New Born Assessment

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New Born Assessment
2011-11-28 10:30:00
New Born Assessment

New Born Assessment
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  1. New Born Vital Signs (Temperature)
    • Temperature
    • 36.5o-37.5o C (97.7o-99.5o) axillary
    • 36.5o-37.6o C (97.7o-99.7o) rectal
    • Axilla is perfered site
    • decreased (cold environment, hypoglycemia, infection, CNS problem)
    • increased (infection, environment to warm)

    • Interventions:
    • if decreased:
    • institute warming measures and check in 30 min.
    • Check blood glucose
    • if increased:
    • remove excessive clothing
    • check for dehydration
    • either drcreased or increased:
    • look for signs of infection
    • check radiant warmer temperature setting
    • check thermometer for accuracy if skin is warm or cool to touch
    • report abnormals to physician
  2. New Born Vital Signs (Pulses)
    • Heart Rate: 120-160 BPM (100 sleeping, 180 crying)
    • rhythm regular
    • PMI at third to fourth intercostal space, slightly to left of midclavicular line, may be visible
    • brachial, femral, and pedal pulses present and equal bilaterally

    Tachycardia (respiratory problems, anemia, infection, cardiac conditions)

    Bradycardia (asphyxia, increased intracranial pressure)

    PMI to right (dextrocardia, pneumothorax)

    Murmurs (functional or congenital heart defects)

    Arrhyrhmias absent or unequal pulses (coarctation of the aorta)

    Note location of murmurs refer abnormal rates, rhythms, sounds and pulses
  3. New Born Vital Signs (Blood Pressure)
    Varies with gestational age

    • hypotention (hypovolemia, shock, sepsis)
    • defference of 20mm Hg between arms and legs (coarctation of the aorta)

    • refer abnormal blood pressures
    • prepare for intensive care if very low
  4. New Born Vital Signs (weight)
    • 2500g-4000g
    • 5lb 8oz- 8lb 8oz
    • weight loss up to 10%
    • High (LGA, maternal diabetes)
    • Low (SGA, preterm, multifetal pregnancy, medical conditions in mother that affect intrauterine growth)
    • Weight loss above 10% (dehydration, feeding problems)

    determine cause: monitor for complications common causes
  5. New Born Measurements
    • length 48-53 cm (13-14 inches)
    • Below normal (SGA, congenital dwarf)
    • Above normal (LGA, maternal diabetes)

    • Head Circumference 33-35.5 (13-14 inches)
    • head approximately 1/4 of infant's length
    • Small (SGA, microcephaly, anencephaly)
    • Large (LGA, hydrocephalus, increased intracranial pressure)

    • Chest circumference 30.5-33cm (12-13 inches) is2-3cm less then head circumference
    • Large (LGA
    • Small (SGA)

    determine cause and monitor for complications common to the cause
  6. New Born Posture
    • Normal:
    • 1) flexed extremities resist extension, return quickly to flexed state
    • 2) hands usually clenched movements symmetric
    • 3) slight tremors on crying
    • 4) Breech(extended, stiff legs)
    • 5) "Molds" body to caretaker's when held
    • 6) responds by quieting when needs met

    • Abnormal:
    • 1) limp flaccid, floppy or rigid extremities (preterm, hypoxia, medications, CNS trauma)
    • 2) hypertonic (neonatal abstinence syndrome, CNS damage)
    • 3) jitteriness or tremors (ow glucose, or calcium level)
    • 4) Opisthotonus, seizures, stiff when held (CNS damage)
  7. New Born Cry
    • Normal:
    • lusty, strong

    • Abnormal:
    • high pitched (increased intercranial pressure)
    • weak, absent, iritable, cat-like, "mewing" (neurologic problems)
    • hoarse or crowing (laryngeal irritation)

    interventions: observe for changes, report abnormalities
  8. New Born Skin assessment
    color pink or tan with acrocyanosis.

    vernix caseosa in creases (white substance)

    small amounts of lanugo (fine hair) over sholders, sides of face or forehead, upper back.

