Physical Assessment of the Newborn PDF

THE APPEARANCE OF A NEWBORN SKIN: At birth: bright red, puffy, smooth 2nd-3rd day: pink, flaky, dry  LANUGO: very thin, soft, usually unpigmented, downy hair that is sometimes found on the body of a fetal or new-born human appears 6 weeks of life at...

THE APPEARANCE OF A NEWBORN SKIN: At birth: bright red, puffy, smooth 2nd-3rd day: pink, flaky, dry  LANUGO: very thin, soft, usually unpigmented, downy hair that is sometimes found on the body of a fetal or new-born human appears 6 weeks of life at shoulder and back  ACROCYANOSIS: blue hands and feet (peripheral circulation is sluggish within 24 hours)  CUTIS MORMORATA: transient mottling of skin when exposed to decreased temperature  VERNIX CASEOSA: also known as vernix or birthing custard, is the waxy white substance found coating the skin of newborn human babies. It is produced by dedicated cells and is thought to have some protective roles during fetal development and for few hours after birth.   Signs of distress(potential) COMMON VARIATIONS: ▪ Progressive jaundice within 24 ▪ Neonatal jaundice(physiologic jaundice) hours of life after the 1st 24 hours ▪ Generalized cyanosis after 24 ▪ Ecchymoses or petechial caused by birth hours: congenital heart defect trauma ▪ Pallor ▪ Milia: tiny white papules on cheeks, chin, nose ▪ Mottling ▪ Erhythema toxicum: pink popular rash ▪ Grayness with vesicles in thorax, back ,buttocks and abdomen. Appears in 24 to 48 hours ▪ Plethora and subsides after several days ▪ Sclerema ▪ Harlequin color change: outlined color change as infant lies on side, lower half ▪ Poor skin turgor becomes pink and upper half is pale ▪ Rashes, pustules or blisters ▪ Mongolian spots: irregular areas of deep blue pigmentation in sacral and gluteal ▪ Café-au-lait spots(light brown regions spots) ▪ Telangiectatic nevi or stork bites: flat ▪ Nevus flammeus deep pink localized area on back of the neck. Disappears at 2 years of age ▪ Hemorrhage, ecchymoses or petechiae that persist Milia Harlequin sign Mongolian spots Erythema toxicum Cutis mormorata Head  Anterior fontanelle: diamond shape (2.5cm -4cm),closes at 12 to 18 months  Posterior fontanelle: triangular shape (0.5-1 cm),closes at 2 months  Fontanelles should be flat, soft and firm. Widest part measured from bone to bone, not suture to suture HEAD Signs of Distress (Potential) ▪ Fused sutures Common variations: ▪ Bulging or depressed ▪ Molding following vaginal fontanels when quiet delivery ▪ Widened sutures and ▪ Bulging fontanelle because fontanels of crying and coughing ▪ Craniotabes- snapping ▪ Caput succedaneum- sensation along the lamboid edema of soft scalp tissue suture(resembles indention ▪ Cephalhematoma of pingpong balls) (uncomplicated)-hematoma between the periosteum and skull bones Molding Caput vs cephalhematoma Eyes  Lids usually edematous  Color-slate gray, dark blue and brown  Absence of tears  Corneal reflex (responses to touch)  Pupillary reflex (response to light)  Blink reflex (response to touch or light)  Rudimentary fixation on objects and ability to follow to midline  Signs of distress(potential) Common variations: ▪ Pink color of iris ▪ Epicanthal folds: oriental ▪ Purulent discharge infants ▪ Upward slant in non-orientals ▪ Nystagmus or strabismus ▪ Hypertelorism (3cm greater) ▪ Subconjunctival ▪ Hypotelorism (scleral)hemorrhage ▪ Congenital cataracts ▪ Constricted or dilated fixed pupil ▪ Yellow sclera ▪ Absence of red reflex, papillary or corneal reflex ▪ Inability to follow object or bright light to midline  Hypertelorism is an abnormally increased distance between two organs or bodily parts, usually referring to an increased distance between the orbits (eyes), or orbital hypertelorism. In this condition the distance between the inner eye corners as well as the distance between the pupils is greater than normal.  Hypotelorism is an abnormally decreased distance between two organs or bodily parts, usually pertaining to the eye sockets(orbits) also known as orbital hypotelorism.  Strabismus (crossed eyes) is a common eye condition among children. It is when the eyes are not lined up properly and they point in different directions (misaligned). One eye may look straight ahead while the other eye turns in, out, up, or down. The misalignment can shift from one eye to the other.  