Nb Assessment

Table 21-2 SUMMARY OF NEWBORN ASSESSMENT *MCH pages 479-473 NORMAL ABNORMAL (POSSIBLE CAUSES) condole with for CONSIDERATIONS Initial AssessmentAssess for obvious problems first. If infant is stable and has no problems that require immediate attention, continue with complete assessment. Vital Signs TemperatureAxillary 36. 5 37. 5C (97. 7 99. 5F). Axilla is preferred site. Decreased (cold environment, hypoglycemia, infection, CNS problem). change magnitude (infection, environment to warm). Decreased Institute warming measures and check in 30 minutes. Check blood glucose. Increased the excessive clothing.Check for dehydration. Decreased or increased look for signs of infection. Check radiant warmer or incubator temperature setting. Check thermometer for accuracy if skin is warm or cool to touch. explanation ab typical temperature to physician. PulsesHeart rate 120 160 BPM. (100 sleeping, 180 crying). Rhythm regular. PMI at 3rd-4th intercostal space lateral to mid-clavicular l ine. Brachial, femoral, and pedal pulses present and extend to reversiblely. Tachycardia (respiratory problems, anemia, infection, cardiac conditions). Bradycardia (asphyxia, increased intracranial pressure).PMI to right (dextrocardia-heart situated to right of body, pneumothorax). Murmurs (normal or congenital heart defects). Dysrhythmias. Absent or unbalanced pulses (coarctation of the aorta). Note location of murmurs. diagnose abnormal rates, rhythms and practiceds, pulses. RespirationsRate 30 -60 (AVG 40 -49) BrPM. Respirations irregular, shallow, unlabored. Chest movements symmetric. Breath sounds present and clear bilaterally. Tachypnea, especially afterwards the first hour (respiratory disoblige). Slow respirations ( paternal medications). Nasal flaring (respiratory distress). Grunting (respiratory distress syndrome).Gasping (respiratory depression). Periods of apnea to a greater extent than 20 seconds or with change in heart rate or color (respiratory depression, sepsis, cold stress). Asymmetry or decreased chest amplification (pneumothorax). Intercostal, xiphoid, supraclavicular retractions or see-saw (paradoxical) respirations (respiratory distress). Moist, coarse breath sounds (crackles, rhonchi) (fluid in the lungs). catgut sounds in chest (diaphragmatic hernia). Mild variations require continued monitoring and usually clear early hours after birth. If persistent or more than mild, suction, give oxygen, call physician, and initiate more intensive care. Blood Pressure Varies with age, weight, activity, and gestational age. Average systolic 65-95 mm Hg, mean(a) diastolic 30-60 mm Hg. Hypotension (hypovolemia, shock, sepsis). BP 20 mm Hg or higher in build up than legs (coarctation of the aorta). restore abnormal blood pressures. Prepare for intensive care and very low. Measurements Weight2500-4000 g (5 lbs. 8 oz. to 8 lbs. 13 oz. ). Weight loss up to 10% in early days. High (low gestational age LGA, maternal diabetes). Low (small for gestational age SGA, preterm, multifetal pregnancy, medical conditions and m separate that affected fetal growth).Weight loss above 10% (dehydration, feeding problems). Determine beatMonitor for complications common to cause. Length48-53 cm (19-21 inches) down the stairs normal (SGA, congenital dwarfism). Above normal (LGA, maternal diabetes). Determine causeMonitor for complications common to cause. Head Circumference32-38 cm (12. 5-15 inches). Head and neck are approximately ? of infants body surface. pure (SGA, microcephaly, anencephaly-absence of commodious part of brain or skull). Large (LGA, hydrocephalus, increased intracranial pressure). Determine causeMonitor for complications common to cause. Chest Circumference30-36 cm (12-14 inches).Is 2 cm less than gunpoint circumference. Large (LGA). miniature (SGA). Determine causeMonitor for complications common to cause. Posture Flexed extremities move freely, resist extension, return quickly to flexed state. Ha nds usually clenched. Movements symmetric. Slight tremors on crying. Breech extended, wet legs. Molds body to caretakers body when held, responds by quieting when needs met. Limp, flaccid, floppy, or rigid extremities (preterm, hypoxia, medications, CNS trauma). Hypertonic (neonatal abstinence syndrome, CNS imperfection). Jitteriness or tremors (low glucose for calcium take aim).Opisthotonos- positive hyperextension of body, seizures, stiff when held (CNS injury). Seek cause, refer abnormalities. CryLusty, strong. High-pitched (increased intracranial pressure). Week, wanting, irritable, cat-like mewing ( neurologic problems). Hoarse or crowing (laryngeal