NEWBORN ASSESSMENT

PREPARED BY: ABIGAIL M. MADRIAGA, RN, MAN

NEWBORN ASSESSMENT AND NURSING CARE

Temperature - range 36.5 to 37 axillary Common variations -Crying may elevate temperature - Stabilizes in 8 to 10 hours after delivery - Temperature is not reliable indicator of infection - A temperature less than 36.5 Temp: rectal- newborn to rule out imperforate Anus - take it once only, 1 inch insertion

NEWBORN ASSESSMENT AND NURSING CARE

Heart Rate range 120 to 160 beats per 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 - Although murmurs may be due to transitional circulation-all murmurs should be followed-up and referred for medical evaluation Cardiac rate: 120 160 bpm newborn Apical pulse left lower nipple Radial pulse normally absent. If present PDA Femoral pulse normal present. If absent COA

NEWBORN ASSESSMENT AND NURSING CARE

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 findings -Asymmetrical chest movements - Apnea >15 seconds - Diminished breath sounds - Seesaw respirations - Grunting

NEWBORN ASSESSMENT AND NURSING CARE

- Nasal flaring - Retractions - Deep sighing - Tachypnea - respirations > 60 - Persistent irregular breathing - Excessive mucus - Persistant fine crackles - Stridor

NEWBORN ASSESSMENT AND NURSING CARE

Blood Pressure - not done routinely Factors to consider Varies with change in activity level Appropriate cuff size important for accurate reading 65/41 mmHg

NEWBORN ASSESSMENT AND NURSING CARE

General Measurements - Head circumference - 33 to 35 cm - Expected findings - Head should be 2 to 3 cms larger than the chest - Abdominal circumference 31-33 cm - Weight range - 2500 - 4000 gms (5 lbs. 8oz. - 8 lbs. 13 oz.) - Length range - 46 to 54 cms (19 - 21 inches) - Normal length- 19.5 21 inch or 47.5 53.75cm, average 50 cm - Head circumference 33- 35 cm or 13 14

HEAD TO TOE NEWBORN ASSESSMENT

CIRCULATORY STATUS - UMBILICAL VEIN and DUCTUS VENOSUS constrict after cord is clamped -DUCTUS ARTERIOSUS constrict with establishment of respiratory function - FORAMEN OVALE closes functionally as respirations established, but anatomic or permanent closure may take several months - HEART RATE averages 140 b.p.m. - BP 73/55 mmHg - PERIPHERAL CIRCULATION acrocyanosis within 24 hours - RBC high immediately after birth; falls after 1 week - ABSENCE/ NORMAL FLORA INTESTINE Vitamin K

HEAD TO TOE NEWBORN ASSESSMENT

CIRCULATORY STATUS

HEAD TO TOE NEWBORN ASSESSMENT

RESPIRATORY STATUS Adequate levels of surfactants (Lecithin and spingomyelin) ensure mature lung function; prevent alveolar collapse and respiratory distress syndrome RR = 30-80 breaths /minutes with short periods of apnea (< 15 seconds) = assess for 1 full minute change noted during sleep or activity NOTE: Periodic apnea is common in preterm infants. Usually, gentle stimulation is sufficient to get the infant to breathe

HEAD TO TOE NEWBORN ASSESSMENT

RENAL SYSTEM Urine present in the bladder at birth but NB may not void for the 1st 12-24 hours Later pattern is 6-10 voidings/ day indicative of sufficient fluid intake Urine is pale and straw colored initial voidings may leave brick-red spots on diaper ( d/t passage of uric acid crystals in urine) Infant unable to concentrate urine for the 1st 3 months

HEAD TO TOE NEWBORN ASSESSMENT

DIGESTIVE SYSTEM IMMATURE CARDIAC SPHINCTER may allow reflux of food, burped, REGURGITATE- placed NB right side after feeding Newborn cant move food from lips to pharynx. Insert nipple well to mouth FEEDING PATTERS vary - Newborns may nurse vigorously immediately afterbirth or may need as long as several days to suck effectively - Provide support and encouragement to new mothers during this time as infant feeding is very emotional doe most mothers

HEAD TO TOE NEWBORN ASSESSMENT

DIGESTIVE SYSTEM IMPORTANT CONSIDERATIONS: - Breastfeeding can usually begin immediately after birth; bottle-fed newborns may be offered few milliliters of sterile water or 5% dextrose 1 to 4 hours after birth prior to a feeding with formula - An infant with gastrostomy tube should receive a pacifier during feeding unless contraindicated to provide normal sucking activity and satisfy oralneeds. - At age4-6 months, an infant should begin to receive solid food foods one at a time and 1 week apart.

