Neonatal Assessment Neonatal Assessment

Child Health NursingChild Health NursingGhada Abu ShoshaGhada Abu Shosha

20092009

Neonatal AssessmentNeonatal Assessment Assessment of the neonates is a critical function Assessment of the neonates is a critical function

of the nurse immediately after birth. The of the nurse immediately after birth. The purposes of neonatal assessments are to :purposes of neonatal assessments are to :

1.1. Identify prenatal influences on health status and Identify prenatal influences on health status and determine risk status . determine risk status .

2.2. Provide baseline information on the infant for Provide baseline information on the infant for use as a reference marker .use as a reference marker .

3.3. Identify anomalies , actual health problems , or Identify anomalies , actual health problems , or potential health problems .potential health problems .

4.4. Plan appropriate nursing care for infant and Plan appropriate nursing care for infant and identify teaching needs of parents .identify teaching needs of parents .

Neonatal assessment include Neonatal assessment include

Evaluation of maternal , obstetric , and Evaluation of maternal , obstetric , and perinatal history .perinatal history .

Physical and behavioral assessment of Physical and behavioral assessment of the neonate . the neonate .

Physical examinationPhysical examination

The newborn clinical examination must The newborn clinical examination must be carried out in a regular sequence so be carried out in a regular sequence so that items are not forgotten that items are not forgotten

A useful approach is the head to toe A useful approach is the head to toe techniquetechnique

Whenever possible the infant should Whenever possible the infant should be examined in the presence of at be examined in the presence of at least one parentleast one parent

Apgar scoreApgar score

The The Apgar scoreApgar score was devised in was devised in 19521952 by Virginia Apgar as a simple by Virginia Apgar as a simple and repeatable method to quickly and repeatable method to quickly and summarily assess the health of and summarily assess the health of newborn children immediately after newborn children immediately after childbirth.childbirth.

Apgar scoreApgar score

The Apgar score is determined by The Apgar score is determined by evaluating the newborn baby on five evaluating the newborn baby on five simple criteria on a scale from zero simple criteria on a scale from zero to two and summing up the five to two and summing up the five values.The resulting Apgar score values.The resulting Apgar score ranges from zero to 10.ranges from zero to 10.

Apgar scoreApgar score

PinkPinkBody pink , Body pink , extremities blueextremities blue

Blue or paleBlue or paleColorColor

CryCryGrimaceGrimaceNo responseNo responseReflex Reflex irritabilityirritability

Active motion , Active motion , extremities well flexed .extremities well flexed .

Some flexion of Some flexion of extremitiesextremities

nonenone Muscle toneMuscle tone

Good , strong cryGood , strong cryWeak cryWeak cryAbsentAbsentRespiratory Respiratory efforteffort

Above 100Above 100Below 100Below 100AbsentAbsentHeart rate Heart rate

221100Sign Sign

Significance of Apgar scoreSignificance of Apgar score

Healthy newborn: 7-10 at both 1 and 5 Healthy newborn: 7-10 at both 1 and 5 minutes .minutes .

Moderately depressed newborn : 3-6 ( Need Moderately depressed newborn : 3-6 ( Need resuscitation )resuscitation )

Severely depressed newborn : 1-2 ( Intensive Severely depressed newborn : 1-2 ( Intensive resuscitation )resuscitation )

AssessmentAssessment of vital signof vital sign temperature : the axillary method is the safest .temperature : the axillary method is the safest .Normal axillary temperature is 36 – 36.5 °C Normal axillary temperature is 36 – 36.5 °C

Heart Rate ( HR ) :Heart Rate ( HR ) :HR is counted for 60 seconds at the apex of the heart HR is counted for 60 seconds at the apex of the heart

(Range (Range from 100- 160 b/m immediately after from 100- 160 b/m immediately after birth ) .birth ) .

Respiratory Rate ( RR ) :Respiratory Rate ( RR ) :RR varies from 30- 60 b/m when the infant is not RR varies from 30- 60 b/m when the infant is not

crying .crying .

