Power point -_assessment_of_the_neonate (1)
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This document provides guidelines for assessing the health of a newborn infant. It describes evaluating the infant's history including prenatal and delivery factors. Physical appearance is assessed including skin, tone, head size and overall appearance. Vital signs like temperature, heart rate, respiratory rate and status are examined. Laboratory tests including arterial and capillary blood samples are outlined. Gestational age assessment tools like the Dubowitz Scale and Ballard Scale are presented. Proper technique for obtaining capillary blood samples is also covered.
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Power point -_assessment_of_the_neonate (1)
- 1. Assessment of the Neonate 220a
- 2. History – Prenatal • Gestational age • History of previous pregnancies
- 3. History – Prenatal • Problems during pregnancy – Eclampsia – History of drug abuse – Maternal history of diabetes – History of infections
- 4. History – Labor • Length of labor • Difficulties during labor • Monitoring results during labor
- 5. History – Delivery • APGAR scores • Presentation • Interventions in the delivery room
- 6. Physical Examination – Assessment of Gestational Age • Two primary evaluation tools used to determine gestational age – Dubowitz Scale – Ballard Scale
- 7. Dubowitz Scale – External Superficial Criteria EXTERNAL SIGN SCORE RECORD SCORE 0 1 2 3 4 HERE EDEMA Obvious edema of hands & feet; pitting over tibia No obvious edema of hands & feet; pitting over tibia No edema SKIN TEXTURE Very thin, gelatinous Thin & smooth Smooth, medium thickness. Rash or superficial peeling Slight thickening. Superficial cracking and peeling, esp. hands, feet Thick and parchment like; superficial or deep cracking SKIN COLOR (Infant not crying) Dark red Uniformly pink Pale pink, variable over body Pale. Only pink over ears, lips palms, or soles SKIN CAPACITY (Trunk) Numerous veins and venules clearly seen, esp. over abdomen Veins and tributaries seen A few large vessels clearly seen over abdomen A few large vessels seen indistinctly over abdomen No blood vessels seen
- 8. Dubowitz Scale – External Superficial Criteria – Cont EXTERNAL SIGN SCORE RECORD SCORE 0 1 2 3 4 HERE LANUGO (Over back) No lanugo Abundant; long thick over whole back Hair thinning, esp. over lower back Small amount of lanugo and bald areas At lest half of back devoid of lanugo PLANTAR CREASES No skin creases Faint red marks over anterior half of sole Definite red marks over more than anterior half; indentations over less than anterior third Indentations over more than anterior third Definite deep indentations over more than anterior third NIPPLE FORMATION Nipple barely visible; nor areola Nipple well-defined; areola smooth and flat; diameter < 0.75 cm Areola stippled, edge not raised; diameter < 0.75 cm BREAST SIZE No breast tissue palpable Breast tissue on one or both side <0.5 cm diameter Breast tissue both sides, one or both 0.5-1.0 cm
- 9. Dubowitz Scale – External Superficial Criteria – Cont EXTERNAL SIGN SCORE RECORD SCORE 0 1 2 3 4 HERE EAR FORM Pinna flat and shapeless, or no incurving of edge Incurving of part of edge of pinna Partial incurving of whole of upper pinna EAR FIRMNESS Pinna soft, easily folded, no recoil Pinna, soft, easily folded, slow recoil Cartilage to edge of pinna, but soft in places, ready recoil Pinna firm, cartilage to edge, instant recoil GENITALIA MALE/FEMALE (With hips half abducted) Neither testi in scrotum Labia majora widely separated, labia minora protruding At lest one testis high in scrotum Labia majora almost cover labia minora At least one testis fully descended. Labia majora complete cover labia minora
- 10. Dubowitz Scale – Neurological Criteria Neurological Sign Score Record Score Here 0 1 2 3 4 5 Posture Square Window Ankle Dorsiflexion Arm Recoil Leg Recoil Popliteal Angel Heel to Ear Scarf Sign Head lag Ventral Suspension
- 11. Dubowitz Scale – Neurological Criteria – Cont Total Score Gestational Age (weeks) Total Score Gestational Age (weeks) Total Score Gestational Age (weeks) 10 12 14 16 18 20 22 24 26 28 27.2 27.8 28.3 28.8 29.4 29.9 30.4 30.9 31.5 32.0 30 32 34 36 38 40 42 44 446 48 32.5 33.0 33.6 34.1 34.6 35.2 35.7 36.2 36.7 37.3 50 52 54 56 58 60 62 64 66 68 37.8 38.3 38.9 39.4 39.9 40.4 41.0 41.5 42.0 42.6
- 12. Ballard Scale
- 13. Ballard Scale - Cont
- 14. Physical Examination – Assessment of Gestational Age • Necessary to determine course of infant and anticipate problems that may occur
- 15. Physical Examination – Physical Appearance • Skin – Generally pink – During first 24 hours of life, may have acrocyanosis, bluish tinge of the hands and feet
- 16. Physical Examination – Physical Appearance • Skin – Yellowish tinge • Indicates the presence of hyperbilirubinemia with bilirubin level > 4 mg/dL
