or intermittent muscle contractions cause twisting and repetitive movements, abnormal postures, or both
Rigidity
Resistance to external stretch is present at very low speeds of movement, does not depend on speed, and doesn’t exhibit speed or angle threshold
Spasticity Physiology
Injury to pyramidal tracts (corticospinal)
CVA, CP, TBI
UMN Syndrome (babinski and clonus)
Chronic spasticity leads to contractures, deformity, activity limitations
Clasp knife response: feeling of letting go of resistance when stretching spastic muscle (autogenic inhibition)
Modified Ashworth Scale
Grades tone from:
0 (no increased tone)
4: Extremely stiff
Rigidity Physiology
Basal Ganglia lesion
Leads to contractures and activity limitations
Types of Rigidity
Cogwheel: alternating letting go and increased resistance (PD)
Leadpipe: constant
Decorticate: UE flexed and LE extended; above superior colliculus, reduce stimuli and position (TBI)
Decerebrate: UE and LE extended; between vestibular nucleus and superior colliculus; reduce stimuli and posture (TBI)
Positions that affect tone
UE: antigravity: UE flexed, adducted, wrist flexed = spasticity
LE: antigravity: LE extended, adducted, plantarflexed: spasticity
Dynamic components of tone
Volitional effort Arousal Stress Position Medications Temperature
Functional Balance Tests
Berg/PBS Tinetti TUG and TUDS Dynamic Gait Index; Functional Gait Assessment BOT-2 Pediatric Functional Reach
Coordination
Ability to execute smooth, accurate, controlled motor responses
Based on intact and functioning nervous system
Fluidity of movement
Coordination characterized by:
Appropriate speed Distance (dysmetria) Direction Timing Accuracy
Dysdiadochokinesia
Problems with alternating pronation/supination
Dysmetria
Problem with pointing and past pointing
Tremor
Either a resting tremor or intention worsens
Bradykinesia
Slowed gross and fine motor movement
Sensation Testing
Results from sensory testing => clinical judgments about diagnosis, prognosis, and outcomes
Sensory input impacts motor output
Sensory Testing Principles
Position Patient: informal with supine Socks off Strict about eyes closed Simple instructions Remove clothing Obscure vision
Sensory System classification
Receptors
Spinal Pathways
Receptors
Mechano, thermo, chemo, and pain
Cutaneous: nociceptors, Meissner’s corpuscles (touch), Pacinian corpuscles (deep pressure); Merkel’s disks (light pressure, 2 point discrimination)
Deep Sensory: Ruffini corpuscles (muscle and joint receptor)
Spinal Pathway
Spinothalamic: pain and temperature
Dorsal Column: discriminative touch
Spinothalamic
Nondiscriminative
Small, slow conduction
Skin origin
From dorsal root horn, cross in spinal cord, lower brainstem, thalamus
Dorsal Column
Discriminative
Large, fast conduction
Skin, joint, tendon origin
Dorsal column, cross in medulla to contra thalamus, sensory cortex
Dermatome Testing
Cutaneous area supplied by single dorsal root
Less likely to be dermatomal and more likely to to homunculus, but still test
Sensory Exam
Light touch (sharp/dull)
2 point: dorsal column
Kinesthesia/proprioception: dorsal column
Vibration: early screening in diabetic cases
Pain and temperature: lateral spinothalamic tract
Cranial nerve screening
Cranial Nerve Testing
CN I: Smell CN II: Read nametag and check visual fields CN II, IV, and VI: eye movement and pupillary reflexes; Ptosis, diplopia, and strabismus CN V: Open and close jaw CN VII: Smile CN VIII: hearing and scratch test CN XI: MMT of SCM and trap CN XII: stick tongue out
Cerebellum Function
Regulates coordinated movements
Rapid movement
Maintain posture, muscle tone, and equilibrium
Cerebellar Dysfunctions
Ataxia: uncoordinated
Hypotonia: Gamma input determined by cerebellum, so less function
Dysmetria: can’t judge distance or range
Dysdiadochokinesia: can’t perform rapid alternating movements
Tremor
Cerebellar Dysfunction Features
Movement decomposition: inability to perform smooth, coordinated movements
Gait Disorder: wide BOS, high guard
