newborn physical assessment

Newborn Physical Assessment : 

Newborn Physical Assessment Tiffany Stanley ARNP

Overview : 

Overview Newborn cannot provide verbal information   Most infants are normal   Initially physical assessment is time consuming   Sequence is not as important as consistent and organized approach maximizes information gained and ensures things are not forgotten

Techniques : 

Techniques Observation   Auscultation   Palpation   Percussion   Transillumination

Observation : 

Observation Distress Color Nutrition Hydration Gestational age Neurologic Respiratory Cardiovascular Abdomen Head Eyes Ears Nose Mouth Neck Genitalia Skin Extremities

Auscultation : 

Auscultation Technique of listening to sounds produced by the body   Indirect auscultation requires a stethoscope   should be placed firmly on bare skin   quiet infant and environment   warm room and stethoscope

Palpation : 

Palpation Examiner uses sense of touch to assess sperficial and deeper body characteristics   Tips, palmar, and lateral surfaces of the fingers and hands are used to assess external structures, vibrations, and internal structures   One hand can be used or a bimanual technique may enhance palpation of deeper organs

Palpation : 

Palpation Infant should be quiet and relaxed   Warm hands, progress from superficial to deeper palpation   Elevate infant's hips off bed to keep abdominal muscles relaxed

Percussion : 

Percussion Tapping or striking a part of the body to put the underlying tissue into motion   Movement produces audible sounds and palpable vibrations

Transillumination : 

Transillumination Technique of applying high-intensity light directly to a body part and assessing amount of pink light that can be seen as a corona around the fiberoptic device

Basics : 

Basics Review history for clues to potential pathology   Assess the infant's color for potential pathology   Auscultate only in a quiet environment   Keep infant warm   Have necessary tools ready   Handle the infant gently   Complete the exam

Sample Approach : 

Sample Approach 1. Observe - before touching the infant as well as during each part of the hands-on exam   2. Auscultate - after close observation auscultate lungs, heart, and abdomen, concentrate and separate each of the sounds   3. Palpate - first femoral pulses, then brachial pulses; next abdomen, first superficial then deep.   4. Head-to-Toe exam - assess infant from head to toe.

Neonatal History : 

Neonatal History A comprehensive history is necessary for adequate assessment   Starts with maternal/pregnancy/delivery that leads up to infant's transitional experience   Alerts the examiner to potential or suspected problems   Provides context

Gestational Age Assessment : 

Gestational Age Assessment Process of estimating age from conception until time of evaluation   Provides knowledge of neonatal risk

Determining Gestational Age : 

Determining Gestational Age 1. Calculation based on mother's last mentstrual period   2. Evaluation of obstetric parameters obtained during prenatal period   3. Physical examination

Gestational Age Assessment : 

Gestational Age Assessment Anterior vascular capsule of the lens limited to 27-34 weeks, and can be influenced by maternal factors, such as hypertension, and must be examined by 24 - 48 hours of life Neuromuscular and physical criteria (Ballard score) 6 neuromuscular and 6 physical

Ballard/Dubowitz Score : 

Ballard/Dubowitz Score Infant is examined for the 6 neuromuscular and 6 physical criteria and given a score for each. The nuromuscular and physical category scores are added to obtain final maturity rating Exam should be performed in the first 48 hours Sometimes neuromuscular exam is unreliable - asphyxia, medications administered in the pre and postnatal periods - may use physical criteria multiplied by 2 (not as accurate)

Neuromuscular Maturity : 

Neuromuscular Maturity

Physical Maturity : 

Physical Maturity

Maturity Rating : 

Maturity Rating

Skin Assessment : 

Skin Assessment Follow the same pattern every time   Adequate light and warmth   Inspect color, consistency, thickness, and opacity   Distribution of hair   Note any obvious markings or anomalies   Inspect all skin surfaces, including back, axilla, groin

Skin Assessment : 

Skin Assessment Erythema Toxicum Normal peeling

Skin Assessment : 

Skin Assessment Palpate assess turgor, thickness, and subcutaneous fat presence of edema irregularities in texture or consistency

Head : 

Head Shape molding distortions Sutures may be overriding mobile Fontanels soft and flat Scalp caput succedneum cephalhematoma subgaleal hemorrhage trauma Face  shape and symmetry

Eyes and Ears : 

Eyes and Ears Eyes bruises or edema of eyelids may be normal conjunctival or subconjunctival hemorrhages nevus simplex (stork bite) drainage observe placement ophthalmoscope - red retinal reflex, pupillary reflex Ears Observe shape and symmetry Observe placement Assess for malformations - can be associated with other anomolies

Eyes and Ears : 

Eyes and Ears Subjunctival hemorrhage Eyelid edema

Nose and Mouth : 