    • skin tugor good with quick recoil
    • some cracking and peeling of skin

    • Normal variations:
    • Milia, Erythema toxicum (flea bite rash)
    • Puncture on scalp (from electrode)
    • monogolian spots
    • telangiectatic nevi (nevus simplex or stork bites)
  9. Abnormal skin assessment (color)
    • Color:
    • cyanosis of mouth and central areas(hypoxia)

    Pallor (anemia, hypoxia)

    Gray (hypoxia, hypotension

    • red, sticky, transparent skin
    • (very preterm)

    Ruddy (polycythemia)

    Greenish-brown color of skin, nails, cord (possable fetal compromise, post term)

    yellow vernix (blood incompatibilities

    Jaundice (pathologic if first 24 hrs not good, physilogic if appears after the first 24 hrs)

    thick vernix (preterm)
  10. Nursing considerations for abnormal skin assessments of New Born
    differentiate facial brusing from cyanosis

    central cyanosis requires suction, oxygen, and further treatment

    refer jaundice in first 24 hrs to the physician

    watch for respiratory problems in infants with meconium staining

    look for other signs and complications of preterm or post-term birth

    record location, size, shape, color, type of rashes and marks

    check for facial movement with forceps marks

    watch for jaundice with brusing (hematoma)

    point out and explain normal skin variations to parents
  11. Abnormal Skin assessments (delivery marks)
    • bruises on body (pressure)
    • scalp (vacume extractor)
    • face (cord around neck)
    • petechiae (pressure, low paltlets, infection)
    • forceps marks
  12. Abnormal skin assessments (birthmarks)
    • nevus flammeus (port wine stain)
    • nevus vasculosus (strawberry hemangioma)
    • cafe' au lait spots (more then six or >1.5 cm in size, neurofibromatosis)
  13. Excessive lanugo
  14. Excessive peeling, cracking
  15. Skin tags, pustules or other rashes
  16. Tenting of skin
  17. Head assesments of the New born
    Sutures palpable with small separation between each

    anterior fontanel diamond shaped, 1-4 cm, soft and flat, may bulge slightly with crying

    Posterior fontanel triangular, 0.5-1 cm.

    Hair silky and soft with individual hair strands

    Normal variations: Overrriding sutures (Molding), Caput succedaneum or cephalhematome (pressure during birth)

    • abnormal head assesments:
    • head large: hydrocephalus, increased inracranial pressure

    head to small: microcephaly

    widely spread sutures: hydrocephalus

    sutures not palpable: craniosnostosis

    anterior fontanel depressed: dehydration, molding

    anterior fontanel full or buldging at rest: increased intracranial pressure

    woolly, bunchy hair: preterm

    unusual hair growth: chromosomal abnormalities

    Nursing considerations: seek cause of variations. Observe for signs of dehydration with depressed fontanel, increased intracranial pressure with bulging of fontanel and wide spraration of sutures. Refer for treatment.

    Differentiate caput succedaneum from cephalhematoma and reassure parents of normal outcome. Observe for jaundice with cephalhematoma
  18. Ear assesment of the New Born
    Ears well formed and complete, area where upper ear meets head even with imaginary line drawn from inner to outer cantus of eye

    Startle response to loud noises

    Alert to high-pitched voices

    • Abnormal assessments:
    • Low-set ears: (chromosomal disorders) skin tags, preauricular sinuses dimples (Kidney abnomalies) No response to sound (deafness)

    Nursing considerations: check voiding if ears abnormal, look for signs of chromosomal abnormality if position abnormal refer for evaluation if no response to sound deafness
  19. Face assesments of the New Born
    symmetric in appearance and movement, parts proportional and appropriatel placed

    • Abnormal assesments:
    • asymmetry: pressure and position in utero

    drooping of mouth or one side of face "one sided cry" facial nerve damage

    abnormal appearance chromosomal abnormalities

    nursing considerations: seek cause of variations, check delivery history for possible cause of damage to facial nerve
  20. Eye assesment of the New Born
    symmetric, eyes clear, transient stabismus. Scant or absent tears, pupils equal, react to light, alerts to interesting sights. Follows objects 180 degrees. Doll's eye sign, red reflex present. May have subonjunctival hemorrhage or edema of eyelids from pressure during birth