Blood Pressure ( BP ) :Blood Pressure ( BP ) :Not routinely assessed in healthy term infants .Not routinely assessed in healthy term infants .The range of normal blood pressure in term infants is The range of normal blood pressure in term infants is

60- 90 60- 90 mmhg for systolic pressure and 40 – 50 mmhg for systolic pressure and 40 – 50 mmhg for diastolic mmhg for diastolic pressure . pressure .

Assessment of GrowthAssessment of Growth

AssessmentAssessment of Growthof Growth

1. Weight :1. Weight :Birth weight is the baseline value for future assessment of Birth weight is the baseline value for future assessment of weight .weight .Normal weight is 2500 – 4000 gm Normal weight is 2500 – 4000 gm

2. Length: 45 – 55 cm 2. Length: 45 – 55 cm

3. Head circumference :34 – 37 cm3. Head circumference :34 – 37 cm

4. Chest circumference : 30 – 33 cm 4. Chest circumference : 30 – 33 cm

An infant is considered appropriate for gestational age if An infant is considered appropriate for gestational age if weight , length , and head circumference are between 10 th weight , length , and head circumference are between 10 th and 90 th percentile . and 90 th percentile .

Below 10 th percentile , the infant is termed small for Below 10 th percentile , the infant is termed small for gestational age gestational age

Above 90 th percentile , the infant is termed large for Above 90 th percentile , the infant is termed large for gestational age gestational age

Head CircumferenceHead Circumference

AssessmentAssessment of Growthof Growth

During the first 3-5 days of life, infants During the first 3-5 days of life, infants usually lose between 5-10% of their usually lose between 5-10% of their birth wt as the kidneys excrete the small birth wt as the kidneys excrete the small physiological excess of body fluid physiological excess of body fluid present at birth. present at birth.

By the 10th day, birth wt is resumed. By the 10th day, birth wt is resumed. Then wt gain is usually between 180and Then wt gain is usually between 180and 210g each week. Days of slow progress 210g each week. Days of slow progress are followed by days of compensatory are followed by days of compensatory gain.gain.

Measurement of the lengthMeasurement of the length

Measurement done in the supine Measurement done in the supine position, head straight and legs fully position, head straight and legs fully extended, measurement between extended, measurement between topmost point of the head and the topmost point of the head and the heals.heals.

Physical Assessment of the Physical Assessment of the NewbornNewborn

General appearance :General appearance :

Body symmetry , Pinkish skin color , Body symmetry , Pinkish skin color , responsiveness and crying . Well-flexed, responsiveness and crying . Well-flexed, full range of motion, spontaneous full range of motion, spontaneous movementmovement

SKINSKIN - Observation and palpation .Observation and palpation .

ColorColor Pallor - associated with low hemoglobin Pallor - associated with low hemoglobin Cyanosis - associated with hypoxemia Cyanosis - associated with hypoxemia Plethora - associated with polycythemia Plethora - associated with polycythemia Jaundice - Elevated bilirubin Jaundice - Elevated bilirubin

LesionsLesions Milia - pinpoint white papules of keratogenous material Milia - pinpoint white papules of keratogenous material

usually on nose, cheeks and forehead, last several usually on nose, cheeks and forehead, last several weeks. weeks.

Erythema toxicum - Most common newborn rash. Erythema toxicum - Most common newborn rash. Variable, irregular macular patches. Lasts a few days. Variable, irregular macular patches. Lasts a few days.

Birth markBirth mark Mongolian spotsMongolian spots  

SKINSKIN At 24 - 36 hours of age, skin flaky, dry and At 24 - 36 hours of age, skin flaky, dry and

pink pink in colorin color

Edema around eyes, feet, and genitalsEdema around eyes, feet, and genitals- Vernix caseosa - Vernix caseosa - Lanugo- Lanugo- Turgor good with quick recoil- Turgor good with quick recoil- Hair silky and soft.- Hair silky and soft.

