NEWBORN ASSESSMENT INTRODUCTION: Newborn assessment is done as soon as after birth as possible, the mother should be allowed to spend some time with the baby immediately after birth to initiate the bonding process. Early assessment can assist the nurse in ascertaining if the newborn is infant is within the range of ‘normal’.
Definition: • Health assessment is a thorough inspection or a detailed study of the entire body or some part of the body to determine the general physical or mental conditions of the body.
Purposes: • To understand the physical and mental well being of the child. • To detect disease in early stage. • To determine the cause and effect of the disease.
• To teach child and parent. • To measure the health in future. • To determine the nature of treatment or
care needed for the child. • General Points to be Remembered During Examination of a Newborn: – examine 1 hour after feeding – examine in neutral thermal environment – examine the presence of the mother. – examine gently, methodically ( from top to bottom) – examine those system which require a quiet child first and later do examination that tend to disturb the child. Eg. Reflex testing, ear examination.
Recommendations for general physical examination is to examine patient in a supine position from the patient’s right side. Right side is preferred because;
• Right jugular veins are more reliable for estimating venous pressure.
• Palpating hand rests more comfortably on apical impulse.
• A kidney is more frequently palpable.
Health assessment: Assessment of the newborn as soon as possible after birth and subsequent assessment in the neonatal period are responsibility of the mucous working in the hospital and in the community. PHASES ASSESSMENT:
Initial Transitional Assessment of gestational age Systemic physical examinations
• INITIAL ASSESSMENT: • The most frequently used method to assess the newborns immediate assessment is done in newborn life including Apgar Scoring System. Apgar Scoring: In 1953, virgenia Apgar introduced a simple systematic assessment of intrapartum stress and neurologic depression at birth.
Causes of low Apgar Score:
• • • • • •
Asphyxia Maternal drugs Central nervous system disease Congenital muscular disease Prematurity Fetal sepsis
TRANSITIONAL ASSESSMENT:
1 stage: lasts for 6 hours, first 30 minutes awake, remaining hours baby will be sleeping.
• 2 stage: 6 to 12 hours observation should be made until the vital signs are stabilized.
ASSESSMENT OF GESTATIONAL AGE: Dubowitz scale:It is an important criteria because perinatal morbidity and mortality are related to gestational age and birth weight. A frequently used method is by the use of determining gestational age is by the ‘ Dubowitz scale’ a simplified version developed by Ballard,Novack and Driver (1979). Ballard scale: the new ballard scale is a revised scale of dubowitz scale. It can be used with newborns as young as 20 weeks of gestation. The tool has the same physical and neuromuscular sections but includes -1 and -2 scores. Neuromuscular maturity include: posture, square window, arm recoil, popliteal angle, scarf sign, heel to ear. Physical maturity: skin, lanugo, plantar surface, breast, eye/ear, genital(male, female)
• GENERAL PHYSICAL EXAMINATIONS: Vital signs: Temperature: --neonates normally respond to infection with low temperatures. -- in neonates the temperature can be taken from the groin, axilla or groin. Normal temperature 36.5-37.5oC Hypothermia
< 36o C
Hyperthermia
> 41oC
Respiration: -- count by observing the abdominal movements in infants as the movement are primarily diaphgramatic. -- count for one full minute for accuracy. normal respiration 35 breath/ min tachypnea bradycardia
•
Pulse:
>40 < 20 breath/min
breath/min
apical pulse are more reliable for infants (between 4th and 5th intercoastal). Pulse is counted for one full minute in infants and young children.
Blood pressure: manual blood pressure monitoring is not routinely done in neonatal nursery but in certain circumstances with Oscillometry. The average systolic/ diastolic pressure is 65/44mmHg at 1 to 3 days of age.
•
ANTHROPOMETRIC MEASUREMENTS:
Puposes: 1. To assess the body’s size against known standards for the population. 2. To compare the size with estimated period of gestation
3.
To provide a baseline against which susequent progress can be measured. Weight: it should be recorded within an hour of birth. Average weight for term babies is about 2.5kg to 3.5kg.
• Length: the length can be taken more accurately in a measuring table or a board with a fixes head piece on which the infant lies supine with his legs fully extended. The average length of a newborn is 48-50cm.
Head circumference: this measurement may slight change during the first three days owing to moulding during labor, scalp edema or bruising and cephalhematoma.
• Normally head circumference is 33-35cm in a term baby. • Head circumference is 2-3 cm larger than chest circumference.
• Chest circumference: it is measured around nipple line in mid expiration. Normal chest circumference 3033cm. Abdominal circumference: it will be same as that of the chest circumference.
