Physical Assessment of the Newborn PDF

Physical Assessment of the Newborn Amal Abu Nijmeh/Fakhouri 1. Head to toe examination of the neonate https://www.youtube.com/watch?v=0SgKAxj5UHwhtt 2. https://www.youtube.com/watch?v=hW3n9seV4SY  https://www.youtube.com/watch?v=vdiCep6OStAP rimitive reflexes ...

Physical Assessment of the Newborn Amal Abu Nijmeh/Fakhouri 1. Head to toe examination of the neonate https://www.youtube.com/watch?v=0SgKAxj5UHwhtt 2. https://www.youtube.com/watch?v=hW3n9seV4SY  https://www.youtube.com/watch?v=vdiCep6OStAP rimitive reflexes  Introduction: A period from bi After the initial observation for neonatal condition requiring immediate intervention, the baby is sent to the normal newborn nursery or maternity floor for the purpose of follow up and stabilization. 3 GESTATIONAL AGE CLASSIFICATION Classification Gestation Early-term 37 to < 39 weeks Full-term 39 to < 41 weeks Late-term 41 to < 42 weeks Post-term 42 weeks and beyond  The role of the neonatal nurse & physician inside the normal newborn nursery or maternity floor: Stabilization of the Transitioning Newborn Use Mnemonics!  S = Sugar  T = Temperature  A = Artificial Breathing  B = Blood Pressure  L = Labs  E = Emotional Support for the Family Admission Care: The role of the nurse is: - To carry out good interpersonal communication. - To take complete history about the mother and neonate. - To be sure that the neonate has identification band. - To perform complete physical assessment (General appearance, V.S, Gestational age assessment). - Prevention of hemorrhage (administer vit K if not given in the delivery room). - Documentation. Assessment:  The initial assessment: APGAR scoring system  Purpose: is to assess the newborn’s immediate adjustment to extrauterine life  Normal Newborn General Appearance Well-flexed, full range of motion, spontaneous movement Common variations – Legs extended with breech Signs of potential distress or deviations from expected findings Posture limp Asymmetry of movement Persistent tremor, twitching Vital Signs Temperature - range 36.5 to 37 axillary Common variations Crying may elevate temperature Stabilizes in 8 to 10 hours after delivery Signs of potential distress or deviations from expected findings Temperature is not reliable indicator of infection A temperature less than 36.5 Vital Signs  Heart rate - range 120 to 160 beats per minute. Apical rate Listen for 1 full minute Common variations Heart rate range to 100 when sleeping to 180 when crying Color pink with acrocyanosis Heart rate may be irregular with crying Signs of potential distress or deviations from expected findings Although murmurs may be due to transitional circulation-all murmurs should be followed-up and referred for medical evaluation Deviation from range Faint sound Vital Signs Respiration - range 30 to 60 breaths per minute Common variations  Bilateral bronchial breath sounds  Moist breath sounds may be present shortly after birth Signs of potential distress or deviations from expected finding Asymmetrical chest movements Apnea >15 seconds Diminished breath sounds Seesaw respirations Grunting Nasal flaring Retractions Deep sighing Tachypnea - respirations > 60 Persistent irregular breathing Excessive mucus Persistant fine crackles Stridor Vital Signs  Blood pressure - not done routinely  Factors to consider Varies with change in activity level Appropriate cuff size (2/3 the length from elbow to shoulder) important for accurate reading. Average newborn (1 to 3 days) oscillometry pressure value: 65/41 in both upper and lower extremities  Sign of potential distress or deviations from expected findings Calf systolic pressure 6 to 9 mm Hg less than systolic pressure in upper extremities may be indicative of coarctation of the aorta  General Measurements  Head circumference - 33 to 35 cm  Expected findings Head should be 2 to 3 cms larger than the chest  Chest circumference - 30.5 to 33 cm  Common variations Molding of head may result in a lower head circumference measurement Head and chest circumference may be equal for the first 24 to 48 hours of life  Weight range - 2500 - 4000 gms Skin Expected findings  Skin reddish in color, smooth and puffy at birth  At 24 - 36 hours of age, skin flaky, dry and pink in color  Edema around eyes, feet, and genitals Skin  Vernix Caseosa: The white, cheesy substance covering the newborn's body. Often present only in the skin folds. Lanugo  Lanugo: Fine downy body hair usually distributed over shoulders, sacral area, and back of newborns. Usually disappears before birth or during the first weeks of life.  