Physical Assessment of the Newborn: Part 1...Physical Assessment of the Newborn: Part 1 The...
Transcript of Physical Assessment of the Newborn: Part 1...Physical Assessment of the Newborn: Part 1 The...
Physical Assessment of the Newborn: Part 1
The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 1
® ®
®
© K. Karlsen 2013
Review history
Prenatal
Labor/delivery
Presentation of illness
Approach
Systematic
Gentle
© K. Karlsen 2013
Perform hand hygiene (hand sanitizer or wash)
Wear personal protective equipment as indicated(gloves, mask, gown)
Perform while infant in quiet state whenever possible
Use clean equipment
Keep infant warm
Shield eyes from exam light
Comfort during / after exam
Change soiled diapers / redressfollowing exam
Perform hand hygiene after exam
© K. Karlsen 2013
Observe before touching
Physical Assessment of the Newborn: Part 1
The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 2
© K. Karlsen 2013
Observe before touching
Auscultate before palpating – in quiet environment
© K. Karlsen 2013
Observe before touching
Auscultate before palpating – in quiet environment
Gentle palpation
Avoid if acute abdomen
Extra care withpreterm infants
© K. Karlsen 2013
Ballard et al. (1991). J Pediatr.,119(3): 417-423.Neuromuscular illustrations were adapted
with permission of Dr. Ballard
A detailed monograph and explanationabout how to perform the Ballard exam(written by Dr. Ballard), may be found
at www.BallardScore.com
.
Ballard Score
Developed by Jeanne L. Ballard, MD
Set of procedures and assessment parameters usedto determine gestational age
Evaluation of physical and neuromuscular maturity
© K. Karlsen 2013
Principles of Ballard Exam
Timing
Most reliable if performedby 12 hours of life
Keep infant warm
© K. Karlsen 2013
-1 0 1 2 3 4 5
Skin
Sticky
Friable
Transparent
Gelatinous
Red
Translucent
Smooth pink
Visible veins
Superficialpeeling
and/or rash
Few veins
Cracking
Pale areas
Rare veins
Parchment
Deepcracking
No vessels
Leathery
Cracked
Wrinkled
Lanugo No lanugo Sparselanugo
Abundantlanugo
ThinningLanugo Bald areas Mostly bald
Plantarsurface
Heel- toe40-50 mm
<40 = 2
Heel- toe> 50 mm
No crease
Faint redmarks
Anteriortransversecrease only
Creasesanterior 2/3
Creases overentire sole
Breast Im-perceptible
Barelyperceptible
Flat areolano bud
Stippledareola
1-2 mm bud
Raisedareola
3-4 mm bud
Full areola
5-10 mm bud
Eyes /ears
Lids fused:
Loosely: -1
Tightly: -2
Lids open
Pinna flat
Stays folded
Slightly
curved pinna
Soft slowrecoil
Well-curvedpinna
Soft butready recoil
Formedand firm
Instant recoil
Thickcartilage
Ear stiff
MaleGenitals
Scrotumflat, smooth
Scrotumempty
Faint rugae
Testes inupper canal
Rare rugae
Testesdescending
Few rugae
Testes down
Good rugae
Testespendulous
Deep rugae
FemaleGenitals
Clitorisprominent
Labia flat
Prominentclitoris
Small labiaminora
Prominentclitoris
Enlargingminora
Majora andminoraequally
prominent
Majora large
Minora small
Majora coverclitoris and
minora
© K. Karlsen 2013
Skin – largest organ in the body
Stratum corneum outer layer of epidermis
Begins to develop after 21 weeks
28 to 30 weeks is a few cell layers thick
By term is 10 to 20 cell layers thick
Before epidermis and stratum corneum develop,skin is transparent and thin