Rebound: loss of check reflex
Dysarthria: inability to perform motor component of speech articulation
Coordination Exams
Nonequilibrium: finger to nose, pronation/supination, tapping, heel to toe, heel on shin
Equilibrium: standing, feet together, tandem, perturbations, eyes open/closed
Basal Ganglia Function
Regulates initiation of movement, planning of complex motor tasks, automatic and postural adjustments
Basal Ganglia Dysfunctions
Bradykinesia
Rigidity: lesion in basal ganglion and extrapyramidal tracts
Resting Tremor
Akinesia
Chorea: ongoing, involuntary, discrete movements, rapid, jerky motions
Athetosis: continuous, flowing motions, writhing, twisting
Hyperkinetic Disorders
Unwanted excess movement (involuntary or voluntary)
Chorea
Athetosis
Dystonia
Cerebral Cortex Function
Perceiving and interpreting sensory information
Controlling voluntary movement
Controlling co-contraction
Cerebral Cortex Dysfunction
Spasticity
Activity Limitations Domain
Bed Mobility
Transfers
Locomotion
MOST IMPORTANT ASPECT OF EXAM
What are the core dimensions of PT Expert Practice?
Knowledge
Clinical Reasoning
Movement
Virtues
Knowledge
Multidimensional
Patient-Centered
Clinical Reasoning
Collaborative Process
Reflection-in-action
Movement
Central Focus
Centered on Function
Virtues
Caring
Commitment
Clinical Reasoning
Sum of the thinking and decision-making processes associated with clinical practice
Process of reflective inquiry, in collaboration with a patient or family, which seeks to promote a deep and contextually relevant understanding of the clinical problem to provide a sound basis for clinical intervention
Clinical reasoning is…
a continuous reflective activity
engages the patient and family in a collaborative decision-making process
acknowledges key contextual factors that will impact clinical interventions and patient outcomes
Types of reflection
Reflection-on-Action: after the experience
Reflection-in-Action: make changes in real time
Reflection-for-Action: anticipate change for future interactions
Types of clinical reasoning
Hypothetico-deductive (Deductive Reasoning) Pattern Recognition (Inductive Reasoning)
Hypothetico-Deductive Reasoning
Generation of a hypothesis based on results of tests/measures and testing that hypothesis
Used by novices in all situations and experts in challenging/unfamiliar situations
Pattern Recognition
Quick retrieval of info from a well-structured knowledge base contrived upon previous clinical experience
Frequently used by experts during familiar situations as they recognize patterns previously encountered
Deductive Reasoning Process
ICF Framework Patient Management Model Clinical Practice Guidelines Clinical Prediction Rules Algorithms
Inductive Reasoning Process
Requires previous experience Involves recognition of familiar clinical patterns Reflection Open-Ended questions Writing clinical narrative
Clinical Reasoning Framework
Cognitive Knowledge/Experiences
Analytical Skills/Critical Thinking
Situational Awareness/Context/Reflection/Frames of Reference
Normal Newborn Behaviors
Flexion contractures at hips and knees
Flexion for everything in order to fit inside
Respond to auditory stimuli
Abnormal Newborn Behaviors
Less flexion/resting extension
Shine light and disgusted/not alert/not crying
Cognition correlates to motor performance
Normal Newborn Tone
Constant flexion
Abnormal Newborn Tone
Passive motion easier to perform
More flaccid
Normal Newborn Head
Little neck flexion, but keep chin off chest and keep head up a few seconds
Abnormal Newborn Head
Zero flexion in UEs and neck
Can’t keep head up in sitting
Components of pediatric PT Exam
Child/Family History
Systems Review
Tests and Measures
Pediatric Exam
Developmental milestones: have they always been delayed or are there certain things they are behind in
Re-evaluation/roles in growth: expect to get better as they age
Culture/Family dynamics/Environment: some populations don’t let kids lay on ground, less motion in extremities, less neck muscles, decreased strength
