Module: Physical Assessment Session 1

Physical Assessment of the Newborn

Julniar M Tasli Herman Bermawi

Module: Physical Assessment Session 1

Purpose
The purpose of this session is to emphasize the importance of physical assessment in the quality of care offered to neonates. The guidelines for complete neonatal physical assessments are presented, including vital signs, growth measurements, and evaluation of specific body systems, as are the details on correct documentation.
Session Purpose Visual 2

Module: Physical Assessment Session 1

Task Analysis: Task

Complete a newborn assessment and implement admission/discharge policies and procedures according to the service standards and protocol to promote and implement successful breastfeeding of the newborn.

Task Analysis

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Module: Physical Assessment Session 1

Task Analysis: Competency 1

Competency: Perform a complete physical assessment of the neonate
Skills
1.1 Perform and document a complete clinical assessment at the beginning of each shift and for new admissions. 1.2. Assess vital signs at the proper times and intervals:

Measure temperature. Count heart rate. Count respiratory rate. Measure blood pressure on all four limbs according to the neonates condition.
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Task Analysis

Module: Physical Assessment Session 1

Task Analysis: Competency 1

Competency: Perform a complete physical assessment of the neonate
Skills 1.3. Assess the three components of growth measurements according to individual neonatal needs:

Weight Length Head circumference

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Task Analysis

Module: Physical Assessment Session 1

Task Analysis: Competency 1

Competency: Perform a complete physical assessment of the neonate
Skills
1.4. Perform a complete assessment of the following body systems:

Neurological system Respiratory system Cardiovascular system Gastrointestinal system Assessment of other systems when needed
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1.5. Perform gestational age assessment.

Task Analysis

Module: Physical Assessment Session 1

Learning Objectives
1. Recognize the importance of performing and documenting a complete neonatal physical assessment at the beginning of each shift and for new admissions. 2. Know how to assess vital signs at the proper times and intervals:

Measure temperature Count heart rate Count respiratory rate Measure blood pressure on all four limbs according to the neonate's condition
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Learning Objectives

Module: Physical Assessment Session 1

Learning Objectives
3. Know how to assess the three components of growth measurements according to individual neonatal needs: Weight Length Head circumference

Learning Objectives

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Module: Physical Assessment Session 1

Learning Objectives (cont.)

4. Know how to perform a complete assessment of the following body systems: Neurological system Respiratory system Cardiovascular system Gastrointestinal system Assessment of other systems when needed Know how to assess gestational age.
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5.

Learning Objectives

Module: Physical Assessment Session 1

Guidelines for Physical Assessments

A complete physical assessment should be performed on every newborn admitted to the nursery. Make sure to document your assessment appropriately. Assessment includes:

Vital signs Growth measurements Systems assessment Equipment checks

Learning Objective 1

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Module: Physical Assessment Session 1

Assessment: Vital Signs

Stable growing neonates will have vital signs and systems assessed before feeding time Unstable neonates and neonates on respiratory support will have vital signs and systems assessment every 1-2 hours

Learning Objective 2

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Module: Physical Assessment Session 1

Assessment: Temperature

Obtain rectal temperature only once on admission to exclude imperforate anus All subsequent temperatures are taken axillary The normal temperature for neonates is 36.5 - 370C Neonates under warmer bed should have a skin probe temperature every hour, and axillary temperature every hour until stable

Learning Objective 2

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Module: Physical Assessment Session 1

Assessment: Hypothermic Neonate

Make sure the warmer bed or isolette is on and working appropriately before the baby is introduced Rewarm the neonate slowly Check neonates temperature every hour until you can obtain a normal temperature Beware of over-heating
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Learning Objective 2

Module: Physical Assessment Session 1

Assessment: Hypothermic Neonate (sick or LBW)

To prevent further hypothermia, make sure the head cap is on and use a heat lamp while opening the isolette for procedures or checks. Try to use portholes in the isolette whenever possible, especially if temperature is unstable or neonates weight is less than 1.0 kg Check for any source of heat loss such as cold oxygen, low-set heat on ventilator humidifier, or cold room
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Learning Objective 2

Module: Physical Assessment Session 1

Assessment: Hypothermic Neonate (sick or LBW)

If hypothermia persists consider sepsis especially when associated with vital signs instability and changes in glycemia.

