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Physical assessment of the neonate
- 1. Physical Assessment of theNewborn Presented by: Ms. Prajakta Patil SYMsc Nursing Student LTCON, Mumbai
- 2. Aim : Atthe end of session , the group will be able to implement knowledge of physical assessment of neonate while caring for neonate. Specific Objective : At the end of the session , the students will be able to : ♣ explain classification of newborn ♣ identify apgar score ♣ calculate growth measurements ♣ monitor vital signs ♣ estimate the gestational age ♣ check the different body systems ♣ describe normal findings in the newborn examination ♣ recognize common newborn problems
- 3. Assessment Gathering accurate, detaileddata that includes four components Review history Review results of physical exam Review available data Formulating an impression and plan
- 4. Comprehensive History Prerequisite foradequate assessment Alerts examiner to potential problems and may indicate the need for more frequent exam Gives clues to potential pathology
- 5. HISTORY Demographics Past Maternal illness& surgeries Maternal conditions Family History of congenital conditions Reproductive History Antepartum History Intrapartum History Social History
- 6. Prenatal Factors Affectingthe Newborn Diabetes Mellitus Hyperthyroid Phenylketonuria Systemic Lupus Erythematous Hypertension Smoking & substance abuse
- 7. Principles of PhysicalAssessment 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
- 8. Techniques of Physical Assessment Observation/Inspection Palpation Percussion Auscultation
- 9. Palpation Using the senseof touch Superficial Deep
- 10. Percussion The body’s structuresdiffer in density. To discern the location, size and density of a structure. Tympany Resonance Hyperresonance Dullness
- 11. MiniMuM prerequisites o Mother& baby together o Warm room o fresh clean sheet/clothes o Thermometer o Weighing scale o Watch with seconds o Stethoscope
- 12. Classification of newborn Classificationby birth weight Low birth weight < 2500 g Very low birth weight < 1500 g Extreme low birth weight < 1000 g
- 13. Classification of newborn Classificationby gestational age preterm <37 wks full term 37-4 postterm >42 wks Post term
- 14. Classification of newborn Classificationclassification by weight percentiles AGA 10th -90th percentile for GA
- 15. SGA < 10thpercentile for GA
- 16.
- 17. APGAR 0 12 1 min 5 min Activity (Muscle tone) Floppy Some flexion Well Flexed Pulse (HR) 0 <100 >100 Grimace (reflex irritability) No respons e Grimace Cough or sneeze Appearance (Color) Blue or pale Pink AC Pink all over Respirations Absent Slow, irregular, weak cry Good, strong cry 1958 APGAR SCORE
- 18. Apgar score maybe influenced by Preterm birth Administration of maternal drugs Congenital anomalies
- 19. Examination of newbornphysical examination include the following: 1. Vital signs 2. Physical exam 3. Neurological exam 4. Estimation of gestational age
- 20. 1. vital signs ♣temperature ♣ heart rate ♣ respiratory rate ♣ blood pressure ♣ capillary refill time
- 21. Temperature ♣ temperature shouldbe taken axillary ♣ the normal temperature for infant is 36.5 C - 37.5 C.ᵒ ᵒ ♣ axillary temp.is 0.5 C - 1 C lowerᵒ ᵒ than rectal temp
- 22. Heart rate ♣ itshould be obtained by auscultation and counted for a full minute ♣ normal heart rate is 120-160 bpm. ♣ if the neonate is tachycardic (heart rate >170 bpm), make sure the baby is not crying or moving vigorously.
