Examination and Documentation of the Pediatric Client Flashcards
5 parts of the Guide to PT Practice in the examination process
- Examination
- Evaluation
- Diagnosis
- Prognosis
- Intervention
Term: a classification system used to focus on positive patient abilities and identify patient goals in order to guide our practice
International Classification of Functioning, Disability and Health (ICF)
2 parts that the ICF organizes information into
- Functioning
2. Disability
Term: the process of obtaining an history, performing a systems review, and selecting and administering tests and measure to gather data about the patient/client
Examination
Term: a dynamic process in which the PT makes clinical judgments based on data gather during the examination
Evaluation
Term: both the process and the end result of evaluating examination data, which the PT organizes into defined clusters, syndromes, or categories to help determine the prognosis and the most appropriate intervention strategies
Diagnosis
Term: determination of the level of optimal improvement that may be attained through intervention and the amount of time required to reach that level; includes the plan of care
Prognosis
Term: purposeful and skill interaction of the PT with the patient/client using various PT methods and techniques to produce changes in the condition that are consistent with the diagnosis and prognosis
Intervention
ICF Category: physiologic and psychologic functions of the body
Body functions
ICF Category: organs, limbs, trunk and components
Body structures
ICF Category: performance of a task or action
Activity
ICF Category: physical, social, and environment in which people conduct their lives
Environmental factors
ICF Category: involvement in life situations- home, school, community activities and organizations, social relationships with friends
Participation
ICF Category: background of a person’s life and living that is not part of the health condition
Personal factors
Component of PT Exam: systemic gathering of data to determine why the client is seeking PT services, interview
History
Component of PT Exam: examination of the anatomical/physiological status of CV/pulm, integumentary, MS and NM systems and communication, affect, cognition, language, learning style
Systems review
Component of PT Exam: used to investigate diagnostic hypothesis generated during the history and systems review
Tests and measures
When examine the pediatric client, do we used the top-down or bottom-up approach.
Top-down
“Beginning with the end in mind”
Plan the intervention based on the desired outcome/goal
Name 3 parts of the subjective examination of the pediatric client.
Birth/medical history (GA at birth/birth weight, current age, medical complications, ongoing medical concerns)
Developmental history (milestones)
Social history, functional status/activity level
Communication abilities
Cognition
Home/childcare/school environment
Current complaints/concerns
Name 3 parts of the tests and measures that can be taken for pediatric clients.
Assistive device Orthotics Gait/locomotion/balance/mobility Motor function Posture ROM Self-care Ventilation/respiration Home/school/play Pain Arousal, attention, cognition
Name 3 specific tests and measures that can be taken for pediatric clients.
Anthropometrics ADL Strength (MMT, dynamometer, functional) Functional ROM Reflexes Balance assessments Standardized assessment
Full-term new boss have limited hip and knee ___________ and greater ___________ when compared to adults.
extension
dorsiflexion
MMT is reliable in children with ____ and Down Syndrome, but not reliable in children with ____.
DMD
CP
Hand held dynamometers are reliable for ages as young as ___ years.
2
Isokinetic’s are reliable for ages as young as ____ years.
6
Use findings of tests and measures to determine impairments of body __________ and ___________.
function structure
Use findings of observation, mobility assessments and/or standardized assessments to determine _________ limitations.
activity
Use findings of observation and interview to determine restrictions in ____________.
participation
Name 3 special considerations when examining an infant.
Time of day (feeding and nap time) Parents' schedules Natural environment Naturalistic observation Examination may be in random order based on desires/needs of the infant
Name 3 special considerations when examining a young child.
Time of day (nap time) One or both parents' schedules Natural environment Naturalistic observation Comprehensive developmental assessment- cognitive, motor, social, speech-language and self-help in natural environment
Name 3 special considerations when examining a preschooler or school-aged child.
Schedule Natural environment Naturalistic observation Team approach Comprehensive developmental assessment- cognitive, motor, social, speech-language and self-help in natural environment
Name 4 components that should be included in goals/outcomes.
Determined in collaboration with the child, parent, teacher, and/or other team members
Related to functional skills
Focused on participation and activities
Realistic and achievable
Easily understood and free of professional jargon
Goals not intervention
Statement of the behavior to be achieved
When and under what conditions the behavior will be achieved
Measurement criteria used to determine achievement
What does the SMART acronym for goals/objectives stand for?
Specific Measurable Attainable Routine-based Tied to a functional priority
What does the ROUTINE acronym for goal strategies stand for?
Routine-based Outcome-related Understandable Transdisciplinary Implemented by teacher/family Non-judgmental Evidence-based
A premature birth is less than ____ weeks GA.
37
A low birth weight (LBW) is less than _____ grams.
A very low birth weight (VLBW) is less than _____ grams.
An extremely low birth weight (ELBW) is less than _____ grams.
Small for gestational age (SGA) is less than the ____ percentile.
2500
1500
1000
10th
What are 2 reasons why an infant from the NICU would receive a PT referral?
Infants who show signs of CNS impairment
Specific neuromuscular or orthopedic problems
Multiple medicinal or genetic problems
Other symptoms that put infant at risk for developmental problems
Name 2 purposes of the examination/evaluation.
Identify participation restrictions, particularly barriers to normal development
Identify activity limitations, particularly in terms of parent-child interaction
Identify body structure/function impairments that require intervention
Identify methods of positioning and handling and ways to adapt the environment to optimize development
What does the APGAR score stand for?
Activity Pulse Grimace Appearance Respirations
A HR of 90 ppm would be scored as a ___ on the APGAR scale.
1
A respiration description of good, crying would be scored as a ___ on the APGAR scale.
2
A muscle tone description of limp would be scored as a ___ on the APGAR scale, while some flexion would be scored as a ___.
0
1
A grimace description of cough or sneeze would be scored as a ___ on the APGAR scale, while no response would be scored as a ___.
2
0
A color description of blue, pale would be scored as a ___ on the APGAR scale, while body pink, extremities blue would be scored as a ___.
0
1
The APGAR scores are done at 1 min and 5 min after birth. A score of ___ to ___ at 1 minute is normal. A score of ___ to ___ at 1 and 5 minutes indicates risk of neonatal death.
8 to 10
0 to 3
Name 5 complications of prematurity.
Compromised respiration (respiratory distress syndrome) Bronchopulmonary Dysplasia Chronic lung disease Feeding problems Seizures Amniotic band syndrome Myelomeningocele Microcephaly Intraventricular hemorrhage (IVH) Periventricular Leukomalacia (PVL)
Name 2 test and measures done in the NICU.
Active movements and posture Muscle tone Reflexes Feeding Standardized assessments
The following test are done for the ___________ infant:
- Neurobehavioral Assessment of Premature Infants (NAPI)
- Test of Infant Motor Performance (TIMP)
- Neonatal Neurobehavioral Examination (NNE)
- Neonatal Behavioral Assessment Scale (NBAS)
- Preemie-Neuro
premature
Name 3 neonatal signs of physiological stress.
Increased/decreased HR Deceased RR Increased BP Decreased O2 sat Apnea Bradycardia Skin color change
Name 3 neonatal signs of behavioral stress.
Gaze aversion Finger spays Trunk extension Facial grimace Leg extension Drowsiness Hyper alertness
Name 3 self-calming neonatal coping methods.
Hand to mouth Sucking Flexed posture Hands/feet to midline Closing eyes/gaze aversions Drowsy state
Name 3 assisted calming neonatal coping methods.
Nestling, positioning in flexion Holding in flexion Rocking Swaddling Quiet voice