History-Parent/Child Interview
Major Concerns Developmental Goals Start asking child around age 5 Important people in child's life Typical day
School, Behavioral, Psycho-social history
MH, LD, ADHD/ADD, TBI
Behaviors: sleeping and eating habits, activity level, temperament, drive/motivation, compliance/motivation, discipline, interests
Time spent in school/daycare, transport, play
Cardiopulmonary Systems Review (Peds)
Heart Defects
Cystic Fibrosis
Muscular Dystrophy
Quieter voice, can’t breathe as deep, won’t be as physically active
Musculoskeletal Systems Review (Peds)
Decreased strength on that side of body
Contractures
Integumentary Systems Review (Peds)
Pressure Ulcers
Neuromuscular Systems Review (Peds)
Tone Synergy patterns Bed mobility Transfers Locomotion Balance
Cognitive-Affective Domain
Cognition: what toys they use, ask questions if older
Communication: hearing, vision, and ability to verbalize
Reflexes: differentiate UMN and normalcy
Integumentary Domain
Visual tracking/attending
Auditory attending/Orienting
Sensory processing (body awareness, proprioception, motor planning, tactile input)
Musculoskeletal Domain
Observation Palpation (soft tissue, bony) Assessment of static/dynamic posture AROM/PROM Postural Alignment: thigh folds, leg length, pelvic height, genu varus/valgus, ankle/foot position
Neuromuscular Domain
Reflexes (developmental and MSR) Coordination and balance Tone Functional Strength Sensory Testing
Activity Limitations/Gross Motor Skills Domain
Knowledge of age appropriate gross motor skills
Determine where child is in relation to norms
Pediatric HOP-FA
Clinical framework designed to guide clinical reasoning in peds PT practice
Provides systematic, stepwise guide to the patient/client management process where the PT is asked to consider factors and issues that may affect clinical reasoning for the child and family
Examination for infants and young children
Observation! Establish rapport in a relaxed atmosphere Interactive play Undress if appropriate "Hands on" may be last to assess Arena/play-based assessments Change your agenda as you go
Exam for preschool
Observation Play Explain what you're doing Arena/play-based Self-care and ADL's
Exam for School-aged children, adolescents, and adults with developmental delays
Custom techniques
Talk with patient
Approach cognitive age, not chronological
Functional exam of motor function
Playground, school, home, and community Fine motor skills Language skills Receptive/Expressive Self help-adaptive skills Social/behavioral skills
Purpose for Tests and Outcome Measures
Discriminative Measure: identify gross motor delay from “norm”
Predictive measure: prognosis - GMFCS
Evaluative Measure: detect progress over time
Baseline Measures: diagnosis and prognosis
Measure effectiveness of intervention
Research
Construction of Peds Tests
Screening vs outcome measures
Norm vs criterion-referenced
Norm-Referenced Tests
Utilize normal subject tests results as standards for interpreting scores
Not needed if given a diagnosis
Compare to typically developing children
Tests: AIMS, PDMS-2, PEDI, BOT-2
Criterion-Referenced Tests
Scores interpreted on absolute criteria
Scores based on number of items performed correctly
Tests: GMFM, PBS
Standardization of Tests
Process of systemization of the methods used to obtain a measurement
Reliability
Validity
MCID
Screening Tools
Purpose: identify developmental delays Quick and cost effect Identify need for outcome measure Overview of child's development Don't establish diagnosis Milani-Comparetti Motor Development, Denver, AIMS, BINS
Outcome Measures
Purpose: in-depth view of gross motor development
Help provide diagnosis or school placement
More time consuming and costlier
AIMS, PDMS-2, PEDI, GMFM, BOT-2, SFA, Wee-FIM
Selection of Peds Tests
Child and family goals Disability domain Test purpose Age criteria Norm vs criterion-referenced Sensitivity vs specificity MCID
Domain of Disability: Body Structure/Function
PBS
