NEW BORN ASSESSMENT & CARE OF NEONATE, Summaries of Nursing

Download NEW BORN ASSESSMENT & CARE OF NEONATE and more Summaries Nursing in PDF only on Docsity! Rupinder Deol Assistant Professor College of Nursing AIIMS, RISHIKESH NEW BORN ASSESSMENT & CARE OF NEONATE INTRODUCTION • Monitoring of neonates is the keynote to their successful outcome. • Accurate nursing observation is a vital factor in the survival and future development of newborn. • The initial physical examination should be performed as soon as after the birth. • All newborns should be thoroughly examined in the first 24-48 hrs of age. SPECIFIC INSTRUCTIONS To perform thorough skilled examination of newborn, the following specific instructions should be kept in mind: 1. Observation should be made when newborn is quiet and awake. 2. Ensure adequate light in examination room. 3. The temperature of the examination room is maintained at 28 +/- 2 degree C. avoid draft and chills in the examination room. 4. Wash your hands till elbow for 3 minutes before and after handling the newborn. Effective Handwashing 2. Fight palm over ten dorsum and left pakn over right dorsum ?. Palm to palm 3. Pairn to palm fingers 4. Backs of fingers to imertaces opposing p=aims with fingers imeriocked $_ Rotational rubbing of 6. Rotational rubbing, fight thurnt clasped in lett backwards and forwards Pan and vice versa with clasped fingers of fight hand in let palm and vice versa SYSTEMATIC ASSESSMENT OF NEWBORN Neonatal assessment is done systematically from birth till discharge of neonate. Examination of newborn soon after birth is done very quickly. Examination at birth includes assessment of certain important parameters, to evaluate the adjustment of newborn to these life processes. Immediate response of newborn to extra uterine life can be determined by: - Apgar score at one, five and ten minutes. - Birth weight - Length - Axillary temperature - Patency of orifices – anal patency, esophageal atresia. A detailed examination of newborn is performed after 24 hrs of birth. FIRST DAY • New born can tolerate much handling after first day, as they recover from labour stress. • Examination of newborn within first 24 hrs include information about physiological establishment and future physiological changes that the newborn might undergo. • Therefore, a thorough assessment that identifies normal and abnormal findings , facilitates planning of care by nurses. PUPROSES The purposes of first day examination are to: 1. Identify any congenital anomaly missed out at birth. 2. Assess feeding behavior. 3. Ensure passage of urine and stool. 4. Perform thorough head to toe examination. 5. Record measurements. Immediate newborn assessment includes:  APGAR scoring  Recording of birth weight  Umbilical cord is examined for presence of 2 umbilical arteries and 1 vein.  Orifice counting & checking their patency. • Mouth is checked for cleft palate and lip. • Ears and nose • Anus is checked for imperforation or malformation. • Urethra is checked for hypospadias or epispadias. • Any visible lesions on back or front. Examination at 24 hrs: Assess Ask o Breastfeeding o Activity of the baby o Any other problems* Check o Weigh the baby o Temperature Record EN- 16 •Passage of meconium up to 24 hrs and urine up to 48 hrs of life is usually normal ROUTINE EXAMINATION • Detailed examination on routine basis is not required. • But till the time, the new born remains in the hospital the new born should be observed for feeding behavior and maintenance of temperature, jaundice, seizures and any superficial infections. • The mother should be enquired about the behaviour of the new born eg; feeding problems, passage of urine and stool, vomiting. STEPS OF EXAMINING THE NEW BORN • Place the newborn on a flat surface at a comfortable height to yourself. • The examiner’s hands must be dry and warm, as cold hands startle the new born. Warm up your hands by drying and rubbing. • The examiner’s nail should be short and free of nail polish. • Handle newborn gently. • Don’t expose the newborn unnecessarily. Redress after completion of examination. STEPS OF EXAMINING THE NEW BORN • Avoid performing a detailed assessment just before or after feeding. • The