Newborn Assessment PDF

Newborn Systems Overview Newborn Assessment Process 1. Normal Newborn Assessment : - Start by identifying what is normal in a newborn. - Many normal newborn findings may differ from what was learned in med-surg. These distinctions are critical for understandin...

Newborn Systems Overview Newborn Assessment Process 1. Normal Newborn Assessment : - Start by identifying what is normal in a newborn. - Many normal newborn findings may differ from what was learned in med-surg. These distinctions are critical for understanding the physiology of newborns. - Important to differentiate between normal variants and true abnormalities (e.g., physiologic jaundice vs. hyperbilirubinemia). 2. Assessment Key Areas : - Cardiorespiratory System : This is the most critical system to assess right after birth. - Thermoregulation : Ensuring the newborn can maintain body temperature is vital, especially in preterm infants. Respiratory System 1. Development : - The respiratory system is the last to develop in the fetus, which makes it the most vulnerable in preterm infants. - Knowing the gestational age helps anticipate respiratory function. Preterm babies (under 37 weeks) often have compromised respiratory systems and may require assistance such as CPAP or mechanical ventilation. Cpap Machine Assistance 2. Gestational Age and Respiratory Function : - The respiratory behavior of a newborn depends heavily on their gestational age. - 34-week infants often need respiratory support, while 37-week infants should not typically have respiratory issues. - If a term baby (37 weeks or more) shows signs of respiratory distress, this could indicate an underlying issue requiring investigation. 3. Fetal Circulation and Transition : - At birth, the newborn transitions from fetal to neonatal circulation. In fetal life, the foramen ovale and other structures bypass the lungs. - Upon taking the first breath, these shunts close and blood is redirected to the lungs for oxygenation. - Key early assessment: Is the baby breathing effectively? 4. Signs of Respiratory Distress : - Assess for tachypnea (respiratory rate >60 breaths/min), which indicates a problem. - Other signs of distress include: - Retractions : Intercostal or subcostal muscles pulling in during breathing. - Nasal flaring : Widening of the nostrils to increase oxygen intake. - Cyanosis : Bluish tint of the skin due to poor oxygenation. - Grunting : A noise made by the baby when exhaling, indicating difficulty breathing. --- Thermoregulation 1. Importance of Brown Fat : - Preterm infants (under 37 weeks) often lack brown fat, a specialized tissue that helps maintain body temperature. - Without brown fat, preterm infants cannot thermoregulate effectively and lose heat rapidly. 2. Full-Term vs. Preterm Thermoregulation : - Full-term infants can often be kept warm through skin-to-skin contact with the mother. - Preterm infants , however, need to be placed under a radiant warmer immediately after birth to maintain their temperature. --- Gestational Age and Assessment 1. Importance of Knowing Gestational Age : - The gestational age helps determine what to expect in terms of the newborn’s breathing and thermoregulation.  - For example, a 34-week infant may have compromised breathing and will likely require CPAP or other interventions, which is normal for their age. However, a term baby with similar symptoms would require further investigation. --- Newborn Circulation and Birth Transition 1. Respiratory Transition at Birth : - After birth, the newborn takes their first breath, which triggers the closure of the fetal shunt and starts the lung oxygenation process. - This involves changes in the ductus arteriosus , foramen ovale , and ductus venosus , all of which need to close for the newborn to start circulating blood through the lungs. - Assessment of the newborn includes checking for effective breathing and ensuring that circulatory transition has occurred properly. --- Focus on Anomalies 1. Recognizing Anomalies : - The initial assessment of the newborn should include a head-to-toe check for anomalies. Even with modern prenatal testing, some issues may go undetected until birth. - One critical anomaly is spina bifida , where an opening in the spine can expose the spinal cord or create a fluid-filled sac. Care must be taken to avoid causing harm to this area during the newborn exam. 2. Other Anomalies : - Look for clubfoot , cleft lip , cleft palate , and other physical abnormalities that may not have been diagnosed prenatally. - These anomalies can be identified early in the first few minutes after birth during the focused assessment. --- Neonatal Resuscitation Program (NRP) - The Neonatal Resuscitation Program is critical for any newborn showing signs of distress or failure to transition properly after birth. - Early intervention for breathing and heart rate issues is essential to prevent complications. --- Preterm Infant Specifics 1. Preterm Lungs :  - While preterm infants (22-24 weeks and older) are considered viable because they have functioning organs, their lungs are often not fully developed. - Respiratory support, such as CPAP or ventilators, is common for these infants until their lungs can function independently. 