-1 0 1 2 3 4 5
Sticky
Friable
Transparent
Gelatinous
Red
Translucent
Smoothpink
Visible veins
Superficialpeeling
and/or rash
Few veins
Cracking
Pale areas
Rare veins
Parchment
Deepcracking
No vessels
Leathery
Cracked
Wrinkled
Physical Assessment of the Newborn: Part 1
The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 3
© K. Karlsen 2013
01
–1
-1 0 1 2 3 4 5
Sticky
Friable
Transparent
Gelatinous
Red
Translucent
Smoothpink
Visible veins
Superficialpeeling
and/or rash
Few veins
Cracking
Pale areas
Rare veins
Parchment
Deepcracking
No vessels
Leathery
Cracked
Wrinkled
© K. Karlsen 2013
-1 0 1 2 3 4 5
Sticky
Friable
Transparent
Gelatinous
Red
Translucent
Smooth pink
Visible veins
Superficialpeeling
and/or rash
Few veins
Cracking
Pale areas
Rare veins
Parchment
Deepcracking
No vessels
Leathery
Cracked
Wrinkled
2
© K. Karlsen 2013
-1 0 1 2 3 4 5
Sticky
Friable
Transparent
Gelatinous
Red
Translucent
Smooth pink
Visible veins
Superficialpeeling
and/or rash
Few veins
Cracking
Pale areas
Rare veins
Parchment
Deepcracking
No vessels
Leathery
Cracked
Wrinkled
3
© K. Karlsen 2013
-1 0 1 2 3 4 5
Sticky
Friable
Transparent
Gelatinous
Red
Translucent
Smooth pink
Visible veins
Superficialpeeling
and/or rash
Few veins
Cracking
Pale areas
Rare veins
Parchment
Deepcracking
No vessels
Leathery
Cracked
Wrinkled
4
© K. Karlsen 2013
5
-1 0 1 2 3 4 5
Sticky
Friable
Transparent
Gelatinous
Red
Translucent
Smooth pink
Visible veins
Superficialpeeling
and/or rash
Few veins
Cracking
Pale areas
Rare veins
Parchment
Deepcracking
No vessels
Leathery
Cracked
Wrinkled
© K. Karlsen 2013
Fine, downy hair that begins to appear 24 to 25 weeks
Abundant across shoulders and upper back by28 weeks
With increasing gestation lower back area thins first
bald areas appear over lumbo-sacral area
By term, minimal to no lanugo present on back
Amount and location may vary with nutritional status,ethnicity, hormonal and metabolic factors
-1 0 1 2 3 4
No lanugo Sparse Abundant Thinning Bald areas Mostly bald
Physical Assessment of the Newborn: Part 1
The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 4
© K. Karlsen 2013
-1 0
-1 0 1 2 3 4
No lanugo Sparse Abundant Thinning Bald areas Mostly bald
© K. Karlsen 2013
-1 0 1 2 3 4
No lanugo Sparse Abundant Thinning Bald areas Mostly bald
1
© K. Karlsen 2013
-1 0 1 2 3 4
No lanugo Sparse Abundant Thinning Bald areas Mostly bald
1
© K. Karlsen 2013
4
2 3
-1 0 1 2 3 4
No lanugo Sparse Abundant Thinning Bald areas Mostly bald
© K. Karlsen 2013
Prior to foot creases appearing, for very preterminfants, measure foot length from tip of great toe toback of heel
Foot crease begins to appear on ball of foot between28 and 30 weeks gestation
As infant approaches term, creases should coverentire plantar surface
-1 0 1 2 3 4
Heel–toe40 – 50 mm
< 40 = – 2
> 50 mm
No crease
Faint redmarks
Anteriortransverse
crease only
Creasesanterior 2/3
Creasesover entire
sole
© K. Karlsen 2013
-1 0 1 2 3 4
Heel–toe40 – 50 mm
< 40 = – 2
> 50 mm
No crease
Faint redmarks
Anteriortransversecrease only
Creasesanterior 2/3
Creasesover entire
sole
0-1 1
Physical Assessment of the Newborn: Part 1
The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 5
© K. Karlsen 2013
4
3
-1 0 1 2 3 4