HEAD TO TOE NEWBORN ASSESSMENT

DIGESTIVE SYSTEM FIRST STOOL is MECONIUM - Black, tarry residue from lower intestine - Usually passed within 12-24 hours after birth If the amniotic fluid shows evidence of meconium staining, the physician most likely do immediately after delivery is to suction the oropharynx immediately after the head is delivered and before the chest is delivered. TRANSITIONAL STOOLS thin, brownish green in color After 3 days MILK STOOLS are usually passed a. MILK STOOLS for BF infant loose and golden yellow b. MILK STOOLS for FORMULATED FED- formed and pale yellow

HEAD TO TOE NEWBORN ASSESSMENT

HEPATIC Liver responsible for changing Hgb into conjugated bilirubin, which is further changed into conjugated (water soluble) bilirubin that can be excreted Excess unconjugated bilirubin can permeate the sclera and the skin, giving a jaundiced or yellow appearance to these tissues

HEAD TO TOE NEWBORN ASSESSMENT

TEMPERATURE HEAT PRODUCTION in newborn accomplished by: a. Metabolism of BROWN FAT - A special structure in NB is a source of heat - Increased metabolic rate and activity Axillary temperature: 96.8 to 99F Newborn cant shiver as an adult does to release heat Newborns are unable to maintain a stable body temperature because they have an immature vasomotor center, and unable to shiver to increase body heat.

HEAD TO TOE NEWBORN ASSESSMENT

TEMPERATURE NBs body temperature drops quickly after birth after stress occurs easily Body stabilizes temperature in 8-10 hours if unstressed Cold stress increases o2 consumption may lead to metabolic acidosis and respiratory distress

HEAD TO TOE NEWBORN ASSESSMENT

IMMUNOLOGIC NB develops own antibodies during 1st 3 months but at risk for infection during the first 6 weeks Ability to develop antibodies develops sequentially

NEONATAL PHYSICAL ASSESSMENT

Birth weight=2500-400 grams (5 lbs. 8oz. 8 lbs. 13 oz.) Length= 45.7 55.9 cm. (18-22 inches)

NEONATAL PHYSICAL ASSESSMENT

HEAD Head circumference = 33-35 cm (2-3 cm. Greater than chest circumference) Anterior fontanel (diamond shape) = closes 12-18 months Posterior fontanel (triangle shape)= closes 2-3 months NOTE: The posterior fontanel is located at the intersection of the sagittal and lambdoid suture is the space between the pariental bones; the lambdoid suture separates the two parietal bones and the occipital bone

NEONATAL PHYSICAL ASSESSMENT

HEAD Molding- asymmetry of head as a result of pressure in birth canal

NEONATAL PHYSICAL ASSESSMENT

NEONATAL PHYSICAL ASSESSMENT

NEONATAL PHYSICAL ASSESSMENT

EYES Blue/ gray d/t scleral thinness; permanent color established w/in 3-12 mos. Lacrimal glands immature at birth; tearless cry up to 2 months Absence of tears is common because the neonates tear glands are not yet fullydeveloped Transient strabismus Dolls eye reflex persist for about ten days Red Reflex: A red circle on the pupils seen when an ophthalmoscopes light is shining onto the retina is a normal finding. This indicates that the light is shining onto the retina.

NEONATAL PHYSICAL ASSESSMENT

CONVERGENT STRABISMUS (CROSS EYED) It is common during infancy until age 6 months because of poor oculomotor coordination

NEONATAL PHYSICAL ASSESSMENT

NOSE -Nose breathers for first few months of life

MOUTH Scant saliva with pink lips Epsteins Pearls - small shiny white specks on the neonates gums and hard palate which are normal

NEONATAL PHYSICAL ASSESSMENT

NEONATAL PHYSICAL ASSESSMENT

EARS Incurving of pinna and cartilage deposition

NECK Short and weak with deep fold of skin

NEONATAL PHYSICAL ASSESSMENT

CHEST Characterized by cylindrical thorax and flexible ribs NOTE: - appears circular since anteroposterior and lateral diameters are about equal - Respirations appear diaphragmatic - Nipples prominent and often edematous - Milky secretion (witch's milk) common ( effect of estrogen)

NEONATAL PHYSICAL ASSESSMENT

ABDOMEN Cylindrical with some protrusion; scaphoid appearance indicates diaphragmatic hernia Umbilical cord is white and gelatinous with two arteries and one vein and begins to drywithin 1-2 hours after delivery NOTE: Umbilical cord