- 23. Respiratory rate ♣ normalrespiratory rate is 40 –60/minute ♣ respiratory rate should be obtained by observation for one full minute ♣ newborns have periodic rather than regular breathing
- 24. Blood pressure ♣ itis not measured routinely ♣ normal blood pressure varies with gestational and postnatal ages
- 25. Capillary refill time ♣normally < 3 seconds over the trunk ♣ may be as long as 4 seconds on extremities ♣ delayed capillary refill time indicates poor perfusion
- 26. Physical examination Measurements There arethree components for growth measurements in neonates ♣ weight ♣ length ♣ head circumference ♣ All should be plotted on standardized growth curves for the infant’s gestational age
- 27. Weighing the baby Preparethe scale: cover the pan with a clean cloth/autoclaved paper; ensure the scale reads zero Preparing and weighing the baby Remove all clothing Wait till the baby stops moving Weigh naked Read and record Return the baby to the mother Scale maintenance Calibrate daily Clean the scale pan between each weighing EN-Teaching Aids: ENC 27
- 28. weight • weight offull term baby at birth is 2.6– 3.8kg. • babies less than 2.5 kg are considered low birth weight. • babies loose 5% – 10% of their birth weight in the first few days after birth and regain their birth weight by 7 – 10 days. • weight gain varies between 15-20 gm/day.
- 29. Length ♣ crown toheel length should be obtained on admission and weekly ♣ acceptable newborn length ranges from 48- 52 cm at birth
- 30. Head circumference ♣ headcircumference should be measured on admission and weekly ♣ using the measuring paper tape around the most prominent part of the occipital bone and the frontal bone ♣ acceptable head circumference at birth in term newborn is 33-38 cm
- 31. Plotting Weight, Length,Head Circumference
- 32. General examination 1-colour pallor: associatedwith low hemoglobin or shock cyanosis: associated with hypoxemia plethora: associated with polycythemia jaundice: elevated bilirubin Cyanosis, Acrocyanosis
- 33. skin • purpura,echymosis • mottling •vernix caseosa- a lubricant found on the skin or skin fold ,disappears as the fetus ages, almost absent in post- term Edema, Mongolian spots - dark blue bruise-like macular spots usually over sacrum ♣ in 90% of blacks and asians ♣ disappear by 4 yrs Collodion baby Rashes: Milia, Erythema toxicum, bullous impetigo, diaper rash, nevi
- 34. Cutis Marmorata Bluish mottlingor marbling of the skin (vascular response to cold)
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- 39. Bullous impetigo: pemphigus neonatorum Milia ♣ whitepapules < 1 mm in diameter scattered across the forehead, nose,cheeks ♣ sebaceous retention cysts disappear within wks
- 40. HEAD skull ♣macrocephaly and microcephaly, Anancephaly, Hydrocephalus ♣subgaleal hemorrhage ♣fontanelle ♣Caput succedaneum -edema of scalp skin, -crosses suture lines ♣Cephalhematoma • sub-periosteal • not cross suture lines
- 41.
- 42. Anterior and posteriorfontanelle • large anterior fontanelle is seen in hypothyroidism, osteogenesis imperfecta, hydrocephalus • small ant.fontanelle in microcephaly and craniostenosis •Bulging ant. Fontanelle in meningitis and hydrocephalus intracranial hemorrhage • depressed ant.fontanelle in dehydration • large post.fontanelle suspicious of hypothyroidism
- 43. Eyes ♣pupils: equality, reactivityto light. ♣ squint ♣ cornea ,conjunctiva, iris Subconjunctival hemmorrhage - benign condition resolve by 2-4 wks Congenital cataract: rubella Glaucoma Dysconjugate eye movements
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- 46. Ear examination -assess forasymmetry or irregular shape - note presence of auricular or pre-auricular pits, fleshy appendages, lipomas, or skin tags. - low set ears - • below lateral canthus of eye - • associated with genitourinary anomalies, because these areas develop at similar times. -malformed ears • can be associated with downs or turners syndromes
- 47.