Heel–toe40 – 50 mm
< 40 = – 2
> 50 mm
No crease
Faint redmarks
Anteriortransverse
crease only
Creasesanterior 2/3
Creasesover entire
sole
2
© K. Karlsen 2013
As gestation advances, breast tissue is stimulated togrow by maternal estrogen
Evaluate size of areola and presence of any stippling
Palpate breast tissue and estimate diameter inmillimeters
36 weeks 1 to 2 mm nodule of breast tissuepalpable
By term 10 mm nodule of breast tissue usuallypalpable
-1 0 1 2 3 4
Im-perceptible
Barelyperceptible
Flat areolano bud
Stippledareola
1–2 mm bud
Raisedareola
3–4 mm bud
Full areola
5–10 mmbud
© K. Karlsen 2013
-1
-1 0 1 2 3 4
Im-perceptible
Barelyperceptible
Flat areolano bud
Stippledareola
1–2 mm bud
Raisedareola
3–4 mm bud
Full areola
5–10 mmbud
0
1
© K. Karlsen 2013
3
2
-1 0 1 2 3 4
Im-perceptible
Barelyperceptible
Flat areolano bud
Stippledareola
1–2 mm bud
Raisedareola
3–4 mm bud
Full areola
5–10 mmbud
4
© K. Karlsen 2013
Cartilage content increases as infant matures
Palpate for cartilage thickness, then fold pinnatoward face and release it evaluate speed pinnasprings back
If pinna remains folded, evaluate whether eyelids arefused or whether one or both eyelids are open
If eyelids loosely or partially fused, assign a numberof minus one (-1)
-1 0 1 2 3 4
Lids fused:
Loosely: -1
Tightly: -2
Lids open
Pinna flat
Stays folded
Slightlycurved pinna
Soft slowrecoil
Well-curvedpinna
Soft butready recoil
Formedand firm
Instantrecoil
Thickcartilage
Ear stiff
© K. Karlsen 2013
-2
-1 0 1 2 3 4
Lids fused:
Loosely: -1
Tightly: -2
Lids open
Pinna flat
Stays folded
Slightlycurved pinna
Soft slowrecoil
Well-curvedpinna
Soft butready recoil
Formedand firm
Instantrecoil
Thickcartilage
Ear stiff
0
Physical Assessment of the Newborn: Part 1
The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 6
© K. Karlsen 2013
34
2
-1 0 1 2 3 4
Lids fused:
Loosely: -1
Tightly: -2
Lids open
Pinna flat
Stays folded
Slightlycurved pinna
Soft slowrecoil
Well-curvedpinna
Soft butready recoil
Formedand firm
Instantrecoil
Thickcartilage
Ear stiff
1
© K. Karlsen 2013
Testes
Begin to descend from peritoneal cavity between28 to 30 weeks
Both palpated in lower inguinal canals by end of33rd to 34th week / scrotal skin thickens
Completely descended by 40 weeks
Rugae (creases over scrotum)
Extremely preterm scrotum flat and smooth
By 40 weeks, scrotum covered with numerousthickened rugae and scrotum pendulous
-1 0 1 2 3 4
Scrotumflat, smooth
Scrotumempty
Faint rugae
Testes inupper canal
Rare rugae
Testesdescending
Few rugae
Testesdown
Good rugae
Testespendulous
Deep rugae
© K. Karlsen 2013
01
-1 0 1 2 3 4
Scrotumflat, smooth
Scrotumempty
Faint rugae
Testes inupper canal
Rare rugae
Testesdescending
Few rugae
Testesdown
Good rugae
Testespendulous
Deep rugae
3
4
2
© K. Karlsen 2013
Assess with hips abducted to 45
Extremely preterm labia flat, clitoris very prominent
As fetus matures, clitoris less prominent, labia minorabecomes more prominent
Closer to term clitoris and labia minora envelopedby enlarging labia majora
Labia majora contains fat – size affected by intrauterinenutrition correlate findings with assessment ofgrowth (small, average or large for gestational age)
-1 0 1 2 3 4
Clitorisprominent
Labia flat
