Transcript Newborn Skills - Dr. NurseAna's Nursing Reviews

Newborn Assessment & Skills
Ana H. Corona, DNP, FNP-BC
Nursing Instructor
Revised September 2013
Bates’ Pocket Guide to Physical Examination and History Taking, 2008; Foundations of Nursing, Duncan &
White, 2010.
Normal Newborn: General Appearance
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Well-flexed, full range of motion
spontaneous movement
Common variations
 Legs extended with frank breech
Signs of potential distress or deviations from
expected findings
 Posture limp
 Asymmetry of movement
 Persistent tremor, twitching
Vital Signs
Temperature - range 36.5 to 37 axillary (97.7-98.6)
Common variations
 Crying may elevate temperature
 Stabilizes in 8 to 10 hours after delivery
Signs of potential distress or deviations from
expected findings
 Temperature is not reliable indicator of infection
 A temperature less than 36.5
Heart Rate
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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
Signs of potential distress or deviations from
expected findings
 Although murmurs may be due to transitional
circulation-all murmurs
should be followed-up and referred for medical
evaluation
 Deviation from range
 Faint sound
Respirations
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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
 Nasal flaring
 Retractions
 Deep sighing
 Tachypnea - respirations > 60
 Persistent irregular breathing
 Excessive mucus
 Persistant fine crackles
 Stridor
Blood Pressure
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Blood pressure - not done routinely
Factors to consider
Varies with change in activity level
Appropriate cuff size important for accurate reading
Average newborn (1 to 3 days) oscillometry
pressure value: 65/41 in both upper and lower
extremities
Sign of potential distress or deviations from
expected findings
 Calf systolic pressure 6 to 9 mm Hg less than
systolic pressure in upper extremities may be
indicative of coarctation of the aorta
General Measurements
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Head circumference - 33 to 35 cm
Expected findings
Head should be 2 to 3 cms larger than the chest
Chest circumference - 30.5 to 33 cm
Common variations
Molding of head may result in a lower head
circumference measurement
Head and chest circumference may be equal for the
first 24 to 48 hours of life
Weight range - 2500 - 4000 gms (5 lbs. 8oz. - 8 lbs.
13 oz.)
Length range - 48 to 53 cms (19 - 21 inches)
Skin
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Expected findings
Skin reddish in color, smooth and puffy at birth
At 24 - 36 hours of age, skin flaky, dry and pink in
color
Edema around eyes, feet, and genitals
vernix caceosa
Lanugo (baby hair)
Turgor good with quick recoil
Hair silky and soft with individual strands
Nipples present and in expected locations
Cord with one vein and two arteries
Cord clamp tight and cord drying
Nails to end of fingers and often extend slightly
beyond
Common Variations
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Acrocyanosis - result of sluggish peripheral circulation
Mongolian 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.
Common variations
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Milia: 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 days
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Petechiae: 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.
Signs of potential distress or deviations from
normal findings
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Jaundice within 24 hours of birth
General cyanosis
Circumoral cyanosis between feedings
Petechiae or ecchymoses other than on presenting
part
All rashes with exception of erythema toxicum
Pigmented nevi
Yellow vernix
Hemangioma
Pallor
Forceps marks
The Head
Expected findings
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Anterior fontanel diamond shaped 2-3 - 3-4 cms
Posterior fontanel triangular 0.5 - 1 cm
Fontanels soft, firm and flat
Common Variations
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Caput 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
Signs of potential distress or deviations
from normal findings
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Fontanels that are bulging or depressed
Hydrocephalus
Macrocephaly
Cephalohematoma
Closed sutures
The Eyes
Expected findings
 Slate gray or blue eye color
 No tears
 Fixation at times - with ability to follow
objects to midline
 Red reflex
 Blink reflex
 Distinct eyebrows
 Cornea bright and shiny
 Pupils equal and reactive to light
Common Variations
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Edematous eyelids
Uncoordinated movements
May focus for a few seconds
Signs of potential distress or deviations
from expected findings
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Discharges
Chemical conjunctivitis
Opaque lenses
Absence of Red Reflex
Epicanthal folds in newborns not of Oriental descent
Doll’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 absent
Subconjunctival hemorrhage
Ears: Expected Findings
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Pinna top on horizontal line with outer
canthus of eye
Loud noise elicits Startle Reflex
Flexible pinna with cartilage present
Common Variations
 Skin tags on or around ears
Signs of potential distress or deviations
from expected findings
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Ear placement low
Preauricular sinus
Clefts present
Malformations
Cartilage absent
The Nose
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Look 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.
The Palate and Mouth
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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.
The Tongue, Teeth and Chin
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Tongue
Macroglossia - Hypothyroidism,
mucopolysaccharidoses
Teeth
Natal teeth - occur in 1/2,000 births. Mostly lower
incisors. Risk of aspiration if loosely attached.