- 17. Physical Examination – Physical Appearance • Skin – Yellowish Tinge • Physiologic jaundice – Present in many infants first few days after birth – Caused by break down of fetal red blood cells and inability of neonatal liver to conjugate the bilirubin
- 18. Physical Examination – Physical Appearance • Skin – Yellowish tinge • Physiologic jaundice – Normally does not require treatment or may require exposure to phototherapy lights or sunlight to aid in lowering the level of bilirubin
- 19. Physical Examination – Physical Appearance • Skin – Yellowish Tinge • Pathologic jaundice – Appears within first 24 hours of life – Indirect bilirubin levels > 13 mg/dL in term infants or > 15 mg/dL in premature infants – Direct bilirubin levels > 1.5 mg/Dl – Indirect levels rise greater than 5 mg/dL in 24 hour period
- 20. Physical Examination – Physical Appearance • Skin • Pathologic Jaundice – Causes Kernicterus » Bilirubin encephalopathy Kernicterus » May result in neurological deficits, including locomotor dysfunction, cerebral palsy, and hearing impairment » In extreme cases, may be treated by exchange transfusion
- 21. Physical Examination – Physical Appearance • Skin – Meconium staining • Indicative of intrauterine asphyxia
- 22. Physical Examination – Physical Appearance • Skin – Pale • Indicates severe anemia • May result from Rh incompatibility • May result from placental abruption
- 23. Physical Examination – Physical Appearance • Skin – Vernix • White, cream cheese-like material covering the fetus • Indicative of prematurity • Decreases at week 36 and disappears by week 41
- 24. Physical Examination – Physical Appearance • Lanugo – Fine, downy hair covering the fetus – Thins around week 28 and disappears by week 32
- 25. Physical Examination – Physical Appearance • General overall tone – Asymmetry in movement • Birth injury • Paralysis • Neurological impairment
- 26. Physical Examination – Physical Appearance • General overall tone – Usually in fetal position • Legs drawn to abdomen, arms flexed, tight to body
- 27. Physical Examination – Physical Appearance • Overall appearance – Head in proportion to body • Large head may indicate hydrocephaly • Small head may indicate microcephaly or anencephaly
- 28. Hydrocephaly
- 29. Microcephaly
- 30. Anencephaly
- 31. Physical Examination – Physical Appearance • Overall appearance – Abdomen • Should move up as chest moves up • Lag on inspiration indicates mild distress • Opposing movement (see-saw movement) in relation to chest indicates severe distress
- 32. Physical Examination – Physical Appearance • Overall appearance – Scaphoid abdomen • Concave abdomen • May indicate diaphragmatic hernia or agenesis of abdominal organs – No obvious defects or abnormalities
- 33. Physical Examination – Vital Signs • Temperature – Normal value – 37⁰ C – Axillary temperature most common site
- 34. Physical Examination – Vital Signs • Temperature – Neutral thermal environment • Environmental temperature at which infant’s metabolic demands and oxygen consumption is minimized – Chilling the infant causes increasing metabolic rate and oxygen consumption; infants incapable of shivering to respond to cold – Overheating infant increases metabolism as infant tries to cool; may cause apnea
- 35. Physical Examination – Vital Signs • Temperature – Neutral thermal environment • Based upon weight and gestational age • Ratio of body surface area to body mass is greater in newborn, so heat loss is increased in comparison to adult; in 1 kg infant, heat loss is 6 times greater
- 36. Physical Examination – Vital Signs • Heart rate – Normal Value – 120 to 160 beats per minute – Measured either apically or at the brachial artery
- 37. Physical Examination – Vital Signs • Respiratory rate – May be observed, but most accurate if counted via auscultation – Normal value – 30 to 60 breaths per minute
- 38. Physical Examination – Vital Signs • Respiratory rate – Periodic breathing • Periods of apnea lasting less than 20 seconds • Common in pre-term infants • No change in heart rate observed
- 39. Physical Examination – Vital Signs • Respiratory rate – True apnea • Lasts at least 20 seconds • Accompanied by bradycardia
- 40. Physical Examination – Vital Signs • Respiratory rate – True apnea • Primary apnea – Initial apnea after attempt at breathing – Responds to stimulation
- 41. Physical Examination – Vital Signs • Respiratory rate – True apnea • Secondary apnea – Occurs after continuing oxygen deprivation and attempts to gasp – Does not respond to stimulation; assisted ventilation required
- 42. Physical Examination – Vital Signs • Respiratory status – Retractions • Inward movement of the skin of the chest during inspiration
- 43. Physical Examination – Vital Signs • Respiratory status – Retractions • Location of retractions – Intercostal – Subcostal – Substernal – Supraclavicular
