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Pediatric Lecture

Advanced Physical Assessment

Feeding / nutritional assessment Breast vs. formula – if formula what type ? 24 hr recall -Frequency, Duration AND Tolerance
Head circumference done until 24 months b/c fontanelles close- anterior 24 mo and posterior is at 12 mo
Growth chart outliers >95th % or <5th%- what could be a reason for this?
Denver Standardized screening tool- Designed to be used on well children between 1month & 6 years of age- done by professional- assesses performance
4 categories of Denver II Personal-Social: getting along w/peopleFine Motor-Adaptive: eye-hand coordination, manipulation & problem-solving, Language: hearing, understanding, & language, Gross Motor: sitting, walking, jumping
Term 38-41 weeks
Brain growth continues until 12 to 15 years of age
The patellar tendon reflexes are present at birth, and the Achilles and brachioradial tendon reflexes appear at 6 months of age
Suck reflex begins at 32nd week of prego so premature can be a problem
Moro reflex startle reflex because it usually occurs when a baby is startled by a loud sound or movement- gone by 4-6 months
Tonic neck reflex head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow- "fencing" position till 4-6 months- cannot roll over if it doesn’t go away.
Palmer Grasp reflex Stroking the palm of a baby's hand causes the baby to close his/her fingers in a grasp. Disappears by 4 months
Babinski reflex When the sole of the foot is firmly stroked, toes fan out- up to 2 years of age.
Step reflex - This reflex is also called the walking or dance reflex because a baby appears to take steps with feet touching a solid surface- diminished by 4 months
Meningitis high pitch cry b/c neck rigidity is hard to assess—maybe fever, not eating
2 months Gross motor – lifts head , Fine motor/adaptive – follow past midline, Language – vocalize / laugh, Social-emotional – smile
6 months Gross motor – roll over, Fine motor – reach, Language – turn to sound of rattle, Social – work of toy out of reach, feed self
9 months Gross motor – pull to stand – stand holding on , Fine motor – transfer objects between hands, Language – single syllables – mama / dada, Social-emotional – wave bye bye
18 months Gross motor – walk backwards, run, Fine motor – scribble, Language – uses at least 3 words, Social – helps in house
2 years Gross motor – walk up & down stairs (gate), Fine motor/adaptive – tower of 4 cubes , Cognitive, language – combined words, point to 2 pictures, Social – remove clothes
3 years old Gross motor – rides a tricycle, Fine motor – tower of 8 blocks, Cognitive / language –name 6 body parts, Social – name a friend
Cerebral palsy anoxia? Prolonged labor, stay in the NICU- Permanent d/o of movement and posture development
Cephalohematoma collection of blood in the head so check Hb
Lymph Nodes of concern Supra-clavicular nodes are a concern at any age-
Normal lymph node finding small, firm, discrete, movable nodes with no warmth, tenderness, non-matted, non-erythematous located in (cervical/inguinal areas in child)…
Vision development depends on nervous system maturation and occurs over time.
Term infants vision hyperopic [20/400]
Peripheral vision fully developed at birth
Central vision develops later
By 6 months of age, binocular vision development is complete and the infant can differentiate colors.
Red light reflex retinoblastoma for lack of reflex/blindness
Full vision at what age 4
Strabismus / pseudo strabismus inward deviation of eye vs flat bridge and optical illusion but light reflex will be equal so it’s pseudo- do Hirschberg test – corneal light reflex
Lacrimal duct clogs up- clean b/c it starts to drain
Absence of fix and follow by 3-4 months of age eyes red flag- refer
Unresolved strabismus by 3 months of age red flag- refer
More than 20/40 in a 5 year old red flag- refer
Retinoblastoma Malignant tumor arising from retina
Retinopathy of prematurity Disruption of normal progression of retinal vascular development in preterm infant
Retinal hemorrhages in infancy Occurs in infant victims of shaken-baby syndrome
Ears, Eustachian tubes are shorter, more horizontal than adults- Position – superior portion of the auricle should line up with the outer canthus of eye
What can cause hearing issues hyperbilirubinemia in the hx
Test hearing by age? 4 but 1st hearing test is in the hospital and by 3 months make sure infant can hear
Tag in front of the ear renal issue- how many diapers a day?