- Nipples present and in expected locations- Nipples present and in expected locations- Cord with one vein and two arteries- Cord with one vein and two arteries Cord clamp tight and cord drying Cord clamp tight and cord drying- Nails to end of fingers and often extend - Nails to end of fingers and often extend slightly slightly beyondbeyond

SKINSKIN

Common variationsCommon variations Acrocyanosis - result of sluggish Acrocyanosis - result of sluggish

peripheral circulation.peripheral circulation.

Mongolian spotsMongolian spots

Mottling Mottling

Physiologic jaundicePhysiologic jaundice

MiliaMilia

Erythema toxicum Erythema toxicum

Symmetric and round .Symmetric and round .

Check for overriding sutures, the number of fontanelles Check for overriding sutures, the number of fontanelles and their size. Check for abnormal shape of head. and their size. Check for abnormal shape of head. Check for encephalocoeles. Measure the head Check for encephalocoeles. Measure the head circumference.circumference.

Eyes Eyes Cornea Cornea ConjunctivaConjunctiva ScleraSclera IrisIris pupilspupils

HeadHead

HeadHeadExpected findingsExpected findings Anterior fontanelle diamond Anterior fontanelle diamond

shaped 3- 4cm,1.5-3cm shaped 3- 4cm,1.5-3cm - Posterior fontanelle triangular - Posterior fontanelle triangular 0.5 - 1 0.5 - 1 cmcm- fontanelles soft, firm and flat- fontanelles soft, firm and flat- Sutures palpable with small - Sutures palpable with small separation between eachseparation between each

fontanellesfontanelles

HeadHead

Common variationsCommon variations Caput succedaneumCaput succedaneum

Common variationsCommon variations

Molding of head may result in a lower Molding of head may result in a lower head circumference measurement.head circumference measurement.

Molding of fontanels and Molding of fontanels and suture spaces suture spaces

Signs of potential distress or Signs of potential distress or deviations from normal deviations from normal findingsfindings

Fontanels that are bulging or Fontanels that are bulging or depresseddepressedHydrocephalusHydrocephalusMacrocephalyMacrocephalyCephalhematomaCephalhematoma

Closed sutures Closed sutures

EarsEars

Check for asymmetry, irregular shapes , or skin tags. Check for asymmetry, irregular shapes , or skin tags.

Pinna must be curved with firm cartilage with upper Pinna must be curved with firm cartilage with upper part of the pinna at or above outer canthus of the part of the pinna at or above outer canthus of the eye eye

NoseNose

Look for flaring of the alae nasi , symmetric , nasal Look for flaring of the alae nasi , symmetric , nasal discharge , patency of the nares .discharge , patency of the nares .

PalatePalate

Check for cleft lip and palate.Check for cleft lip and palate.

MouthMouth Observe the size and shape of the mouth. Observe the size and shape of the mouth. Mucosa and gum .Mucosa and gum . TongueTongue

TeethTeeth

Natal teeth - occur in 1/2,000 births. Mostly lower Natal teeth - occur in 1/2,000 births. Mostly lower incisors. Risk of aspiration if loosely attached.incisors. Risk of aspiration if loosely attached.

NeckNeck

Full movements Full movements

Palpate over all muscles, palpate clavicles for Palpate over all muscles, palpate clavicles for possible fracture.possible fracture.

CHEST AND LUNGSCHEST AND LUNGS

Observe respiratory rate, respiratory Observe respiratory rate, respiratory pattern (periodic breathing, periods of pattern (periodic breathing, periods of apnea). Observe chest movements for apnea). Observe chest movements for symmetry and for retractions. Listen for symmetry and for retractions. Listen for breathing sounds. Note that there may be breathing sounds. Note that there may be some enlargement of the breasts some enlargement of the breasts secondary to maternal hormones.secondary to maternal hormones.

