Presentation on theme: "Newborn Assessment & Skills"— Presentation transcript:
1Newborn Assessment & Skills Ana H. Corona, DNP, FNP-BCNursing InstructorRevised September 2013Bates’ Pocket Guide to Physical Examination and History Taking, 2008; Foundations of Nursing, Duncan & White, 2010.
2Normal Newborn: General Appearance Well-flexed, full range of motionspontaneous movementCommon variationsLegs extended with frank breechSigns of potential distress or deviations from expected findingsPosture limpAsymmetry of movementPersistent tremor, twitching
3Vital Signs Temperature - range 36.5 to 37 axillary (97.7-98.6) Common variationsCrying may elevate temperatureStabilizes in 8 to 10 hours after deliverySigns of potential distress or deviations from expected findingsTemperature is not reliable indicator of infectionA temperature less than 36.5
4Heart Rate Heart rate - range 120 to 160 beats per minute Common variationsHeart rate range to 100 when sleeping to 180 when cryingColor pink with acrocyanosisHeart rate may be irregular with cryingSigns of potential distress or deviations from expected findingsAlthough murmurs may be due to transitional circulation-all murmurs should be followed-up and referred for medical evaluationDeviation from rangeFaint sound
5Respirations Respiration - range 30 to 60 breaths per minute Common variationsBilateral bronchial breath soundsMoist breath sounds may be present shortly after birthSigns of potential distress or deviations from expected findingsAsymmetrical chest movementsApnea >15 secondsDiminished breath soundsSeesaw respirationsGruntingNasal flaringRetractionsDeep sighingTachypnea - respirations > 60Persistent irregular breathingExcessive mucusPersistant fine cracklesStridor
6Blood Pressure Blood pressure - not done routinely Factors to consider Varies with change in activity levelAppropriate cuff size important for accurate readingAverage newborn (1 to 3 days) oscillometry pressure value: 65/41 in both upper and lower extremitiesSign of potential distress or deviations from expected findingsCalf systolic pressure 6 to 9 mm Hg less than systolic pressure in upper extremities may be indicative of coarctation of the aorta
7General Measurements Head circumference - 33 to 35 cm Expected findingsHead should be 2 to 3 cms larger than the chestChest circumference to 33 cmCommon variationsMolding of head may result in a lower head circumference measurementHead and chest circumference may be equal for the first 24 to 48 hours of lifeWeight range gms (5 lbs. 8oz. - 8 lbs. 13 oz.)Length range - 48 to 53 cms ( inches)
8Skin Expected findings Skin reddish in color, smooth and puffy at birth At hours of age, skin flaky, dry and pink in colorEdema around eyes, feet, and genitalsvernix caceosaLanugo (baby hair)Turgor good with quick recoilHair silky and soft with individual strandsNipples present and in expected locationsCord with one vein and two arteriesCord clamp tight and cord dryingNails to end of fingers and often extend slightly beyond
9Common VariationsAcrocyanosis - result of sluggish peripheral circulationMongolian Spots: Patch of purple-black or blue-black color distributed over coccygeal and sacral regions of infants of African-American or Asian descent. Not malignant. Resolves in time.Mottling: Generalized red and white discoloration of skin of chilled infants with fair complexion.Physiologic Jaundice: Hyperbilirubinemia not associated with hemolytic disease or other pathology in the newborn. Jaundice that appears in full term newborns 24 hours after birth and peaks at 72 hours. Bilirubin may reach 6 to 10 mg/dl and resolve in 5 to 7 days.Unconjugated bilirubin circulating in the blood stream that is deposited in the skin. Skin color may range from yellow to orange to greenish hues.
10Common variationsMilia: Tiny white papules (plugged sebaceous glands) located over nose, cheek, and chin.Erythema toxicum: Most common newborn rash. Variable, irregular macular patches. Lasts a few daysPetechiae: 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)Harlequin Coloring: 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.
