ASSESSMENT OF NEONATE http://faculty.washington.edu/alexbert/MEDEX/Winter/MCHAssessment%20Neonate s.

htm Head
Assessment
Hair: color, amount Circumference Sutures and Fontanels

Norms
Distributed over top of head 32 cm - 35 cm Sutures may override, called molding, lasting 5-7 days. May bulge when infant is crying or coughing. Depressed fontanels indicates dehydration. Anterior - diamond-shaped, at front and top of head; may notice it pulsate; closes between 12 and 18 months. Posterior is triangle-shaped, at top and to the back of the head; closes at birth or within 2 months. May be asymmetrical due to molding, this should disappear in 5-7 days. May have edema formation (caput succedaneum not bound by suture lines) or bleeding into subperiosteum (cephalhematoma - not crossing suture lines). Mouth should be round, symmetrical. Hard palate should be intact with high arch. Epstein's pearls are common (small, white, epithelial cysts along sides of midline of hard palate) and will disappear in a few weeks. Face may be asymmetrical due to soft tissue damage and swelling during birth process. Milia - pin-head sized white spots (clogged oil glands) over the nose, chin, or cheeks. These are normal and disappear within a few weeks without treatment. Should not be picked or squeezed. Visualize the uvula and pharynx when the infant is crying. Tonsils are not visible in the newborn. Check for extrusion, sucking and rooting reflexes. See section on normal reflexes. Eyes may be swollen and red from trauma of birth or from reaction to medication routinely used in infant's eyes upon admission. Tears my not be present for several weeks or even 3-4 months. Eyes will be dark blue at birth, and will become their permanent color at 3 months of age. Color changes may not be complete for one year. Check for red reflex; blink, corneal and pupil reflexes. Nystagmus is a common finding. Top of ears should be level with outer canthus of eye. Ear cartilage should be formed so that ear holds shape. Audiology screening

Shape

Mouth / lips/ gums

Face

Palate

Eyes: color, pupil reaction, discharge

Ears: size, placement, hearing, symmetry, amount of cartilage

Nose: shape, placement, patency

Nose should be midline, symmetrical. Check for nasal flaring. Nose may need to be suctioned with bulb syringe to maintain patency. Infants are obligate nose breathers - they cannot breathe through their mouths at birth. It is common for neonates to sneeze frequently. Thin white mucus is common.

Chest
Assessment
Circumference Clavicles Breast Tissue

Norms
30 - 35 cms, 12.5-13.5". Chest is almost circular. Slight intercostal retractions are normal. Check for bumps, clavicle may have been broken during birth. Should be smooth. Breast of the newborn of both sexes may be swollen the first few days due to high level of maternal hormones. They may also excrete a whitish fluid that looks like milk (witch's milk). These are both normal and will disappear without treatment by 4-6 weeks of age. Breasts of infants should never be squeezed.

Integument
Assessment
Color, consistency, hydration

Norms
Newborn is usually bright red with puffy skin. By the second to third day the skin should be pink, dry and flaky. Normal color changes: Acrocyanosis - blueness of hands and feet Mottling - transient when infant exposed to cold Jaundice - yellow skin due to increased breakdown of red blood cells "Newborn rash" - eruptions that appear 'hivelike' and may appear and disappear at intervals during the first few days of life. Milia Mongolian spots Stork bites - telangiectatic nevi - flat, deep pink areas seen on the upper eyelids, between the eyebrows, on the upper lip, or at the nape of the neck. These eventually fade and disappear

Birthmarks

between 1 and 2 years of age. Vernix, lanugo Vernix caseosa. Lanugo

Vital Signs Assessment

Apgar Temperature (axillary) Heart rate and rhythm murmurs Apgar 97.5 to 99 120 - 160 Blood Pressure only taken with signs of illness. Blood pressure based upon age Heart rate based upon age Strong & equal bilaterally.

Norms

Pulses apical femoral Perfusion, capillary refill Lungs rate and rhythm, breath sounds, effort

Refill less than 3 seconds Normal rate is 30-60 breaths per minute. Periods of apnea less than 15 seconds is normal.

Abdomen
Assessment
Bowel sounds Size, Contour 2-4 per minute Usually rounded with prominent veins. If scaphoid, suspect a diaphragmatic hernia. Liver is usually palpable 2-3 cm below costal margin.

Norms

Vessels (abdominal) Condition of cord Number of vessels Will fall off in approximately 7-14 days. There may be brownish- colored drainage after the cord falls off. Cord should be cleansed with alcohol and cotton balls until area is completely healed and drainage has ceased. There should be 3 vessels

present in the cord.

Genitalia
Assessment Norms

Male: testes, Scrotum may appear swollen at birth due to maternal scrotum, penis hormones. Check that both testes are descended.

Female: labia, clitoris, vagina, discharge

Smegma - white, mucous discharge secreted for about 6 weeks that protects the area. Pseudo-menstruation - pinkish-red discharge from the vagina, caused by the withdrawal of maternal hormones. Labia - may be swollen and red due to high level of maternal hormones.