Prominentclitoris
Small labiaminora
Prominentclitoris
Enlargingminora
Majora andminoraequally
prominent
Majoralarge
Minorasmall
Majoracover
clitoris andminora
© K. Karlsen 2013
1
3
4
-1 0 1 2 3 4
Clitorisprominent
Labia flat
Prominentclitoris
Small labiaminora
Prominentclitoris
Enlargingminora
Majora andminoraequally
prominent
Majoralarge
Minorasmall
Majoracover
clitoris andminora
0
© K. Karlsen 2013
-1 0 1 2 3 4 5
Posture
Squarewindow(wrist)
Armrecoil
Poplitealangle
Scarfsign
Heel toear
Physical Assessment of the Newborn: Part 1
The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 7
© K. Karlsen 2013
Positioning
Head midline
Hips flat
Reliability ofexam altered by:
Sedation
Anesthesia
Paralysis
Critically ill state
Breech position
Neuromuscular exam may be toostressful for preterm and sick infants
should only be performed ifindicated and by skilled neonatal ICUpersonnel once infant stabilized and
able to tolerate the exam
© K. Karlsen 2013
-1 0 1 2 3 4
1
2
© K. Karlsen 2013
-1 0 1 2 3 4
3
4
© K. Karlsen 2013
-1 0 1 2 3 4
Assesses wrist flexibility and/or resistance to extensorstretching at the wrist
Press gently on knuckles to straighten fingers
Apply gentle pressure on back of hand close to fingers avoid wrist rotation
Stop pressing when resistance felt
Angle decreases as gestational age increases
90 60 45 30 0> 90
© K. Karlsen 2013
-1 0 1 2 3 4
1
90 60 45 30 0> 90
0
–1
© K. Karlsen 2013
23
4
-1 0 1 2 3 4
90 60 45 30 0> 90
Physical Assessment of the Newborn: Part 1
The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 8
© K. Karlsen 2013
0 1 2 3 4
Tests for passive flexor tone of biceps muscle
Test one arm at a time in order to avoid Moro reflex
Supine position
Hold infant’s hand
Briefly flex arm then momentarily extend armand release hand
Scores based on angle of recoil when arms returnto flexion
180 140-180 110-140 90-110 < 90
© K. Karlsen 2013
0 1 2 3 4
180 140-180 110-140 90-110 < 90
FlexFlex
ExtendExtend
ReleaseRelease
ScoreScore
© K. Karlsen 2013
0 1 2 3 4
1 2
180 140-180 110-140 90-110 < 90
© K. Karlsen 2013
4
0 1 2 3 4
180 140-180 110-140 90-110 < 90
3
© K. Karlsen 2013
4 53210-1 4 53210-1
Assesses maturation of passive flexor tone aboutthe knee joint
Refrain from touching hamstrings (muscle group beingtested) during maneuver
Measurement unreliable if frankbreech in utero
180 160 140 120 < 90100 90
© K. Karlsen 2013
4 53210-1 4 53210-1
Place thigh in knee-chest position with knee fully flexed
Allow infant to relax, then grasp foot at sides
Extend leg until resistance is felt
Estimate angle behind the knee
180 160 140 120 < 90100 90
Physical Assessment of the Newborn: Part 1
The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 9
© K. Karlsen 2013
4 53210-1 4 53210-1
0
1
180 160 140 120 < 90100 90
© K. Karlsen 2013
2
4
3
4 53210-1 4 53210-1
180 160 140 120 < 90100 90
© K. Karlsen 2013
-1 0 1 2 3 4
Tests passive tone of the posteriorshoulder girdle flexor muscles
Supine position with head midline
neck axillaryline
nippleline
xiphoidprocess
nippleline
axillaryline
© K. Karlsen 2013
-1 0 1 2 3 4
Tests passive tone of the posteriorshoulder girdle flexor muscles
Supine position with head midline
Hold infant’s handacross chest
neck axillaryline