irritation). Observe for changes in report abnormalities. throw togethercolor pink or tan with acrocyanosis (cyanotic discoloration of extremities). Vernix caseosa in creases. Small amounts of lanugo (fine,soft downy hair) over shoulders, postures of face, fore leave, upper back. Skin turgor good with quick recoil. Som e cracking and peeling of skin.Normal variations Milia (tiny white bumps). Skin tags. Erythema toxicum (flea prick up rash). Puncture on scalp (from electrode). Mongolian spots. Color cyanosis of mouth and central areas (hypoxia). Facial bruising (nuchal cord). Pallor (anemia, hypoxia). Gray (hypoxia, hypotension). Red, sticky, transparent skin (very preterm). immature brown discoloration of skin, nails, cord (possible fetal compromise, postterm). Harlequin color (normal transient autonomic imbalance). Mottling (normal or cold stress, hypovolemia, sepsis). Jaundice (pathologic if first 24h). Yellow vernix caseosa (blood incompatibilities). Thick vernix (preterm).Delivery Marks bruises on body (pressure), scalp (vacuum extractor), or face (cord around neck). Petechiae (pressure, low platelet count, infection). Forceps marks. Birthmarks Mongolian spots. Nevus simplex (salmon patch, stork bite). Nevus flammeus (port-wine stain). Nevus vasculosus (strawberry hemangioma). Cafe au lai t spots (6+) larger than 0. 5cm in size (neurofibromatosis). Other excessive lanugo (preterm). Excessive peeling, cracking (postterm). Pustules or other rashes (infection). tent of skin (dehydration). Differentiate patient bruising from cyanosis. Central cyanosis requires suction, oxygen and further treatment.Refer genus Icterus in first 24 hours or more extensive than expect for age. Watch for respiratory problems in infants with meconium staining. Look for signs and complications of preterm or postterm birth. Record location, size, shape, color, type of rashes and marks. Differentiate Mongolian spots from bruises. Check for facial movement with forceps marks. Watch for jaundice with bruising. Point out and explain normal skin variations to parents. Head Sutures palpable with small separation between each. Anterior fontanel diamond shaped, 4-5 cm, soft and flat. more bulge slightly with crying. Posterior fontanel triangular, 0. 5-1 cm.Hair silky and soft with individual hair s trands. Normal variations overriding sutures (molding). Caput succedaneum or cephalohematoma (pressure during birth). Head large (hydrocephalus, increased intracranial pressure) or small (microcephaly). Widely separated sutures (hydrocephalus) or hard, ridged area at sutures (craniosynostosis- birth defect that causes one or more sutures on a babys head to close earlier than normal). Anterior fontanel depressed (dehydration, molding), full or bulging at rest (increased intracranial pressure). Woolly, bunchy hair (preterm). Unusual hair growth (genetic abnormalities). Seek cause of variations.Observe for signs of dehydration with depressed fontanel increased intracranial pressure with bulging of fontanel and coarse separation of sutures. Refer for treatment. Differentiate Caput succedaneum from cephalohematoma, and reassure parents of normal outcome. Observe for jaundice with cephalohematoma. Ears Ears well-formed and complete. Area where upper ear meets head even with imaginary number line drawn from outer canthus of eye. Startle response to loud noises. Alerts to high-pitched voices. Low set ears (chromosomal disorders). Skin tags, pre-auricular sinuses, dimples (whitethorn be associated with kidney or other abnormalities).No response to sound (deafness). Check voiding if ears abnormal Look for signs of chromosomal abnormality if position abnormal. Refer for evaluation if no response to sound. FaceSymmetric and appearance and movement. Parts proportional and appropriately placed. Asymmetry (pressure imposition in utero). Drooping of mouth or one side of face, one-sided cry (facial tenderness injury). Abnormal appearance (chromosomal abnormalities). Seek cause of variations. Check delivery history for possible cause of injury to facial middle. Eyes Symmetric. Eyes clear. Transient strabismus. Scant or go away tears.Pupils equal, react to light. Alerts to interest sights. Dolls eye sign- reflex movement of the eyes in the opposite direction to th at which the head is moved, the eyes being lowered as the head is raised, and the reverse (Cantelli sign) an indication of functional integrity of the brainstem tegmental pathways and cranial nerves involved in eye movement. Red reflex present- reddish-orange reflection of light from theeyesretina. may have subconjunctival hemorrhage or edema of