Newborn Pa

Physical Examination and Assessment Of The Newborn

APGAR SCORING SYSTEM ❂ ❂

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Developed in 1950s Cardiopulmonary status Dr. Virginia Apgar 1 minute after birth 5 minutes after birth 5 parameters

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A = Appearance (skin color) P = Pulse (heart rate) G = Grimace (reflex irritability) A = Activity (muscle tone) R= Respiration • (respiratory effort)

Criteria for Apgar Scoring Category

0 Points

1 Point

2 Points

Heart Rate

Absent

Under 100

Over 100

Respiratory Effort

Absent

Irregular, Weak

Crying, Vigorous

Muscle Tone

Flaccid, Limp

Some flexion

Reflex Irritability

Unresponsive

Frown/Grimace Active motionw/ stimulation cry, cf. sneeze

Skin Color

Cyanosis

Acrocyanosis

Active flexion, good motion

Completely Pink

APGAR SCORING SYSTEM ❂

One Minute Score • • •

Identifies need for immediate intervention Score 2 0r less = immediate resuscitation Score 3 to 6 = some assistance, usually stimulation, suctioning, oxygen • Score 7 or more = routine care and observation

APGAR SCORING SYSTEM ❂

Five Minute Score • • • •

Assess infant’s recovery from depression Also assess effectiveness of intervention Score 7 to 10 = Few, if any, supportive measures Score 4 to 6 = Mild to moderate asphyxia; suctioning, oxygenation, mech ventilation • Score 0 to 3 = Full cardiopulmonary resuscitation

SILVERMAN SCORE Looks at level of respiratory distress ❂ Scoring in 5 areas, range from 0 to 2 ❂

• Upper chest movement – Synchronized = 0 – Lag of chest on inspiration = 1 – Seesaw movement upper chest = 2

• Lower chest movement

SILVERMAN SCORE- continued ❂

Lower chest movement (continued) • • •

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No retractions = 0 Retractions - just visible = 1 Marked retractions = 2

Xiphoid retractions • • •

No retractions = 0 Retractions - just visible = 1 Marked retractions = 2

SILVERMAN SCORE- continued ❂

Dilation of nares • • •

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None = 0 Minimal dilation = 1 Marked dilation = 2

Expiratory Grunt • • •

None = 0 Heard only w/ stethoscope = 1 Heard w/ naked ear = 2

SILVERMAN SCORE- continued ❂

Scoring Scale • 0 to 3 = no respiratory distress to mild distress • 4 to 6 = moderate respiratory distress • 7 to 10 = severe respiratory distress

ESTIMATION OF GESTATIONAL AGE ❂

Dubowitz Score • • •

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Dr. Dubowitz and co-workers (Early 1970s) 10 external characteristics 11 Neuromuscular signs

New Ballard Score (NBS) • Increase accuracy in very low birthweight • 7 physical & 6 neurologic criteria – No lifting patient ; intubated & monitored

ESTIMATION OF GESTATIONAL AGE NBS - continued

Each category scored from -1 to +4 or +5 ❂ Physical Maturity ❂

• Skin - transparent to leathery, cracked • Lanugo - none to mostly bald, upper back only • Plantar Surface - little or no creases to creases over entire sole • Breast - imperceptible to full areola

ESTIMATION OF GESTATIONAL AGE NBS - continued

• Eye/Ear - lids fused, pinna flat to well curved pinna, thick cartilage ear stiff • Genitals male -scrotum flat, smooth to testes pendulous • Genitals female - clitoris prominent, labia flat to majora cover clitoris and minora

ESTIMATION OF GESTATIONAL AGE NBS - continued ❂

Neuromuscular Maturity • Posture & extremities / muscle tone: • Posture - hypotonic w/ arms & legs extended to arms & legs flexed w/ recoil • Square Window (wrist) - greater than 90* to 0* • Arm Recoil - none to full recoil w/ angle < 90* • Knee Joint Angle (popliteal) - from 180* to less than 90*

ESTIMATION OF GESTATIONAL AGE NBS - continued ❂

Scarf Sign - no resistance to full resistance

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Heel to Ear - no resistance w/ little or no knee flexion to significant resistance with flexed knee

ESTIMATION OF GESTATIONAL AGE NBS - continued -10 -5 0 5 10 15 20

20 wks 22 wks 24 wks 26 wks 28 wks 30 wks 32 wks

SCORING SYSTEM 25 30 35 40 45 50

34 wks 36 wks 38 wks 40 wks 42 wks 44 wks

ESTIMATION OF GESTATIONAL AGE - continued: External Criteria

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• Preterm covered • Term has very little, only in body creases • Post-term has none

