physical assessment of the newborn. assessment n two fundamental types of exams u periodic...
TRANSCRIPT
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PhysicalAssessment of the Newborn
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Assessment
Two fundamental types of exams
Periodic comprehensive exam
Problem specific exam
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Assessment
Gathering accurate, detailed data that includes four components Review history Review results of physical exam Review available data Formulating an impression and
plan
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Comprehensive History
Prerequisite for adequate assessment
Alerts examiner to potential problems and may indicate the need for more frequent exam
Gives clues to potential pathology
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Medical History
Demographics Past Maternal illness & surgeries Maternal conditions Family History of congenital
conditions Reproductive Hx Antepartum Hx Intrapartum Hx Social Hx
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Prenatal Factors Affecting the Newborn
Diabetes Mellitus Hyperthyroid PKU Systemic Lupus Erythematosus Hypertension Smoking & substance abuse
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Principles of Physical Assessment
Assess infant for clues for potential pathology
Auscultate in a quiet environment
Keep the infant WARM & calm during the exam
Handle gently! Record & report abnormalities
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Refresh your anatomy
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Techniques of Physical Assessment
Observation / Inspection
Palpation Percussion Auscultation
Inspection Auscultation Palpation Percussion
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Inspection / Observation
Most important technique to master
Alerts examiner to areas needing more thorough assessment
General / Visual Auditory Olfactory
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Palpation Using the sense of touch
Superficial Deep
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Percussion
The body’s structures differ in density.
To discern the location, size and density of a structure. Tympany Resonance Hyperresonance Dullness
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Percussion techniques
Direct Indirect Blunt
Not use frequently in the neonate
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Auscultation
Listening to sounds produced by internal body structures Indirect - using the appropriate
stethoscope Direct - audible
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Order of Examination
General observation Head and neck region
Facies Nose Mouth Ears
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Order of Examination
Trunk Cardiopulmonary systems Abdomen Back Genitalia and rectum
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Order of Examination
Extremities Neurologic exam Eye Exam
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Equipment
Ophthalmoscope Stethoscope Otoscope Transilluminater
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APGAR 0 1 2 1 min
5 min
Activity (Muscle tone)
Floppy Some flexion
Well Flexed
Pulse (HR) 0 <100 >100
Grimace (reflex irritability)
No response
Grimace Cough or sneeze
Appearance (Color)
Blue or pale
Pink AC Pink all over
Respirations Absent Slow, irregular, weak cry
Good, strong cry
1958
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Baby A
Born SVD to a G2 P2 26yo, no complications
At 1 min: Comes out crying and vigorous but color is still blue. When you bulb syringe the baby he gets mad!
At 5 min: Crying off and on, pink with blue hands and feet, good flexion, HR 140’s.
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Baby A1 min 5 min
Activity (Muscle tone) Flexed - 2 Flexed - 2
Pulse (HR) HR>100 - 2 HR >100 - 2
Grimace (reflex irritability)
Coughed with bulb - 2 Cough with bulb - 2
Appearance (Color) Blue – 0 Pink with AC - 1
Respirations Crying – 2 Crying - 2
Total 8 9
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Baby B
Mom 35, G1P1, PIH induction. Having “lates”, vacuum assisted delivery.
At 1 min: Infant is floppy, HR 120, when you bulb syringe baby turns away, color is blue and the breathing is slow & irregular.
At 5 min: There is now some flexion, HR 180, coughing, pink with AC, good breathing but not crying.
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Baby B
1 min 5 min
Activity (Muscle tone) Floppy - 0 Some flexion - 1
Pulse (HR) 120 - 2 180 - 2
Grimace (reflex irritability) Turns away from bulb - 1 Coughs - 2
Appearance (Color) Blue - 0 Blue with AC - 1
Respirations Slow, irregular - 1 Good, not crying - 2
Total 4 8
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Apgar score may be influenced by
Preterm birth Administration of maternal drugs Congenital anomalies
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Before leaving the DR
Inspect for birth injuries/anomalies Evaluate pulmonary &
cardiovascular stability Inspect extremities Inspect genitalia
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Evaluating Transition
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Transition requires significant adjustments to tolerate the relatively stable fluid filled environment where nutrition and respiration are provided through the placenta and amniotic fluid to an environment where the newborn is physiologically independent in a few hours
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Circulation changes from fetal to neonatal routes
Brief period when oxygen saturation of the blood going to the head, upper body, and right arm are significantly higher than the lower body
Line of demarcation across the chest
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Evaluating Transition
Auscultate the chest - Is there sufficient air exchange?
Evaluate the cry - Describe the quality of the cry. Lusty or weak? Is there an obstruction or narrowing of the airway?
Is the infant vigorous? What is the perfusion, oxygenation and appropriateness of state?