eyelids from pressure during birth. Inflammation or drainage (chemical or infectious conjunctivitis). Constant tearing (plugged lacrimal duct).Unequal pupils. Failure to hap objects (blindness). White areas over pupils (cataracts). Setting sun sign- downward deviation of the eyes so that each iris appears to set beneath the lower lid, with white sclera exposed between it and the upper lid indicative of increased intracranial pressure or irritation of the brain stem. (hydrocephalus). Yellow sclera (jaundice). Blue sclera (osteogenesis imperfecta- condition causing extremely fragile bones). Clean and monitor any drainage seek cause. Reassu re parents that subconjunctival hemorrhage and edema will clear. Refer other abnormalities. NoseBoth nostrils open to air flow. May have slight flattening from pressure during birth. Blockage of one or both nasal passages (choanal atresia). Malformations (congenital conditions). Flaring, mucus (respiratory distress). Observe for respiratory distress. Report malformations. Mouth Mouth, gums, tongue pink. Tongue normal in size and movement. Lips and palate intact. Sucking inkpads. Sucking, rooting, s palisadeowing, gag reflexes present. Normal variations precocious teeth, Epsteins pearls-Multiple small white epithelial inclusion cysts found in the midline of the palate in most newborns. Cyanosis (hypoxia). White patches on cheek or tongue (candidiasis). Protruding tongue (Down syndrome). debased movement of tongue, drooping mouth (facial nerve paralysis). Cleft lip, palate or both. Absent or weak reflexes (preterm, neurologic problem). Excessive drooling (tracheoesophageal atresi a). Oxygen for cyanosis. Expect slow down teeth to be removed. Obtain order for antifungal medication for candidiasis. Check mother for vaginal or breast infection. Refer anomalies. Feeding Good lactate/swallow coordination. Retains feedings. Poorly coordinated suck and swallow (prematurity).Duskiness or cyanosis during feeding (cardiac defects). Choking, gagging, excessive drooling (tracheoesophageal fistula, esophageal atresia). Feed slowly. Stop frequently if difficulty occurs. Suction and shake off if necessary. Refer infants with continued difficulty. Neck/Clavicles Short neck turns head easily side to side. Infant raises head when prone. Clavicles intact. Weakness, contractures, or ridgidity (muscle abnormalities). Webbing of neck, large fat pad at back of neck (chromosomal disorders). Crepitus, lump, or crying when clavicle or other bones palpated, diminished or absent arm movement (fractures). respite of clavicle more frequent in large infants with shoulder dystoci a at birth. Immobilize arm. Look for other injuries. Refer abnormalities. Chest Cylinder shape. Xiphoid process may be prominent. Symmetric. Nipples present and located properly. May have engorgement, white nipple discharge (maternal hormone withdrawal). Asymmetry (diaphragmatic hernia, pneumothorax). Supernumerary nipples. Redness (infection). Report abnormalities. Abdomen Rounded, soft. Bowel sounds present within first hour after birth. Liver palpable 1-2cm below right costal margin. Skin intact. 3 vessels in cord. Clamp moneyed and cord drying.Meconium passed within 12-48hr. Urine generally passed within 12-24h. Normal variation Brick dust staining of diaper (uric acid crystals). Sunken abdomen (diaphragmatic hernia). Distended abdomen or loops of bowel visible (obstruction, infection, and large organs). Absent bowel sounds after first hour (paralytic ileus). Masses palpated (kidney tumors, distended bladder). Enlarged liver (infection, heart failure, hemolytic disease). A bdominal wall defects (umbilical or inguinal hernia, omphalocele, gastroschisis, exstrophy of bladder). Two vessels in cord (other anomalies). Bleeding (loose clamp). Redness, drainage from cord (infection).No passage of meconium (imperforate anus, obstruction). Lack of urinary output (kidney anomalies) or inadequate amounts (dehydration). Refer abnormalities. Assess for other anomalies if only two vessels in cord. Tighten or replace loose cord clamp. If stool and urine output abnormal, look for confused recording, increase feedings, report. Genitals Female Labia majora dark, cover clitoris and labia minora. Small amount of white mucus vaginal discharge. Urinary meatus and vagina present. Normal variations Vaginal bleeding (pseudomenstruation). hymenal tags. Clitoris and labia minora larger than labia majora (preterm).Large clitoris (ambiguous genitalia). Edematous labia (breech birth). Check gestational age for immature genitalia. Refer anomalies. Male Testes within scrotal s ac, rugae on