Nb Assessment

submit 21-2 SUMMARY OF NEWBORN ASSESSMENT *MCH pages 479-473 NORMAL anomalous (POSSIBLE CAUSES) NURSING CONSIDERATIONS sign AssessmentAssess for obvious problems prototypic. If infant is stable and has no problems that require immediate attention, reach out with complete assessment. Vital Signs TemperatureAxillary 36. 5 37. 5C (97. 7 99. 5F). Axilla is preferred site. reduced (cold environment, hypoglycemia, infection, systema nervosum centrale problem). Increased (infection, environment to warm). Decreased Institute warming measures and check in 30 minutes. correspond credit line glucose. Increased the excessive clothing.Check for dehydration. Decreased or increased look for signs of infection. Check radiant warmer or incubator temperature setting. Check thermometer for accuracy if kowtow is warm or cool to touch. Report abnormal temperature to physician. PulsesHeart rate one hundred twenty 160 BPM. (100 sleeping, 180 crying). Rhythm regular. PMI at 3rd-4th intercost al space sidelong to mid-clavicular line. Brachial, femoral, and pedal pulses present and equal bilater everyy. Tachycardia (respiratory problems, anemia, infection, cardiac conditions). Bradycardia (asphyxia, increased intracranial pressure).PMI to unspoiled (dextrocardia- boldness situated to right of body, pneumothorax). Murmurs (normal or congenital heart defects). Dysrhythmias. Absent or unsymmetrical pulses (coarctation of the aorta). Note location of murmurs. carry on abnormal rates, rhythms and sounds, pulses. RespirationsRate 30 -60 (AVG 40 -49) BrPM. Respirations irregular, sh everyow, unlabored. Chest faecal matters symmetric. Breath sounds present and clear bi squint-eyedly. Tachypnea, especially afterward the first hour (respiratory distress). Slow respirations (maternal(p) musics). Nasal flaring (respiratory distress). Grunting (respiratory distress syndrome).Gasping (respiratory depression). Periods of apnea to a greater extent than than 20 seconds or with change in heart rate or ruse (respiratory depression, sepsis, cold stress). Asymmetry or decreased chest expansion (pneumothorax). Intercostal, xiphoid, supraclavicular retractions or see-saw (paradoxical) respirations (respiratory distress). Moist, coarse breath sounds (crackles, rhonchi) (fluid in the lungs). intestine sounds in chest (diaphragmatic hernia). batty variations require continued monitoring and usually clear early hours after birth. If persistent or more than mild, suction, give oxygen, call physician, and initiate more intensive care. Blood Pressure Varies with age, weight, activity, and gestational age. Average systolic 65-95 mm Hg, average diastolic 30-60 mm Hg. Hypotension (hypovolemia, shock, sepsis). BP 20 mm Hg or higher in arms than legs (coarctation of the aorta). uphold abnormal blood pressures. instal for intensive care and very low. Measurements Weight2500-4000 g (5 lbs. 8 oz. to 8 lbs. 13 oz. ). Weight loss up to 10% in early days. mellowed (l ow gestational age LGA, maternal diabetes). Low (small for gestational age SGA, preterm, multifetal pregnancy, aesculapian conditions and m some other that affected fetal growth).Weight loss above 10% (dehydration, provide problems). Determine causeMonitor for complications communal to cause. Length48-53 cm (19-21 inches) Below normal (SGA, congenital dwarfism). above normal (LGA, maternal diabetes). Determine causeMonitor for complications common to cause. heading Circumference32-38 cm (12. 5-15 inches). Head and deal are approximately ? of infants body surface. Small (SGA, microcephaly, anencephaly-absence of large subtract of brain or skull). epic (LGA, hydrocephalus, increased intracranial pressure). Determine causeMonitor for complications common to cause. Chest Circumference30-36 cm (12-14 inches).Is 2 cm less than head circumference. Large (LGA). Small (SGA). Determine causeMonitor for complications common to cause. Posture Flexed extremities move freely, re sist auxiliary, come down quickly to flexed state. Hands usually clenched. Movements symmetric. Slight tremors on crying. Breech extended, sealed legs. Molds body to caretakers body when held, responds by quieting when needs met. Limp, flaccid, floppy, or unmitigated extremities (preterm, hypoxia, medications, CNS trauma). Hypertonic (neonatal abstinence syndrome, CNS injury). Jitteriness or tremors (low glucose for atomic number 20 level).Opisthotonos- extreme hyperextension of body, seizures, stiff when held (CNS injury). Seek cause, refer abnormalities. CryLusty, strong. High-pitched (increased intracranial pressure). Week, absent, irritable, cat-like mewing ( neurological