Nose and Mouth Nose nasal flaring stuffiness symmetry patency Mouth color shape sucking callous philtrum lips jaw - micrognathia toungue palate Epstein pearls teeth

Neck : 

Neck Observe length symmetry masses range of motion Palpate masses redundant skin/webbed neck

Chest and Lungs : 

Chest and Lungs Observe color, tone, and activity respiratory rate and pattern general appearance - relaxed, symmetry retractions nipples

Chest and Lungs : 

Chest and Lungs Auscultate  use both bell and diaphragm begin at the top of the chest and move systematically from side to side breath sounds in lower lobes best heard on back

Chest and Lungs : 

Chest and Lungs Normal breath sounds vesicular soft, short, low pitched during expiration higher pitched during inspiration bronchial short inspiration and longer expiration - not generally heard in neonates

Chest and Lungs : 

Chest and Lungs Adventitious sounds (abnormal) Crackles - crackling or bubbling Rhonchi - more musical, not usually heard in neonate Wheezes - high pitched, inspiratory/expiratory, not usually heard in newborn Rubs - associated with inflammation of pleura, generally only heard during mechanical ventilation Stridor - high pitched, hoarse; during inspiration or expiration; indicative of airway obstruction Bowel sounds - referred from abdomen, or diaphragmatic hernia

Chest and Lungs : 

Chest and Lungs Palpation clavicles especially if history of shoulder dystocia breast tissue

Cardiovascular : 

Cardiovascular Newborn cardiovascular system very dynamic as infant transitions from fetal circulation Changes over the first hours, days, and weeks of life Assessment should be done at 6-12 hours of life and again at 1-3 days of life History is important as many maternal conditions have potential cardiovascular implications for infant Includes most of the other systems

Cardiovascular : 

Cardiovascular Observe overall appearance and behavior color - central vs peripheral cyanosis perfusion - pallor or mottling respiratory pattern precordium apical impulse

Cardiovascular : 

Cardiovascular Auscultate heart rate rhythm - note any irregularity heart sounds S1 - closure of the mitral and tricuspid valves S2 - closure of the aortic and pulmonic vavles 4 ausculatory areas of heart

Cardiovascular : 

Cardiovascular Auscultate Murmur turbulent blood flow innocent and pathologic Palpate capillary refill time pulses - femoral and brachial apical impulse - 4th intercostal space midclavicular line use light palpation

Abdominal Assessment : 

Abdominal Assessment Observe Skin pink, rash, veins Shape round easy movements with respirations flat or distended Umbilical Cord shiny, gelatinous, 2 arteries, 1 vein

Abdominal Assessment : 

Abdominal Assessment Auscultation warm stethascope, quiet infant listen to all four quadrants relatively quiet until feeds start every 15-20 seconds Palpation liver (1-2 cm below right costal margin) spleen - not usually palpable kidneys entire abdomen groin and femoral area - quiet and crying bulges (hernias)

Genitourinary Assessment : 

Genitourinary Assessment Male Genitalia observe skin color, rugae palpate scrotal sac and inguinal canal for testes firm, smooth, mobile, and equal in size gentle traction to foreskin to visualize urethral meatus penis straight length and width may need to depress fat pad

Genitourinary Assessment : 

Genitourinary Assessment Normal term male

Genitourinary Assessment : 

Genitourinary Assessment Female Genitalia observe labia majora usually cover minora and clitoris vaginal opening hymenal tag discharge palpate labia and inguinal area for bulges, masses, swelling   Anus observe for normal placement/stool

Genitourinary Assessment : 

Genitourinary Assessment Normal term female

Musculoskeletal Assessment : 

Musculoskeletal Assessment Observe symmetry movement, size flexion position hands and feet fingers and toes palmar creases spine straight, tufts of hair, dimple

Musculoskeletal Assessment : 

Musculoskeletal Assessment Symmetry of leg creases

Musculoskeletal Assessment : 

Musculoskeletal Assessment Palpation neck - range of motion upper extremities - range of motion, strength, symmetry spine - hold prone and suspended, palpate entire length of spine lower extremities - range of motion, strength symmetry hips - Ortolani and Barlow maneuvers to evaluate stability

Neurologic Assessment : 

Neurologic Assessment Observe before disturbing infant evidence of dysmorphic features, trauma, skin lesions, posture, and activity Motor Exam traction response (pull to sit) grasp infant's hand and pull slowly from supine to sitting should contract shoulder and arm muscles and head lags minimally

Neurologic Assessment : 

Neurologic Assessment Motor Exam sucking reflex rooting reflex moro reflex

References : 

References Tappero, E. P., & Honeyfield M. E. (2009). Physical assessment of the newborn (4th ed.). Santa Rosa: NICU.INK.   Stanford School of Medicine Newborn Nursery Photo Gallery (http://newborns.stanford.edu/PhotoGallery/)