UNIT 2 New Born Assessment

HEALTHY NEWBORN INFANT

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CHARACTERISTICS OF THE TYPICAL NEWBORN INFANT • GENERAL • The nurse is in a unique position to aid the newborn

infant in the stressful transition from a warm, dark, fluid-filled environment to an outside world filled with light, sound, and novel tactile stimuli. During this period of the newborn adjusting from intrauterine to extrauterine life, the nurse must be knowledgeable about a newborn's normal biopsychosocial adaptations to recognize any deviations.


• To begin life as an independent being, the baby must immediately establish pulmonary ventilation in conjunction with marked circulatory changes. These radical and rapid changes are crucial to the maintenance of life. All other neonatal body systems change their functions or establish themselves over a longer period of time. The nurse performs an initial assessment to evaluate the neonate, its immediate postbirth adaptations, and the need for further support


Erythema toxicum

Port Wine Stain

Vernix

Cheesy-white Normal Antibacterial

properties Protects the

newborn skin

CHARACTERISTICS OF THE NEWBORN

INFANT'S HEAD The newborn infant's head

represents one-fourth of his total body length. Its circumference is equal to that of his abdomen or chest. The average size is 13" to 14" (33-35 cm). The head is shaped or molded as it is forced through the birth canal in vertex presentations.

Molding. During delivery, for the large head

to pass through the small birth canal, the skull bones may actually overlap in a process referred to as molding. Such molding reduces the diameter of the skull temporarily. This elongated look usually disappears a few hours after birth as the bones assume their normal relationships

Fontanels.

The infant's skull is separated into six bones one from another along the suture lines .Where more than two bones come together, the space is called a fontanel. This is the unossified space or soft spot between the cranial bones of the skull in an infant. The infant's pulse is sometimes visible there. The anterior fontanel is located at the intersection of the sutures of the two parietal bones and the frontal bones.

It is diamond-shaped and strongly pulsatile. It normally closes at 9 to 18 months of age. The posterior fontanel is located at the junction of the sutures of the 2 parietal bones and 1 occipital bone. It is small, triangular shaped, and less pulsatile. It normally closes at 1 1/2 to 3 months of age. The anterior fontanel is the larger of the two.

Molding’s of infant’s head

Cephalhematoma.

This is a collection of blood between a cranial bone and its overlying periosteum. Bleeding is limited to the surface of the particular bone. It is caused by pressure of the fetal head against the maternal pelvis during a prolonged or difficult labor. This pressure loosens the periosteum from the underlying bone, therefore rupturing capillaries and causing bleeding.

It may be apparent at birth but sometimes are not seen until 24 to 48 hours of life because subperiosteal bleeding is slow. It varies in size, rather firm to the touch and tends to increase in size from 1 to 3 days and then become softer and more fluctuant. Most cephalhematomas are absorbed within several weeks. No treatment is required in the absence of unexplained neurologic abnormalities

Cephalhematoma is a collection of blood between the surface of a cranial bone and the periosteal membrane.

Not crossing suture line

Caput Succedaneum.

This is an abnormal collection of fluid under the scalp on top of the skull that may or may not cross the suture lines, depending on the size. Pressure on the presenting part of the fetal head against the cervix during labor may cause edema of the scalp . This diffuse swelling is temporary and will be absorbed within 2 or 3 days

Caput succedaneum is a collection of fluid (serum) under the scalp.

Crossing suture line

Structure of infant's ear

Infant’s Stool

VITAL SIGNS OF THE NEWBORN INFANT

a. Temperature Regulation. (1) The infant's body temperature drops

immediately after birth in response to the extrauterine environment. His internal organs are poorly insulated and his skin is very thin and does not contain much subcutaneous fat. The infant's heat regulating mechanism has not fully developed. His temperature rapidly reflects that of his environment. The flexed position that the infant assumes is a safeguard against heat loss because it substantially diminishes the amount of body surface exposed.

Nursing implications are centered on regulating an environment to provide constant body temperature of a neutral thermal environment. The infant is placed in blankets, hat, and a controlled temperature environment after birth to counteract the drop in body temperature that occurs immediately after birth. After admission to the nursery, the infant is placed in isolation (isolette) and a temperature probe may be used for continuous monitoring. The infant's axillary temperature is maintained at 36.4 to 37.2o C.

NOTE: An isolette is a self-contained unit that controls the temperature, humidity, and oxygen concentration for an infant.

Pulse.

The normal pulse range for an infant is 120 to 140 beats per minute (bpm). The rate may rise to 160 bpm when the infant is crying or drop to 100 bpm when the infant is sleeping. The apical pulse is considered the most accurate.