2. Functioning Organs : - At 12 weeks gestation , all major organs, including kidneys and lungs, are present, but the growth and functionality improve throughout the third trimester. - The third trimester focuses on growth and respiratory development to prepare the fetus for life outside the womb. --- Summary of Critical Points 1. Respiratory Assessment : - Monitor for tachypnea , retractions, nasal flaring, cyanosis, and grunting. - Any term baby showing signs of respiratory distress requires immediate investigation. 2. Thermoregulation : - Preterm babies are at higher risk of heat loss due to their lack of brown fat and must be placed under warmers. 3. Gestational Age Importance : - Knowing the gestational age helps predict respiratory and thermoregulatory challenges. Term babies should breathe and regulate their temperature more effectively compared to preterm babies. --- Respiratory Distress in Newborns - Key Signs of Respiratory Distress : - Retractions : When the baby's ribs are visible, indicating they are working hard to breathe. - Nasal Flaring : The baby’s nostrils flare as they struggle to inhale more oxygen. - Cyanosis : Central cyanosis (bluish tint around the lips and torso) indicates poor oxygenation. However, acrocyanosis (blue hands and feet) is normal in newborns as the circulatory system transitions. - Grunting : A sound babies make when exhaling, often mistaken as a baby "talking," but it’s a sign of respiratory difficulty. - Normal vs. Abnormal :  - In full-term babies , the presence of these signs (retractions, nasal flaring, cyanosis, and grunting) is abnormal and requires immediate attention to identify lung or circulatory issues. - In preterm infants (e.g., 34 weeks) , these signs are common due to underdeveloped lungs. However, they still require interventions such as CPAP or oxygen support to assist their breathing. - Tachypnea : - Defined as a respiratory rate greater than 60 breaths per minute. - It is important to recognize tachypnea and monitor the newborn’s breathing patterns closely. - Choanal Atresia : - A congenital condition where the nasal passages are blocked or underdeveloped. - You can suspect this if the newborn turns blue when lying on their back but improves when upright. - This is checked during the respiratory assessment. --- Cardiovascular System - Heart Rate : - The normal heart rate for a neonate is 110-160 bpm , the same as the fetal heart rate. - Femoral and brachial pulses should be assessed, though blood pressure is typically not measured in uncomplicated newborns, as it provides little useful information in routine assessments. - Capillary Refill : - This is checked to assess circulation and oxygenation, similarly to adult assessments. --- Thermoregulation and Sugar 1. Temperature Regulation : - Full-term infants should ideally remain skin-to-skin with the mother to maintain their temperature. - Newborns lose heat through convection , conduction , evaporation , and radiation , so they need to be dried and warmed quickly after birth.  - If placed under a warmer, the warmer must be set to 100% and manually monitored to prevent the baby from overheating. 2. Impact on Respiratory Function : - Maintaining a stable temperature is important to support the baby’s respiratory system. If they get too hot or too cold, it could compromise their ability to breathe effectively. 3. Assessment Frequency : - In the first two hours after birth, the newborn’s heart rate , temperature , and respiratory rate should be checked every 30 minutes. --- Newborn Head Assessment 1. Molding : - This occurs when the bones of the baby's skull overlap as they pass through the birth canal. It is a normal finding. - Molding crosses the fontanelles and is expected during the birth process. 2. Caput Succedaneum : - This is soft tissue swelling on the baby's head due to pressure during delivery. - Like molding, caput succedaneum crosses the suture lines and is a normal occurrence. 3. Cephalohematoma : - This is a collection of blood under the periosteum (the layer covering the skull), usually caused by the use of vacuum extraction or forceps during delivery. - Unlike caput, a cephalohematoma does not cross suture lines and can take time to resolve. Careful monitoring is required to ensure no ongoing bleeding. - Subgaleal hemorrhage is bleeding below the brain, Newborns will die from this and nothing can be done. --- Newborn Facial and Body Assessment 1. Facial Symmetry : - Check if the baby’s face is symmetrical , with both ears aligned with the eyes. - Low-set ears can be a sign of certain genetic conditions like Down syndrome. 2. Eyes and Ears :  - Assess whether the baby has eyeballs and whether their ears have a complete canal. 3. Digits: - Count the fingers and toes to check for extra digits (polydactyly), which is often familial. 4. Hips : - Check for any hip clicks to rule out developmental issues like hip dysplasia. 