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Evaluating Transition
Term newborns generally complete transition in a few hours
Premature infant take a longer period of time to complete transition and may require external assistance to complete the process
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Evaluating Transition
Monitor vital signs Observe general alertness Color Signs of respiratory distress Cardiac rhythm and rate Ability to suck and swallow Handling of secretions
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Erythema neonatorum
Blushed or bright red color Few hours after birth Last several minutes to an hour Signals the successful completion
of fetal to neonatal transition of the cardiopulmonary system
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Three particular observations are reassurances of a healthy baby
Normal variations in behavior state Comfortable respiratory effort with
intermittent vigorous cry Transitional blush or erythema
neonatorum
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Periods of Reactivity
Sympathetic activity Color Respiration Heart Rate Behavioral state Gastrointestinal function Temperature
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Periods of Reactivity
Initial Period of reactivity (birth to 30 min) Period of relative inactivity (30 m -2 hours after) Second period of reactivity (2-6 hours after) Stability period (6-24 hours) Actual times vary by baby, but there should always
be a pattern of activity/sleep/activity. The presence of periods of reactivity indicate a
positive adjustment to extrauterine life
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Sensory
Chemistry
Thermal
Mechanical
Stimulus for breathing
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Cardiovascular Adaptations
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Renal Intrauterine – kidney function not
essential to life Fetal urine helps to make up amniotic
fluid At birth
Vascular resistance of the renal vessels decreases Increased blood flow through kidneys
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Maintenance of Body Temperature
Thermogenesis (brown fat
metabolism) Can find on the body in:
Intrascapular region Thorax Peri-renal area
Newborn’s ability to conserve heat is lacking due to not able to shiver.
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Convection Body surface to air
(drafts) Radiation
Body surface to cooler object not in contact (cold walls or window)
Evaporation Conversion of a liquid
to a vapor (dry infant) Conduction
Body surface to cooler object in contact with baby ( warm surface)
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Cold Stress
Increased Metabolic Rate Increased need for O2 Increased respiratory rate Anaerobic metabolism Metabolic Acidosis, fatigue & CV
collapse
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Observe for signs of physical abnormalities
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Newborn Vital Signs
Heart rate: Apical pulse (120-160, irregular)
RR (30 to 60, no retractions, no grunting)
Temperature (97.8-99.6)
Blood pressure 70’s/40’s
Color: centrally pink with acrocyanosis
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Signs of Distress
Increased respiratory rate (tachypnea) Difficult respirations (dyspnea) Retractions Excessive mucous Cyanosis Facial grimacing Abdomen scaphoid or distended
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Silverman-Anderson Observations of synchrony in the chest &
abdomen Retractions of the lower ribs Retractions of the sternum Nasal flaring Presence & intensity of grunt on expiration 0 = no respiratory disease 10 = sever respiratory disease >7 = impending respiratory failure
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Morley
The need to relate signs & symptoms to grades of illness rather than to specific diagnoses d.t.: S/S nonspecific Diagnosis not always predictive of degree of
illness Parents & practitioners can inform parents of
the severity of illness even in the absence of a diagnosis
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Evaluating Transition
Tachypnea C/S or preciptous delivery Metabolic acidosis
Absence of tachypnea in the presence of cyanosis & poor air movement then it indicates inadequate respiratory drive May suggest depression from
maternal drugs, stress
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Remember…
Delay determining sex of infant until accurate assessment of ambiguity is complete
Inspect the infant for major anomalies
Check the umbilical cord for the presence of 3 vessels (2 arteries, 1 vein)
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Remember...
Establish patency of upper airway A term fetus swallows 450ml of
amniotic fluid/day. Gastric emptying at 20 ml/hr.
Aspirated gastric contents >15 ml is increased
> 25ml is abnormal and suggests obstruction at the pylorus or duodenum
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Remember...
May be green-brown in color(old swallowed meconium), or blood
Blood may be fetal or maternal APT test can distinguish
Don’t forget to look at the back Check that the palate is intact Look for the anus! Is there an
opening?
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Before leaving DR
Inspect for birth injuries Congenital anomalies Evaluation of pulmonary &
cardiovascular stability Extremities Genitalia
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Facilitate Infant’s Relationship with Parents
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Newborn Care to Prevent Complications Vitamin K, Eye prophylaxis, &
glucose evaluation Medves, Jennifer. (2002).
Three infant care interventions: Reconsidering the evidence. JOGNN,31(5), pp563-569
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Assessing Growth
Weight, Length, Head & Chest
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Assessing Growth
A normal growth pattern is an indicator of fetal and neonatal well-being.