Blood Pressure

The average blood pressure(BP) of an infant at birth is 72/42. A drop in systolic BP of about 15 mm Hg the first hour after birth is common. The newborn's BP may be taken with a Doppler blood pressure device. This greatly improves accuracy.

Respirations.

The respirations of a newborn infant are irregular in depth, rate, and rhythm and vary from 30 to 60 beats per minute. Respirations are affected by the infant's activity (that is, crying). Normally, respirations are gentle, quiet, rapid, and shallow. They are most easily observed by watching abdominal movement because the infant's respirations are accomplished mainly by the diaphragm and abdominal muscles (see figure 7-1). No sound should be audible on inspiration or expiration


ENDOCRINE SYSTEM The endocrine glands are considered

better organized than other systems. Disturbances are most often related to maternally provided hormones (estrogen, luteal, and prolactin) that may cause the following conditions

Vaginal discharge and/or bleeding may occur in female infants. This discharge is white mucoid in color. Bleeding may occur as a result of withdrawal from maternal hormones at the time of birth. There are usually only a few blood spots seen on the diapers. The entire process terminates in one to two days

Enlargement of the mammary glands may occur in both sexes. This is particularly noticeable about the third day of life. Breast secretion may also occur. Swelling usually subsides in two to three weeks. The breast should not be squeezed; it only increases the chances of infection and injuries to the tender tissue.

NEUROLOGICAL ASSESSMENT OF NEWBORN


NEUROMUSCULAR SYSTEM The newborn infant exhibits

remarkable sensory development and an amazing ability for self-organization in social interactions. The infant's muscles are firm and resilient. He has the ability to contract when stimulated, but lacks the ability to control them. He wiggles and stretches, but movements are uncoordinated.

Cephalo-Caudal (Head to Toe) in Development. Gross motor development occurs first, followed by finer motor development. Reflex actions present at birth serve the infant until neuromuscular development is improved. Absence of reflex activity often indicates some form of brain damage

NEONATAL REFLEXES

INTRODUCTION

Actions in response to specific stimuli that are present in newborn infants.

These are unconditioned reflexes and not

learned or developed through experience.

Normally developing neonates or infants are expected to respond to specific stimuli with a specific, predictable behaviour or action.

MORO’S REFLEXEELICITED BY :

PLACING THE BABY IN SEMI UPRIGHT POSITION

↓SUDDEN DROPING OF HEAD IN RELATION TO

TRUNK AND CATCHING THE FALLING HEAD

DISAPPEARS AT 3 TO 6 MTHS

RESPONSE

OPENING OF HAND

EXTENSION AND ABDUTION OF UPPER EXTRIMITIES

ANTERIOR FLEXION OF UPPER EXTRIMITIES

AUDIBLE CRY

ABNORMALITIES:

DEPRESSED OR ABSENT GENERALISED DEPRESSION OF CNS

ASYMMETRICAL RESPONSE FRACTURE CLAVICLE ERB PALSY HEMIPARESIS

EXAGERGERATED RESPONSE KERNECTERUS

STARTLE REFLEX

It is variant of Moro’s Reflex.

Ellicited by: sudden loud noise or by tapping the sternum

Response is like Moro’s reflex but elbow remain flexed and hands closed

PALMER GRASP Elicited By: Placing finger or object in open

palm of each hand Response: Infant grasp the object and with

attempted removal grip reinforced

Appears at 28 weeks of gestation and disappears at 2-3 months of life

Persistence beyond 6mths: Athetoid CP

TONIC NECK REFLEX

ASYMMETRIC TONIC NECK REFLEX Elicited By: Passive rotation of head in

supine position Response: Extension of upper limb of same

side and flexion of upper limb of opposite side

Appears at birth and disappear at 3 months

Persistence > 3 months: Spastic CP

Importance: Prevents body from rolling

TONIC NECK REFLEX SYMMETRIC TONIC NECK REFLEX

Elicited By: Passive extension of head in prone position

Response: Extension of both UL & flexion of both LL

Appears in 3 mths and disappear in 6mths Persistence > 6mths : CP Importance: When baby learn to turn to prone

position chocking over bed may asphyxiate him so if baby lift his chin by extension of neck both upper limbs extend automatically and chocking avoided.