Module: Physical Assessment Session 1

Assessment: Hyperthermic Neonate (cont.)

May be related to maternal fever at birth Maternal epidural sometimes Check if the neonate is crying or moving vigorously, or excessively bundled Check for signs of dehydration (breast fed infants in the first 3-4 days of life) If persists in full term infants consider bacteremia
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Learning Objective 2

Module: Physical Assessment Session 1

Hyperthermia in LBW Infants

Make sure the warmer bed or isolette is working appropriately, with appropriate temperature setting
If the infant is on ventilatory support ensure proper temperature regulation of inspired air and humidifier

Module: Physical Assessment Session 1

Assessment: Heart Rate

Heart rate should be obtained by auscultation and counted for a full minute For stable neonates it should be obtained with the scheduled handling every 3-4 hours For unstable neonates it should be obtained hourly Normal heart rate in neonates is 120 160 beats per minute (bpm) at rest
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Learning Objective 2

Module: Physical Assessment Session 1

Assessment: Heart Rate (cont.) 1. Tachycardia

Consider if the heart rate >170/min Neonate is not crying or moving excessively. Rule out hypo-volemia Rule out hyperthermia Rule out anemia Rule out heart failure Check maternal medication or thyrotoxicosis
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Learning Objective 2

Module: Physical Assessment Session 1

2. Bradycardia

If the neonate is bradycardic (heart rate <100 bpm): Bradycardia may be normal in sleeping full-term neonates If persistent in an asymptomatic baby consider EKG to rule out cardiac conduction problems Assess the neonates color and pattern of breathing, determine the need for resuscitation and start bag and mask ventilation if baby is apneic or cyanosed.

Module: Physical Assessment Session 1

Assessment: Respiration

Normal respiratory rate is 40 60 breaths per minute. Respiratory rate should be obtained by observation for one full minute. For stable neonates it should be obtained with scheduled handling every 3-4 hours. If the neonate is unstable it should be obtained hourly.
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Learning Objective 2

Module: Physical Assessment Session 1

Growth Measurements

There are three components for growth measurements in neonates.

Weight - should be obtained daily. Length - should be obtained on admission and weekly. Head circumference - should be obtained on admission and weekly.

Learning Objective 3

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Module: Physical Assessment Session 1

Weight

All infants should be weighed on admission Normal newborns may lose up to 10% of birth weight in the first week especially when breast fed Birth weight may be regained by 2 weeks of life If excessive weight loss is noted, evaluate the newborn for adequate fluid intake and any signs of dehydration Expected weight gain is +30 gm/day

Module: Physical Assessment Session 1

Weight

Weight will be obtained daily at midnight. Weight should be plotted on a weight chart on admission and weekly thereafter. If the weight is significantly different than the previous day it should be checked twice. If a neonate is too unstable to be moved and weighed, a physicians order not to weigh the neonate should be obtained.
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Learning Objective 3

Module: Physical Assessment Session 1

Weight

Infants are classified as low birth weight (LBW) if weight is <2,500 gm [rule out prematurity and small for gestational age (SGA) status] Infants >3,800 gm should be evaluated for large for gestational age (LGA) status In both cases accurate gestational age assessment should be obtained Follow glycemia carefully in both situations

Module: Physical Assessment Session 1

Length

Crown to heel length should be obtained on admission and weekly thereafter. Length should be plotted on the length chart weekly and compared to weight Neonates should be in supine position while obtaining the length. Knee and hip joints should be in full extension.
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Learning Objective 3