Growth follows a predictable path Influenced by genetic and
environmental patterns May be proportionate or
disproportionate
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Assessing Growth
Standard measurements are head circumference, height and weight
Compare the individual to himself over time by looking at the rate of growth or the expected pattern of an infant of similar characteristics
Validity & Reliability of measurements
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Measurements
Weight Length Head Circumference Chest Circumference Abdominal Circumference
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Gestational Age Assessment
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Gestational Age Assessment: Estimating post-conceptual age of the neonate
An accurate assessment of age is important for 2 reasons Age and growth patterns
appropriate to that age aid in identifying neonatal risks
Help in developing management plans
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Gestational AgeAssessment There are 3 general methods to
determine gestational age Calculation of dates based on LMP Evaluation of obstetrical patterns Physical exam of the neonate
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Gestational Age Assessment Physical Assessment
Assessment of anterior vascular lens capsule using opthalmoscope Best done on the 2nd day of life
Assessment of neuromuscular and physical criteria by inspection and palpation
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Assessment of the
Anterior vascular lens capsule
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Grade 4, 27 – 28 wks
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Grade 3, 29 – 30 wks
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Grade 2, 31 – 32 wks
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Grade 1, 33 – 34 wks
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Modified Ballard
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Plotting Weight, Length, HC
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Pre-term: born before end of 37th week gestation
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Term
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AGA
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SGA: < 10th %
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LGA: >90th%
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Post term: Born after the 42nd week of pregnancy
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Low birth weight: 1500-2500g
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Very Low Birth weight: 1000-1500g
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Extremely very low birthweight: 500-1000g
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Skin
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Lanugo
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Plantar creases
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Ear cartilage
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Genitalia
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Neuromuscular Criteria
Posture Observe in the supine position Score is assigned based on the
degree of flexion of arms, knees and hips
Increased flexion and hip adduction with increased gestational age
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Neuromuscular Criteria
Square Window Infants hand is flexed on the
forearm between the thumb and index finger of the examiner
Apply enough pressure to get FULL flexion without rotating the wrist
Angle between the forearm and palm is measured
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Neuromuscular Criteria
Arm Recoil Flex the neonates arms for 5
seconds while in the supine position
Fully extend the arms by pulling on the hands and release
The degree of arm flexion and strength of recoil are scored
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Neuromuscular Criteria
Popliteal Angle Place infant in supine position with
the pelvis on the mattress Using the thumb and index finger of
one hand, examiner holds the knee adjacent to the chest and abdomen. Gently extend the leg with the index finger
Look at the angle between the lower leg, thigh and posterior knee
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Neuromuscular Criteria
Scarf sign Place infant in supine position with
head in mid-line position. Grasp the infants hand and pull the
arm across the chest and around the neck.
Look at the relationship of elbow to mid-line of body when arm pulls across the chest
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Neuromuscular Criteria
Heel to ear Place the infant supine with pelvis
flat on table. Grasp one foot with thumb and
index finger and draw foot as near to head as possible.
Note the distance between the foot and head as well as degree of knee extension
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Physical Criteria
Skin less transparent and tougher with
increasing gestational age 36-37 weeks loses transparency
and underlying vessels are no longer visable
Increasing gestational age the veins become less viable and increasing subcutaneous tissue
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Physical Criteria
Lunago Fine downy hair covering fetus
from 20-28 weeks Disappears around face and
anterior trunk ~28 weeks Term infants may have a few
patches over shoulders
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Physical Criteria Sole creases
28-30 weeks appear and cover the anterior portion of of the plantar surface of the foot
Extend toward the heel as increases gestational age
After 12 hours sole creases are not valid indicator of gestational age due to drying of the skin
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Physical Criteria
Breast tissue and aerola Aerola is raised by 34 weeks A 1-2 mm nodule of breast tissue
is palpable by 36 weeks By 40 weeks the nodule is 10mm
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Physical Criteria
Ears Incurving of the upper pinna
begins by 34 weeks gestation and extend entire lobe by 40 weeks
Before 34 weeks, pinna has very little cartilage (Stays folded on itself)
At 36 weeks, there is some cartilage and will spring back
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Physical Criteria
Female Genitalia Early gestation, clitoris prominent
and widely separated labia By 40 weeks, fat deposits have
increased in size in labia majora so labia minora are completely covered
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Physical Criteria
Male genitalia Testes begin to descend from
abdomen around 28 weeks At 37 weeks, testes can be
palpated high in scrotum At 40 weeks, testes are completely
descended and covered with rugae As gestation progresses, scrotum
becomes more pendulous
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CANSCORE Nine signs for assessing nutritional status in term infants
Hair Cheeks Chin & neck Arms Back
Buttocks Legs Chest Skin on Abdominal
wall
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CANSCORE, Fletcher, p34 Nine signs for assessing nutritional status in term infants
Hair Cheeks Chin & neck Arms Back
Buttocks Legs Chest Skin on
Abdominal wall
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Assessing Growth
Normal growth pattern Follows a predictable path Influenced by genetic &
environmental patterns Compare individual to himself over
time.
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State Related Behaviors
Visual responses Auditory responses Motor behavior Smile Habituation Consolability Cuddliness Readability