GALANT REFLEX Elicited By: Holding the child in ventral

suspension or placed in prone position and running finger down in paravertebral area on one side

Response: Swinging of pelvis towards stimulated side

Appears at birth disappear by 1 year

Used for mapping sensory level of trunk

ROOTING REFLEX (SEARCH REFLEX)

Elicited By: Touching the corner of mouth lightly with finger

Response: Bottom lip is lowered on same side and tongue moves towards the point of stimulation as finger slides away head turns to find it.

Appear 28 week & disappear 4-7 mths

Importance: Absence at birth and persistence beyond 7

months indicate developmental delay

Helps the baby for finding the breast

SUCKING REFLEX

Elicited By: Introducing finger into babies mouth

Response: Baby starts sucking vigorously Appear at 28 week disappear at 4-7 months Absence sucking at birth indicate sickness,

persistence beyond 7 mths developmental delay

PLACING REFLEX

Elicited by: Bringing the anterior aspect of tibia against edge of table

Response: Lifts leg on the table

Appear at birth and disapper at 6 weeks.

WALKING REFLEX

Elicited by: holding the baby upright over the table so that sole of foot presses against the table

Response: Reciprocal flexion and extension of leg simulating walking

Appears at birth and disappear at 6 week

PALMOMENTAL REFLEX

Elicited by: Pressing the palm

Response: Opening of mouth

Appear at birth and disappear at 3 year

PARACHUTE REFLEX

Elicited By: Holding the child in ventral suspension and suddenly brought down the baby towards ground from height

Response: Extension of both UL in attempt to avoid injury

Appears at 6-9 months persists life long.

Absent in CP and hemiplegia of affected limb

NEONATAL GESTATIONAL AGE ASSESSMENT

Objectives

By the end of this presentation the learner should….Understand the prenatal gestational age assessment

toolsClassify the size differences between IUGR, SGA, AGA,

& LGA infantComplete the physical maturity portion of the neonatal

gestational age assessment toolConduct the neuromuscular portion of the neonatal

gestational age assessmentCompile the maturity score on the neonatal gestational

age assessment toolIdentify those common differential findings found on

newborn exam

Prenatal Gestational Age Assessment

Calculation by the mother estimated date of confinement (EDC)Collection of prenatal data

First fetal movement (16-20 weeks) Fetal heart tones (20 weeks) (with doppler 9-12

weeks) Fundal height (One cm = 1 week after 18-20

weeks) 20 weeks (fundus normally at umbilicus) Term (fundus at xyphoid) Amniotic fludi creatinine levels Maternal serum and urine estriols Fetal US

Prenatal Gestational Age Assessment

FETAL US MEASUREMENTS

Crown to rump length

Biparietal diameter Femur length Abdominal

Circumference Head Circumference Placental grade

Basics of Newborn Physical Exam

Review the perinatal history for clues to potential pathologyBegins with conception and includes events

that occurred throughout gestationGenetic historyLabor & delivery history

Assess the infant’s color for clues for potential pathology

Auscultate in a quiet environmentKeep infant warm during examCalm the infant before examHandle gently

Classification of Size

Classification of size forgestational age

Growth for dates can be determined by weight, length, and head circumference

Plotted on a graph appropriate for gestation • Preterm before 37 weeks• Term 38-41 weeks• Post term after 42 weeks

Classification of size for gestational age

Using the gestational age score the weight, height and head circumference can be plotted on the infants growth chart

This information is how the infant is diagnosed as SGA, LGA, or AGA

Classification of size for gestational age

SGA- small for gestational age-weight below 10th percentile

AGA-weight between 10 and 90th percentiles (between 5lb 12oz (2.5kg ) and 8lb 12 oz (4kg).

LGA-weight above 90th percentile IUGR-deviation in expected fetal growth

pattern, caused by multiple adverse conditions, not all IUGR infants are SGA, may or may not be “head sparing”

Neonatal Gestational Age- Ballard Exam

The physical maturity part of the examination should be done in the first two hours of birth

The neuromuscular maturity examination should be completed with 24 hours after delivery

Derived to look at various stages in an infants gestational maturity and observe how physical characteristics change with gestational age

Neonates who are more physically mature normally have higher scores than premature infants

Points are awarded in each area -2 for extreme prematurity to 5 for postmature infants

Physical Maturity

Skin Lanugo Plantar surface Breast Eyes & Ears Genital

Neonatal Gestational AgePhysical Maturity

Physical Maturity-Skin

Examine the texture, color and opacity As the infant matures:

More subcutaneous tissue develops Veins become less visible and the skin

becomes more opaque

Neonatal Gestational Age Assessment

Physical Maturity Skin

Before 28 weeks-gelatinous red, friable

28-37 weeks-skin over abdomen thin, translucent, pink with visible veins

37-39 weeks smooth, pink, increased thickness, rare veins over abdominal wall


Physical Maturity Skin

40 Weeks-vessels have now appeared, skin may be leathery with deep cracking

Differential Skin Findings

Scalp Electrode


Forcep Marks


Vacuum Bruising


Milia-exposed sebaceous glands

No treatment necessary


Sebaceous hyperplasia

More yellow than milia

Result of maternal androgen in utero

Resolves in time


Mongolian Blue-Grey Spots

Most common in Asian, Hispanic, and African descent

Gradual fade over the first years


Skin Tags Most

common on ears

Usually tied off or clipped


Salmon patches or nevus simplex

Angel kisses Stork bites


Erythema toxicum

White or yellow papule or pustule

With erythematous base

No treatment necessary


Café Au Lait spots Increased amount

of melanin, may increase in number in age

Presence of 6 or more- greater then 0.5 cm in size may be indicative of neurofibromatosis


• Physical Maturity• Lanugo

• After 20 weeks-begins to appear

• 28 weeks-abundant• After 28 weeks-

thinning, starts to disappear from the face first

• 38 weeks-bald areas slight amount may be present on shoulders


Vernix Before 34 weeks-vernix

thick and covers entire body

34-38 weeks-vernix is absorbed gradually, portions over shoulder and neck is the last to be absorbed

38-40 weeks-vernix only present in folds of skin

After 40 weeks-no vernix present


Plantar SurfaceBefore 28 weeks-no

creases28-32 weeks-virtually no

sole creases, faint thin red lines over anterior aspect of foot

34-37 weeks-1-2 anterior creases

37-39 weeks-creases now over the anterior 2/3 of the sole

Differential FindingsBilateral Club

Feet

Polysyndactyly

Syndactyly


Physical MaturityBreast

Before 28 weeks-nipples imperceptible28-32 weeks-nipple barely visible, no areola32-37 weeks-well defined nipple areola38-40 weeks-well defined nipple raised areola


Physical MaturityEyes

Eyes are evaluated as either fused as seen in extremely premature infants or open

Before 26 weeks eyes are fused

Differential Findings

Congenital Cataracts Eyelid Edema Subconjunctival Hemorrhage


Physical MaturityEars

Before 34 weeks-pinna is very immature cartilage not present, lies flat, remains folded

34-37 weeks-pinna curved with soft recoil

37-40 weeks-formed, firm instant recoil

After 40 weeks-thick cartilage ear stiff


Ear Tags Ear Pits (Preauricular pits) Lop Ear Prominent Ear


Physical Maturity Genitalia-Male

Before 28 weeks-scrotum empty and flat

28-30 weeks-testes undescended into scrotal sac

30-36 weeks testes descending with a few rugae over the scrotum

36-39 weeks-testes have descended into scrotum which is now pendulous and complete with rugae

Genitalia-Female• Before 28 weeks-clitoris

prominent labia flat• 28-32 weeks-prominent

clitoris, enlarging labia minora

• 33-36 weeks-labia majora widely spaced with equally prominent labia minora

• 33-39 weeks-labia extends over the labia minora but not over the clitoris

• 39 weeks-labia majora completely covers the labia minora and clitoris


Hydrocele

Hypospadias

Undescended testicles

Hymenal Tag

Neonatal Gestational Age Neuromuscular Assessment


Neuromuscular MaturityPosture & ToneSquare WindowArm RecoilPopliteal AngleScarf SignHeel to Ear


• Neuromuscular Maturity• Posture/Tone-Total body muscle tone is

reflected in the infants preferred posture at rest and resistance to stretch of individual muscle groups• Make sure infant is quiet• The more mature an infant is the greater their

tone will be• A more flexed position indicated greater tone


• Neuromuscular Maturity

• Posture & Tone• Before 30 weeks-

hypotonic, little or no flexion seen

• 30-38 weeks-varying degrees of flexed extremities

• 38-42 weeks-may appear hypertonic


Neuromuscular Maturity Square Window-wrist

flexibility and/or resistance to extensor stretching resulting in angle or flexion at wrist Flex hand down to wrist-

measure the angle between the forearm & palm Before 26 weeks-wrist

can’t be flexed more than 90 degrees

Before 30 weeks-wrist can be flexed no more than 90 degrees

36-38 weeks-wrist can be flexed no more than


Neuromuscular MaturityArm Recoil-measures the angle of recoil

following a brief extension of the upper extremity

For 5 seconds flex the arms while infant is in the supine position, pulling the hands fully extend the arms to the side, then release-measure the degree of arm flexion & strength (recoil)Before 28 weeks-no recoil28-32 weeks-slight recoil32-36 weeks-recoil does not pass 90 degrees36-40 weeks-recoils to 90 degreesAfter 40 weeks-rapid full recoil