Module: Physical Assessment Session 1

Expected Growth Patterns 1st Month of Life

Weight: 20-30 gm/day Length: 0.5-1 cm/week Head circumference 0.5 cm/week

Module: Physical Assessment Session 1

Head Circumference

Head circumference should be measured on admission and weekly thereafter. The head circumference connects 4 points: 2 frontal bosses and 2 occipital protuberances Place measuring tape around the most prominent part of the occipital and the frontal bones. It should be measured at least daily in neonates with neurological problems such as intraventricular hemorrhage, hydrocephalus, or asphyxia.
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Learning Objective 3

Module: Physical Assessment Session 1

Respiratory Assessment

An initial assessment at the time of birth should evaluate the infants successful transitioning:

Comfortable breathing No tachypnea No grunting No retractions No cyanosis or pallor

A respiratory assessment should be done with the scheduled handling time.

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Learning Objective 4

Module: Physical Assessment Session 1

Respiratory Assessment

Should include the following parameters:

Parameter Skin color Breathing Comment Pink, cyanotic, pale, dusky, mottled, or jaundiced Unlabored, grunting, nasal flaring, or retractions

Breath sounds Chest wall

Learning Objective 4

Distant, shallow, stridor, wheezing, or diminished, equal or unequal Symmetrical or asymmetrical movement
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Module: Physical Assessment Session 1

Respiratory Assessment

Should include the following parameters (cont.):

Parameter Comment Apnea or Lowest observed heart rate, color, oximeter bradycardia reading and duration of episode Secretion Amount: scant, moderate, or large Color: white, yellow, clear, green or bloodtinged Consistency: thick, thin or mucoid ETT Length at the level of skin

Learning Objective 4

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Module: Physical Assessment Session 1

Cardiovascular Assessment

Should include the following parameters:

Parameter Precordium Heart sounds Rhythm Murmur Comment Quiet, or active Clear, and splitting of S2 Normal or describe any arrhythmia Describe if any

Capillary refill How many seconds? Peripheral pulses Normal, weak or absent
Learning Objective 4 Visual 32

Module: Physical Assessment Session 1

Gastrointestinal Assessment

Should include the following parameters:

Parameter Bowel sounds Comment Present, absent, hyperactive, or hypoactive. Abdominal girth Record the measurement in cm. Emesis (or residuals) Volume and description.

Abdominal wall
Palpation
Learning Objective 4

Red or discolored.Distended, or any visible loops of bowel. Soft, tender, or guarded.

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Module: Physical Assessment Session 1

Neurological Assessment

A full neurological assessment should be performed at the time of admission. A neurological evaluation is completed by the nurse every shift (review of posture, tone and state). For unstable neonates and neonates with neurological problems it should be performed more frequently as indicated by physician order.

Learning Objective 4

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Module: Physical Assessment Session 1

Neurological Assessment

Evaluation of State
Evaluation of Tone

Axial Segmental

Evaluation of Primitive Reflexes

Module: Physical Assessment Session 1

State

The six levels of state

Distribution of state Response to stimuli and state, consolability control/habituation

Module: Physical Assessment Session 1

Motor Examination

Evaluation of limb posture Spontaneous and elicited movement Primitive reflexes Evaluation os symmetry Evaluation of suck/swallow as an important pyramidal function

Module: Physical Assessment Session 1

Neurological Assessment

Neurological assessment should include:

Parameter Activity State of consciousness Movements Comment Quiet, awake, irritable, or sleeping Lethargic, alert, or sedated Spontaneous, response to pain, or absent

Tone Pupil
Learning Objective 4

Hypertonic, normal, or weak Size: Right Left Reaction: Sluggish, brisk or absent
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Module: Physical Assessment Session 1

Neurological Assessment

Neurological assessment should include (cont.):

Parameter Eye opening Cry Fontanelle Comment To pain, to sound, none, or spontaneous weak, full, or high-pitched Sunken, bulging, or flat

Sutures Seizures
Learning Objective 4

Overriding, or separated If present, you need to write full description.

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