5. Spinal Column : - Examine the spine for anomalies, such as spina bifida , by palpating the vertebrae. --- Measuring and Classifying Newborns 1. Head Circumference : - Measure the baby's head (normally 12-14 inches) to check for anomalies like microcephaly or macrocephaly. 2. Weight and Length : - Plot the baby’s weight and length on a growth chart relative to their gestational age. - Newborns are classified as: - SGA (Small for Gestational Age) - AGA (Appropriate for Gestational Age) - LGA (Large for Gestational Age) - A full-term baby typically weighs 6.5-7.5 lbs , but this varies based on gestation and maternal health factors. --- Summary of Critical Points 1. Respiratory Distress : - Common signs include retractions, nasal flaring, cyanosis, and grunting. Term infants should not exhibit these signs, while preterm infants commonly do but still need interventions. 2. Heart and Temperature Monitoring :  - Regular assessments of heart rate, temperature, and respiratory status are critical in the first hours of life to ensure stability and intervene when necessary. 3. Head and Body Assessment : - Look for normal variants such as molding and caput succedaneum, and distinguish these from cephalohematoma , which requires close observation. --- Newborn Growth Monitoring 1. Large for Gestational Age (LGA) Babies : - LGA infants are typically larger than expected for their gestational age and may be born to mothers with conditions like gestational diabetes. - These babies may have experienced increased growth due to excess glucose from the mother, which may require additional monitoring, especially in the first 24 hours after birth. - It's important to check their glucose levels because they may have developed higher insulin levels in utero due to the increased maternal glucose, which could cause rapid drops in blood sugar once they're no longer receiving glucose from the mother. 2. Small for Gestational Age (SGA) Babies : - SGA infants may be small due to several factors, including placental insufficiency , maternal hypertension , or other issues during pregnancy. - When assessing an SGA infant, it’s crucial to consider whether the baby had adequate oxygenation and nutrition during pregnancy. - SGA infants also need glucose monitoring for the first 24 hours because they may have difficulty maintaining their blood sugar. 3. Growth Monitoring and Graphing : - Babies’ weight , length , and head circumference are plotted on growth charts during pediatric visits (e.g., at one week, one month, two months , etc.) to track growth. - A significant drop in percentile (e.g., from 50th to 10th) could indicate a feeding or growth problem that requires further investigation by the pediatrician. 4. Head and Chest Measurements : - Initial measurements of head and chest circumference are critical to identify potential abnormalities like cephalohematoma , which may require closer observation if the head size increases over time. --- Newborn Physical Assessment 1. Head Assessment : - Molding is normal and occurs when the bones of the skull overlap to help the baby pass through the birth canal. - Caput succedaneum : This refers to swelling of the soft tissues caused by pressure during delivery. It crosses the suture lines and is a normal finding. - Cephalohematoma : This is a blood collection that does not cross the suture lines and is often seen with the use of vacuum extraction or forceps during delivery. It needs to be closely monitored to ensure there is no continued bleeding. 2. Umbilical Cord : - The umbilical cord should have two arteries and one vein. The presence of Wharton’s jelly indicates there is adequate cushioning around the vessels. 3. Clavicle Check : - Infants, especially those who are LGA or experienced shoulder dystocia during delivery, are at risk for clavicle fractures. The clavicles should be palpated to check for any fractures. 4. Neurologic Reflexes : - Reflexes give insight into the newborn’s neurologic integrity. - Key reflexes include: - Grasp Reflex : When the baby grabs your finger. - Stepping/Dancing Reflex : When the baby tries to lift their feet when placed on a surface. - Startle Reflex : When the baby reacts to a sudden movement or noise. - The presence of these reflexes suggests a functioning neurologic system. 5. Sensory Development : - Hearing is intact at birth, but vision is limited. Newborns can only see objects about a hand’s length away. - Other senses, such as smell and taste , are developed and play a role in their interaction with the environment and caregivers. ---  Common Abnormal Findings 1. Tremors and Jitteriness : - Tremors are normal but can also be a sign of low blood sugar or neurologic issues. - If tremors are associated with hypoglycemia (low glucose levels), a glucose check should be performed. - Abnormal tremors , such as those caused by neurologic injury (e.g., from HIV exposure), may present as severe jitteriness, seizures , or irritability , and require further evaluation. --- Hepatic System Assessment 1. Glucose Checks : - Glucose levels are not routinely