- 48. Nose ♣patency of eachnostril: exclude choanal atresia ♣flaring of nostrils Dislocated nasal septum
- 49. Mouth ♣natal teeth ♣tongue size:Normal tongue Ankyloglossia(tongue tie), Macroglossia ♣cleft lip and palate -Unilateral cleft lip and cleft palate -Bilateral cleft lip and cleft palate ♣Epstein pearls & cheeks • small white cysts which contain keratin • frequently found on either side of the median raphe of the palate. • resolves in 1-2 month ♣ranulas – small bluish-white swellings of variable size on the floor of the mouth representing benign mucous gland retention cysts♣Oral thrush
- 50.
- 51. Neck ♣cysts: thyroglossal cyst, cystichygroma masses: sternomastoid tumor, thyroid Webbing hematoma in the middle third of the sternomastoid muscle torticolis, limitation of lateral rotation of the neck
- 52.
- 53. Musculoskeletal ♣ Syndactyly • simple– involves soft tissue attachment only • complex – involves fusion of bone or nail • partial - web extends from base partially • complete - web from base to tip of finger • radiographs needed to determine degree of fusion should refer to orthopedics. Erb’s palsy
- 54. Back inspect back for spinecurvature examine for spina bifida pilonidal dimple meningeocele, Meningiomyelocele
- 55. Normal breathing 30 to60 breaths per minute No chest in-drawing, no grunting on breathing out When assessing breathing: Count number of breaths for a full minute Babies may breathe irregularly for short periods of time Small babies (<2.5 kg or born before 37 wks gestation) may: Have some mild chest in-drawing Periodically stop breathing for a few seconds EN-Teaching Aids: ENC 55
- 56. Chest/lung examination • inspection: –supernumerary breast or nipple is common (10%) – breast enlargement secondary to maternal hormones – unilateral absence or hypoplasia of pectoralis major, - poland's syndrome (poland's sequence) - widely spaced nipples( turner's syndrome) - noonan syndrome
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- 61. Heart and vascularsystem ♣ Check for :♣ tachypnea,tachycardia ♣ increased pericordial activity ♣ cyanosis: hyperoxia test ♣ palpate femoral pulsation: absent in coarctation of the aorta ♣ bounding pulses often indicated PDA ♣ murmurs or irregular heart rhythm ♣ URSB for aortic valve ♣ ULSB for pulmonary valve ♣ LLSB for the tricuspid area for ventricular septal defects ♣ the apex for mitral valve
- 62. Abdomen ♣ cylindrical inshape ♣Normal umbilical cord • bluish white at birth with 2 arteries & one vein. Meconium stained umbilical cord, bleeding, granuloma, discharge, inflammation ♣organomegaly: liver may be palpable 1-2 cm below the costal margin .spleen is at the costal margin ♣ masses, distension , scaphoid abdomen
- 63. Abdomen Omphalocele defect coveredby amnion, with cord attachment to apex of defect. Herniation through defect: any abdominal organs
- 64. Genitalia and rectum ♣male genitalia • in full term,scrotum is well developped,with deep rugae. Both testes are in the scrotum • in preterm,scrotum is small with few rugae.testes are absent or high in the scrotum abnormalities. undescended testis hydrocele, inguinal hernia Hypospadius meatus Epispadius meatus
- 66. Genitalia and rectum ♣Femalegenitalia • in full term,labia majora completely cover labia minora • in preterm,labia majora is widely separated and labia minora protruded • a discharge from the vagina or withdrawal bleeding may be observed in the first few days • infant with ambiguous genitalia should not undergoe gender assignment until endocrinal evaluation is performed Withdrawal bleeding
- 67. Imperforate anus The anusis inspected for its location and patency . An imperforate anus is not always immediately apparent. Thus, patency often is checked by careful insertion of a rectal thermometer to measure the baby's first temperature • Meconium should pass in the first 48h after birth • Delayed passage of meconium may indicate imperforate anus or intestinal obstruction • Urine should pass in the first 24h of life
- 68. ♣neonatal reflexes: Moro Grasp tonic neck steppingand placing rooting &suckling.