- 44. Physical Examination – Vital Signs • Respiratory status – Retractions • Indicates respiratory distress, increased inspiratory effort • Intercostal retractions – occur between the ribs • Xyphoid retractions – occur as the xyphoid is drawn inward
- 45. Physical Examination – Vital Signs • Respiratory status – Nasal flaring • Widening of the nares during inspiration and returning to normal during expiration • Attempt by the infant to get more volume into the lungs • Uses principle of Poiseuille’s Law
- 46. Physical Examination – Vital Signs • Respiratory status – Expiratory grunt • Sound produced as infant exhales against a partially closed glottis • Analogous to pursed lip breathing in COPD patients • Used instinctively to generate positive pressure in the airway to maintain integrity of the alveoli
- 47. Physical Examination – Vital Signs • Respiratory status – Silverman-Anderson Index • Used to evaluate respiratory status
- 48. Silverman-Anderson Index Upper Chest Lower Chest Xyphoid Retractions Nasal Flaring Expiratory Grunt 0 Synchronized No Retractions None None None 1 Lag on Inspiration Just Visible Just Visible Minimal Audible on Auscultation Only 2 See-Saw Marked Marked Marked Audible With Naked Ear • Significance of Silverman-Anderson Score – the Greater the Number, the More Distress the Infant is in
- 49. Laboratory Data – Arterial Samples • Umbilical artery – Preferred site – May not produce valid results in presence of patent ductus arteriosus – May cause infection or thromboembolism
- 50. Laboratory Data – Arterial Samples • Radial artery – More difficult to obtain – May be inaccurate secondary to crying induced by pain of stick
- 51. Laboratory Data – Arterial Samples • Radial artery – Used to determine presence of patent ductus arteriosus – compare samples from right radial artery and umbilical artery (more common method is echocardiogram)
- 52. Laboratory Data – Arterial Samples • Normal values for neonatal arterial samples – PaO2 – 50 to 70 mmHg – PaCO2 – 35 to 45 mmHg – pH – 7.35 to 7.45 – HCO3 - − 22 to 26 mEq/L
- 53. Laboratory Data – Capillary Samples • Less hazardous and more easily obtained than arterial sticks • Useful in assessing pH and PCO2 – PCO2 and pH will approximate arterial values – PO2 less than arterial value, but degree of variation is unreliable for management
- 54. Laboratory Data – Capillary Samples • Indications – Arterial blood gas analysis is indicated but not available – Non-invasive monitor readings are abnormal – Assessment of initiation, administration, or change in therapeutic modalities is indicated
- 55. Laboratory Data – Capillary Samples • Indications – Change in patient status is detected by history or physical assessment – Monitoring of the severity and progression of a documented disease process is desirable
- 56. Laboratory Data – Capillary Samples • Contraindications – Unsuitable sites are only sites available • Posterior curvature of heel • Finger of neonate • Previous puncture site • Inflamed, swollen, or edematous tissue
- 57. Laboratory Data – Capillary Samples • Contraindications – Unsuitable sites are only sites available • Cyanotic or poorly perfused tissue • Localized areas of infection • Peripheral arteries
- 58. Laboratory Data – Capillary Samples • Contraindications – Patients less than 24 hours old – Need for direct analysis of oxygenation – Peripheral vasoconstriction – Polycythemia – Hypotension
- 59. Laboratory Data – Capillary Samples • Hazards and complications – Infection – Burns – Hematomas – Bone calcification
- 60. Laboratory Data – Capillary Samples • Hazards and complications – Nerve damage – Bruising – Scarring
- 61. Laboratory Data – Capillary Samples • Hazards and complications – Laceration of tibial artery – Pain – Hemorrhage
- 62. Technique for Obtaining a Capillary Sample • Verify physician’s order and need for procedure • Ensure that the conditions of the patient have not changed, e.g., no change in FIO2 • Assemble the required supplies
- 63. Technique for Obtaining a Capillary Sample • Wash hands and don gloves • Warm the heel to approximately 42⁰ C using a heat pack or other method • Clean the area with an antiseptic solution
- 64. Technique for Obtaining a Capillary Sample • Puncture the skin with the lancet • Wipe away the first drop of blood and observe flow • Do not squeeze
- 65. Technique for Obtaining a Capillary Sample • Fill the sample tube from the middle of the drop of blood • Place the metal flea in the capillary tube and seal both ends
- 66. Technique for Obtaining a Capillary Sample • Cover the site of the puncture with a band-aid or sterile cotton • Mix the sample by moving the flea back and forth using the magnet
- 67. Technique for Obtaining a Capillary Sample • Place the sample in an icy slush for transport • Dispose of contaminated materials properly • Document the procedure