11Signs of potential distress or deviations from normal findings Jaundice within 24 hours of birthGeneral cyanosisCircumoral cyanosis between feedingsPetechiae or ecchymoses other than on presenting partAll rashes with exception of erythema toxicumPigmented neviYellow vernixHemangiomaPallorForceps marks
12The Head Expected findings Common Variations Anterior fontanel diamond shaped cmsPosterior fontanel triangular cmFontanels soft, firm and flatCommon VariationsCaput succedaneum: Swelling of the soft tissue of the scalp caused by pressure of the fetal head on a cervix that is not fully dilated. Swelling crosses suture line and decreases rapidly in a few days after birth.Molding of fontanels and suture spaces
13Signs of potential distress or deviations from normal findings Fontanels that are bulging or depressedHydrocephalusMacrocephalyCephalohematomaClosed sutures
14The Eyes Expected findings Slate gray or blue eye color No tears Fixation at times - with ability to follow objects to midlineRed reflexBlink reflexDistinct eyebrowsCornea bright and shinyPupils equal and reactive to light
15Common Variations Edematous eyelids Uncoordinated movements May focus for a few seconds
16Signs of potential distress or deviations from expected findings DischargesChemical conjunctivitisOpaque lensesAbsence of Red ReflexEpicanthal folds in newborns not of Oriental descentDoll’s Eyes beyond 10 days of age-----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.Reflexes absentSubconjunctival hemorrhage
17Ears: Expected Findings Pinna top on horizontal line with outer canthus of eyeLoud noise elicits Startle Reflex Flexible pinna with cartilage presentCommon VariationsSkin tags on or around ears
18Signs of potential distress or deviations from expected findings Ear placement lowPreauricular sinusClefts presentMalformationsCartilage absent
19The NoseLook for flaring of the alae nasi as a sign of increased respiratory effort.Look for hyper- or hypo-telorism.Check for choanal atresia (CA) as manifested by respiratory distress (neonates are obligate nose breathers).A soft NG tube should be passed through each nostril to confirm patency if choanal atresia is suspected.
20The Palate and Mouth Check for cleft lip and palate Observe the size and shape of the mouth.Microstomia - seen in Trisomy 18 and 21.Macrostomia - seen in mucopolysaccharidoses.Fish mouth - seen in fetal alcohol syndrome.Epstein pearls - small white cysts that contain keratin, frequently found on either side of the median raphe of the palate.Ranulas - small bluish white swellings of variable size on the floor of the mouth representing benign mucous gland retention cysts.
21The Tongue, Teeth and Chin Macroglossia - Hypothyroidism, mucopolysaccharidosesTeethNatal teeth - occur in 1/2,000 births. Mostly lower incisors. Risk of aspiration if loosely attached.ChinMicrognathia - occurs with Pierre-Robin syndrome, Treacher-Collins syndrome, Hallerman Streiff syndrome.
23The NeckPalpate over all muscles, palpate clavicles for possible fractures.Web neck found in Turner's and Noonan's syndromes.Torticollis usually secondary to sternocleidomastoid hematoma.Cystic hygromas most common neck mass. Lymph nodes are unusual at birth and their presence usually indicates congenital infection.
24Chest and LungsObserve respiratory rate, respiratory pattern (periodic breathing, periods of true apnea).Observe chest movements for symmetry and for retractions.Listen for stridor, grunting.Note that there may be some enlargement of the breasts secondary to maternal hormones.
25The Chest Expected findings Evident xiphoid process Equal anteroposterior and lateral diameterBilateral synchronous chest movementSymmetrical nipplesCommon variations"Witch's milk“Enlarged breastsAccessory nipples
26Signs of potential distress or deviations from expected findings Asymmetrical chest movementsSternum depressedMarked retractionsAbsent breast tissueFlattened chestSupernumerary nipplesNipples widely spacedBowel sounds auscultated
27Cardiovascular System Measure heart rate, blood pressure in upper and lower extremities,respiratory rate.InspectionCheck baby's color for pallor, cyanosis, and plethora.PalpationCheck capillary refill. Check pulses; note any decrease in femoral pulses or radio-femoral delay as a sign of possible coarctation of the aorta, note character of pulses (bounding or thready). Locate PMI with single finger on chest; abnormal location of PMI can be clue to pneumothorax, diaphragmatic hernia, situs inversus, or other thoracic problem.AuscultationNote rhythm and presence of murmurs that may be pathologic.
28Patent Ductus Arteriosis Before birth, there is a natural opening between the aorta (the main artery to the body) and the pulmonary artery (the main artery to the lungs) called the ductus arteriosus.This opening usually closes shortly after birth.PDA occurs when this opening fails to close; PDA occurs in about 10% of infants.PDA is often treated initially with a medication called indomethacin.If the ductus fails to close on its own or with indomethacin, surgery is performed.A small incision is made on the left side of the chest.The ductus is either ligated (tied off) or cut.
29Atrial Septal Defect ASD is a congenital heart defect. In fetal circulation there is normally an opening between the two atria (the upper chambers of the heart) to allow blood to bypass the lungs.This opening usually closes about the time the baby is born.If the ASD is persistent, blood continues to flow from the left to the right atria.This is called a shunt.
30Ventricular Septal Defect Before a baby is born, the right and left ventricles of its heart are not separate.As the fetus grows, a muscular wall forms to separate these lower heart chambers.If the wall does not completely form, a hole remains.This is what is known as VSD.It is estimated that up to 1% of babies are born with this condition.In the vast majority (80-90%) of babies born with this condition, the hole is small.They will have no symptoms, and the hole will close spontaneously as the muscular wall continues to grow after birth.If the hole is large, then too much blood will be pumped to the lungs, leading to congestive heart failure.These babies are often have symptoms related to the problem and may need medicine or surgery to close the hole.