•
GENERAL APPEARANCE: Physical activity: the first 30 min , immediately after birth the baby will be active. The newborn will be at sleep most of the time for the first 3 days. Posture: normal posture is that of universal flexion. Extended posture of newborn may be due to hypotonicity. Head to foot examination:
Area
Normal
Abnormal
Skin
Color: pink in color Texture: soft Turgidity : sensation of fullness derived from the presence of hydrated subcutaneous tissue. Elasticity: when the skin is grasped and released, the skin promptly springs back. Lanugo: Vernix caseosa Mongolian spot Milia etc Pallor: anemia, edema, shock, hypoxia, hypotension. Cyanosis: central cyanosis, CHD, severe respiratory distress. Jaundice: within first 24hrs- hemolytic disease, Rh incompatibility, ABO incompatibility. Within 24hrs- physiological jaundice. Petechiae: infection, DIC Edema: over hydration, renal failure, CHD, anemia. etc
area
normal
Depressed: maternal sedation, asphyxia neonatorum etc. High pitched cry: CNS involvement. Weak cry: respiratory distress.
Cry
Head
Abnormal
Head circumference: 3335cm Sutures are normally palpable as cracks. Fontanelle: anterior fontanelle-closes by 9-18 months. Its having diamond shape. Posterior fontanelle: closes by 2-4 months.
Microcephaly: H.C<2.5cm of standard deviation. Macrocephaly: H.C>2 cm of standard deviation Widely separated sutures: preterm, hydrocephalus, cerebral edema, high ICP . Bulging fontanelle: subdural hemorrhage, hydrocephalus, TORCH, dysmaturity( absence of subcutaneous fat, skin wrinkling ), CHF.
Area
Normal
Abnormal Delayed closure: rickets, hypothyroidism, down syndrome. Caput succedaneum: diffuse swelling of subcutaneous tissue, over presenting part at birth, not restricted to suture line. Cephalhematoma: well demarcated subperiosteal hemorrhage over parietal bone, restricted by suture line.
Hair
Fine silky hair.
Preterm- fuzzy hair Low hair line- turner’s syndrome.
Eyes
Eye movements are not coordinated. Eyelids may be edematous for 2 days. Sclera may be pale colored. Iris of the eyes should be round.
Upper slant- down syndrome Cataract- congenital rubella, CMV etc Conjunctivits: Nystagmus ( eyes condition that makes a repetitive , uncontrolled movement ): Corneal reflex should be ruled out.
Areas
Normal
Abnormal
Nose
Neonates are obligatory nose breathers. Nose is usually flattened after birth. Nasal patency should be assessed.
oral breathing: obstruction by mucus plugs, choanal atresia.
Ears
Top of pinna should be in line with outer canthus of the eyes. Tympanic membrane will be grey in newborn. Normal infants hear at birth and startle or have a complete moro reflex with a sudden noise.
Low set ears- a feature of genetic syndrome.
Areas
Normal
Abnormal
Mouth or throat
Epstein pearls are normally found on both sides of the hard palate. Precocious teeth may be present which fall off soon.(1 in 2000 births)
Excessive salivation: hare lip ( cleft lip ), cleft palate, deviation of angle of mouth – 7th nerve palsy.
Neck
Neonates neck is usually short. To examine the neck, head should be extended.
Webbing of neck- turner’s syndrome ( is a chromosomal condition that affects development in females. The most common feature of Turner syndrome is short stature, which becomes evident by about age 5.)
Thorax
Shape- normally barrel shaped Respiratory rate- 40-60 breath/min Heart rate- 120-160 beats/min Type of breathing –diaphragmatic Witch’s milk- normal Supernumerary nipples- harmless Swollen breast- normal
Swelling of neck- sternomastoid tumor common in breech, forceps delivery etc Emphysematous chestpneumothorax. Dextrocardia (is a rare heart condition in which your heart points toward the right side of your chest instead of the left side. ) ( - suspect diaphgramatic hernia
Abdomen
Normally- protruberant Inspection- round in shape Palpation- liver can be felt 1inch (23cm) below right coastal margin. Tip of the spleen may be palpable by about 1 week after in left upper quadrant
Scaphoid- diaphramatic hernia Distended-ascitis,hydronephrosis, meconium ileus etc. Prominent liver- hematoma, hepatoblastoma. Gastric mass-bag & mask ventilation, duodenal obstruction
Areas
Normal
Abnormal
Abdomen
Percussion- help to identify any fluid or gas collection Auscultation- bowel sounds can be heard soon after the initiation of feeding
Kidney may be palpable in case of hydronephrosis, renal vein thrombosis.
Umbilical cord
Color- blue to white at birth Structure- 2 arteries and 1 vein are seen.
Green in meconium staining Single artery may be associated with cardiac anomalies, intestinal malformations.
Genitalia
Male: normally prepuce covers the entire glans penis. Sometimes prepuce cannot be retracted back up to 4-6 months in normal babies.
Phimosis, hypospadias, epispadias.
Scrotum: varies in size, rugated with descended testis.
Spine Anus
Female: normally labia majora covers labia minora Normally the curvature of the spine is “C” shaped. Anal patency should be checked Meconium should be passed within 24hrs of birth.