The more premature baby is, the heavier the presence of lanugo is Skin  Turgor good with quick recoil  Hair silky and soft with individual strands  Nipples present and in expected locations  Cord with one vein and two arteries  Cord clamp tight and cord drying  Nails to end of fingers and often extend slightly beyond Skin  Common variations Acrocyanosis - result of sluggish peripheral circulation Mongolian spots: Black coloration on the lower back, buttocks, anterior trunk, & around the wrist or ankle. They are not bruise marks or a sign of mental retardation, they usually disappear during preschool years without any treatment.  Skin Physiologic jaundice Skin Milia: Tiny white or yellow papules on cheeks, forehead, chin, and nose Due to accumulations of secretions from the sweat & sebaceous glands that have not yet drain normally. Disappear 1-2 weeks of age they should not expressed. Skin  Erythema toxicum  Pink papular rash with vesicles superimposed on thorax, back, and abdomen;  may appear in 24 to 48 hours and resolve after several days. Skin Petechiae/ bruises over presenting part :Pinpoint, flat hemorrhages often visualized on head, face, and chest. Associated with rapid onset of pressure followed by immediate release of pressure during birthing process. Skin tags usually around ears or digits (tied off). Skin  Harlequin color change: The color of the newborn's body appears to be half red and half pale. This condition is transitory and usually occurs with lusty crying. Harlequin Coloring may be associated with to an immature vasomotor reflex system. Desquamation: - Peeling of the skin over the areas of bony prominence that occurs within 2-4 weeks of life because of pressure and erosion of sheets. Skin Signs of potential distress or deviations from normal findings  Jaundice within 24 hours of birth  General cyanosis  Circumoral cyanosis between feedings  Petechiae or ecchymoses other than on presenting part  All rashes with exception of erythema toxicum  Pigmented nevi  Yellow vernix  Hemangioma  Pallor  Forceps marks  Skin Forceps marks Head Expected findings Anterior fontanel: Diamond shaped. located at the junction of 2 parietal & frontal bones. It is 2-3 cm in width & 3-4 cm in length. It closes between 12- 18 months of age. Posterior fontanel: Triangular 0.5 - 1 cm. Located between the parietal & occipital bones. It closes by the 2nd month of age. Fontanels soft, firm and flat Sutures palpable with small separation between each Head Common variations  Molding of fontanels and suture spaces Common variations Caput succedaneum  Caput Succedaneum is a localized, easily identifiable, soft area of the scalp, generally resulting from a long and difficult labor or vacuum extraction (Figure 24–26). Caput succedaneum extends across the midline and over suture lines.  The sustained pressure of the presenting part against the cervix results in compression of local blood vessels, and venous return is slowed.  Slowed venous return causes an increase in tissue fluids, an edematous swelling, and occasional bleeding under the periosteum.  The caput may vary from a small area to a severely elongated head. The fluid in the caput is reabsorbed within 12 hours to a few days after birth. Caputs resulting from vacuum extractors are sharply outlined, circular areas up to 2 cm (0.8 in.) thick. They disappear more slowly than naturally occurring edema. See Table 24–2. Common variations Caput succedaneum Caput succedaneum does not usually cause complications and usually resolves over the first few days. Management consists of observation only. Caput succedaneum Head  Signs of potential distress or deviations from normal findings Fontanels that are bulging or depressed Hydrocephalus Macrocephaly Cephalhematoma Closed sutures. craniosynostosis: Small fontanelle or early closure Cephalohematoma  is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone (usually parietal) and the periosteal membrane (Figure 24–25). The scalp in these areas feels loose and slightly edematous. These areas emerge as defined hematomas between the first and second day. Although external pressure may cause the mass to fluctuate, it does not increase in size when the newborn cries. Cephalohematomas may be unilateral or bilateral , in which bleeding is limited by suture lines (never cross the suture lines). They are relatively common in vertex births and may disappear within 2 weeks to 3 months. They may be associated with physiologic jaundice because extra red blood cells are being destroyed within the cephalohematoma. A large cephalohematoma can lead to anemia and hypotension. Eyes Expected findings Slate gray or blue eye color. True color is not determined until the age of 3- 6 months. No tears Fixation at times - with ability to follow objects to midline Red reflex, Blink reflex Distinct eyebrows Cornea bright and shiny Pupils equal and