Physical Assessment of Newborn
Transcript of Physical Assessment of Newborn
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Normal Newborn: GeneralAppearance
Well-flexed, full range of motion, spontaneousmovement
Common variations:
Legs extended with frank breech
Signs of potential distress or deviations fromexpected findings:
Posture limpAsymmetry of movement
Persistent tremor, twitching
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Vital Signs and General Measurements Temperature - Range 36.5 to 37 axillary
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 - 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`
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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 expectedfindings: Asymmetrical chest movements
Apnea >15 seconds Diminished breath sounds Seesaw respirations Grunting Nasal flaring Retractions Deep sighingTachypnea - respirations > 60 Persistent irregular breathing Excessive mucus Persistant fine crackles Stridor (Crowing respiratory sound)
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Blood Pressure - not done routinely
Factors to consider:Varies with change in activity levelAppropriate cuff size important for accurate readingAverage newborn (1 to 3 days) oscillometry pressure
value: 65/41 in both upper and lower extremities
Sign of potential distress or deviations fromexpected findings:Calf systolic pressure 6 to 9 mm Hg less than systolic
pressure in upper extremities may be indicative ofcoarctation of the aorta
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General Measurements
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
measurementHead and chest circumference may be equal for the first 24 to 48
hours of life
*Molding refers to the process by which the neonates head is shaped during labor as itpasses through the birth canal. The head may become elongated due to theoverlapping of the cranial bones at the suture lines.
Weight range - 2500 - 4000 gms (5 lbs. 8oz. - 8 lbs. 13 oz.)Length range - 48 to 53 cms (19 - 21 inches)
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SkinExpected Findings:
Skin reddish in color, smooth and puffy at birthAt 24 - 36 hours of age, skin flaky, dry and pink incolor
Edema around eyes, feet, and genitals
Turgor good with quick recoil
Cord with one vein and two arteries
Cord clamp tight and cord drying
Hair silky and soft with individual strands
Nipples present and in expected locations
Nails to end of fingers and often extend slightlybeyond
Vernix caseosa - The white, cheesy substancecovering the newborn's body. Often present only in theskin folds.
Lanugo - Fine downy body hair usually distributed overshoulders, sacral area, and back of newborns. Usuallydisappears before birth or shortly after birth.
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Common variations:
ACROCYANOSISThe result of sluggishperipheral circulation.
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MONGOLIAN SPOTS
Patch of purple-black or blue-black colordistributed over coccygeal and sacralregions of infants of African-American orAsian descent.
Not malignant.
Resolves in time.
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MOTTLING
Generalized red and white discolorationof skin of chilled infants with faircomplexion.
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PHYSIOLOGIC JAUNDICEHyperbilirubinemia not associated with hemolyticdisease or other pathology in the newborn.
Jaundice that appears in full term newborns 24 hoursafter birth and peaks at 72 hours. Bilirubin may reach 6
to 10 mg/dl and resolve in 5 to 7 days.
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MILIA
Tiny white papules (pluggedsebaceous glands) locatedover nose, cheek, and chin.
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ERYTHEMATOXICUM
Petechiae/bruises over presenting part.
Petechiae: Pinpoint, flat hemorrhages often visualizedon head, face, and chest. Associated with rapid onset ofpressure followed by immediate release of pressureduring birthing process.
Bruises/Ecchymoses: Larger than petechia, hemorrhagic
areas associated with rapid delivery or breech birth.
Skin tags usually around ears or digits (tied off)
Harlequin coloring - The color of the newborn's bodyappears to be half red and half pale. This condition istransitory and usually occurs with lusty crying. HarlequinColoring may be associated with to an immature
vasomotor reflex system.
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Signs of potential distress or deviations fromexpected findings:
Jaundice (within 24 hours of birth) - Unconjugated bilirubin circulating in theblood stream that is deposited in the skin. Skin color may range from yellow toorange to greenish hues.
General cyanosis
Circumoral cyanosis between feedings
Petechiae or ecchymoses other than on presenting part
All rashes with exception of erythema toxicumPigmented nevi
Yellow vernix
Hemangioma
Pallor
Forceps marks
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Molding of fontanels and suture spaces
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Signs of potential distress or deviations fromexpected findings:
Cephalhematoma
Subperiosteal extravasation of blood duerupture of vessels. Swelling increases in sizeon second and third day after delivery. Oftenassociated with delivery by forceps. Swellingdoes not cross suture line and may takeseveral weeks after birth. Jaundice may occur
as blood cells are broken down as the swellingresolves.
Hydrocephalus
Macrocephaly
Closed sutures
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Eyes
Expected findings:
Slate gray or blue eye colorNo tearsFixation at times - with ability to follow objects to
midlineRed reflexBlink reflex
Distinct eyebrowsCornea bright and shinyPupils equal and reactive to light
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CommonVariations:
Edematous Eyelids May focus for a few seconds
Uncoordinated movements
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Signs of potential distress or deviations from
expected findings:DischargesOpaque lenses
Absence of Red Reflex
Epicanthal folds in newborns not of Oriental descent
Reflexes absent
"Doll's Eyes" Reflex (beyond 10 days of age):When the head is moved slowly to the right or left, the eyesdo not follow nor adjust immediately to the position of the
head. This reflex should not be elicited once fixation ispresent. The persistence of the Doll's Eyes Reflex suggestsneurologic damage.
