Patient Assessment Flashcards
What are the four critical life functions? (Order of importance)
1) ventilation
2) oxygenation
3) circulation
4) perfusion
What life function is the first priority?
Ventilation
What assessments would measure how well a pt is ventilating?
RR, Vt, chest movement, BS, PET CO2, PA CO2
How would you know if a pt is having problems with oxygenation?
1) heart rate
Color, sensorium, SpO2, PaO2
What is the most common problem in neonates and children?
Oxygenation
What factors in maternal history would indicate a high risk pregnancy
Maternal age (<16 or >40)
Alcohol use
Smoking
Drug abuse
Caffeine
Para
Amount of births after 20 wks
Gravida
Any pregnancy, regardless of outcome, includes current pregnancy
Pre-eclampsia
Maternal hypertension with proteinuria and edema
Eclampsia
Maternal hypertension with seizures/coma
Pre-eclampsia/eclampsia treatment
Treat symptoms: balanced diet, bed rest, antihypertensive, anticonvulsant, mag sulfate
What does mag sulfate do
Decrease BP and delay preterm delivery
Methods of determining GA
Nagele’s rule: first day of last period - 3 mos + 7 days
Fetal US: measure diameter of fetal head or length of femur
Biophysical profile 8-10
Normal; CNS functional, fetus not hypoxic
Biophysical profile 6
Equivocal; repeat within 24 hrs
Biophysical profile <4
Abnormal; repeat test same day if <32 wks
Then delivery if <6
Labor induction if GA >32 wks
Amniotic fluid index (AFI) 8-18
Normal
AFI <5-6
Oligohydramnios (suspect potters syndrome)
AFI >20-24
Polyhydramnios (suspect esophageal atresia, TE fistula, hydrops fetalis)
What procedure is required to obtain fluid for L/S ratio
Amniocentesis
What is the significance of L/S ratio of 1:1
High risk for RDS
What information is obtained from evaluation of phosphatidylglycerol (PG) and what popoplation is this test better for vs L/S?
Pulmonary maturity, shows up at 35 wks, better for maternal diabetics
Describe one advantage of the S/A ration to determine lung maturity
Less expensive, quicker (>55 = lung maturity)
What is the significance of an LBC of >35,000
Fetal lung maturity
What is the significance of the presence of bubbles in the shake test fluid?
Presence of surfactant
What is the Coombs test?
Blood type compatibility between mother and fetus (RH- baby and RH+ mom is bad)
What developmental abnormalities may be detected by AFP testing? + NV
Omphalocele
Gastroschisis
Neural tube defects (spina bufuda)
NV: <10
Why are c-sections done? Why are infants at greater risk with this type of delivery?
Previous c-sections, complications
Risk for RDS, transient Tachypnea of newborn, and depression from anesthesia
What is the action of tocolytic agents? List 2 commonly used
Inhibit contractions
Mag sulfate and beta-Adrenergic agents (-ine)
Four types of breech
Frank: butt first
Complete: butt and lower extremities first
Footling/incomplete: lower extremities first
Transfers: shoulder/arm/trunk first
Which type of presentation has the highest risk of mortality and why?
Breech; increased risk of trauma and asphyxia
3 types of decelerations that can occur during fetal heart rate monitoring
Early deceleration (type 1): slowing to near/below 100 during contraction
Late deceleration (type 2): slowing after contraction begins or persists after, or no hr change
Variable (type 3): slowing independent of contractions, random
How to treat type 2 and 3 decels
Give mom oxygen
Normal FSpO2
40-70%
What is the significance of FSpO2 of <25%?
Hypoxia, emergency delivery
Maternal bleeding and effect on fetus
Any bleeding after first trimester, asphyxia
Premature/prolonged rupture of membrane and effect on fetus
Rupture of amniotic sac before 37 wks, RDS, sepsis
Why would corticosteroids be administered to the mother before birth?
Stimulate surfactant production
Dubowitz method
Determine GA, score of 40 indicates mature infant
New Ballard score
Modified dubowitz for infants <28 weeks
Vernix
Preterm: completely covered
Term: little
Postterm: no vernix
Skin
Preterm: thin, transparent
Term: pale
Postterm: thick, soft, may crack
Lanugo
Preterm: prominent
Term: normal length
Post: absent
Nails
Pre: short
Term: normal
Post: long
Sole (plantar) creases
Pre: 1-2 anterior creases
Term: creases over 2/3rd of sole
Post: entire sole covered in creases
Ears
Pre: flat, soft, little cartilage
Term: firm recoil easily
Five factors evaluate in apgar
Appearance
Pulse
Grimace
Activity
Respiratory effort
Treatment for neonate with apgar of 1
Suction mouth nose, patent aw, ventilate, NRP
Significance of high Silverman anderson score
Severe respiratory distress
Wher is the pre-ductal sample obtained
Right arm/radial artery
Where is the post ductal sample obtained
Umbilical artery or lower extremity
What conclusion could be drawn from the following data:
PaO2 from right radial artery: 95 torr
PaO2 from umbilical artery: 65 torr
Right to left shunt (PDA or PPHN)
What is the purpose of the oxygen challenge test?