scrotum, prepuce nonretractable. Meatus at tip of penis. Testes in inguinal canal or abdomen (preterm, cryptorchidism). Lack of rugae on scrotum (preterm). Edema of scrotum (pressure in breech birth). Enlarged scrotal sac (hydrocele). Small penis, scrotum (preterm, ambiguous genitalia). Empty scrotal sac (cryptorchidism). Urinary meatus located on upper side of penis (epispadias), underside of penis (hypospadias, or perineum.Ventral curvature of the penis (chordee). Check gestational age for immature genitalia. Refer anomalies. Explain to parents why no circumcision can be performed with abnormal placement of meatus. Extremities Upper and glare ExtremitiesEqual and bilateral movement of extremities, Correct number and formation of fingers and toes. Nails to ends of digits or slightly beyond. Felxion, good muscle tone. Crepitus, redness, lumps, swelling (fracture). Diminished or absent movement, especially during Moro reflex (fracture, nerve injury, paralysis). Pol ydactyly (extra digits). Syndactyly (webbing) Fused or absent digits.Poor muscle tone (preterm, neurologic injury, hypoglycemia, and hypoxia). Refer all anomalies, look for others. Upper ExtremitiesTwo transverse palm creases. simian crease (normal or Down syndrome). Diminished movement (injury). Diminished movement of arm with extension and forearm prone (Erb-Duchenne paralysis). Refer all anomalies, look for others. Lower Extremities Legs equal in length, abduct equally, gluteal and thigh creases and knee height equal, no hip clunk. Normal position of feet. Ortolani and Barlow tests abnormal, unequal leg length, unequal thigh or gluteal creases (developmental dysplasia of the hip).Malposition of feet (position in utero, talipes equinovarus). Refer all anomalies, look for others. Check malpositioned feet to see if they can be gently manipulated back to normal position. BackNo openings observed or felt in vertebral column. Anus patent. Sphincter tightly closed. Failure of o ne or more vertebrae to close (spina bifida), with or without sac with spinal anaesthesia fluid and meninges (meningocele) or spinal fluid, meninges, and cord (myelomeningocele), enclosed. Tuft of hair over spina bifida occulta. Pilondial dimple or sinus. Imperforate anus. Refer abnormalities.Observe for movement below level of defect. If sac, cover with sterile dressing wet with sterile saline. Protect from injury. Reflexes See table 21-3. Absent, asymmetric or weak reflexes. Observe for signs of fractures, nerve injury, or injury to CNS. TABLE 21-3 SUMMARY OF NEONATAL reflex responseES *MCH page 493 REFLEX METHOD OF TESTING EXPECTED RESPONSE ABNORMAL RESPONSE/POSSIBLE CAUSE TIME REFLEX DISAPPEARS Babinski Stroke lateral sole of foot from heel to across base of toes. Toes flare with dorsiflexion of the big toe. No response. Bilateral CNS deficit. Unilateral local nerve injury. 8-9 mos Gallant (trunk incurvation) With infant prone, lightly stroke along the side of the verteb ral column. Entire trunk flexes toward side stimulated. No response CNS deficit. 4 mos grok reflex (palmar and plantar) Press finger against of infants fingers or toes. Fingers curl tightly toes curl forward. Weak or absent neurologic deficit or muscle injury. Palmar grasp 2-3 mos. Plantar grasp 8-9 mos Moro Let infants head drop back approx. 30?. Sharp extension and abduction of arms followed by flexion and adduction to embrace position. Absent CNS dysfunction.Assymetry brachial plexus injury, paralysis, or fractured bone of extremity. Exaggerated maternal drug use. 5-6 mos Rooting Touch or stroke from side of mouth toward cheek. Infant turns head to side touched. Difficult to illicit if infant is sleeping or just fed. Weak or absent prematurity, neurologic deficit, depression from maternal drug use. 3-4 mos Stepping Hold infant so feet touch solid surface. Infant lifts alternate feet as if walking. Asymmetry fracture of extremity, neurologic deficit. 3-4 mos Suckin g Place nipple or gloved finger in mouth, rub against palate. Infant begins to suck.May be weak if recently fed. Weak or absent prematurity, neurologic deficit, maternal drug use. 1 yr Swallowing Place fluid on the back of the tongue. Infant swallows fluid. Should be coordinated with sucking. Coughing, gagging, choking, cyanosis tracheoesophageal fistula, esophageal fistula, esophageal atresia, neurologic deficit. Present throughout life. Tonic neck reflex Gently turn head to one side while infant is supine. Infant extends extremities on side to which head is turned, with flexion on opposite side. Prolonged period in position neurologic deficit. May be weak at birth disappears at 4 mos