checked for all newborns but are monitored for babies at risk, such as preterm , LGA , or SGA infants, and for those showing signs of low blood sugar. - Gestational diabetic mothers : Babies born to these mothers need glucose monitoring because they tend to overproduce insulin due to excess glucose in utero. After birth, their insulin can deplete their glucose too quickly. - Newborn glucose levels should stabilize within the first 24 hours , but if they remain unstable, the baby may require NICU care. 2. Bilirubin Levels : - Bilirubin is the byproduct of red blood cell breakdown, and newborns often have elevated levels due to the natural breakdown of their excess red blood cells. - Bilirubin levels are typically checked at 24 hours to monitor for jaundice. - Elevated levels of bilirubin can indicate a need for further treatment, particularly if levels are high enough to cause complications like kernicterus (a form of brain damage caused by very high bilirubin). --- Critical Points for Newborn Care 1. Early Monitoring : - Regular checks on growth , head circumference , and reflexes are critical in the first few hours and days of life to ensure the newborn is adjusting well to life outside the womb. - Any significant changes or abnormalities need immediate follow-up. 2. Parental Concerns :  - Parents often ask whether their baby can see or hear. While hearing is immediate, vision will develop over the coming weeks and months. 3. Complicated Infants : - Preterm and complicated infants, such as those born to diabetic mothers, require closer monitoring of glucose and bilirubin levels to ensure they are adapting well. --- Bilirubin and Its Role in Newborns - Bilirubin is the byproduct of red blood cell breakdown. Since newborns have an excess of red blood cells (supplied by the mother through the placenta), there is a natural process of these cells breaking down after birth. - If the newborn's body does not efficiently eliminate bilirubin, it can accumulate, leading to jaundice , a yellowing of the skin and eyes. - Jaundice is most noticeable in the sclera (whites of the eyes) but can also appear on the skin if levels get higher. Normal Bilirubin Trends - Bilirubin levels increase naturally during the first 96 hours (4 days) of life. This is considered normal as the baby transitions to managing bilirubin on their own. - The baby's ability to tolerate higher bilirubin levels improves as they age. However, the specific bilirubin level that is considered high depends on the baby's age in hours. Bilirubin Screening -A standard bilirubin screening is done 24 hours after birth. - Bilirubin levels are plotted on a graph to determine if the level is in a normal range for the baby's age. - Example: -A bilirubin level of 7 at 24 hours is considered high. -A bilirubin level of 12 at 48 hours is considered low for that time frame. - Understanding the context of time is critical for interpreting bilirubin levels. The same bilirubin value can mean different things depending on the baby's age in hours. Risk Categories and Interventions - If a baby has a high bilirubin level for their age (e.g., 12 at 24 hours), they are placed in a high-risk category , and interventions are required to prevent complications such as kernicterus (a type of brain damage caused by severe jaundice). - The primary intervention involves increasing stool output because bilirubin is excreted through the stool. - One way to do this is to supplement breastfeeding with formula. - Formula feeding increases the baby’s stool output more than breast milk alone, which can help the baby excrete bilirubin faster. - This is especially helpful because colostrum , the first milk produced by the mother, is present in small amounts and may not provide enough volume to stimulate stooling in a baby with high bilirubin. Importance of Stool in Bilirubin Excretion - Babies excrete bilirubin through their stool, so frequent pooping helps lower bilirubin levels. - When bilirubin levels are slightly elevated (but not yet severe), supplementing with formula can be a simple and effective way to increase stool output, which in turn helps eliminate bilirubin from the body. Breastfeeding and Jaundice - In some cases, when a baby is solely breastfeeding , their bilirubin levels may stay elevated longer. This used to be called "breastfeeding jaundice". - This happens because colostrum is present in small amounts and doesn’t promote as much stool output as formula. - Historically, breastfeeding jaundice was considered normal, and many times the baby would resolve the jaundice on their own over time. However, the current approach is to intervene earlier to prevent severe outcomes. - Research shows that formula tends to bring down bilirubin levels more quickly than breast milk. This is one reason why formula supplementation is recommended for at-risk newborns with high bilirubin levels. Modern Approach to Bilirubin Management - Over the past 20 years, healthcare providers have become more proactive about addressing bilirubin early to prevent complications. - Early intervention is