Preterm female babies- labia majora does not cover minora. spina bifida, meningomyelocele.
Hypospadias- is a birth defect (congenital condition) in which the opening of the urethra is on the underside of the penis instead of at the tip.
epispadias is a rare type of malformation of the penis in which the urethra ends in an opening on the upper aspect of the penis.[1] It can also develop in females when the urethra develops too far anteriorly.
Spina bifida is a birth defect where there is incomplete closing of the backbone and membranes around the spinal cord. There are three main types: spina bifida occulta, meningocele, and myelomeningocele.
• SYSTEMIC ASSESSMENT: A careful general examination of a newborn baby provides more information of the condition of the baby. The system to be examined includes: 1. Cardiovascular system 2. Respiratory system 3. Central nervous system
Examination of CVS: history of drug and TORCH (
TORCH, which includes Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes infections, are some of the most common infections associated with congenital anomalies) exposure Anomalies - cleft lip/ cleft palate, cataract, polydactyl ( with extra fingers or toes ) Respiratory rate - normal/ increased or decreased/ type of breathing
Pulse - 120-160 beats/min apical pulse normally taken Average BP - term baby: 70/45mmhg preterm: 60/20mmhg
• Examination of respiratory system: History of cough - pneumonia Diabetes mellitus - RDS Preterm - RDS Polyhydromnios - asphyxia, respiratory distress Character: Dyspnea, tachypnea, apnea, grunting ( abnormal, short, deep, hoarse sounds in exhalation that often accompany severe chest pain)
Examination of central nervous system: - examination of neonatal reflexes- Conventional examinations: > consciousness; immediate and delayed response to external stimuli, response to comforting, excessive crying, excessive quiteness.
> involuntary movements: jitterness (is an involuntary movement that is particularly frequent in the newborn. Its hallmark is tremor), convulsive movement, spasms of tetanus. - neurological examination for the assessment of gestational age -
REFLEXES OF NORMAL NEWBORN Reflexes are involuntary movements or actions. Some movements are spontaneous, occurring as part of the baby's usual activity. Others are responses to certain actions. Reflexes help identify normal brain and nerve activity. Some reflexes occur only in specific periods of development.
Babinski
Babinski reflex. When the sole of the foot is firmly stroked, the big toe bends back toward the top of the foot and the other toes fan out. This is a normal reflex up to about 2 years of age.
Moro Reflex
Moro reflex. The Moro reflex is often called a startle reflex because it usually occurs when a baby is startled by a loud sound or movement. In response to the sound, the baby throws back his or her head, extends out the arms and legs, cries, then pulls the arms and legs back in. A baby's own cry can startle him or her and trigger this reflex. This reflex lasts about 5 to 6 months.
Tonic neck reflex. When a baby's head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow. This is often called the "fencing" position. The tonic neck reflex lasts about 6 to 7 months. Grasp reflex. Stroking the palm of a baby's hand causes the baby to close his or her fingers in a grasp. The grasp reflex lasts until about 5 to 6 months of age. Step reflex. This reflex is also called the walking or dance reflex because a baby appears to take steps or dance when held upright with his or her feet touching a solid surface.
Rooting
Root reflex. This reflex begins when the corner of the baby's mouth is stroked or touched. The baby will turn his or her head and open his or her mouth to follow and "root" in the direction of the stroking. This helps the baby find the breast or bottle to begin feeding.
Sucking
Suck reflex. Rooting helps the baby become ready to suck. When the roof of the baby's mouth is touched, the baby will begin to suck. This reflex does not begin until about the 32nd week of pregnancy and is not fully developed until about 36 weeks. Premature babies may have a weak or immature sucking ability because of this. Babies also have a hand-to-mouth reflex that goes with rooting and sucking and may suck on fingers or hands.
Doll’s Eye
Palmar grasp
Grasp reflex. Stroking the palm of a baby's hand causes the baby to close his or her fingers in a grasp. The grasp
reflex lasts until about 5 to 6 months of age.
• Swallowing Accompanies the sucking reflex. Food reaching the posterior of the mouth is swallowed.
• Extrusion - Substance placed on the anterior portion of tongue. Extrusion of substance to prevent swallowing.
• Sneezing and coughingForeign substance entering the upper or lower airways.clearing of the upper air passages by sneezing.Clearing of the lower passages by swallowing.
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Exposure of eyes to bright light. Sudden movement of object toward eye.
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Startle reflex - (pulling arms and legs in after hearing loud noise) Examples of reflexes that last into adulthood :
Blinking reflex: blinking the eyes when they are touched or when a sudden bright light appears
Cough reflex: coughing when the airway is stimulated
Gag reflex: gagging when the throat or back of the mouth is stimulated
Sneeze reflex: sneezing when the nasal passages are irritated
Yawn reflex: yawning when the body needs more oxygen
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Infant reflexes can occur in adults who have:
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Brain damage Stroke