reactive to light Common variations  Edematous eyelids  Myopic- See best at 7 to 10 inches  Uncoordinated movements  May focus for a few seconds Vision. High-contrast colors, such as black and white Signs of potential distress or deviations from expected findings  Discharges: Chemical conjunctivitis Subconjunctival hemorrhage Signs of potential distress or deviations from expected findings  Opaque lenses  Absence of Red Reflex  Epicanthal folds in newborns not of Oriental descent  "Doll's eyes" beyond 10 days of age  Reflexes absent Doll's Eyes Reflex: When the head is moved slowly to the right or left, the eyes do not follow nor adjust immediately to the position of the head. This reflex should not be elicited once fixation is present. The persistence of the Doll's Eyes Reflex suggests neurologic damage. Signs of potential distress or deviations Congenital Cataracts Congenital Glaucoma Ears Expected findings  Pinna top on horizontal line with outer canthus of eye  Hearing established after first sneeze  Loud noise elicits Startle Reflex  Flexible pinna with cartilage present  Ears Common variations  Skin tags on or around ears  Signs of potential distress or deviations from expected findings  Ear placement low: may indicate chromosomal or kidney problem  Preauricular sinus  Malformations  Cartilage absent  Nose Expected findings  Nostrils patent bilaterally  Obligate nose breathers  No nasal discharge  Nose Common variations  Sneezes to clear nostrils  Bridge appears absent  Thin white nasal mucus discharge  Nose Signs of potential distress or deviations from expected findings  Choanal atresia and discharge  Malformation  Nasal flaring beyond first few moments after birth Dislocated Nasal Septum  Mouth and Throat Expected findings  Mucosa moist.  Palate high arched  Uvula midline  Minimal or absent salivation  Tongue moves freely and does not protrude  Well developed fat pads bilateral cheeks  Sucking reflex  Rooting reflex  Gag reflex  Extrusion reflex  Mouth and Throat Common variations Epstein's pearls on ridges of gums are brittle (‫(جاف‬, white, shine spots near the center of the hard palate. They mark the fusion of the 2 hollows of the palate. If any; it will disappear in time.  Mouth and Throat Signs of potential distress or deviations from expected findings  Cleft lip or cleft palate  Circumoral pallor  Lip movement asymmetrical  Reflexes absent or incomplete  Protruding tongue  Diminished tongue movement  Candida Albicans  Precocious teeth Cleft Palate Cleft Lip  Normal Tongue Ankyloglossia also known as tongue-tie, is a congenital oral anomaly. Is caused by an unusually short, thick lingual frenulum, a membrane connecting the underside 55 of the tongue to the floor of the mouth.  Neck Expected findings  Short and thick  Turns easily side to side  Clavicles intact  Tonic neck reflex present  Neck-righting reflex present  Some head control  Neck Signs of potential distress or deviations from expected findings  Torticollis-stiff neck drawing head to one side Resistance to flexion  Large fat pad on back of neck  Palpable crepitus, movement with palpation of clavicle  Chest Expected findings  Evident xiphoid process  Bilateral synchronous chest movement  Symmetrical nipples. Distance between is about 8 cm  Cough reflex is absent at birth, present by 1-2 days postnatal. Xiphesternal process evident  Chest Common variations  Witch's milk“  Swollen breasts. Appears on 3rd day in both sex, & lasts for 2-3 weeks and gradually disappears without treatment. N.B: The breasts should not be expressed as this may result in infection or tissue damage.  Accessory nipples  Chest Signs of potential distress or deviations from expected findings Asymmetrical chest Flattened chest movements Supernumerary nipples Sternum depressed Nipples widely spaced Marked retractions Bowel sounds Absent breast tissue auscultated  Intercostal Retractions Respiratory distress  Cough reflex is absent at birth, present by 1-2 days postnatal. substernal retraction  Abdomen Expected findings  Dome-shaped abdomen  Abdominal respirations  Soft to palpation  Well formed umbilical cord  Three vessels in cord  Cord dry at base: Stump falls off around 7 to 9 days after delivery  Liver papable 2 - 3 cms below right costal margin  Bilaterally equal femoral pulses  Bowel sounds auscultated within two hours of birth  Voiding within 24 hours of birth  Meconium within 24 - 48 hours of birth Abdomen Bluish white at birth with 2 arteries & one vein. Cylindrical in Shape Meconium Stained Umbilical Cord  Abdomen  Common variations Small umbilical hernia Signs of potential distress or deviations from expected findings Bowel sounds absent Peristaltic waves visible Abdominal distention Palpable masses Scaphoid-shaped abdomen Omphalocele Base of cord with redness or drainage Cord with two vessels  Gastroschisis and omphalocele  are defects of the abdominal wall Gastroschisis that occur in utero, can be detected prenatally using fetal ultrasonography, and result in herniation of abdominal contents.  