Extremities

Assessment
Arms/Hands Acrocyanosis Number of Fingers Range of Motion Palmar Creases Legs/Feet Sole Creases Color Number of Toes Range of Motion Hip Dysplasia Major Gluteal Folds

Norms
Should have 10 fingers. Look for polydactyly and syndactyly. Nail beds should be pink. Slight blueness is common when extremities are cold. Should have 10 toes. Sole usually flat with creases on anterior 2/3 of foot. Symmetry of legs with equal muscle tone and resistance to opposing flexion. Extremities usually have flexion. Ortolani's sign for hip dislocation

Back/Spine Assessment Norms

Spinal Column

Spine intact, no openings, masses or prominent curves. Spine usually rounded with none of curves seen later in life. Trunk incurvation reflex present - stroke back along one side of the vertebral column will cause the infant to move hips toward the stimulated side.

Posture/Muscle Tone Assessment

Awake Asleep

Norms
General appearance Neuromuscular

Reflexes Assessment Norms

Rooting/Sucking When cheek stroked child turns head toward side touched. Strongest during first 2 months. Disappears at 3-4 months. Moro's (Startle) Grasp Palmar Plantar Tonic Neck Pull-to-Sit Babinski's Trunk Incurvature Stepping Extrusion Scarf sign Sudden loud noise causes abduction of arms with elbow flexion, hands clenched. Should disappear by 4 months. Infant will grasp anything placed in hand. Touching sole of foot will cause grasping motion of toes. Should disappear by 3 months. Palmar grasp reflex will gradually become voluntary. When head is quickly turned to one side, arm and leg will extend on that side. Opposite arm and leg will flex. Should disappear by 3-4 months. Head lag common until 3-4 months. Great toe flares and other toes spread when outer edge of sole is stroked. Should disappear about 12 months. When back is stroked beside spinal column, the infant will move hips toward side stimulated. Infant held so sole touches surface, flexion and extension of leg resembling walking. Should disappear by 3-4 weeks. When object is placed in mouth, the infant will push it out with tongue. With the infant supine, take the infant's hand and draw it across the neck and as far across the opposite shoulder as possible. Assistance to the elbow is permissible by lifting it across the body. Infant should resist elbow movement past midline of body.

Urine
Assessment
Color, Number of voidings

Norms
Should void within 24 hours. With adequate hydration should have 6-10 diapers per day. Urine is straw color and odorless. Dark yellow urine indicates dehydration.

Stools
Assessment
Color, Type

Norms
Meconium is passed 8-24 hours. After the infant begins eating transitional stools are passes - less sticky and brownish yellow. By the fourth day a milk stool should be passed - breast fed infants have pasty yellow to golden stools with an odor similar to sour milk. Bottle fed infants have pale yellow to light brown stools, firmer consistency and stronger odor. Midline. Patent anal opening. Passing of meconium stool indicates patent anus

Placement of Anus Patency of Anus

Gestational Age
Assessment Ballard Score

Norms
Dubowitz/Ballard Exam - Includes instructions on how to conduct assessment for gestational age.

ASSESSMENT OF NEONATE http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/hrnewborn/assess.html

Assessments for newborn babies:

Each newborn baby is carefully checked at birth for signs of problems or complications. A complete physical assessment will be performed that includes every body system. Throughout the hospital stay, physicians, nurses, and other healthcare providers continually assess a baby for changes in health and for signs of problems or illness. Assessment may include:

Apgar scoring: The Apgar score is one of the first checks of your new baby's health. The Apgar score is assigned in the first few minutes after birth to help identify babies that have difficulty breathing or have a problem that needs further care. The baby is checked at one minute and five minutes after birth for heart and respiratory rates, muscle tone, reflexes, and color. Each area can have a score of zero, one, or two, with ten points as the maximum. A total score of ten means a baby is in the best possible condition. Nearly all babies score between eight and ten, with one or two points taken off for blue hands and feet because of immature circulation. If a baby has a difficult time during delivery, this can lower the oxygen levels in the blood, which can lower the Apgar score. Apgar scores of three or less often mean a baby needs immediate attention and care. However, only 1.4 percent of babies have Apgar scores less than seven at five minutes after birth. Sign Score = 0 Absent Absent Flaccid Score = 1 Score = 2

Heart Rate Respiratory Effort Muscle Tone

Below 100 per minute Above 100 per minute Weak, irregular, or gasping Some flexion of arms and legs Grimace or weak cry Body pink, hands and feet blue Good, crying Well flexed, or active movements of extremities Good cry Pink all over

Reflex/Irritability No response Color Blue all over, or pale

Birthweight and measurements: A baby's birthweight is an important indicator of health. The average weight for term babies (born between 37 and 41 weeks gestation) is about 7 lbs. (3.2 kg). In general, small babies and very large babies are at greater risk for problems. Babies are weighed daily in the nursery to assess growth, fluid, and nutrition needs. Newborn babies may lose as much as 10 percent of their birthweight. This means that a baby weighing 7 pounds 3 ounces at birth might lose as much as 10 ounces in the first few days. Premature and sick babies may not begin to gain weight right away. Most hospitals use the metric system for weighing babies. This chart will help you convert grams to pounds.