key because it is easier to lower bilirubin levels when they are addressed early. - While breastfeeding is still highly encouraged for its immune benefits , formula supplementation is used in certain cases to help manage bilirubin levels more effectively. High-Risk Newborns and Further Interventions - Phototherapy (light therapy) and blood exchange transfusions are more advanced interventions used for high-risk newborns with very high bilirubin levels, though these are covered in more detail in discussions about complicated newborn care. - For now, the focus is on early recognition and using simple interventions like formula supplementation to help reduce bilirubin levels. --- Key Takeaways : 1. Bilirubin rises naturally in newborns during the first 96 hours, but must be carefully monitored. 2. Jaundice appears as a yellowing of the skin and sclera when bilirubin accumulates. 3. Bilirubin screening at 24 hours is critical to assess the baby’s risk level. 4. Supplementing with formula can help babies poop more and excrete excess bilirubin. 5. Early intervention is now prioritized to prevent severe complications like kernicterus. Gestational Age and Skin Characteristics - Skin Condition and Gestational Age : - As gestational age progresses, the baby's skin undergoes significant changes. Babies past 40, 41, or 42 weeks show dry, wrinkled, and peeling skin. This is due to the loss of protective substances like vernix caseosa and lanugo. - Vernix caseosa is a white, waxy coating that protects the skin in utero. - Lanugo is fine hair covering the fetus, which typically disappears by the end of gestation. - Postmature Babies : - These babies (born after 42 weeks) often exhibit more peeling and wrinkling of the skin, giving insight into their gestational age. A more mature baby might appear dry and flaky, while preterm babies have softer, smoother skin. --- Birthmarks and Skin Conditions - Toxemia (likely referring to a skin condition or birthmark) : - Appears as a red patch on the baby's skin. - Common Birthmarks : - Milia : Small white bumps often seen on the newborn's face. - Harlequin Sign : A temporary condition where one side of the baby’s body turns red while the other remains pale. - Stork Bites : Reddish marks, typically seen on the back of the neck or between the eyebrows. --- Ballard Score - Purpose : - A scoring system used to estimate a newborn's gestational age based on physical and neuromuscular signs. - Experienced nurses might not need to formally calculate the score but can visually assess the newborn to estimate gestational age. - Neuromuscular Signs : - One of the primary indicators of gestational age is the baby’s posture. - Premature babies are often curled up tightly. - Full-term babies tend to spread out more and appear more relaxed. - Other signs include tone and reflexes, such as the ability to pull their limbs back into a flexed position. - Physical Characteristics : - Skin : Assess whether it’s dry or moist, peeling or smooth. - Plantar Creases : These are wrinkles on the soles of the baby’s feet. As the baby matures, more creases cover the foot (e.g., one-third, two-thirds, or full coverage). - Breast Tissue : More developed breast tissue is an indicator of higher gestational age. - Ear Cartilage : More mature babies have firmer ears that spring back when folded. Less mature babies’ ears remain folded due to softer cartilage. - Ballard Score in Use : - The Ballard Score is often used when prenatal care information is lacking, helping to estimate the baby’s gestational age after birth. - It involves both neuromuscular and physical assessments, and the score helps guide the care needed for the baby (e.g., determining whether they are preterm, term, or post-term). --- Behavioral Signs and Care - Behavioral Development : - Newborns have predictable behavior patterns. Early on, they enter the "golden hour" of bonding, where they're awake and alert after birth. After this, they typically enter a period of quiet sleep. - Nurses and parents should observe reflexes like the startle reflex (reaction to loud sounds) and their response to swaddling (being comforted when wrapped snugly). --- Other Considerations - Nail Development : - A newborn’s nails are soft and should not be clipped for the first two weeks, as they are still developing and are part of the skin. - Assessing Growth : - In some cases, a baby may be full-term but smaller in size (Small for Gestational Age – SGA). This is where assessments like the Ballard Score become important, as they help differentiate between gestational age and size discrepancies. --- Summary of Key Assessments 1. Skin Condition : Check for dryness, peeling, or vernix presence. 2. Posture : Tightly curled indicates preterm; more spread out suggests full-term or post-term. 3. Plantar Creases : More wrinkles = more mature baby. 4. Breast Tissue : Assess the amount of breast tissue present. 5. Ear Cartilage : Firmer, springy ears suggest higher maturity. 6. Behavior : Reflexes like the startle and comfort response give insights into neurological development.