In contrast to omphalocele, there is no sac covering the intestines in gastroschisis. omphalocele  Female Genitalia Expected findings Edematous labia and clitoris Labia majora are larger and surrounding labia minora Urethral meatus is located behind the clitoris. Vernix between labia  Female Genitalia Common variations  Hymenal tag  Pseudomenstruation  Increased pigmentation  Ecchymosis and edema after breech birth  "Red brick" pink-stained urine due to uric acid crystals  Female Genitalia Signs of potential distress or deviations from expected findings  Labia fused  Fecal discharge from vaginal opening  Imperforate hymen  Ambiguous genitalia  Widely separated labia  Male Genitalia Expected findings  Urinary meatus at tip of gland penis  Large, edematous, pendulous scrotum, with rugae. Scrotum is usually pigmented. Palpable testes in scrotum: If not palpated, observe for inguinal hernia  Smegma beneath prepuce( secretion of sebaceous glands, thick, cheesy secretion.  Stream adequate on voiding  Male Genitalia Common variations  Prepuce covering urinary meatus  Erections  Increased pigmentation  Edema and ecchymosis after breech delivery  Male Genitalia Signs of potential distress or deviations from expected findings  Non palpable testes  Phimosis: Foreskin adhered to glans penis  Hypospadius: If urinary meatus on undersurfac  Epispadius: If urinary meatus on upper surface  Scrotum smooth  Ambiguous genitalia  Back and Rectum Expected findings Intact spine without masses or openings Trunk incurvature reflex Patent anal opening  Back and Rectum Signs of potential distress or deviations from expected findings  Limitation of movement  Fusion of vertebrae  Spina bifida  Tuft of hair  Imperforate anus  Anal fissures  Pilonidal cyst  Extremities Expected findings Maintains posture of flexion  Equal and bilateral movement and tone  Full range of motion all joints  Ten fingers and ten toes  Nail beds pink  Legs appear bowed  Feet appear flat  Palmar creases present  Sole creases present  Signs of potential distress or deviations from expected findings  Unequal tone  Asymmetrical movement of extremities  Polydactyly: Extra digits  Syndactyly: Webbing of digits  Signs of potential distress or deviations from expected findings  Unequal leg length  Asymmetrical skin Dislocation of hip creases posterior thigh  Simean crease: Hands should have three creases  Persistent cyanosis of nail beds  Club Feet Ortolani Maneuver  Marked metatarus varus  Neuromuscular System Expected findings  Maintains postion of flexion  When prone, turns head side to side  Holds head and back in horizontal plane when held prone  Ability to hold head momentarily erect  Neuromuscular System Signs of potential distress or deviations from expected findings  Hypotonia  straightening of extremities  Clonic jerking  Paralysis The Central Nervous system:  Reflexes: Successful use of reflex mechanism is a strong evidence of normal functioning CNS. Moro Reflex  https://www.youtube.com/watch?v=0_5NrDW2GLE  Neonatal reflexes  https://www.youtube.com/watch?v=ARZD9Qid9lU  Neonatal reflexes  https://www.youtube.com/watch?v=zmX7mJj2XZs Behavioral Assessment  Phases of reactivity newborn passes through during first 6 to 8 hours after birth Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 82 Behavioral States  Sleep states – Quiet sleep – Active sleep  Transitional state – Drowsiness  Awake state – Quiet alert – Active alert – Crying Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 83 Understanding Newborn Cues Newborn Desires Newborn Desires to End Interaction Interaction Focuses on face of parent Turns head away Ceases random body Fussy movement Yawns Reaches out Squirms Newborn Is Hungry Newborn Is Not Hungry Places hand at mouth Arches back Sucking, rooting are evident Falls asleep Flexes arm and clenches fist Relaxes arms at sides Copyright © 2012, 2008 by over body Saunders, an imprint of Elsevier Turns head away from nipple Inc. 84 Screening  Procedure used to detect abnormal condition before symptoms appear  Not diagnostic  Enables early interventions  Most are state-funded  Screening for PKU mandatory in all states Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 85 Screening (cont.)  Screening may include – Endocrine conditions – Organic acid metabolism – Fatty acid metabolism – Amino acid metabolism – Hearing – Cystic fibrosis Copyright © 2012, 2008 by – Hip Ultrasound Saunders, an imprint of Elsevier Inc.