Determine heart or lung problem, if no change with 100%, heart problem
What is the purpose of the hyperoxia-hyperventilation test
Differentiate PPHN v CHD
Four mechanisms by which and infant can lose heat to the environment
Conduction
Convection
Evaporation
Radiation
What causes hyperthermia in a neonate?
Infection, warm environment, dehydration, CNS issues, medications
What happens to oxygen consumption as the infant loses heat?
Increases
Na+ normal value
133-149 (140)
Cl- Normal value
87-114 (100)
K+ normal value
5.3-6.4 (5)
HCO3- (total CO2 content) normal value
19-24 (21)
BUN and Creatinine normal values and what it relates to
BUN: 4-17
Creatinine: 0.11-0.68
Renal function
Urine output normal value and what critical life function it relates to
1 ml/kg/hr
Circulation/perfusion
RBC function, NV, significance in low value, significance in high value
Carries hemoglobin
4.1-5.7
Anemia
Polycythemia
Hb function, NV, significance in low value, significance in high value
Carries oxygen
12.7-18.6
Anemia
Polycythemia
Hct function, NV, significance in low value, significance in high value
43-63 %
Anemia
Polycythemia
WBC function, NV, significance in low value, significance in high value
Infection
10,000-30,000
What lab procedure is recommended to check for different types of hemoglobin
Hemoglobin electrophoresis
Hemoglobin S
Sickle cell anemia
Hemoglobin C
Does not carry oxygen well
What is the source of bilirubin
Byproduct of breakdown of RBC in liver
Normal value for bilirubin in a full-term infant at birth?
1.4-1.9
How is hyperbilirubinemia treated?
Phototherapy
Normal blood glucose level for a term infant
50-100
Most common cause of hyperglycemia
Septicemia
3 causes of hypoglycemia
Infection
Hyperinsulinism
Cold stress and resuscitation
Normal value for serum protein
6-8
Normal value for albumin
3.5-5.5
Normal value for globulin
2.0-3.5
Normal value for albumin/globulin ratio
0.8-2.0
What causes a decrease in the albumin/globulin ratio?
Autoimmune disease, renal failure, liver disease
What causes an increase in albumin/globulin ratio?
Renal failure, liver disease, low thyroid activity
How should hypotension or decreased urine output be treated in the neonate?
Infusion of normal saline
Central cyanosis
Whole body
Acrocyanosis
Blue extremities (hands/feet)
Mottling
Lacy pattern of dilated blood vessels under skin
Harlequin sign
Deep red on one side of face, pale on other
Potential cause of mottling
Chilling/prolonged apnea
Normal respiratory rate for term infant
30-60
What term would describe a respiratory rate of <15
Bradypnea
Causes of bradypnea
Narcotics
Hypothermia
CNS diseases
Causes of Tachypnea
Hypoxemia
Hyperthermia
Metabolic/respiratory acidosis
CHD
Pathology that would result in unequal (asymmetrical) chest movement
Pneumo
Atlectasis
Improperly placed ETT
Diaphragmatic hernia
What is the significance of marked substernal and intrasternal retractions accompanied by Tachypnea?
Obstructed ETT, significant anatomical obstruction
Grunting
Expiration before rapid inspiration
When should the specialist recommend trans illumination?
Suspected pneumo
What findings would indicate a pneumothorax
Entire hemithorax lights up
What does a decrease in trans illumination indicate?
Diaophragmatic hernia, consolidation, absent hemidiaphragm
What pathology is indicated by a scaphoid abdomen?
Diaphragmatic hernia
Gastroschisis v omphalocele
Gastroschisis: protruding intestines not in membrane/sac
Omphalocele: protruding intestines contained in translucent membrane
What is myelodysplasia and how is it diagnosed prenatally?
AFP
What blood vessel should be used to evaluate the pulses in:
Infants <1yr
Infants >1yr
Following delivery of newborn
Brachial
Carotid
Umbilical
Normal HR for term infant
120-170
Bradycardia causes
Hypoxia
Apnea
Heart disease
Drugs
Hypothermia
Poor femoral pulse could be an indication of
Coarctation of the aorta
Bounding pulses could be indicative of
PDA, AV fistula, anemia, CHD, Tetralogy of falot
Tachycardia causes
Hyperthermia
Heart disease
Pain
Crying
Pulsus Alterans
Alternating weak/strong pulses (myocardial failure)
Pulsus paradoxis
Weaker on inspiration, stronger on exhalation, emergency! Cardiac tamponade, pleural effusion, RDS
What pathologies would cause the trachea to shift toward the affected side
Atelectasis
Diaphragmatic paralysis
What pathologies would cause the trachea to shift away from the affected side?