Otoscope with insufflator – provides puff of air to assess if TM is mobile- means it flutters and not sticky against fluid and puss (effusion, or resolving)- no need for anbx
Drooling is normal at what age 6 months- when teeth come in- not appropriate at 2 months when they cannot swallow
Epstein’s Pearls in the back of the mouth are normal- go away in a few days
Well child care height weight, eating habits, 24h recall
Cleft lip make sure you take extra care with assessment of lungs for aspiration
Recommend weaning from bottle by 12 months to avoid dental decay
1st dental appointment by 6 months- 1st tooth
Chest/respiratory percussion less reliable, chest circumference 2 to 3 cm smaller than head, RR 40- 60 per minute, Coughing and hiccups are rare; sneezing is frequent
Periodic breathing a sequence of relatively vigorous respiratory efforts followed by apnea of as long as 10 to 15 seconds, is common.
Oxygen during an anoxic event is a potent vasoconstrictor- closes ducts
Child’s chest is thinner and ordinarily more resonant than the adult’s chest- Listen out laterally – under the axilla in an effort to isolate the right and left lungs and RML
Breath sounds More resonant, Hyperresonance common, Easy to miss dullness, Bronchovesicular sounds may predominate.
Infant & Toddler = apex of the heart is at the 4th left ICS MCl
Changes at birth with the heart Ductus arteriosus and interatrial foramen ovale close. Right ventricle assumes pulmonary circulation. Left ventricle assumes systemic circulation.
Adult heart size at age 7
Systolic ejection murmurs heard best at the LLSB, vibratory or musical quality. grade 2 or 3, short in duration, well located, Usually begin age 3-4, disappear approx 7 years of age
Venous hum common and has no pathologic significance- Caused by the turbulence of blood flow in the internal jugular veins
HTN most often caused by kidney disease, renal disease, coarctation or pheochromocytoma.
Atrial septal defect Congenital defect in the septum dividing the left and right atria
Acute rheumatic fever Systemic connective tissue disease occurring after streptococcal pharyngitis or skin infection
Kawasaki disease Condition causing inflammation in walls of small and medium-sized arteries throughout the body, including coronary arteries
Hepatomegaly is a red flag because - right sided heart failure- fluids
Diastasis recti is caused by a relative weakness of the fascia between the two rectus abdominus muscles. It is not a herniation and is not pathologic. Resolves over time
Umbilical cord usually detaches by 10th day but can take up to 3 weeks…once detached stump should remain dry & heal within a few days
Umbilical cord Drainage (serous with umbilical granulomas—prolonged drainage may need cauterization or may be cyst)-Infection (purulent, erythemic, swollen, malodorous…REFER IMMEDIATELY for aggressive treatment!
Omphalitis –serious infection- infection around umbilical cord
Palpation of the abdomen THE MOST IMPORTANT TECHNIQUE, assess last, Infant pain scale & FACES, Lesions, Masses, Organomegaly, infant/toddler=detectable liver tip common <3 cm; Spleen tip may be felt in 5-10%, DO NOT do deep
Necrotizing enterocolitis Inflammatory disease of GI mucosa associated with prematurity and immaturity of GI tract
Meconium ileus Distal intestinal obstruction caused by thick impacted meconium in the lower intestine
Adduct to dislocate Barlow (in)
Abduct to reduce = ortalani (out)
Barlow-Ortolani maneuver to detect hip dislocation or subluxation- performed each time you examine the infant during the first year of life.
Bowlegs (genu varum) –normal in toddlers but pat a certain measurement you want to refer to ortho
Knock-knees (genu valgum)
Seborrheic dermatitis within the first 3 months of life.
Miliaria (prickly heat) Caused by sweat retention from occlusion of sweat ducts during periods of heat and high humidity. Clear fluid filled pimples
Impetigo Common, contagious superficial bacterial skin infection- Honey crusted lesions
Red flags for infants in need for f/u Fever of 100.4, Seizure, Skin rash or ecchymotic spots, Change in activity or behavior that raises a parent’s concern, Excessive irritability or lethargy, Failure to eat, Falling “off” growth curve, Vomiting, Diarrhea, Dehydration, jaundice, Cough
Infant Developmental Warning Signs – must know! No rx to noise/voice, Apparent visual delay, Does not raise head when prone by 3 months, Hyper OR Hypotonic; scissoring of legs, Does not pick up toy by 6 months, Does not laugh, no interpersonal contact, Does not sit up
Created by: arsho453