Nystagmus is a condition where the eyes move rapidly and uncontrollably.  They can move: side to side (horizontal nystagmus) up and down (vertical nystagmus) in a circle (rotary nystagmus) EARS Signs of distress(potential) ▪ Low set ears and minor  Pinna in line with outer abnormalities(chromos canthus of the eye omal defect and  Pinna flexible, cartilage kidney anomaly) present ▪ Absence of startle  Startle reflex is elicited by reflex in response to loud, sudden noise loud noises Common variations ▪ Inability to visualize tympanic membrane(filled aural canals) ▪ Pinna flat against head ▪ Irregular shape or size ▪ Pits or skin tags NOSE Signs of distress(potential)  Nasal patency ▪ Non-patent canals  Thin white mucus ▪ Thick, bloody discharge  Sneezing ▪ Alae nasi (nasal flaring) Common variations: ▪ Flattened and bruised MOUTH AND THROAT Common variations: ▪ Natal teeth-teeth present  Intact, high-arched palate at birth, benign but my be  Uvula in midline associated with congenital defects  Sucking reflex(strong and coordinated) ▪ Epstein pearls-small, white epithelial cysts(midline of  Other reflexes: rooting, gag hard palate) and extrusion Signs of distress:  Absent or minimal salivation ▪ Cleft lip  Vigorous cry ▪ Cleft palate ▪ Large, protruding tongue or posterior displacement of tongue ▪ Profuse salivation or drooling ▪ candidiasis  Cleft lip and cleft palate, also known as orofacial cleft, is a group of conditions that includes cleft lip, cleft palate, and both together.  A cleft lip contains an opening in the upper lip that may extend into the nose. The opening may be on one side, both sides, or in the middle.  A cleft palate occurs when the roof of the mouth contains an opening into the nose.  These disorders can result in feeding problems, speech problems, hearing problems, and frequent ear infections. Less than half the time the condition is associated with other disorders.  Cleft lip and palate are the result of tissues of the face not joining properly during development. As such, they are a type of birth defect. The cause is unknown in most cases. Risk factors include smoking during pregnancy, diabetes, obesity, an older mother and certain medications and certain medications (such as some used to treat seizures).Cleft lip and cleft palate can often be diagnosed during pregnancy with an ultrasound exam.  A cleft lip or palate can be successfully treated with surgery. This is often done in the first few months of life for cleft lip and before eighteen months for cleft palate. Speech therapy and dental care may also be needed. With appropriate treatment, outcomes are good. CHEST Signs of distress:  Anterior-posterior and lateral ▪ Depressed sternum diameters equal ▪ Marked retraction of chest  Slight sternal retractions (evident and ICS(during respiration) during inspiration) ▪ Assymmetric chest  Xiphoid process evident expansion  Breast enlargement ▪ Redness and firmness around nipples Common variations: ▪ Wide-spaced nipples ▪ Pectus excavatum (funnel chest) ▪ Pectus carinatum (pigeon chest) ▪ Supernumerary nipples ▪ Witch’s milk LUNGS Signs of distress: ▪ Inspiratory stridor  Abdominal respiration ▪ Expiratory grunt and retractions  Cough reflex: absent at birth, present by 1-2 days ▪ Persistent irregular breathing  Bilateral equal bronchial breath ▪ Periodic breathing with repeated sounds apneic spells Common variations: ▪ Seesaw respirations(paradoxical) ▪ Irregular rate and depth respirations ▪ Unequal and diminished breath sounds ▪ Periodic breathing ▪ Persistent fine crackles ▪ Crackles shortly after birth ▪ Wheezing ▪ Peristaltic bowel sounds on one side, with diminished breath sounds on the same side HEART Signs of distress: ▪ Dextrocardia-heart on right side  S2 slightly sharper and higher pitch than S1 ▪ Cardiomegaly  Apex: 4th to 5th ICS, lateral to left ▪ Displacement of apex, muffled sternal border ▪ Abdominal shunts Common variations: ▪ Murmurs and thrills ▪ Sinus arrthymias: heart rate ▪ Persistent cyanosis increases with inspiration and decreases with expiration ▪ Hyperactive precordium ▪ Transient cyanosis when crying or straining  Signs of distress: ABDOMEN ▪ Abdominal distention  Cylindrical in shape ▪ Localized bulging  liver: palpable 2-3 cm below right ▪ Distended veins costal margin ▪ Absent bowel sounds  Spleen: tip palpable at end of 1st week of age ▪ Enlarged spleen and liver  Kidneys: palpable 1-2cm above ▪ Ascites umbilicus ▪ Visible peristaltic waves  Umbilical cord: bluish white at birth,2 arteries and 1 vein ▪ Scaphoid or concave abdomen  Femoral pulses: equal bilaterally ▪ Green umbilical cord Common variations: ▪ Presence of only 1 artery in ▪ Umbilical hernia cord ▪ Diastasis recti-midline gap ▪ Urine or stool leaking from between recti muscles cord ▪ Wharton jelly ▪ Palpable bladder distention following scanty voiding  Signs of distress: FEMALE GENITALIA ▪ Enlarged clitoris with urethral meatus at tip  Edematous labia and clitoris ▪ Fused labia  Urethral meatus behind clitoris ▪ Absence of vaginal opening  Vernix caseosa between ▪ Masses in labia labia ▪ Meconium from vaginal opening  Urination within 24 hours ▪ Ambiguous genitalia ▪ No urination within 24 hours Common variations: ▪ Pseudomenstruation: blood tinged or mucoid discharge  Signs of distress: MALE GENITALIA ▪ Hypospadias(urethral opening at ventral surface)  Urethral opening at the tip of glans penis ▪ Epispadias (urethral opening at  Testes palpable in each scrotum dorsal surface  Scrotum usually large, edematous, pendulous, and covered with rugae, ▪ Chordee (ventral curvature) usually deep pigmented(dark skinned) ▪ Testes not palpable in scrotum or  Urination within 24 hours inguinal canal ▪ No urinal within 24 hours Common variations: ▪ Inguinal hernia ▪ Urethral opening covered by prepuce ▪ Hypoplastic scrotum ▪ Inability to retract foreskin ▪ Hydrocele ▪ Epithelial pearls(small, firm, white lesion at tip of prepuce) ▪ Masses in scrotum ▪ Erection or priaprism ▪ Discoloration of testes ▪ Testes palpable in inguinal canal ▪ Ambiguous genitalia ▪ scrotum  Signs of distress(potential) BACK AND RECTUM ▪ Anal fissures or fistulas  Spine intact, no openings, ▪ Imperforate anus masses or prominent curves ▪ Absence of anal reflex  Trunk incurvation reflex ▪ Pilonidal cyst or sinus  Anal reflex ▪ No meconium within  Patent anal opening 36-48 hours  Passage of meconium within 48 ▪ Tuft of hair (spine) hours ▪ Any degree of spina bifida Common variations: ▪ Green liquid stools in infants ( under phototherapy) ▪ Delayed passages of meconium in very low-birth-weight neonates  Signs of distress EXTREMITIES  Complete fingers and toes ▪ ▪ Polydactyly Syndactyly  Full range of motion ▪ Phocomelia (hands or feet attached close to trunk)  Nail beds pink, with transient cyanosis (immediately after birth) ▪ Hemimilia (absence of distal part extremity  Creases on anterior 2/3 of sole ▪ Hyperflexibility of joints  Sole usually flat ▪ Persistent cyanosis of nail beds  Symmetry of extremities ▪ Yellowing of nail beds  Equal bilateral muscle tone ▪ Sole covered with creases  Equal bilateral brachial pulses ▪ Simian crease Common variations: ▪ Fractures ▪ Partial syndactyly between 2nd and 3rd ▪ Decreased or absent range of motion toes ▪ Dislocated or subluxated hip ▪ 2nd toe overlapping the 3rd toe ▪ Limitation in hip abduction ▪ Wide gap between 1st ( hallux) and 2nd toes ▪ Unequal gluteal or leg folds ▪ Deep crease on plantar surface of foot ▪ Allis or Galeazzi’s sign(unequal knees between 1st and 2nd toes height) ▪ Asymmetric length of toes ▪ Ortolani’s sign ▪ Dorsiflexion and shortness of hallux ▪ Asymmetry of extremities ▪ Unequal muscle tone or range of motion NEUROMUSCULAR Signs of distress(potential)  Extremities maintain some degree of flexion ▪ Hypotonia  Extension of extremity followed ▪ Hypertonia by previous position of flexion ▪ Asymmetric posturing  Head lag while sitting, (except tonic-neck reflex) momentary ability to hold head erect ▪ Opisthotonic posturing  Turns head from side to side ▪ Tremors, twitches, and myoclonic jerks ( prone) ▪ Marked head lag in all position  Hold head in horizontal line with back( prone) Common variations: ▪ Quivering or momentary tremors THAT IN ALL THINGS GOD MAY BE GLORIFIED!