findings should be recorded promptly, accurately and systematically. • Collect required articles, ensure proper functioning and that they are accessible. ARTICLES & PURPOSES ARTICLE PURPOSE WEIGHING MACHINE TO MEASURE WEIGHT. MEASURING TAPE TO MEASURE HC,CC & ABDOMINAL GIRTH. INFANTOMETER TO MEASURE CROWN TO HEEL LENGTH. T.P.R. TRAY TO CHECK TEMPERATURE STETHOSCOPE TO AUSCULTATE H.R. TORCH TO CHECK PUPILLARY REFLEX & TO OBSERVE ORAL CAVITY. RECORD SHEET TO RECORD THE FINDINGS. Assess: Listen for Grunting, Cry, Heart sounds EN- 27 1. INFORMATION RELATED TO PREVIOUS PREGNANCY: - Gravida, para, abortions, number of alive children, still born. - Nature of previous pregnancy/ies, nature of puerperium. 2. Information related to present pregnancy: - LMP & EDD/ period of gestation. - Parity - Registered/ unregistered or booked/unbooked case - Mother’s immunization – tetanus toxoid. - Nutrition during pregnancy - Folic acid, calcium and iron supplementation. - Any history of illness and infections during 1st, 2nd and 3rd trimester, medications taken or treatment required viz; PIH, eclampsia, anemia, fever, and diabetes. - Blood group, Hb, urine for albumin, sugar. 3. History of Labour: - Presentation - Duration of labour (during 1st stage, duration of 2nd stage) - ROM - Medication during labour - Method of delivery Erythema Toxicum Erythema Toxicum • Erythematous macules and firm 1-3 mm yellow or white papules or pustules • Etiology obscure • Pustules contain eosinophils and are sterile • Appear in the first 3-4 days of life – Range: Birth to 14 days • Benign and self limited Erythema Toxicum MONGOLIAN SPOTS • 90% of African infants, 81% of Asian, and 9.6% of Caucasian infants • Slate-gray to blue-black lesions • Usually over lumbosacral area and buttocks • Accumulation of melanocytes within the dermis • Generally fade by age 7 years Mongolian Spots BENIGN PUSTULAR MELANOSIS OF THE NEWBORN WHAT TO ASSESS? TECHNIQUE FOR ASSESSMENT CHARACTERISTICS OF NORMAL NEW BORN v) Lanugo Examine on back, shoulders, forehead and cheeks. Lanugo (fine hair) seen on back, shoulders, forehead and cheeks. vi) Normal Variation Physiological Jaundice Erythema Toxicum Milia Mongolian spot Check by blanching skin over bridge of nose. Observe back, shoulders and trunk of new born. Observe chin, nasal bridge and nasolabial folds. Observe sacral region for mongolian spot. Yellowish discoloration of skin. Small isolated areas of redness with a yellowish white wheal in the center commonly seen on back, shoulders and trunk. Whitish pin head sized spots on around the nose or the chin may be present. Smooth, bluish green naevus measuring 2-10 cm in diameter may be present in the sacral region. WHAT TO ASSESS? TECHNIQUE FOR ASSESSMENT CHARACTERISTICS OF NORMAL NEW BORN 3) VITAL SIGNS i) Respiration Determine rate, rhythm ii) Heart rate Determine rate iii) Temperature Observe by watching abdominal movement and count for 1 min. Check by placing the stethoscope apically i.e. 5th intercostal space in the mid clavicular line for 1 min. Axillary temperature is preferable and should be taken for atleast 3 mins. You should also gain experience in assessing the temperature of newborn using hand. Norma RR = 40-60 breaths/min Normal H.R =120-160 beats/min. crying increases & deep sleep decreases HR. Normal axillary temp= 36.5- 37.5 0 C (95.5- 99.3o F) Trunk feels warm, extremities are reasonably warm and pink. Temperature • At birth-warmth, keep the baby in skin to skin contact with the mother EN- 47 Weighing the baby • Prepare the scale: cover the pan with a clean cloth/autoclaved paper; ensure the scale reads zero • Preparing and weighing the baby  Remove all clothing  Wait till the baby stops moving  Weigh naked  Read and record  Return the baby to the mother • Scale maintenance  Calibrate daily  Clean the scale pan between each weighing EN- 50 WHAT TO ASSESS? TECHNIQUE FOR ASSESSMENT CHARACTERISTICS OF NORMAL NEW BORN 5) HEAD i) Fontannels Palpate anterior and posterior fontanelles when newborn is quiet. AF is diamond shaped, flat, soft, firm. Measures 2.4*4.0 cm PF is triangular in shape, 1.2 cm wide. Fontanel may bulge when newborn cries. ii) Sutures Palpate sutures Sutures may override during vaginal