nippleline
xiphoidprocess
nippleline
axillaryline
© K. Karlsen 2013
-1 0 1 2 3 4
Use thumb of other hand to gently pushelbow across chest or gently pull armacross chest
Stop when resistance is felt
Scores based on position of elbow atlandmarks
neck axillaryline
nippleline
xiphoidprocess
nippleline
axillaryline
© K. Karlsen 2013
-1 0 1 2 3 4
1
neck axillaryline
nippleline
xiphoidprocess
nippleline
axillaryline
2
Physical Assessment of the Newborn: Part 1
The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 10
© K. Karlsen 2013
3 4
-1 0 1 2 3 4
neck axillaryline
nippleline
xiphoidprocess
nippleline
axillaryline
© K. Karlsen 2013
-1 0 1 2 3 4
Tests for passive flexion or resistance to extensionof posterior hip flexor muscles
Measurement unreliable iffrank breech in utero
ear nose chin nippleline
umbilicalarea
femoralcrease
© K. Karlsen 2013
Refrain from touching gluteusmuscle (muscle group beingtested) during maneuver
Rest leg alongside body
-1 0 1 2 3 4
ear nose chin nippleline
umbilicalarea
femoralcrease
© K. Karlsen 2013
Refrain from touching gluteusmuscle (muscle group beingtested) during maneuver
Rest leg alongside body
Grasp foot along both sides
-1 0 1 2 3 4
ear nose chin nippleline
umbilicalarea
femoralcrease
© K. Karlsen 2013
Gently pull toward ear untilresistance felt
Scores based on location of heelto landmarks
-1 0 1 2 3 4
ear nose chin nippleline
umbilicalarea
femoralcrease
© K. Karlsen 2013
1
0
-1 0 1 2 3 4
ear nose chin nippleline
umbilicalarea
femoralcrease
2
Physical Assessment of the Newborn: Part 1
The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 11
© K. Karlsen 2013
43
-1 0 1 2 3 4
ear nose chin nippleline
umbilicalarea
femoralcrease
© K. Karlsen 2013
Neuromuscular Maturity
Posture
Squarewindow(wrist)
Arm recoil
Poplitealangle
Scarf sign
Heel to ear
Physical Maturity
-1 0 1 2 3 4 5
Skin
Sticky
Friable
Transparent
Gelatinous
Red
Translucent
Smooth pink
Visible veins
Superficialpeeling and/or
rash
Few veins
Cracking
Pale areas
Rare veins
Parchment
Deep cracking
No vessels
Leathery
Cracked
Wrinkled
Lanugo No lanugo Sparse lanugo Abundantlanugo
ThinningLanugo Bald Areas Mostly bald
Plantarsurface
Heel- toe40-50 mm
< 40 = -2
> 50 mm
No creaseFaint red marks
Anteriortransversecrease only
Creasesanterior 2/3
Creasesoverentire sole
Breast Im-perceptible Barelyperceptible
Flat areola nobud
Stippled areola
1-2 mm bud
Raised areola
3-4 mm bud
Full areola
5-10 mm bud
Eyes / ears
Lids fused:
Loosely: -1
Tightly: -2
Lids open
Pinna flat
Stays folded
Slightly
curved pinna
Soft slow recoil
Well-curvedpinna
Soft but readyrecoil
Formed andfirm
Instant recoil
Thick cartilage
Ear stiff
MaleGenitals
Scrotum flat,smooth
Scrotum empty
Faint rugae
Testes in uppercanal
Rare rugae
Testesdescending
Few rugae
Testes down
Good rugae
Testespendulous
Deep rugae
FemaleGenitals
Clitorisprominent
Labia flat
Prominentclitoris
Small labiaminora
Prominentclitoris
Enlargingminora
Majoraandminora equally
prominent
Majora large
Minorasmall
Majoracoverclitoris and
minora
© K. Karlsen 2013
Sum scores
Physical maturity
Neuromuscular maturity
Total score correlates toweeks gestation
Score Weeks
-10 20
-5 22
0 24
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50 44
25 34