Vernix • grayish white cheeselike substance • composed of – sebaceous gland secretions – lanugo – shed epithelial cells

• amount is age related

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Nails • present and cover nail bed all ages • may be especially long in post-term

Growth Assessment

Colorado intrauterine growth curve

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Plot gestational age against: • • • •

Birth weight Length Head circumference Data from Colorado infants 1948 to 1961

Colorado intrauterine growth curve ❂

Score between 10th and 90th percentiles = AGA

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Score below the 10th percentile = SGA

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Score above the 90th percentile = LGA

VITAL SIGNS

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RESPIRATORY RATE

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BLOOD PRESSURE

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HEART RATE

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TEMPERATURE

RESPIRATORY RATE Normal = 30 to 60, variable ❂ Periodic Breathing = respiration interrupted by short periods of apnea, up to 10 seconds, not associated w/ other abnormalities ❂

• Common in preterm infants

Very little chest wall movement ❂ Count for full minute ❂

HEART RATE Normal newborn = 110 to 160 ❂ Determined by auscultation ❂ Transient increases w/ agitation ❂ Persistent tachy associated w/ congenital heart defects ❂ Brady associated w/ significant apnea ❂ Apical impulse - normal vs. abnormal location ❂

BLOOD PRESSURE ❂

Normal Ranges: • • •

Low birth weight = 50/35 mmHg. Mid b.w. above 2000 gm. = 60/35 mmHg. High b.w. above 3000 g. = 65/40 mmHg.

Assessed with doppler and cuff ❂ Peripheral pulses for indirect assessment ❂

• - brachial - radial - femoral

TEMPERATURE ❂

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Normal core = somewhat variable Rectum is best assessment of core Axilla, usually lower but may be falsely high

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Skin Temp • Allow continual measurement • Pt. Care not interfered • Maintained about 36.5 degrees (C) • Minimize O2 consumption

OTHER CLINICAL ASSESSMENTS SIGNS OF RESPIRATORY DISTRESS ❂

5 Common • • • • •

Tachypnea Cyanosis Nasal Flaring - Silverman score Expiratory Grunting - Silverman score Retractions - Partially Silverman score

RESPIRATORY DISTRESS -continued ❂

Tachypnea = RR > 60 • Over 50 should increase suspicion • Full minute assessment

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Cyanosis = bluish discoloration • Local vs. General • Central – Involves mucous membranes – Indicates excessive unsaturated hemoglobin

RESPIRATORY DISTRESS -continued • Central Cyanosis - continued – In excess of 5 g / dl – Presence usually indicative of PO2 < 40 mmHg – Slight drop in PO2 yields dangerous sharp decline in hemoglobin saturation, O2 carrying capacity – Anemic baby may have no cyanosis w/ extreme hypoxemia

• Acrocyanosis - hands & feet – common in newborns

RESPIRATORY DISTRESS -continued ❂

Retractions = inward movement of chest wall • • • • •

Intercostal = between ribs Supraclavicular = above clavicles Subcostal = below rib margins Suprasternal = top margins of sternum Xiphoid = bottom margins at xiphoid process

RESPIRATORY DISTRESS -continued Apnea = periods of no respiration for at least 20 seconds ❂ Or periods of absence of respiration accompanied by bradycardia (HR < 100) ❂

Chest Auscultation ❂

Rales • “crackles” • short, interupted sounds • usually during inspiration • associated with – – –

HMD Pulmonary Edema Pneumonia

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Rhonchi • changes in pitch • narrowing of airways – – – –

secretions swelling foreign matter smooth muscle spasm

• “Course” = low pitch • “Wheeze” = high pitch

Head, Face, & Neck Exam Assessment of Congenital Anomalies ❂ Head ❂

• Shape & Size – Compression during birth - self correcting

• Occipital Frontal Circumference (OFC) • Ears – Shape, Size, Position, Presnce of ear canals

Head, Face, & Neck Exam - cont. ❂

Face • Eyes – Size -Shape

-Position

• Nose – Size

-Shape

-Patency of Nasal Pasages

• Mouth – Lips -Hard/Soft Palate

-Size of tongue & jawbone

Head, Face, & Neck Exam - cont. Neck ❂ Inspected for; ❂

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Range of motion Goiter Presence of cysts

ABDOMEN, SKIN, EXTREMETIES ❂

Abdomen • Protrusion of abdominal contents • Appearance & position of umbilicus

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Skin • Pigmentation, Rashes, Bruising, Unusual • Jaundice

ABDOMEN, SKIN, EXTREMETIES ❂

Extremeties - fingers & toes • • •

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Position Size Number

Hands & Feet • Color

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Pulses • Brachial & Femoral