Cardiovascular SystemCardiovascular System

Cardiovascular SystemCardiovascular System

Check baby's color for pallor, cyanosis, and Check baby's color for pallor, cyanosis, and plethora.plethora.Measure heart rate, respiratory rate.Measure heart rate, respiratory rate.

Check capillary refill. Check pulses, note character of Check capillary refill. Check pulses, note character of pulses . Locate PMI with single finger on chest; pulses . Locate PMI with single finger on chest; abnormal location of PMI can be clue to abnormal location of PMI can be clue to pneumothorax, diaphragmatic hernia, or other pneumothorax, diaphragmatic hernia, or other thoracic problem.thoracic problem.

Note : rhythm and presence of murmurs that may be Note : rhythm and presence of murmurs that may be pathologicpathologic..

ABDOMENABDOMEN

Note shape of abdomen. Note shape of abdomen.

Examine umbilical cord and count the Examine umbilical cord and count the vessels. Note color of cord. Palpate liver vessels. Note color of cord. Palpate liver and spleen. It may be normal for the liver and spleen. It may be normal for the liver to be about 2 cm below the right costal to be about 2 cm below the right costal margin. The spleen is not usually palpable, margin. The spleen is not usually palpable, palpate for any abnormal masses. palpate for any abnormal masses. Auscultate for bowel sounds. Examine for Auscultate for bowel sounds. Examine for hernias - umbilical or inguinal . hernias - umbilical or inguinal .

GenitourinaryGenitourinary ExamExam

KidneysKidneysExamined by palpation deeply .Examined by palpation deeply .

Male genitaliaMale genitalia Term normal penis is 3.6±0.7 cm stretched Term normal penis is 3.6±0.7 cm stretched

length. Inspect urethral opening, and shaft. length. Inspect urethral opening, and shaft. Observe for hypospadias, epispadias. Inspect Observe for hypospadias, epispadias. Inspect penis for edema, incision, bleeding. Full term penis for edema, incision, bleeding. Full term infant should have brownish pigmentation infant should have brownish pigmentation and fully rugated scrotum. Palpate the testes.and fully rugated scrotum. Palpate the testes.

Female genitaliaFemale genitalia

Inspect the labia, clitoris, urethral Inspect the labia, clitoris, urethral opening and external vaginal vault. opening and external vaginal vault. Often a whitish discharge is present; Often a whitish discharge is present; this is normal, as is a small amount this is normal, as is a small amount of bleeding, which usually occurs a of bleeding, which usually occurs a few days after birth and is secondary few days after birth and is secondary to maternal hormone withdrawal . to maternal hormone withdrawal .

Extremities and Skeletal SystemExtremities and Skeletal System

Scoliosis, kyphosis, lordosis, spinal defects, Scoliosis, kyphosis, lordosis, spinal defects, meningomyelocoeles.meningomyelocoeles.

Upper extremityUpper extremityLook for clavicular fracture, Inspect creases Look for clavicular fracture, Inspect creases

and fingers.and fingers.

Lower extremityLower extremityInspect posture . Do Ortolani maneuver to Inspect posture . Do Ortolani maneuver to

check for congenital hip dislocation. Check check for congenital hip dislocation. Check toes.toes.

ExtremitiesExtremitiesExpected findingsExpected findings Maintains posture of Maintains posture of

flexionflexionEqual and bilateral Equal and bilateral movement and tonemovement and toneFull range of motion all Full range of motion all joints joints - Ten fingers and ten - Ten fingers and ten toestoes

Palmer creases presentPalmer creases present Negative hip clickNegative hip click

Grasp reflex presentGrasp reflex present

Dislocation of hipDislocation of hip

Neonatal Primitive ReflexesNeonatal Primitive Reflexes

ReflexesReflexes

include the Moro , startle , palmer and include the Moro , startle , palmer and planter grasps, sucking and rooting and planter grasps, sucking and rooting and swallowing reflexes, tonic neck swallowing reflexes, tonic neck reflex ,stepping , and babinski sign .reflex ,stepping , and babinski sign .