Converting grams to pounds and ounces:

1 lb. = 453.59237 grams; 1 oz. = 28.349523 grams; 1000 grams = 1 Kg.

Pounds

Ounces 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

2 907 936 964 992

1361 1814 2268 2722 3175 3629 4082 1389 1843 2296 2750 3203 3657 4111 1417 1871 2325 2778 3232 3685 4139 1446 1899 2353 2807 3260 3714 4167

1021 1474 1928 2381 2835 3289 3742 4196 1049 1503 1956 2410 2863 3317 3770 4224 1077 1531 1984 2438 2892 3345 3799 4252 1106 1559 2013 2466 2920 3374 3827 4281 1134 1588 2041 2495 2948 3402 3856 4309 1162 1616 2070 2523 2977 3430 3884 4337 1191 1644 2098 2551 3005 3459 3912 4366 1219 1673 2126 2580 3033 3487 3941 4394 1247 1701 2155 2608 3062 3515 3969 4423 1276 1729 2183 2637 3090 3544 3997 4451 1304 1758 2211 2665 3118 3572 4026 4479 1332 1786 2240 2693 3147 3600 4054 4508 Measurements: Other measurements are also taken of each baby. These include the following:
o

head circumference (the distance around the baby's head) - is normally about onehalf the baby's body length plus 10 cm abdominal circumference - the distance around the abdomen length - the measurement from crown of head to the heel

o o

Physical examination: A complete physical examination is an important part of newborn care. Each body system is carefully examined for signs of health and normal function. The physician also looks for any signs of illness or birth defects.

Physical examination of a newborn often includes the assessment of the following:

o

vital signs:

temperature - able to maintain stable body temperature 98.6 F (37 C) in normal room environment pulse - normally 120 to 160 beats per minute breathing rate - normally 30 to 60 breaths per minute

o o o

general appearance - physical activity, tone, posture, and level of consciousness skin - color, texture, nails, presence of rashes head and neck:

appearance, shape, presence of molding (shaping of the head from passage through the birth canal) fontanels (the open "soft spots" between the bones of the baby's skull) clavicles (bones across the upper chest)

o o o o o o o

face - eyes, ears, nose, cheeks mouth - palate, tongue, throat lungs - breath sounds, breathing pattern heart sounds and femoral (in the groin) pulses abdomen - presence of masses or hernias genitals and anus - for open passage of urine and stool arms and legs - movement and development

Gestational assessment: Assessing a baby's physical maturity is an important part of care. Maturity assessment is helpful in meeting a baby's needs if the dates of a pregnancy are uncertain. For example, a very small baby may actually be more mature than it appears by size, and may need different care than a premature baby. An examination called The Dubowitz/Ballard Examination for Gestational Age is often used. A baby's gestational age often can be closely estimated using this examination. The Dubowitz/Ballard Examination evaluates a baby's appearance, skin texture, motor function, and reflexes. The physical maturity part of the examination is done in the first two hours of birth. The neuromuscular maturity examination is completed within 24 hours after delivery. Information often used to help estimate babies' physical and

neuromuscular maturity are shown below.

Physical maturity: The physical assessment part of the Dubowitz/Ballard Examination looks at physical characteristics that look different at different stages of a baby's gestational maturity. Babies who are physically mature usually have higher scores than premature babies. Points are given for each area of assessment, with a low of -1 or -2 for extreme immaturity to as much as 4 or 5 for postmaturity. Areas of assessment include the following:

o o

skin textures (i.e., sticky, smooth, peeling). lanugo (the soft downy hair on a baby's body) - is absent in immature babies, then appears with maturity, and then disappears again with postmaturity. plantar creases - these creases on the soles of the feet range from absent to covering the entire foot, depending on the maturity. breast - the thickness and size of breast tissue and areola (the darkened ring around each nipple) are assessed. eyes and ears - eyes fused or open and amount of cartilage and stiffness of the ear tissue. genitals, male - presence of testes and appearance of scrotum, from smooth to wrinkled. genitals, female - appearance and size of the clitoris and the labia.

Neuromuscular maturity: Six evaluations of the baby's neuromuscular system are performed. These include:
o o o o o o

posture - how does the baby hold his/her arms and legs. square window - how far the baby's hands can be flexed toward the wrist. arm recoil - how far the baby's arms "spring back" to a flexed position. popliteal angle - how far the baby's knees extend. scarf sign - how far the elbows can be moved across the baby's chest. heel to ear - how close the baby's feet can be moved to the ears.

A score is assigned to each assessment area. Typically, the more neurologically mature the baby, the higher the score. When the physical assessment score and the neuromuscular score are added together, the gestational age can be estimated. Scores range from very low for immature babies (less than 26 to 28 weeks) to very high scores for mature and postmature babies. All of these examinations are important ways to learn about your baby's well-being at birth. By identifying any problems, your baby's physician can plan the best possible care.