PhysicalAssessment of the Newborn

Assessment

Two fundamental types of exams

Periodic comprehensive exam

Problem specific exam

Assessment

Gathering accurate, detailed data that includes four components Review history Review results of physical exam Review available data Formulating an impression and

plan

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

Medical History

Demographics Past Maternal illness & surgeries Maternal conditions Family History of congenital

conditions Reproductive Hx Antepartum Hx Intrapartum Hx Social Hx

Prenatal Factors Affecting the Newborn

Diabetes Mellitus Hyperthyroid PKU Systemic Lupus Erythematosus Hypertension Smoking & substance abuse

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

Refresh your anatomy

Techniques of Physical Assessment

Observation / Inspection

Palpation Percussion Auscultation

Inspection Auscultation Palpation Percussion

Inspection / Observation

Most important technique to master

Alerts examiner to areas needing more thorough assessment

General / Visual Auditory Olfactory

Palpation Using the sense of touch

Superficial Deep

Percussion

The body’s structures differ in density.

To discern the location, size and density of a structure. Tympany Resonance Hyperresonance Dullness

Percussion techniques

Direct Indirect Blunt

Not use frequently in the neonate

Auscultation

Listening to sounds produced by internal body structures Indirect - using the appropriate

stethoscope Direct - audible

Order of Examination

General observation Head and neck region

Facies Nose Mouth Ears

Order of Examination

Trunk Cardiopulmonary systems Abdomen Back Genitalia and rectum

Order of Examination

Extremities Neurologic exam Eye Exam

Equipment

Ophthalmoscope Stethoscope Otoscope Transilluminater

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

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.

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

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.

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

Apgar score may be influenced by

Preterm birth Administration of maternal drugs Congenital anomalies

Before leaving the DR

Inspect for birth injuries/anomalies Evaluate pulmonary &

cardiovascular stability Inspect extremities Inspect genitalia

Evaluating Transition

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

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

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?

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

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

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

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

Periods of Reactivity

Sympathetic activity Color Respiration Heart Rate Behavioral state Gastrointestinal function Temperature

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

Sensory

Chemistry

Thermal

Mechanical

Stimulus for breathing

Cardiovascular Adaptations

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

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.

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)

Cold Stress

Increased Metabolic Rate Increased need for O2 Increased respiratory rate Anaerobic metabolism Metabolic Acidosis, fatigue & CV

collapse

Observe for signs of physical abnormalities

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

Signs of Distress

Increased respiratory rate (tachypnea) Difficult respirations (dyspnea) Retractions Excessive mucous Cyanosis Facial grimacing Abdomen scaphoid or distended

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

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

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

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)

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

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?

Before leaving DR

Inspect for birth injuries Congenital anomalies Evaluation of pulmonary &

cardiovascular stability Extremities Genitalia

Facilitate Infant’s Relationship with Parents

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

Assessing Growth

Weight, Length, Head & Chest

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

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

Measurements

Weight Length Head Circumference Chest Circumference Abdominal Circumference

Gestational Age Assessment

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

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

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

Assessment of the

Anterior vascular lens capsule

Grade 4, 27 – 28 wks

Grade 3, 29 – 30 wks

Grade 2, 31 – 32 wks

Grade 1, 33 – 34 wks

Modified Ballard

Plotting Weight, Length, HC

Pre-term: born before end of 37th week gestation

Term

AGA

SGA: < 10th %

LGA: >90th%

Post term: Born after the 42nd week of pregnancy

Low birth weight: 1500-2500g

Very Low Birth weight: 1000-1500g

Extremely very low birthweight: 500-1000g

Skin

Lanugo

Plantar creases

Ear cartilage

Genitalia

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

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

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

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

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

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

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

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

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

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

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

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

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

CANSCORE Nine signs for assessing nutritional status in term infants

Hair Cheeks Chin & neck Arms Back

Buttocks Legs Chest Skin on Abdominal

wall

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

Assessing Growth

Normal growth pattern Follows a predictable path Influenced by genetic &

environmental patterns Compare individual to himself over

time.

State Related Behaviors

Visual responses Auditory responses Motor behavior Smile Habituation Consolability Cuddliness Readability