- 69. Recaptualisation Baby of Archanawas born to a Primigravida mother at term, baby is now 20 hours of age noticed to have yellowness of face and trunk. Q. - What is the problem? Q. - What action you will take? Baby of Radhika was born with weight of 1.5kg. Baby weighs 1.3 kg today on day 2. Q. - What are your concerns? Q. - What action you will take?
- 70. ASSIGNMENT Exact locations ofRetractions in neonate ? Explain classification of neonate.
- 71. Conclusion All newborn babiesmust be examined at Birth 24 hrs Before discharge and Follow-up A systematic approach consisting of ‘Ask, Check, Look, Listen, Feel’ should be followed at each assessment
Editor's Notes
- #35 Bluish mottling or marbling of the skin. Seen in response to: chilling, stress, overstimulation. Caused by dilation of the capillaries and disappears when the infant is warmed. So….. If you have a calm warm infant and see this it might alert you to: trisomy 21, 18, cornelia de lange syndrome.
- #36 Only seen in the newborn period. It occurs in both healthy and ill infants. It is the temporary imbalance of the autonomic regulatory mechanism of the cutaneous vessels. It can last anywhere from 1-30 minutes. It can change depending on which side of the body is the dependent half of the body (red color in the dependent part, white in the superior part).
- #38 Discolored flat spot less than 1 cm in diameter Nevi-lower back and buttocks, with or without hair Café au lait- can be normal but greater than 3-5 can be indicative of neurofibromatosis
- #39 Transient neonatal pustular melanosis. This is a benign neonatal dermatosis that is most common among African- American infants. The original lesion is a vesiculopustule, which may be present at birth. This small blister quickly ruptures and leaves a typical collarette of superficial scale processes, such as neonatal herpes simplex. Tzanck smear of a pustule of erythema toxicum neonatorum will reveal numerous eosinophils but no multinucleated giant cells or bacteria. An affected baby may suddenly lose his or her active behavior and become lethargic. The baby may stop caring about things such as feeding, or may do just the opposite and become very irritable. This, of course, is a very common thing in normal babies as well, but an irritable baby should be assessed to make sure it is nothing more than &quot;just colic.&quot; Shaking, twitching, or fits - like epileptic fits - should be checked out by a physician without delay. Babies with herpes infection of the nervous system may have skin sores, but very often a baby with serious herpes infection shows no skin problem whatsoever.
- #45 A coloboma (from the Greek koloboma, meaning defect,[1]) is a hole in one of the structures of the eye, such as the iris, retina, choroid, or optic disc. The hole is present from birth and can be caused when a gap called the choroid fissure, which is present during early stages of prenatal development, fails to close up completely before a child is born. The classical description in medical literature is of a key-hole shaped defect. A coloboma can occur in one eye (unilateral) or both eyes (bilateral). Most cases of coloboma affect only the iris. People with coloboma may have no vision problems or may be blind, depending on severity. It affects less than one in every 10,000 births. These red spots are called subconjunctival hemorrhages. They are common in newborns and typically result from the normal trauma of birth. As newborns are squeezed through the birth canal blood vessels (on the eyes and elsewhere) can rupture. Subconjunctival hemorrhages are basically bruises of the eye. As with any bruising in newborns, they increase the risk of jaundice. Subconjunctival hemorrhages resolve over 2 to 4 weeks. blue when you were born. Why? Melanin, the brown pigment molecule that colors your skin, hair, and eyes, hadn&apos;t been fully deposited in the irises of your eyes or darkened by exposure to ultraviolet light. The iris is the colored part of the eye that controls the amount of light that is allowed to enter. Some other animals are born with blue eyes, too, such as kittens. Melanin is a protein. Like other proteins, the amount and type you get is coded in your genes. Irises containing a large amount of melanin appear black or brown. Less melanin produces green, gray, or light brown eyes. If your eyes contain very small amounts of melanin, they will appear blue or light gray.