Neuromuscular Maturity Popliteal Angle-assesses

maturation of passive flexor tone about the knee joint by testing resistance to extension of the leg

The angle decreases with advancing gestational ageBefore 26 weeks-angle 180

degrees26-28 weeks-angle 160

degrees28-32 weeks-angle 140

degrees32-36 weeks angle 120

degrees


Neuromuscular Maturity Scarf Sign-tests the passive

tone of the flexors about the shoulder girdle

Increased resistance to this maneuver with advancing gestational ageBefore 28 weeks-elbow passes

torso28-34 weeks-elbow passes

opposite nipple line34-36 weeks-elbow can be

pulled past midline, no resistance

36-40 weeks-elbow to midline with some resistance

After 40 weeks-doesn’t reach midline


Neuromuscular Maturity Heel to Ear-measures

passive flexor tone about the pelvic girdle by testing passive flexion or resistance to extension of the posterior hip flexor muscles

Breech infants will score lower than normal

Before 34 weeks-no resistance

40 weeks-great resistance may be difficult to perform

References

Aby, J. (2008). Stanford School of Medicine. Newborn Nursery at LPCH. Retrieved October 10th, 2009 from

http://newborns.stanford.edu/RNMDEducation.html

Ballard J. (1991). New Ballard Score, expanded to include extremely premature infants. Journal of Pediatrics, 119, 417-423.

Tappero, E. & Honeyfield, M. (1996). Physical assessment of the newborn. Santa Rosa, CA: NICU Ink Publishers.

CARE OFNEWBORN

Dry the Baby

Hypothermia is common Wet newborns rapidly

lose heat Use a warm, dry, soft

towel Any absorbent material:

Shirt T-shirt Socks Battle dressings

Replace the Wet Towels

Then let the mother hold the baby

Her body heat will help keep the baby warm

Cover the head to prevent heat loss

Position the Baby

Keep the baby on its’ back or side, not on its’ stomach

Neither extend nor flex the head. Either may obstruct the airway.

Newborn babies normally make this adjustment themselves. If depressed, however, you may need to position the head to get a good airway.

Suction the Airway

May need to help them clear mucous and amniotic fluid from the airway

Use a bulb syringe Use it gently If bulb syringe is not available,

use any suction device, including a small hypodermic syringe without the needle.

Evaluate the Baby

Breathing Color Heart Rate Tactile

stimulation (rubbing) with a towel.may effectively stimulate a mildly depressed baby

Color

Most newborns have acrocyanosis (body is centrally pink, but hands and feet are blue

Cyanosis requires treatment: Oxygen Airway Ventilation

Pink

Acrocyanosis

Cyanosis

Ventilate if Necessary If not breathing following

brief stimulation, ventilate

Ideally, bag/mask, 100% oxygen, pressure gauge, flow control valve

May need to use mouth-to-mouth

Cover nose and mouth Use shallow puffs to

ventilate

Check the Heartbeat

Normal newborn rate is >100

Palpate umbilical cord or brachial artery

If pulse <100, ventilate the baby, using whatever skills and equipment you have

Keep the Baby Warm

Keep the airway open Keep the head

covered Use any available

cloth or heat-retaining material

Check temp several times: 97.7-99.3F axillary

Assign Apgar Scores0 Points 1 Point 2 Points

Heart Rate Absent <100 >100

Respiratory Effort Absent Slow, Irregular Good, crying

Muscle Tone Flaccid Some flexion ofextremities

Active motion

Reflex Irritability No Response Grimace Vigorous cry

Color Blue, pale Body pink,extremities blue

Completelypink

Field Expedient Bottle

Breast feeding is better If mother not available:

Formula Warm to body temperature If formula not available, use

sugar water Avoid cow’s milk unless there

is no alternative and baby formula is not expected soon.

Vernix

Cheesy-white Normal Antibacterial

properties Protects the

newborn skin

Eye Prophylaxis 1% silver nitrate 1% TTCN ophthalmic

ointment 0.5% erythromycin ointment

Vitamin K• First few hours• 0.5-1.0 mg IM• Prevents hemorrhagic

disease

Umbilical Cord Care Clean & dry Alcohol wipe once a day Topical antiseptic only

in contaminated areas

UNIT 2 New Born Assessment

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