delivery. iii) Hair Observe texture Silky separate strands. iv) Head lag Holding at the hands lift the supine baby gently. Observe the position of the head in relation to trunk. Able to maintain head in line with the body and bring head anterior to the body. WHAT TO ASSESS? TECHNIQUE FOR ASSESSMENT CHARACTERISTICS OF NORMAL NEW BORN vi) NORMAL VARIATION MOULDING Observe for appearance, shape of head. May have elongated appearance in vaginal birth newborns. Bruising, abrasion Inspect head for bruising, abrasion or swelling. No bruising or abrasions Caput succedaneum Observe for subcutaneous edema (soft tissue swelling) and locate the extent. Localised edema on the newborn scalp crossing the suture lines may present at birth. Cephal hematoma Observe for swelling on the scalp. A localised effusion (serum blood) firmer to touch than edematous area, feels like a water filled balloon usually appears on 2nd or 3rd day after birth. Does not cross suture line. NEWBORN SCALP HEMATOMATA OTT eM aE OFM oe STULL ——, DE » re N yee ae Oy TULA aaa We TaIOSI AS Ryans es bari) I Caput succedaneum vs. cephalohematoma  Normal vs. Abnormal EN-Teaching Aids: ENC 56 Infant skull Coronal suture Side view Lamboidal suture Sphenoidal fontanelle Squamosal suture Maxilla Mastoid fontanelle Mandible Top view Frontal bone Anterior fontanelle Parietal bone Sagittal suture Posterior fontanelle Occipital bone ®ADAM. WHAT TO ASSESS? TECHNIQUE FOR ASSESSMENT CHARACTERISTICS OF NORMAL NEW BORN 6) EYES Glabellar Tap Observe eyes, color of sclera & iris, discharge etc. Tap sharply at galbella & look for closure of eyes. Eyes usually closed, lids usually edematous. Sclera-white to bluish white. Iris- dark gray & brown. No discharge, eyes clean & healthy. Brisk closure of eyes. 7)EARS i) Location ii) Ear cartilage iii) Ear recoil Draw a horizontal line from outer canthus of eye. Assess ear firmness by palpation. Check ear recoil by folding pinna forward and releasing it. Top of pinna of ear is in a horizontal plane to the outer canthus. Pinna firm, cartilage felt along with edge. Instant recoil. WHAT TO ASSESS? TECHNIQUE FOR ASSESSMENT CHARACTERISTICS OF NORMAL NEW BORN 8) NOSE Nasal passage Observe patency of nasal passage. Nasal passage is patent. 9) ORAL CAVITY i) Cleanliness ii) Rooting reflex iii) Sucking reflex iv) Extrusion reflex Observe oral cavity (lips, gums, teeth, palate, tongue) by stimulating newborn to cry. Touch/ stroke the cheek along the side of mouth. Observe while mother is breast feeding the new born Touch or depress tongue of newborn. Clean oral cavity. Intact high arched palate. Uvula in midline. No precocious teeth. No epstein pearls & no oral thrush. Touching/stroking the cheek along the side of the mouth stimulates the newborn to turn head towards the side. Sucking & swallowing reflex is well developed & coordinated. When tongue is touched or depressed, newborn responds by forcing it outwards. WHAT TO ASSESS? TECHNIQUE FOR ASSESSMENT CHARACTERISTICS OF NORMAL NEW BORN 10)NECK Tonic Neck Reflex Inspect & palpate lymph nodes in neck & also check for range of motion. Place the newborn in supine position, turn the head to one side. Neck is short, symmetrical, no glands palpable, full ROM. The arm & leg on the side to which head is turned extend while the opposite arm and leg flex. (a symmetric response). 11) CHEST Breast Nodule Observe size, shape of chest, retractions. Hold the breast tissue between thumb & finger. Observe for breast engorgement & discharge. Round, symmetrical, slightly smaller than head. Retraction may be present immediately after birth. Breast tissue >10 mm diameter. Areola raised. May have gynaecomastia, may have milky white discharge (white milk) SUPERNUMERARY NIPPLES GENITALIA • Penile size • Hypospadias, epispadias • Testes – 2% crypoorchid • Female: – Prominent clitoris and minora – Vaginal skin tag – Vaginal discharge /blood – Labial fusion • Anus : Patency and location INGUINAL HERNIAS SUBLUXATION OF THE HIP LUMBAR HAIR TUFT & HAEMANGIOMA WHAT TO ASSESS? TECHNIQUE FOR ASSESSMENT CHARACTERISTICS OF NORMAL NEW BORN 12) ABDOMEN i) Bowel Sound ii) Umbilical Cord Auscultate bowel sound. Observe & count number of blood vessels, observe for any