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Chemical
conjunctivitis
Subconjunctivalhemorrhage
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Ears
Expected findings:
Loud noise elicits StartleReflex
Flexible pinna withcartilage present Pinna top on horizontal linewith outer canthus of eye
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Signs of potential distress or deviations fromexpected findings:
Ear placement low
Clefts present
Malformations Cartilage absent
Preauricular sinus
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Nose
Expected findings:
Nostrils patent bilaterally
Obligate nose breathers
No nasal discharge
Common variations:
Sneezes to clear nostrils
Bridge appears absent
Thin white nasal mucus
discharge
Signs of potential distress or deviations fromexpected findings:
Choanal atresia and discharge Malformation Nasal flaring beyond first few moments after birth
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Mucosa moist
Shortly after birth mayvisualize sucking calluses oncentral portions of lips.
PalateHigh arched
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Commonvariations:
Epstein's pearls on ridgesof gums
Signs of potential distress or deviations fromexpected findings: Cleft lip or cleft palate Circumoral pallor Lip movement asymmetrical Reflexes absent or incomplete Protruding tongue Diminished tongue movement
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CandidaAlbicans
Percocious teeth
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Neck
Expected findings:Short and thickTurns easily side to sideClavicles intactTonic neck reflex present
Neck-righting reflex presentSome head control
Signs of potential distress or deviations from expectedfindings:
Torticollis-stiff neck drawing head to one sideResistance to flexionWebbing of neckLarge fat pad on back of neckPalpable crepitus, movement with palpation of clavicle
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Chest
Expected findings:
Evident xiphoid process
Equal anteroposterior andlateral diameter
Bilateral synchronous chestmovement
Symmetrical nipples
Common variations:
"Witch's milk"
Enlarged breasts
Accessory nipples
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Signs of potential distress or deviations fromexpected findings:
Asymmetrical chest movements
Sternum depressed
Marked retractions
Absent breast tissueFlattened chest
Supernumerary nipples
Nipples widely spaced
Bowel sounds auscultated
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Abdomen
Expected findings:Dome-shaped abdomenAbdominal respirationsSoft to palpationWell formed umbilical cord
Three vessels in cordCord dry at baseLiver papable 2 - 3 cms below right costal marginBilaterally equal femoral pulsesBowel sounds auscultated within two hours of birthVoiding within 24 hours of birthMeconium within 24 - 48 hours of birth
Common variations:Small umbilical hernia
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Signs of potential distress or deviations fromexpected findings:
Bowel sounds absent
Peristaltic waves visible
Abdominal distention
Palpable masses
Scaphoid-shaped abdomenOmphalocele
Base of cord with redness or drainage
Cord with two vessels
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Genitalia
Female Male
Expected findings: Edematous labia and clitoris
Labia majora are larger and surrounding labiaminora
Vernix between labia
Common variations:
Hymenal tag
Pseudomenstruation Smegma
Increased pigmentation
Ecchymosis and edema after breech birth
"Red brick" pink-stained urine due to uric acidcrystals
Signs of potential distress or deviations fromexpected findings:
Labia fused Fecal discharge from vaginal opening
Imperforate hymen
Ambiguous genitalia
Widely separated labia
Expected findings: 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: Prepuce covering urinary meatus Erections Increased pigmentation Edema and ecchymosis after breech
delivery
Signs of potential distress or deviationsfrom expected findings:
Non palpable testes Hypospadius Epispadius Scrotum smooth Ambiguous genitalia
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es
Expected findings:
Maintains posture of
flexionEqual and bilateralmovement and tone
Full range of motion alljoints
Ten fingers and ten toes
Negative hip clickGrasp reflex present
Legs appear bowed
Feet appear flat
Palmar creases present Sole creases present
Signs of potential distress or deviations from
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g pexpected findings:
Unequal tone
Asymmetrical movement ofextremities
Syndactyly
Unequal leg length
Dislocation of hip
Persistent cyanosis of nail beds
Asymmetrical skin creasesposterior thigh
Polydactyly
Simean crease
Marked metatarus varus
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Neuromuscular System
Expected findings:Maintains postion 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 jerkingParalysis
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REFERENCESBurns, C.E., Barber, N., Brady, M.A., Dunn, A.M., (1996)Pediatric Primary Care: A Handbook for Nurse Practitioners,Philadelphia, W.B. Saunders Company.
Gorrie, Trula Myers, McKinney, Emily Stone, and Murray,Sharon Smith. (1994). Foundations of maternal newbornnursing,Philadelphia; W. B. Saunders Company.
Wong, Donna L. (l995). Whaley & Wong's nursing care ofinfants and children; contributing editor, David Wilson. 5thedition. St. Louis: Mosby.
Variations and minor departures in infants (1994), MeadJohnson & Company: Evansville, Indiana.