Milani-Comparetti
Domain of Disability: Activity
AIMS Denver II PDMS-2 PEDI BOT-2 SFA Wee-FIM
Domain of Disability: Participation
PEDI
SFA
Scoring and Score Interpretation
Raw Score
Standard Score: expressed as deviation from mean; needed for norm-referenced
Percentile Score
of children of same age expected to score lower than child tested
Age Equivalent Score
Chronological age for which a certain score represents the average performance
Scaled Score
Performance along a continuum
Not related to age
Don’t report, but helps you get deviation
PDMS-2
Purpose: Gross and fine motor development by direct observation
Age: Birth - 6 years
Areas tested: reflexes (0 - 12 months), stationary, locomotion, object manipulation, grasping, visual-motor
Norm Referenced
Entire: 45 min
GM portion: 30 min
PDMS-2 Scoring
Must directly observe action Scored "0", "1", or "2" Basal Level: 3 "2's" Ceiling Level: 3 "0's" 12 months or less: reflexes last
PEDI
Purpose: Children with disability (physically or cognitively) and measures functional skills vs normality
Age: 6 months - 7.5 years
Areas: self-care, mobility, and social function
Norm-referenced
Time: 30-60 minutes
PEDI Scoring
0 or 1
Caregiver assistance and modification 0 - 5
SNAPPS
Advanced clinical reasoning process Summarize the most important aspects Determine 2-3 appropriate tests Compare and contrast tests to determine most appropriate Ask about areas of uncertainty Select areas to review and study
BOT-2
Purpose: Assess gross and fine motor skills
Age: 4-21 years; higher level balance and coordination
Areas: fine manual control, manual coordination, body coordination, strength, and agility
Norm-referenced
OT and PT both use
BOT-2 Administration
Must observe child performing
Used in school systems with children who are mildly involved due to high level coordination and balance required
GMFM
Purpose: measure change in gross motor function over time in kids with CP
Age: 5 months to 16 years
Areas: GM function (lying, rolling, sitting, crawling, kneeling, standing, walking, running, and jumping)
Typically developing 5 yo should get 100%
Criterion-referenced with norm values using GMFCS for CP and DS
45-60 min
GMFCS - CP
Purpose: Classification for children with CP looking at trunk control and walking to describe the level of involvement/severity
Age: 6 - 12 years
Levels I - V based on severity of involvement
GMFCS General Classifications
Level I: walks without limitations
Level II: walks with limitations
Level III: walks using a hand-held mobility device
Level IV: self-mobility with limitations, may use power mobility
Level V: transported via manual chair
GMFCS Level I
Walk at home/school/outdoors/community
Climb stairs without using railing
Perform running and jumping, but speed, balance, and coordination are limited
GMFCS Level II
Children walk in most settings and climb stairs holding rail
Difficulty walking long distances and balancing uneven terrains/inclines/confined spaces
Walk with physical assistance, hand-held mobility device, or used wheeled mobility over long distances
Minimal ability to perform gross motor skills (running and jumping)
GMFCS Level III
Walk using hand-held device in most indoor settings
May climb stairs holding rail with supervision/assistance
Use wheeled mobility when traveling long distances and may self-propel for shorter distances
GMFCS Level IV
Use methods of mobility that require physical assistance or powered mobility in most settings
May walk for short distances at home with physical assistance or use powered mobility or body support walker when positioned
Manual wheelchair or powered mobility at school/outdoors/community
GMFCS Level V
Transported in manual wheelchair in all settings
Limited in their ability to maintain antigravity head and trunk postures and control leg/arm movements
Level I vs Level II
Level II - limitations walking long distances and balancing; may need a hand-held mobility device when first learning to walk