ReflexReflexss Moro ReflexMoro Reflex: Sudden change in : Sudden change in

equilibrium causes sudden extension and equilibrium causes sudden extension and abduction of extremities and fanning of abduction of extremities and fanning of fingers ,with index finger and thumb fingers ,with index finger and thumb forming c shape, followed by flexion and forming c shape, followed by flexion and adduction of extremities; legs may adduction of extremities; legs may weakly flex; infant may cry; weakly flex; infant may cry; disappears disappears after age 3-4months. after age 3-4months.

Palmer graspPalmer grasp: touching palm of hand : touching palm of hand near base of digits cause flexion of near base of digits cause flexion of hands, hands, lessens after age 3 months.lessens after age 3 months.

planter graspplanter grasp: touching feet near base : touching feet near base of digits cause flexion to toes, of digits cause flexion to toes, lessens lessens by 8months age by 8months age

Babniski reflexBabniski reflex: stroking outer sole of : stroking outer sole of foot upward from heel and across foot upward from heel and across ball of foot causes toes to ball of foot causes toes to hyperextend and hallux to dorsiflex hyperextend and hallux to dorsiflex disappears after age 1 year disappears after age 1 year

Rooting reflexRooting reflex: touching the cheek : touching the cheek along side of mouth causes infant to along side of mouth causes infant to turn head toward that side and begin turn head toward that side and begin to suck ;to suck ;disappear at age 3-4 disappear at age 3-4 months, may persist for up to 12 months, may persist for up to 12 months. months.

Sucking reflexSucking reflex: infant begins : infant begins sucking movement in response to sucking movement in response to stimulation ; persists though –out stimulation ; persists though –out infancy , even without infancy , even without stimulation ,such as during sleep. stimulation ,such as during sleep.

Asymmetric tonic neck reflexAsymmetric tonic neck reflex: : when infant head is turn to one when infant head is turn to one side, arm and leg extend on that side, arm and leg extend on that side, and opposite arm and leg flex side, and opposite arm and leg flex , , disappears by age 3-4 months disappears by age 3-4 months

Swimming reflexSwimming reflex :: If you were to put a If you were to put a baby under six months of age in water, baby under six months of age in water, they would move their arms and legs they would move their arms and legs while holding their breath. This is why while holding their breath. This is why some families believe in swim training some families believe in swim training for very little babies. It is not for very little babies. It is not recommended for you to test this reflex recommended for you to test this reflex at home for obvious safety reasons.at home for obvious safety reasons.

Doll’s eye reflexDoll’s eye reflex : : as a head of infant as a head of infant moved slowly to right or left, eyes lag moved slowly to right or left, eyes lag behind and do not immediately adjust behind and do not immediately adjust to new position of head; disappears as to new position of head; disappears as fixation developed, if persists indicate fixation developed, if persists indicate neurological damage.neurological damage.

Dance or step reflexDance or step reflex: : if infant is held so if infant is held so that the sole of foot touch a hard surface that the sole of foot touch a hard surface there is flexion and extension of the leg there is flexion and extension of the leg stimulating walking. stimulating walking. disappear after age disappear after age 3-4week.3-4week.

Startle reflexStartle reflex: sudden loud noise causes : sudden loud noise causes abduction of the arms wit flexion of abduction of the arms wit flexion of elbow, hand remain clenched ;elbow, hand remain clenched ;disappears disappears by age of 4 monthsby age of 4 months

Moro ReflexMoro Reflex

Palmer graspPalmer grasp

planter graspplanter grasp

Babniski reflexBabniski reflex

Rooting reflexRooting reflex

Sucking reflexSucking reflex

Asymmetric tonic neck Asymmetric tonic neck reflexreflex

Swimming reflexSwimming reflex

Dance or step reflexDance or step reflex

Startle reflexStartle reflex