discharge or bleeding. Bowel sounds are present. Initially umbilical cord is white & gelatinous, later it dries & shrivels. Two arteries & one vein (clean, no discharge or bleeding) 13) GENITALIA i) Female Observe development of Labia majora, urethral meatus & vaginal opening & any discharge. Labia majora well developed. Labia majora completely covers the labia minora. Urethral meatus is located above the vaginal opening. Whitish mucoid or bloody discharge (Pseudomensturation may be present) ABDOMEN • Inspection – Scaphoid – Distention – Abdominal wall defect (gastroschisis) • Palpation; baby sucking and use warm hands – Kidneys are normaly palpable – Liver 2-3 cm – Spleen palpable – Umbilical vessels • 2 artery, one vein – Hernias ; umbilical and inguinal WHAT TO ASSESS? TECHNIQUE FOR ASSESSMENT CHARACTERISTICS OF NORMAL NEW BORN ii) Male Observe the scrotal rugae and palpate testes in the scrotum. Observe location of urethral opening. Testes descended in scrotum. Scrotum pendulous and deeply pigmented Urethra opening located at tip of glans. 14) BACK i) Spinal curve Observe spinal curve while newborn is in prone position. Observe for location & anal opening. H/O passage of meconium during the 1st 24-48 hrs. Spinal curve round. Patent & opening. NEUROLOGIC ASSESSMENT The neurologic assessment is based on 4 four fundamental observations: 1. Muscle tone 2. Joint mobility 3. reflexes 4. Body movements WHAT TO ASSESS? TECHNIQUE FOR ASSESSMENT CHARACTERISTICS OF NORMAL NEW BORN vi) Moro’s Reflex vi) Babinski’s reflex vii) Step or dance reflex Elicit by sudden change in equilibrium. Stroke plantar surface of newborn’s foot. Hold newborn in upright position so that sole of foot touches examination table. Sudden extension & abduction of extremities & fanning of fingers followed by flexion & adduction of extremities. The toes flare open. New born make stepping movement. REFLEXES OF EYE EXPECTED BEHAVIORAL RESPONSE AGE OF APPEARA NCE AGE OF DISAPPEAR ANCE 1. BLINKING Infant blinks at sudden appearance of bright light or approach of any object towards light. Birth Does not disappear. 2. PUPILLA RY REACTIO N Pupil constricts when bright light falls on it. Birth Does not disappear 3. DOLL’S EYE As head is moved to right or left, eyes lag behind & do not immediately adjust to new position. Birth 3-4 months. REFLEXES OF NOSE EXPECTED BEHAVIORAL RESPONSE AGE OF APPEAR ANCE AGE OF DISAPPEA RANCE 4. SNEEZE Spontaneous response of nasal passage to any irritant. Birth Does not disappear 5. GLABELLAR Tapping briskly on bridge of nose (Gabella) causes eyes to close tightly. Birth Does not disappear MASS REFLEXES EXPECTED BEHAVIORAL RESPONSE AGE OF APPEARANCE AGE OF DISAPPEA RANCE 13. MORO’S When loud voice is made or there is sudden change in equilibrium, it causes sudden extension and abduction of extremities and fanning of fingers. Birth 3-4 months 14. Perez When infant is prone on a firm surface, thumb is pressed along the spine from sacrum to neck, infant responds by crying, flexing extremities and elevating pelvis and head and lordosis of spine. Birth 4-6 months 15. Tonic neck When infant’s head is turned to one side, arm and leg extend on that side and opposite arm and leg flex. 2nd month 3-4 months MASS REFLEXES EXPECTED BEHAVIORAL RESPONSE AGE OF APPEARANCE AGE OF DISAPPEARAN CE 16. Galant reflex Stroking infant back alongside spine causes hip to move towards stimulated side. At birth 4 weeks 17. Dance or stepping If infant is held such that side of foot touches a hard surface, there is reciprocal flexion and extension of legs. At birth 3-4 weeks 18. Crawl When placed on abdomen, infant makes crawling movements. Birth 5 weeks It is NORMAL for a baby  To pass urine six or more times a day after day 2  To pass six to eight watery stools (small volume) in 24 hrs  Female baby may have some vaginal bleeding for a few days during the first week after birth. It is not a sign of a problem.  Loses weight and regains by 7-10 days EN-Teaching Aids: ENC 87 Conclusion • All newborn babies must be examined at – Birth – 24 hrs – Before discharge and – Follow-up • A systematic approach consisting of ‘Ask, Check, Look, Listen, Feel’ should be followed at each assessment Thank You!