May use wheeled mobility when traveling long distances outdoors and in the community
Requires use of a railing to walk up and down stairs, and are not as capable of running and jumping
Level II vs Level III
Level II: can walk without a device after age 4 (but may choose to use it)
Level III: need handheld device to walk indoors and use wheeled mobility in community
Level III vs Level IV
Level III: sit on own, but require limited support; slightly independent in standing transfers, walk with handheld device
Level IV: supported sitting but self-mobility is limited; more likely to use manual or powered mobility in community
Level IV vs Level V
Level V: severe limitations in head/trunk control, require extensive assisted technology and physical assistance; self-mobility achieved if child/youth can learn to operate power wheelchair
MACS
Purpose: Describes how children with CP use their hands to handle objects in home/school/community
Age: 4-18 years
MACS Level I
Handles objects independently and successfully
MACS Level II
Handles most objects but with reduced quality and/or speed
MACS Level III
Handles objects with difficulty; need help to prepare/modify environment
MACS Level IV
Handles a limited selection of easily managed objects in adopted situations
MACS Level V
Does not handle objects and has severely limited ability to perform simple actions
Pediatric Balance Scale
Purpose: assess balance in children; pediatric version of Berg Age: Any age Areas: Balance Criterion-referenced Time: 20 min
PBS Bottom Line
Use with caution if not normalizing for age and gender, as they can’t determine delays in balance if not
SFA
Purpose: assess function and guide planning for students in school
Age: K-6th grade
Areas: participation, task supports, activity performance, physical tasks, cognitive tasks
Criterion-referenced
Time: up to 2 hours
Wee-FIM
Pediatric version of the FIM
Locomotion and transfers
Appropriate for child in inpatient rehab to observe functional abilities
GMFM Scoring
Section C: crawling and kneeling
Section D: standing
Section E: walking, running, and jumping
When does suck, swallow, and breathing on their own begin?
35 weeks
Neural tube is formed at…
4 weeks
Divisions of thigh, knee, calf, and foot; forming of umbilical forms…
8-9 weeks
Eyes are almost fully formed…
9-12 weeks
Inspiratory movements at the head/neck occur; ossification of skeleton, very active…
16 weeks
Initial CNS/PNS myelination…
22 weeks
Lungs mature to potentially viable state and begin to secrete surfactant… usually administer in addition to, but can breathe on their own…
24 weeks
Generalized avoidance reflexes at lips and nose to light touch…
8-9 weeks
Palmar grasp starts to emerge; mouth opening (without sucking) can be elicited; global flex/ext movements occur…
9-12 weeks
Sucking reflex emerges…
17 weeks
Head and extremities can move in isolated fashion; sucking/swallowing both present…
20 weeks
Alert state, random movements, overall hypotonia…
28 weeks
State differentiation more pronounced, movement dominated by trunk; hand to mouth movement begin; hypotonia decreases some but UE > LE…
32 weeks
Vigorous; sustained cry; behavioral states clear; visually fixates and can briefly follow movement; hip knee and ankle flexion contractures are minimally present; well-coordinated suck-swallow-breathe…
36 weeks
Physiologic flexion for UEs and LEs; more organized and coordinated movement; brief but sustained behavioral states; hand to mouth well establish; able to regulate systems better…
40 weeks
Birth weight classifications
Extremely Low Body Weight < 2.2 lbs
Very Low Body Weight < 3.3 lbs
Low Body Weight: 3.3 - 5.5 lbs
Small for Gestational Age < 10%
Maternal malnutrition vs gestational diabetes
Shoulder problems, brachial plexus injuries, hypotonic
Cigarette smoking problems
Decreased circulation
Alcohol use problems
Impacts Nervous System
Illicit Drug Use
Impacts Nervous System
HIV problems
Prophylactic medications reduce transmission
Multiple Pregnancy
Twins => conditions, smaller, one may take more nutrition