NEONATAL PHYSICAL ASSESSMENT

ABDOMEN NOTE: Umbilical cord - Three vessels, two arteries and one vein, in cord; if fewer than three vessels are noted notify the physician -Small, thin cord may be associated with poor fetal growth - Assess for intact cord, and ensure that damp is cured - Cord should be clamped for at least the first 4 hours after birth; clamp can be removed hen the cord is dried and occluded - Umbilical clamp can be removed after 24 hours

NEONATAL PHYSICAL ASSESSMENT

GENITALIA MALE: includes rugae on the scrotum and testes descended into the scrotum Urinary meatus: - Hypospadias (ventral surface) -Epispadias (dorsal surface)

NEONATAL PHYSICAL ASSESSMENT

NEONATAL PHYSICAL ASSESSMENT

NOTE: -Meatus at tip of penis - Testes descended but may retract with cold -Assess for hernia or hydrocele - First voiding should occur within 24 hours FEMALE: labia majora cover labia minora and clitoris - Pseudomenstruation possible (blood-tinged mucus) effect of estrogen - First voiding should occur within 24 hours

NEONATAL PHYSICAL ASSESSMENT

EXTREMITIES All neonates have bowlegged and flat feet NOTE NORMAL FEATURES: - Major gluteal folds even - Creases on soles of feet Assess for fractures (especially clavicle) or dislocations (hip) Assess for hip dysplasia; when thighs are rotated outward, no clicks should be heard Some neonates may have abnormal extremities: - Polydactyl (more than 5 digits on extremity) - Syndactyl (two or more digits fused together)

NEONATAL PHYSICAL ASSESSMENT

NEONATAL PHYSICAL ASSESSMENT

SPINE Should be straight and flat Anus should be patent without any fissure Dimpling at the base is associated with spina bifida A degree of hypotonicity or hypertonicity is indicative of central nervous system (CNS damage)

NEONATAL PHYSICAL ASSESSMENT

SKIN Assessment for Jaundice The #1 technique is to blanch the skin over the bony prominence such as the forehead, chest or tip of the nose. NOTE: Jaundice starts at the head first, spreads to the chest, then the abdomen, then the arms and legs, followed by the hands and feet, which are the last to be jaundiced. Jaundice in the first 24 hours after the birth is a cause for concern that requires further assessment. Possible causes of early jaundice are blood incompatibility, oxytocin induction, and severe hemolytic process. Mongolian Spots - Gary, blue or black marks that are frequently found on the sacral area, buttocks, arms shoulders or other areas.

NEONATAL PHYSICAL ASSESSMENT

NEONATAL PHYSICAL ASSESSMENT

Harlequins Sign Occurs on one side of the body turns deep red color. It occurs when blood vessels on one side constrict, while those on the other side of the body dilate.

NEONATAL PHYSICAL ASSESSMENT

Erythema toxicum - Is an eruption of lesions in the area surrounding a hair follicle that are firm, vary in size from 1-3 mm, and consist of a white or pale yellow papule or pustule w/ an erythematous base. - It is often called newborn rash or flea-bite dermatitis - The rash may appear suddenly, usually over the trunk and diaper area and is frequently widespread. - The lesions do not appear on the palms of the hands or soles of the feet. - The peak incidence is 24-48 hours of life. -Cause is unknown and no treatment necessary

NEONATAL PHYSICAL ASSESSMENT

NEONATAL PHYSICAL ASSESSMENT

Milia are blocked sebaceous glands located on the chin and the nose of the infant. VERNIX CASEOASA - Should not be removed by oil or hand lotion, because it is a protective layer of the neonate after birth, and it disappears after birth. Never remove it with alcohol or cotton balls, unless meconium skinned.

NEONATAL PHYSICAL ASSESSMENT

GESTATIONAL ASSESSMENT
PARAMETER NURSING ACTION EAR Fold the pinna forward Measure TERM born between PRETERM born 37-42 weeks before 37 weeks gestation gestation Pinna recoils Pinna opens slowly or stays folded in very premature infants Less than 3 mm

BREAST TISSUE

3 mm

FEMALE GENITALIA

Observe

Labia majora cover labia minora Scrotal sac very wrinkled

Labia minora are more prominent, vaginal opening can be seen Fewer shallow rugae on the scrotum

MALE GENITALIA

Observe

HEEL CREASES

observe

Extend 2/3 of the way Soles are smoother,