Chin
Micrognathia - occurs with Pierre-Robin syndrome,
Treacher-Collins syndrome, Hallerman Streiff
syndrome.
The Neck
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Palpate 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.
Chest and Lungs
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Observe 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.
The Chest
Expected findings
 Evident xiphoid process
 Equal anteroposterior and lateral diameter
 Bilateral synchronous chest movement
 Symmetrical nipples
Common variations
 "Witch's milk“
 Enlarged breasts
 Accessory nipples
Signs of potential distress or deviations
from expected findings
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Asymmetrical chest movements
Sternum depressed
Marked retractions
Absent breast tissue
Flattened chest
Supernumerary nipples
Nipples widely spaced
Bowel sounds auscultated
Cardiovascular System
Measure heart rate, blood pressure in upper and lower
extremities,
respiratory rate.
 Inspection
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Palpation
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Check baby's color for pallor, cyanosis, and plethora.
Check 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.
Auscultation
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Note rhythm and presence of murmurs that may be
pathologic.
Patent Ductus Arteriosis
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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.
Atrial Septal Defect
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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.
Ventricular Septal Defect
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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.
The Abdomen
Expected findings
 Dome-shaped abdomen
 Abdominal respirations
 Soft to palpation
 Well formed umbilical cord
 Three vessels in cord
 Cord dry at base
 Liver papable 2 - 3 cms below right costal margin
 Bilaterally equal femoral pulses
 Bowel sounds auscultated within two hours of birth
 Voiding within 24 hours of birth
 Meconium within 24 - 48 hours of birth
Common variations
 Small umbilical hernia
Signs of potential distress or deviations
from expected findings
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Bowel sounds absent
Peristaltic waves visible
Abdominal distention
Palpable masses
Scaphoid-shaped abdomen
Omphalocele
Base of cord with redness or drainage
Cord with two vessels
The Abdomen
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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.
The Abdomen
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Examine 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.
Genitourinary
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Kidneys
Examined by palpation.
The kidneys should be about 4.5-5.0 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).
Expected Findings
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Edematous labia and clitoris
Labia majora are larger and surrounding labia minora
Vernix between labia
Common Variations
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Hymenal tag
Pseudomenstruation
Smegma
Increased pigmentation
Ecchymosis and edema after breech birth
"Red brick" pink-stained urine due to uric acid crystals
Signs of potential distress or deviations
from expected findings
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Labia fused
Fecal discharge from vaginal opening
Imperforate hymen
Ambiguous genitalia
Widely separated labia
Male Genitalia
Expected Findings
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Urinary meatus at tip of glans penis
Palpable testes in scrotum
Large, edematous, pendulous scrotum, with rugae
Smegma beneath prepuce
Stream adequate on voiding
Common variations
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Prepuce covering urinary meatus
Erections
Increased pigmentation
Edema and ecchymosis after breech delivery
Signs of potential distress or deviations from
expected findings
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Non palpable testes
Hypospadius
Epispadius
Scrotum smooth
Ambiguous genitalia
Male Genitalia
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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
Female Genitalia
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Inspect 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.
Extremities and Skeletal System
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Spine
Scoliosis, kyphosis, lordosis, spinal defects,
meningomyelocoeles.
Upper extremity
Look for clavicular fracture, absence of radius
or ulna. Inspect creases and fingers.
Lower extremity
See posture above. Do Ortolani maneuver to
check for congenital hip dislocation. Check
toes.
Extremities
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Expected findings
Maintains posture of flexion
Equal and bilateral movement and tone
Full range of motion all joints
Ten fingers and ten toes
Legs appear bowed
Feet appear flat
Palmar creases present
Sole creases present
Negative hip click
Grasp reflex present
Signs of potential distress or deviations
from expected findings
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Asymmetrical movement of extremities
Polydactyly
Unequal tone
Syndactyly
Unequal leg length
Asymmetrical skin creases posterior thigh
Dislocation of hip
Simean crease
Persistent cyanosis of nail beds
Marked metatarus varus
Back and Rectum
Expected findings
 Intact spine without masses or openings
 Trunk incurvature reflex
 Patent anal opening
 "Wink reflex" present
Signs of potential distress or deviations from expected
findings
 Limitation of movement
 Fusion of vertebrae
 Spina bifida
 Tuft of hair
 Imperforate anus
 Anal fissures
 Pilonidal cyst
Neuromuscular System
Expected findings
 Maintains position of flexion
 When prone, turns head side to side
 Holds head and back in horizontal plane when held
prone
 Ability to hold head momentarily erect
Signs of potential distress or deviations from
expected findings
 Hypotonia
 Quivering
 Limp extremities or straightening of extremities
 Clonic jerking
 Paralysis