Hyperbilirubinemia (jaundice)
Liver function is immature; RBC differences present
Treatment: prevent kernicterus (unconjugated bilirubin at basal ganglia and hippocampus)
Phototherapy or exchange transfusion
Gastroesophageal Reflux
Immature sphincters
Correlated to apnea events in premature and term infants
Treatment: smaller more frequent feedings; thick feedings; elevated head/upright; left sidelying, medication
Necrotizing Enterocolitis
First 6 weeks of life and <2000 g
Factors: intestinal ischemia, infectious gents, poor formula tolerance
s/s: vomiting, abdominal distention, bloody stools, retention of stool, lethargy, decreased urine, respiratory status change
MEDICAL EMERGENCY
Treatment: withhold oral feeding, antibiotics, remove intestine
Patent Ductus Arteriosus, Atrial Septal Defective, Ventricular Septal Defect
May close with or without medication, surgery perhaps
PDA
May give medication and catheter with rubber band, but may need surgery
Usually close fairly easily
Respiratory Distress Syndrome (hyaline membrane disease)
Most common cause of distress (lungs last to mature)
Pulmonary immaturity and lack of surfactant
Steroid pharmacologic management is common
Ventilator or ECMO may be needed
Surfactant may be administered if <30 weeks
Patent Ductus Arteriosus Physiology
Ductus Arteriosus connect the pulmonary artery to the aorta
Usually closes soon after birth
High incidence in premature infants
Mixing of deoxygenated and oxygenated blood, so inadequate amounts of oxygenated blood to all extremities (feeding and breathing are intertwined in young infants)
Ventricularseptal Defect
Similar to PDA in mixing of oxygenated and deoxygenated blood, but on a larger scale
Bronchopulmonary Dysplasia
> 28 days chronological age and still need O2, as well as abnormal physical exam
Chronic diuretic medications may be needed
Monitor closely for infections
Chronic Lung Disease
> 36 weeks and still need O2, as well as abnormal physical and radiographic exams
NICU Musculoskeletal Conditions
Club foot General Asymmetry Arthrogryposis Plagiocephaly: flat spot Congenital torticollis: birthing process Congenital hip dysplasia Tibial Torsion Brachial Plexus Injury
Myelomeningocele
High levels of alpha feto- protein (screened in pregnancy with prenatal care)
Surgery to close open back area often done 1-2 days after being born (C-section)
Periventricular Leukomalacia
Associated with IVH
Symmetric, ischemic lesion of the brain (dying tissue)
With cysts: lots of problems, brain tissue not really there
Without cysts: less neurological issues
Need to try and minimize sequelae and monitor closely for seizures
Retinopathy of Prematurity
Higher risk when on ventilator (can detach retina)
Ischemic event at retinal vessels
5 stages/zones
Contributions: BPD, VLBW, extreme prematurity, hyperoxemia, shock, hypothermia, vitamin E deficiency, light exposure
Hypoxic-Ischemic Encephalopathy
Decreased oxygenation and blood flow: not always death, but deceleration of activity (usually larger term babies with cord wrapped around)
Low APGAR
Therapy = blanket
Seizures and abnormal tone/reflexes/behavioral state
Impairments may present in pulmonary, cardiovascular, hepatic, and renal function
Intraventricular Hemorrhage
Common when <32 weeks and/or <1500 g
Blood filling in ventricles and tissue death along ventricles
Risk factor for CP
Most occur within first 72 hours of birth
Grades I-IV
Failure to Thrive
Nonspecific diagnosis when infant is below 5th percentile on growth charts for height, weight, and head circumference
Can be related to feeding intolerance, cardiac or pulmonary compromise, etc.
Lead Poisoning
Can cause mental retardation, neural tube defects, general risk for neurologic insults
Old homes tend to have lead paint (mouthing infants can ingest)
Maternal Drug Use
May lead to intrauterine growth restriction/retardation (cigarettes, alcohol, heroin, cocaine) Growth Deformities Neonatal Withdrawal syndrome CNS injuries Premature labor