    • abnormal assesments:
    • inflammation or drainage (chemical or infectious conjunctivtis)

    constant tearing (plugged lacrimal duct)

    unequal pupils, failure to follow objects (blindness)

    white areas over pupils (cateracts)

    setting-sun sign (hydrocephalus)

    • nursing considerations:
    • clean and monitor any drainage; seek cause

    reassure parents that subconjunctival hemorrhage and edema will clear

    refer other abnormalities to physician
  21. Nose assesment of the New Born
    both nostrils open to air flow, may have slight flattening from pressure during birth

    • abnormal assessments:
    • blockage of one or both nostrils (choanal atresia {blockage of the bone tissue in the nasal passage})

    malformations (congenital conditions)

    flaring, mucus (respiratory distress)
  22. Mouth assesment of the New Born
    • Mouth, gums, tongue pink
    • Tongue: normal in size and movement
    • Lips and palate intact, sucking pads sucking, rooting, swallowing, gag reflexes present

    Normal variations: precocious teeth, epstein's pearls (small yellow or white cystic vesicels found in New Born's mouth)

    • Abnormal assesments:
    • cyanosis (hypoxia)

    white patches on cheeks or tongue (candidiasis {yeast})

    protruding tongue (down syndrome)

    diminished movement of tongue, drooping mouth (facial nerve paralysis)

    cleft lip or palate or both

    absent or weak reflexes (preterm, neurologic problem)

    excessive drooling (tracheoesophageal fistula, esophageal atresia {closure})

    • nursing concideration:
    • oxygen for cyanosis, expec loose teeth to be removed, obtain order for candidiasis and check mother for vaginal or breast infection refer anomalies to physician
  23. Assesment of feeding the New Born
    Good suck/swallow coordination retains feedings

    • abnormal assesments:
    • poorly coordinated suck and swallow. Duskiness or cyanosis during feeding (cardiac defects). Chocking, gagging, excessive drooling (tracheoesophageal fistula, esophageal atresia)

    • nursing considerations:
    • feed slowly, stop frequently if difficulty occurs, suction and stimulate if necessary refer infants with cintinued difficulty to the physician
  24. Neck and clavicles in the New Born
    short neck turns head easily side to side. Infant raises head when prone. Clavicles intact

    • abnormal assesments:
    • weakness, contractures, or rigidity (muscle abnormalities)

    webbing of neck, large fat pad at back of neck (chromosomal disorders)

    crepitus, lump, or crying when clavicle palpated, diminished or absent arm movement (fractured clavicle)

    • nursing considerations:
    • fracture of clavicle occurs especially in large infants with shoulder dystocia (diffficult dilivery) at birth immobilize arm look for other injuries
  25. Chest assesment in the New Born
    cylinder shape xiphoid process may be prominent, symmertic nipples present and located properly. May have engorgement, white nipple discharge (maternal hormone withdrawal)

    • abnormal assesment:
    • asymmerty (diaphragmatic hernia, pneumohorax)

    supernumerary (extra number) nipples redness (infection)

    nursing interventations: refer abnormalities to physician
  26. Abdomen assesment of the New Born
    rounded, soft, Bowel sounds present soon after birth, liver palpable 1-3 cm below costal margin. Skin intact. Three vessels in cord (2 arteries and one vein), Clamp tight and cord drying, Meconium passed within 24-48 hours, Urine passed within the first 24 hours

    Normal verations: brick dust staining of diaper (urate crystals)