- #46 A coloboma (from the Greek koloboma, meaning defect,[1]) is a hole in one of the structures of the eye, such as the iris, retina, choroid, or optic disc. The hole is present from birth and can be caused when a gap called the choroid fissure, which is present during early stages of prenatal development, fails to close up completely before a child is born. The classical description in medical literature is of a key-hole shaped defect. A coloboma can occur in one eye (unilateral) or both eyes (bilateral). Most cases of coloboma affect only the iris. People with coloboma may have no vision problems or may be blind, depending on severity. It affects less than one in every 10,000 births. These red spots are called subconjunctival hemorrhages. They are common in newborns and typically result from the normal trauma of birth. As newborns are squeezed through the birth canal blood vessels (on the eyes and elsewhere) can rupture. Subconjunctival hemorrhages are basically bruises of the eye. As with any bruising in newborns, they increase the risk of jaundice. Subconjunctival hemorrhages resolve over 2 to 4 weeks. blue when you were born. Why? Melanin, the brown pigment molecule that colors your skin, hair, and eyes, hadn&apos;t been fully deposited in the irises of your eyes or darkened by exposure to ultraviolet light. The iris is the colored part of the eye that controls the amount of light that is allowed to enter. Some other animals are born with blue eyes, too, such as kittens. Melanin is a protein. Like other proteins, the amount and type you get is coded in your genes. Irises containing a large amount of melanin appear black or brown. Less melanin produces green, gray, or light brown eyes. If your eyes contain very small amounts of melanin, they will appear blue or light gray.
- #48 Ear anomalies are usually non specific and are supportive rather than diagnostic
- #51 The small white papule seen in the midline of the palate of this infant is an Epstein pearl. It represents epithelial tissue that becomes trapped during the palatal fusion. It is a very common and benign finding. Neonatal teeth erupt within the first 30 days of life. As many as 85 percent of these are a part of the normal primary dentition and are not supernumerary (extra teeth). Often, these teeth are hypermobile, and aspiration is a concern. Cleft lip (cheiloschisis) and cleft palate (palatoschisis), which can also occur together as cleft lip and palate, are variations of a type of clefting congenital deformity caused by abnormal facial development during gestation. A cleft is a fissure or opening—a gap. It is the non-fusion of the body&apos;s natural structures that form before birth
- #58 Increased work of breathing: Tachypnea: respiratory rate &gt;60/minute (increased respiratory rate to maintain ventilation in the face of decreased tidal volume) Grunt: partial closure of glottis during expiration (attempt to maintain lung volume and allow for adequate gas exchange) Nasal flaring: attempt to decrease airway resistance Suprasternal retractions/ tracheal tug: suggests upper airway obstruction Subcostal retractions: less specific sign, associated with either pulmonary or cardiac disease Direct Auscultation: Grunting can be a sign of respiratory distress in a newborn. Grunting frequently occurs in combination with nasal flaring and intercostal or subcostal retractions as all three are associated with increased work of breathing. The distinctive sound of grunting is produced when the glottis is closed during expiration. This increases end-expiratory pressure in the lungs (similiar to increasing the PEEP setting on a ventilator) and helps to improve oxygenation to the patient. Although occasional grunt can at times be heard in healthy infants during normal crying. Stridor is an occasionally encountered sound in an otherwise healthy newborn. It is a high-pitched whistling sound that occurs on inspiration and is typically audible without using a stethescope. In newborns, it is most commonly caused by laryngomalacia, however other congenital anomalies (vascular slings, double aortic arch, vocal cord paresis, etc) should be considered. Laryngoscopy can confirm the diagnosis of mild laryngomalacia.
- #64 Gastroschisis is an abdominal wall defect to the side of the umbilical cord (umbilicus). The infant is born with intestines protruding through the defect and no protective sac is present. Gastroschisis is rarely associated with other birth defects. Gastroschisis is a life-threatening event requiring immediate intervention.