problems). ill-humoured or crowing (laryngeal irritation). keep abreast for changes in report abnormalities. Skincolor pink or tan with acrocyanosis (cyanotic discoloration of extremities). Vernix caseosa in creases. Small amounts of lanugo (fine,soft flossy haircloth) over shoulders, sides of fa ce, forehead, upper covering fire. Skin turgor good with quick recoil. Some crack and peeling of pare down. normal variations Milia (tiny white bumps). Skin tags. Erythema toxicum (flea bite rash). Puncture on scalp (from electrode). Mongolian spots. Color cyanosis of mouth and central areas (hypoxia). Facial bruising (nuchal heap). gruesomeness (anemia, hypoxia). Gray (hypoxia, hypotension). Red, sticky, transparent skin (very preterm). Greenish brown discoloration of skin, nails, heap (possible fetal compromise, postterm). Harlequin color (normal transient autonomic imbalance). Mottling (normal or cold stress, hypovolemia, sepsis). Jaundice (pathologic if first 24h). yellowness vernix caseosa (blood incompatibilities). Thick vernix (preterm).Delivery Marks bruises on body (pressure), scalp (vacuum extractor), or face (corduroy slightly neck). Petechiae (pressure, low platelet count, infection). Forceps marks. Birthmarks Mongolian spots. birthmark simplex (salmon patch, stork bite). Nevus flammeus (port-wine stain). Nevus vasculosus (strawberry hemangioma). Cafe au lait spots (6+) larger than 0. 5cm in surface (neurofibromatosis). Other excessive lanugo (preterm). Excessive peeling, cracking (postterm). Pustules or other rashes (infection). camping of skin (dehydration). Differentiate patient bruising from cyanosis. Central cyanosis requires suction, oxygen and set ahead treatment.Refer jaundice in first 24 hours or more prolonged than expected for age. Watch for respiratory problems in infants with meconium staining. belief for signs and complications of preterm or postterm birth. indicate location, size, shape, color, type of rashes and marks. Differentiate Mongolian spots from bruises. Check for facial movement with forceps marks. Watch for jaundice with bruising. Point out and explain normal skin variations to parents. Head Sutures transparent with small separation between each. Anterior sapless spotle diamond shaped, 4-5 cm, soft an d flat. Many bulge slightly with crying. Posterior fontanel triangular, 0. 5-1 cm.Hair silky and soft with individual hair strands. Normal variations overriding sutures (molding). mind succedaneum or cephalohematoma (pressure during birth). Head large (hydrocephalus, increased intracranial pressure) or small (microcephaly). Widely separated sutures (hydrocephalus) or hard, ridged area at sutures (craniosynostosis- birth defect that causes one or more sutures on a babys head to close earlier than normal). Anterior fontanel depress (dehydration, molding), practiced or bulging at rest (increased intracranial pressure). Woolly, bunchy hair (preterm). Unusual hair growth (genetic abnormalities). Seek cause of variations.Observe for signs of dehydration with depressed fontanel increased intracranial pressure with bulging of fontanel and full(a) separation of sutures. Refer for treatment. Differentiate Caput succedaneum from cephalohematoma, and reassure parents of normal outcome. Ob serve for jaundice with cephalohematoma. Ears Ears well-formed and complete. Area where upper ear meets head yet with imaginary line drawn from outer canthus of eye. Startle response to yelled noises. Alerts to high-pitched voices. Low set ears (chromosomal disorders). Skin tags, pre-auricular sinuses, dimples (may be associated with kidney or other abnormalities).No response to sound (deafness). Check voiding if ears abnormal Look for signs of chromosomal abnormality if position abnormal. Refer for evaluation if no response to sound. FaceSymmetric and fashion and movement. Parts proportional and appropriately placed. Asymmetry (pressure imposition in utero). flagging of mouth or one side of face, one-sided cry (facial memorial tablet injury). Abnormal appearance (chromosomal abnormalities). Seek cause of variations. Check delivery business relationship for possible cause of injury to facial nerve. Eyes Symmetric. Eyes clear. fugacious strabismus. Scant or absent tears .Pupils equal, react to light. Alerts to interesting sights. Dolls eye sign- reflex movement of the eyes in the opposite steerage to that which the head is moved, the eyes being abaseed as the head is raised, and the flip-flop (Cantelli sign) an indication of functional integrity of the brainstem tegmental pathways and cranial nerves concern in eye movement. Red reflex present- reddish-orange