    • Abnormal assesment:
    • sunken abdomen: diaphragmatic hernia

    disended abdomen or loops of bowel visible: obstruction, infection, enlarged organs

    absent bowel sounds after first hr: paralytic ileus

    masses palpated: kidney tumors, distended bladder

    enlarged liver: infection, heart failure, hemolytic disease

    abdominal wall defects: umbilical or inguinal hernia, omphalocele, gastrochisis, extrophy of bladder

    two vessels in cord: other abnormalities

    bleeding: loose clamp

    redness, drainage from cord: infection

    no passage of meconium: imperforate anus, obsruction

    lack of urinary output: kidney anomalies

    inadequate amounts of urine: dehydration

    nursing interventions: look for other anomalies if only two vessels in cord, tighten or replace loose cord clamp. If stool and urine output abnormal, check to see none was unrecorded, increase feedings,
  27. Genital assesment in the New Born (female)
    • Female:
    • labia majora dark, cover clitoris and labia minora. Small amount of white mucous vaginal discharge. Urinary meatus and vagina present

    Normal variations: vaginal bleeding (Pseudomenstrauation) hymenal tags

    • Abnormal assesments:
    • Clitoris and labia minora larger than labia majora (preterm)

    Large clitoris (ambiguous genitalia)

    Edematous labia (breach births)

    Nursing interventions: check gestational age for immature genitalia
  28. Genital assesment of New Born (male)
    Testes within scrotal sac, rugae (ridges) on scrotum, prepuce nonretractable. Meatus at tip of penis

    • abnormal assesments:
    • Testes in inguinal canal or abdomen (preterm, cryptorchidism)

    lack of rugae on scrotum (preterm)

    edema of scrotum (pressure in breech birth)

    enlarged scrotal sac (hydrocele)

    small penis, scrotum (preterm, ambiguous genitalia)

    urinary meatus located on upper side of penis (epispadias), underside of penis (hypospadias)

    nursing interventions: check gestational age for immature genitalia explain to parents why no circumcision can be performed with abnormal placement of meatus
  29. Upper and Lower extremities assesment in the New Born
    equal and bilateral movement of extremities, correct number and formation of fingers and toes. Nails to ends of digits or slightly beyond, flaxion, good muscle tone

    • Abnormal assesments:
    • Crepitus, redness, lumps, swelling (fracture)

    diminished or absent movement, especially during Moro refles (fracture, nerve damage, paralysis)

    • Polydactyly (extra digits)
    • syndactyly (webbing), fused or absent digits

    poor muscle tone (preterm, neurologic damage, hypoglycemia, hypoxia)

    nursing interventions: look for other abnormalities, refer abnormalities to the physician
  30. Assesment of upper extremities in the New Born
    two transverse palm creases

    • abnormal assesments:
    • simian crease (crease that extend across the hand instead of two transverse creases there is only one) (down syndrome)

    diminised movement of arm with extension and forearm prone (erb-dunchenne) a paralysis of the arm caused by injury to the upper group of the arm's main nerves, specifically the upper trunk C5-C6 is severed

    nursing interventions: look for other abnormalities and refer to the physician
  31. Assesment of the lower extremities in the New Born
    Legs equal in length, abduct equally gluteal and thigh creases and knee height equal, no hip "clunck" Normal position of feet

    abnormal assesments:

    ortolani and barlow test positive unequal leg length (developmental dysplasia of the hip)

    Malposition of feet (position in utero, talipes equinovarus {club foot})

    nursing interventions: refer all anomalies, look for others check malpositioned feet to see if they can be manipulated back to normal position
  32. Assesment of the back in the New Born
    No openings observed or felt in vertebral column. Anus patent, Sphincter tightly closed

    • Abnormal assesments:
    • failure of vertebrae to close (spina bifida)
    • with or without sac of spinal fluid and meninges (meningocele)
    • or cord (myclomeningocele) enclosed

    tuft of hair over spina bifida occulta (hidden) pilonidal dimple (small hole just above the buttocks or sinus imperforate anus

    nursing interventions: observe for movement below level of defect. If sac, cover with sterile dressing wet with sterile saline, protect form injury
  33. Reflex assesment in the New Born
    Moro, palmar and plantar frasp, rooting, sucking, swallowing, tonic neck, babinski, gallant, and steping reflexes present

    • abnormal assesments:
    • absent, asymmetric, or weak reflexes

    nursing interventions: observe for signs of fractures, nerve damage, or injury to CNS