Tension pneumo, tumors, d hernia
Resonance
Normal
Flat/dull percussion
Losing air, atelectasis, consolidation, pleural effusion
Tympanic/hyper resonance
Extra air, pneumo, airtrapping
Type of BS heard in consolidation
Increased
BS heard in IRDS
Decreased
BS heard in IRDS
Decreased
BS heard in occluded ETT
Absent
BS heard in pneumothorax
Unequal
Coarse crackles pathologies
Secretions
Medium crackles pathology
Middle aw secretions
Fine crackles pathology
IRDS, pulm edema, pneuomonia
Wheezes patho
IRDS, BPD, asthma
Stridor patho
Upper aw obstruction
Stridor patho
Upper aw obstruction
Stertor patho
Partial obstruction of upper aw above larynx
What is the significance of the presence of the 3rd and 4th heart sounds
Need echo
Normal range blood pressure for term infant
1000g: 48/25
2000g: 50/30
3000g: 50/35
What pathology should be suspected if the specialist notes the presence of bowel sounds in the left hemithorax
Diaphragmatic hernia
6 levels of consciousness in order from most responsive to least responsive
Alert and responsive
Lethargic
Stupurous/confused
Obtunded
Semi-comatose
Comatose
Gradual onset of illness
Croup, rsv, upper respiratory infection
Sudden onset of illness
Epiglottitis, cardiac abnormalities, FBO
Chronic/recurrent onset of illness
CF, asthma
Glasgow coma scale
Moderate: 9-12
Lower=more severe
Marasmus
6-18 mos, inadequate energy intake, “matchstick” arms
Kwashiorkor
Lack of protein with normal intake, protruding belly, edamatous face and limbs
RBC peds
4-5
Hb peds
10-14
Hct peds
32-40%
WBC peds
5,000-10,000
What pathology is identified with the sweat chloride test? And value
CF, >60
What pathologies can result in peripheral edema?
Fluid overload, CHF
What causes digital clubbing?
Chronic hypoxemia
Kyphoscoliosis and pulmonary function values
Convex and lateral curvature of spine, restrictive
Respiratory rate for peds ages
Infant: 30-60
Toddler: 24-40
Pre-schooler: 22-34
School age: 18-30
Adolescent: 12-20
HR normal values peds
1-2 year: 80-130 (110)
2-6 year: 70-120 (100)
6-10 year: 70-100 (90)
10-16 year: 60-100 (85)
What pathologies could cause inspiratory Stridor
Supraglottic swelling (Epiglottitis)
Subglottic swelling (croup, post extubation)
FBO
Normal blood pressures 1,2,7,15 years old
1: 68-105/22-66
2: 70-105/26-66
7: 79-112/38-71
15: 93-128/66-85
Where should the tip of the ETT be positioned for an infant with an uncuffed ETT
Mid trachea, T2-T4
Where should the tip of the cuffed ETT be positioned for a child with a cuffed ETT?
1-2 cm above carina
How should the NPS evaluate tube placement prior to the CXR
observation. Auscultation, EtCO2
Where should the tip of the NG or OG be positioned when views on X-ray? What does it mean if it’s higher?
T9-T10
D hernia, esophageal atresia, TE fistula
What pathology is is dictated when a feeding tube is seen coiled in the mediastinum on an X-ray?
Esophageal atresia
Describe normal position of the hemiadiaphragms on an X-ray
Both rounded and dome-shaped
Right slightly higher then left
IRDS CXR
reticulogranular densities, reticulonodular, ground glass, honeycomb, air bronchograms
BPD CXR
Diffuse haziness, opacification, Airtrapping, spongelike
Atelectasis CXR
Patchy infiltrates, scattered densities, plate-like, elevated hemidiaphragm, crowding
Congenital diaphragmatic hernia CXR
Hypoplastic lung on affected side, mediastinal shift away, NG tube enters abdomen and passes back above diaphragm
Pneumonia CXR
Air bronchograms, consolidation, discoid-shaped infiltrate
Pneumothorax CXR
Hyperlucensy, absent vascular markings, flattened diaphragm on effected side, mediastinal shift away
Pulmonary interstitial edema (PIE) CXR
Modular, air bubbles radiating outward from hilum, linear licensees and streaks
Pneumopericardium CXR
Hyperlucensy in a ring around the heart or under the inferior heart border
Pleural effusion CXR
Basilar infiltrates with meniscus, blunting of costrophrenic
Pulmonary edema CXR
Bilateral, diffuse, fluffy, infiltrates originating from hilum, butterfly or batwing
RLL pneumonia CXR
Silhouette sign
Elevated thymus (pneumediastinum) CXR
Sail sign
Tetralogy of fallot CXR
Boot-shaped heart
Transposition of great vessels CXR
Egg-shaped heart
Total anomalous pulmonary venous return CXR
Snowman-shaped heart
Indication for inspiratory and expiratory film
FBO
Indication for end-expiratory film
Small pneumo
Indication for lateral decubitus film
Pleural effusion
Indication for lateral neck film
Croup or epiglottitis
Significance of steeple sign on lateral neck X-ray
Croup
Significance of thumb sign on lateral neck X-ray
Epiglottitis
What imaging procedure will be helpful to determine the precise position of a thoracic tumor?
MRI
Which imaging procedure would be helpful to establish a dx of Bronchiectasis?
CT
Which imaging procedure would be helpful to establish the dx of diaphragmatic paralysis?
Fluroscopy
Four indications for cardiac catheterizations
Confirm suspected heart pathology
Quantify severity
Intracardiac/intravascular pressures
Tissue samples