reflection of light from theeyesretina. whitethorn have subconjunctival phlebotomise or edema of eyelids from pressure during birth. Inflammation or drainage (chemical or infectious conjunctivitis). Constant tearing (plugged lacrimal duct).Unequal pupils. unsuccessful person to follow objects (blindness). sinlessness areas over pupils (cataracts). Setting sun sign- downward aberrancy of the eyes so that each iris appears to set beneath the lower lid, with white sclera exposed between it and the upper lid revelatory of increased intracranial pressure or irritation of the brain stem. (h ydrocephalus). Yellow sclera (jaundice). Blue sclera (osteogenesis imperfecta- condition causing extremely soft bones). Clean and monitor any drainage seek cause. Reassure parents that subconjunctival hemorrhage and edema will clear. Refer other abnormalities. NoseBoth nostrils open to air flow. whitethorn have slight flattening from pressure during birth. Blockage of one or some(prenominal) nasal passages (choanal atresia). Mal makeups (congenital conditions). Flaring, mucus (respiratory distress). Observe for respiratory distress. Report malformations. Mouth Mouth, gums, applauder pink. Tongue normal in size and movement. Lips and palate intact. Sucking pads. Sucking, rooting, sinking, pass away reflexes present. Normal variations precocious teeth, Epsteins pearls-Multiple small white epithelial inclusion body cysts found in the midline of the palate in most newborns. Cyanosis (hypoxia). White patches on cheek or tongue (candidiasis). Protruding tongue (Down syndrome). belittled movement of tongue, drooping mouth (facial nerve paralysis). Cleft lip, palate or both. Absent or weak reflexes (preterm, neurologic problem). Excessive drooling (tracheoesophageal atresia). Oxygen for cyanosis. anticipate loose teeth to be removed. Obtain order for antifungal medication for candidiasis. Check mother for vaginal or breast infection. Refer anomalies. provide Good suck/swallow coordination. Retains feedings. Poorly coordinated suck and swallow (prematurity).Duskiness or cyanosis during feeding (cardiac defects). Choking, gagging, excessive drooling (tracheoesophageal fistula, esophageal atresia). Feed slowly. Stop frequently if difficulty occurs. Suction and stimulate if necessary. Refer infants with continued difficulty. Neck/Clavicles in short neck figures head easily side to side. infant raises head when prone. Clavicles intact. Weakness, contractures, or ridgidity (muscle abnormalities). Webbing of neck, large fat pad at back of neck (chromos omal disorders). Crepitus, lump, or crying when clavicle or other bones palpated, pinched or absent arm movement (fractures). Fracture of clavicle more frequent in large infants with shoulder dystocia at birth. Immobilize arm. Look for other injuries. Refer abnormalities. Chest Cylinder shape. Xiphoid process may be prominent. Symmetric. Nipples present and located properly. May have engorgement, white nipple firing (maternal hormone withdrawal). Asymmetry (diaphragmatic hernia, pneumothorax). Supernumerary nipples. Redness (infection). Report abnormalities. Abdomen Rounded, soft. Bowel sounds present within first hour after birth. Liver palpable 1-2cm below right costal margin. Skin intact. 3 vessels in cord. squeeze tight and cord drying.Meconium passed within 12-48hr. Urine generally passed within 12-24h. Normal variation Brick dust staining of diaper (uric acid crystals). Sunken paunch (diaphragmatic hernia). Distended abdomen or loops of intestine visible (obstructio n, infection, and large organs). Absent bowel sounds after first hour (paralytic ileus). Masses palpated (kidney tumors, distended bladder). Enlarged liver (infection, heart failure, hemolytic disease). Abdominal wall defects (umbilical or inguinal hernia, omphalocele, gastroschisis, exstrophy of bladder). Two vessels in cord (other anomalies). Bleeding (loose clamp). Redness, drainage from cord (infection).No passage of meconium (imperforate anus, obstruction). insufficiency of urinary output (kidney anomalies) or inadequate amounts (dehydration). Refer abnormalities. Assess for other anomalies if still two vessels in cord. Tighten or replace loose cord clamp. If stool and urine output abnormal, look for missed recording, increase feedings, report. genitalia Female Labia majora dark, cover clitoris and labia minora. Small amount of white mucus vaginal discharge. Urinary meatus and vagina present. Normal variations Vaginal bleeding (pseudomenstruation). Hymenal tags. release a nd labia minora larger than labia majora (preterm).Large clitoris (am humongousuous genitalia). Edematous labia (breech birth). Check gestational age for jejune genitalia. Refer anomalies. Male Testes within scrotal sacking, rugae on scrotum, prepuce nonretractable. Meatus at tip of penis. 