31The Abdomen Expected findings Dome-shaped abdomen Abdominal respirationsSoft to palpationWell formed umbilical cordThree vessels in cordCord dry at baseLiver papable cms below right costal marginBilaterally equal femoral pulsesBowel sounds auscultated within two hours of birthVoiding within 24 hours of birthMeconium within hours of birthCommon variationsSmall umbilical hernia
32Signs of potential distress or deviations from expected findings Bowel sounds absentPeristaltic waves visibleAbdominal distentionPalpable massesScaphoid-shaped abdomenOmphaloceleBase of cord with redness or drainageCord with two vessels
33The Abdomen Note shape of abdomen. Flat abdomens signify decreased tone, abdominal contents in chest, or abnormalities in abdominal musculature.Note abdominal distension.Observe for diastasis recti.Observe for any obvious malformations e.g. omphalocoele.An omphalocoele has a membrane covering (unless it has been ruptured during the delivery) whereas a gastroschisis does not.
34The AbdomenExamine umbilical cord and count the vessels. Note color of cord.Palpate liver and spleen. It may be normal for the liver to be about 2 cm below the right costal margin.The spleen is not usually palpable; if the spleen is felt, be alert for congenital infection or extramedullary hematopoeisis.After locating these organs (checking for situs inversus), palpate for any abnormal masses.Auscultate for bowel sounds.Examine for hernias - umbilical or inguinal.Inspect anal area for patency and/or presence of fistulas.
35Genitourinary Kidneys Examined by palpation. The kidneys should be about cm vertical length in the full term newborn.The technique for palpation is either a) one hand with four fingers under the baby's back, palpation by rolling the thumb over the kidneys, or b) palpate the left kidney by placing the right hand under the left lumbar region and palpating the abdomen with the left hand (do the reverse for the right kidney).
36Expected Findings Common Variations Edematous labia and clitoris Labia majora are larger and surrounding labia minoraVernix between labiaCommon VariationsHymenal tagPseudomenstruationSmegmaIncreased pigmentationEcchymosis and edema after breech birth"Red brick" pink-stained urine due to uric acid crystals
37Signs of potential distress or deviations from expected findings Labia fusedFecal discharge from vaginal openingImperforate hymenAmbiguous genitaliaWidely separated labia
38Signs of potential distress or deviations from expected findings Male GenitaliaExpected FindingsUrinary meatus at tip of glans penis Palpable testes in scrotum Large, edematous, pendulous scrotum, with rugae Smegma beneath prepuce Stream adequate on voidingCommon variationsPrepuce covering urinary meatus Erections Increased pigmentation Edema and ecchymosis after breech deliverySigns of potential distress or deviations from expected findingsNon palpable testes Hypospadius Epispadius Scrotum smooth Ambiguous genitalia
39Male Genitalia Term normal penis is 3.6 + 0.7 cm stretched length. Inspect glans, urethral opening, prepuce and shaft.Normally difficult to completely retract foreskin.Observe for hypospadias, epispadias. Inspect circumcised penis for edema, incision, bleeding.Full term infant should have brownish pigmentation and fully rugated scrotum. Palpate the testes
40Female GenitaliaInspect the labia, clitoris, urethral opening and external vaginal vault.Often a whitish discharge is present; this is normal, as is a small amount of bleeding, which usually occurs a few days after birth and is secondary to maternal hormone withdrawal.Hymenal tags may be present normally.
41Extremities and Skeletal System SpineScoliosis, kyphosis, lordosis, spinal defects, meningomyelocoeles.Upper extremityLook for clavicular fracture, absence of radius or ulna. Inspect creases and fingers.Lower extremitySee posture above. Do Ortolani maneuver to check for congenital hip dislocation. Check toes.
42Extremities Expected findings Maintains posture of flexion Equal and bilateral movement and toneFull range of motion all jointsTen fingers and ten toesLegs appear bowedFeet appear flatPalmar creases presentSole creases presentNegative hip clickGrasp reflex present
43Signs of potential distress or deviations from expected findings Asymmetrical movement of extremitiesPolydactylyUnequal toneSyndactylyUnequal leg lengthAsymmetrical skin creases posterior thighDislocation of hipSimean creasePersistent cyanosis of nail bedsMarked metatarus varus
44Back and Rectum Expected findings Intact spine without masses or openingsTrunk incurvature reflexPatent anal opening"Wink reflex" presentSigns of potential distress or deviations from expected findingsLimitation of movementFusion of vertebraeSpina bifidaTuft of hairImperforate anusAnal fissuresPilonidal cyst
45Neuromuscular System Expected findings Maintains position of flexion When prone, turns head side to sideHolds head and back in horizontal plane when held proneAbility to hold head momentarily erectSigns of potential distress or deviations from expected findingsHypotoniaQuiveringLimp extremities or straightening of extremitiesClonic jerkingParalysis