APGAR SCORING

A P G SIGN Activity (muscle tone) Pulse Grimace (reflex irritability) Appearance (skin color) Respiration 1 POINT 2 POINTS Arm and legs Active flexed movement Absent Below 100 Above 100 bpm bpm No response Grimace Sneeze ,cough, pulls away Blue Normal Normal over gray,pale all except for entire body over extremities Absent Slow Good crying irregular Nursing Intervention Rarely needs resuscitation Requires resuscitation suction, dry immediately ventilate until stable careful observation Intensive resuscitation,ET ambu bag ventilate with 100% O2, CPR Maintain body temperature Parental support 0 POINTS Absent

Score 7-10 4-6

Interpretation Well baby At risk infants needs intensive care

0-3

Sick baby Prognosis for NB is grave

SEQUENCE OF PE 1.,ADULT Head to Toe Assessment (IPPA) Abdomen- (IAPP) 2.GERIATRIC PATIENT Head to Toe Assessment 1. Adjust examination pace to meet possible slowed pace of the aging person. (break the examination into few visits) 2. Use physical touch (Vision and hearing are diminished) 3.Infant Heart, lungs and abdomen sounds- to seize the opportunity with a sleeping baby Perform least distressing step first Save the invasive steps of examination of the eye ,ear, nose, and throat until last Elicit moro or startle reflex at the end of the examination because it may cause the baby to cry. 4.Toddler Collect some objective data during the history which is the less stressful time. While focusing on the parent, note the child s gross motor and fine motor skills and gait. Begin with games the Denver II Test or cranial nerve testing.  Denver Test-Developmental Tool to assess mental ,physical, emotional and social functional status of newborn to 6 yrs

old child  Cranial Nerve Test(Ex:

1.Cranial nerves III,IV,VI-move a bright colored toy along the infant s line of vision infant older than 1 month responds by following the object. Eval also the papillary response to bright light in each eyes 2. CN V- tested by assessing the rooting or sucking reflexes 3.CN VII-2mos assessing the sucking reflex,symmetrical sucking movements and facial expressions. 4. CN VIII- less than 6 mos old + moro reflex 5.CN IX-X-+ gag reflex 6.CN XI-ability to lift the head up while in prone position 7.CN XII-suck in a pacifier or bottle take note of the lingering sucking movements after you abruptly remove the bottle. Start with non threatening areas. Save distressing procedures such as examining the head, ear, nose or throat for last. 5.Preschool Child Examine the thorax, abdomen, extremities, and genitalia first Assess head ,eye, ear, nose, and throat last 6.School-Age Child 7.Adolescent Head to Toe same as the adult Head to Toe is appropriate. Examine genitalia last and do it quickly.

4 Point Scale of EDEMA

1+ = Mild pitting,slight indentation,no perceptible swelling of the leg 2+ = Moderate pitting indentations subsides rapidly 3+ = Deep pitting indentations remains for a short period time legs looks swollen 4+ =very deep pitting indentations last a long time leg is very swollen

GENERAL APPROACH TO PEDIATRIC PHYSICAL ASSESSMENT: 1.Assess the patient in a warm, quiet room(to prevent hypothermia always keep infants under the age of 6 mos. warm during examination. 2.Use natural lightning(Fluorescent lightning makes assessing varying degrees of cyanosis and jaundice difficult. 3.To help reduce anxiety and uncooperativeness have a familiar caregiver present during assessment. 4.Talk to child in a soothing voice should be calm and supportive approach. 5. Explain all procedures and allow older infants, toodlers, pre schoolers and younger school age patients to touch or manipulate medical equipments. 6. To promote and a child s feeling of security allow the infant who cannot sit up and the younger child to sit

THE PREGNANT FEMALE: I. COLLECT HISTORICAL INFORMATION Menstrual history (timing LMP,pre menstrual symptoms) Gynecological history (diseases,surgeries,medication) Obstetric history(no of pregnancies,diseases,history of congenital anomalies,premature labor,postpartum depression) Present Pregnancies (Contrceptive methods,abnormal symptoms) Past Med History-(Disease acquired during pregnancy) Family History-(Illnesses of the father,mother,brothers) Nutritional History-(special diet, food intolerance) Environmental Hazards (occupation exposure to radiation,chemicals) DETERMINE EDC AND PRESENT NUMBER OF WEEKS GESTATION Computation of EDC ,Gestational age INSTRUCT THE WOMAN TO UNDRESS AND EMPTY HER BLADDER, SAVING HER URINE TO DIP IT FOR PROTEIN AND GLUCOSE. MEASURE WEIGHTPERFORM A PHYSICAL EXAMINATION STARTING FROM GEN SURVEY. Gen Appearance (state of nourishment,grooming posture,mood and affect,maturity) Vital signs/ weight-(28-40 lbs-under wt ;25-35 lbs for normal wt.;15-25 lbs.for over wt women) Mouth-red and moist, pregnancy gingivitis normally occurs Neck-thyroid maybe palpable but smooth,chloasma on the neck(mask of pregnancy) Breast-enlarged, nipples and areola enlarge and darken pigmentation, colostrums is present ,breast tissue is nodular

II.

III. IV. V.

VI. VII. VIII. IX. X. XI. XII. XIII.

Areola with Montgomery s tubercles and lactiferous ducts enlarged and proliferates Thorax and lungs-increased oxygen demands, diaphragm elevates by 4 cm movement of diaphragm increases Heart-develops functional ,soft blowing systolic murmurs due to increase volume,HR increases by 1-15 bpm,BP varies according to positions and trimester mother s heart lies more horizontally and shifts upward due to cardiac dilatation. Peripheral Vasculature-bilateral pitting edema,varicose veins during 3rd trimester;bld vol increases to 30%-50%; Abdomen-linea negra is visible,striae or stretch marks, Leopolds maneuver,(Presentation,attitude and position of the baby.) Fundic measurements,auscultate FHT Genitalia-Chadwick s sign-bluish-purplish discoloration of vagina, enlargement of the labia, INSPECT SKIN FOR PIGMENT,CHANGES,SCARS Check oral mucous membrane Palpate thyroid gland Inspect breast changes and palpate Auscultate heart sounds, heart rate and any murmurs Check lower extremities for edema and varicosities The abdomen: Measure fundic height, perform Leopolds maneuvers,auscultate FHT s The pelvic exam .Note signs of pregnancy, the condition of the cervix and the size of the uterus.

Signs of Pregnancy PRESUMPTIVE Amenorrhea PROBABLE Abdominal enlargement POSITIVE Fetal heart beats

Breast tenderness and enlargement Fatique Changes in skin pigmentation Nausea, vomiting or both

Uterine changes Cervical changes Braxton s hicks contractions Ballottement Quickening Hegar s sign Chadwick s sign Goodell s sign Positive pregnancy test HCG blood or urine

Fetal movements Fetal outline Ultrasound