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). Empty scrotal sac (cryptorchidism). Urinary meatus located on upper side of penis (epispadias), underside of penis (hypospadias, or perineum.Ventral curvature of the penis (chordee). Check gestational age for immature genitalia. Refer anomalies. Explain to parents why no circumcision can be performed with abnormal position of meatus. Extremities Upper and Lower ExtremitiesEqual and bilateral movement of extremities, Correct number and formation of fingers and toe s. Nails to ends of digits or slightly beyond. Felxion, good muscle tone. Crepitus, redness, lumps, swelling (fracture). Diminished or absent movement, especially during Moro reflex (fracture, nerve injury, paralysis). Polydactyly (extra digits). Syndactyly (webbing) consolidated or absent digits.Poor muscle tone (preterm, neurologic injury, hypoglycemia, and hypoxia). Refer all anomalies, look for others. Upper ExtremitiesTwo transverse palm creases. Simian crease (normal or Down syndrome). Diminished movement (injury). Diminished movement of arm with extension and forearm prone (Erb-Duchenne paralysis). Refer all anomalies, look for others. Lower Extremities Legs equal in length, abduct equally, gluteal and thigh creases and knee height equal, no hip clunk. Normal position of feet. Ortolani and Barlow tests abnormal, unequal leg length, unequal thigh or gluteal creases (developmental dysplasia of the hip).Malposition of feet (position in utero, talipes equinovarus). Refer all anomalies, look for others. Check malpositioned feet to see if they can be gently manipulated back to normal position. BackNo openings observed or felt in vertebral column. Anus patent. anatomical sphincter tightly closed. Failure of one or more vertebrae to close (spina bifida), with or without sac with spinal fluid and meninges (meningocele) or spinal fluid, meninges, and cord (myelomeningocele), enclosed. Tuft of hair over spina bifida occulta. Pilondial dimple or sinus. Imperforate anus. Refer abnormalities.Observe for movement below level of defect. If sac, cover with sterile dressing stiff with sterile saline. Protect from injury. Reflexes See table 21-3. Absent, asymmetric or weak reflexes. Observe for signs of fractures, nerve injury, or injury to CNS. TABLE 21-3 SUMMARY OF neonatal REFLEXES *MCH page 493 REFLEX METHOD OF TESTING EXPECTED RESPONSE ABNORMAL RESPONSE/POSSIBLE CAUSE TIME REFLEX DISAPPEARS Babinski Stroke lateral sole of foot from heel to across base of toes. Toes flare with dorsiflexion of the big toe. No response. Bilateral CNS shortage. Unilateral local nerve injury. 8-9 mos venturesome (trunk incurvation) With infant prone, lightly stroke along the side of the vertebral column. intact trunk flexes toward side stimulated. No response CNS deficit. 4 mos range of a function reflex (palmar and plantar) Press finger against of infants fingers or toes. Fingers crook tightly toes curl forward. Weak or absent neurologic deficit or muscle injury. Palmar grasp 2-3 mos. Plantar grasp 8-9 mos Moro allow infants head drop back approx. 30?. conniving extension and abduction of arms followed by flexion and adduction to embrace position. Absent CNS dysfunction.Assymetry brachial plexus injury, paralysis, or fractured bone of extremity. Exaggerated maternal dose use. 5-6 mos Rooting Touch or stroke from side of mouth toward cheek. babe turns head to side touched. Difficult to illicit if infant is sleeping or just fed. Weak or absent prematurity, neurologic deficit, depression from maternal drug use. 3-4 mos Stepping Hold infant so feet touch solid surface. sister lifts alternate feet as if walking. Asymmetry fracture of extremity, neurologic deficit. 3-4 mos Sucking daub nipple or gloved finger in mouth, rub against palate. Infant begins to suck.May be weak if recently fed. Weak or absent prematurity, neurologic deficit, maternal drug use. 1 yr Swallowing Place fluid on the back of the tongue. Infant swallows fluid. Should be coordinated with sucking. Coughing, gagging, choking, cyanosis tracheoesophageal fistula, esophageal fistula, esophageal atresia, neurologic deficit. Present throughout life. Tonic neck reflex Gently turn head to one side while infant is supine. Infant extends extremities on side to which head is turned, with flexion on opposite side. Prolonged detail in position neurologic deficit. May be weak at birth disappears at 4 mos