Physical Assessment of the Newborn: Part 1 ® ® ® Review history . Prenatal . Labor/delivery . Presentation of illness Approach . Systematic . Gentle © K. Karlsen 2013 Perform hand hygiene (hand sanitizer or wash) Observe before touching Wear personal protective equipment as indicated (gloves, mask, gown) Perform while infant in quiet state whenever possible Use clean equipment Keep infant warm Shield eyes from exam light Comfort during / after exam Change soiled diapers / redress following exam Perform hand hygiene after exam © K. Karlsen 2013 © K. Karlsen 2013 The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 1 Physical Assessment of the Newborn: Part 1 Observe before touching Observe before touching Auscultate before palpating – in quiet environment Auscultate before palpating – in quiet environment Gentle palpation . Avoid if acute abdomen . Extra care with preterm infants © K. Karlsen 2013 © K. Karlsen 2013 Ballard Score Principles of Ballard Exam Developed by Jeanne L. Ballard, MD Timing Set of procedures and assessment parameters used . Most reliable if performed to determine gestational age by 12 hours of life . Evaluation of physical and neuromuscular maturity Keep infant warm A detailed monograph and explanation about how to perform the Ballard exam (written by Dr. Ballard), may be found at www.BallardScore.com . Ballard et al. (1991). J Pediatr.,119(3): 417-423. Neuromuscular illustrations were adapted with permission of Dr. Ballard © K. Karlsen 2013 © K. Karlsen 2013 -1 0 1 2 3 4 5 -1 0 1 2 3 4 5 Sticky Gelatinous Superficial Cracking Parchment Leathery Smooth pink peeling Superficial Parchment Skin Friable Red Pale areas Deep Cracked Sticky Gelatinous Smooth Cracking Leathery Visible veins and/or rash cracking peeling Deep Transparent Translucent Rare veins Wrinkled Friable Red pink Pale areas Cracked Few veins No vessels and/or rash cracking Visible veins Sparse Abundant Thinning Transparent Translucent Few veins Rare veins Wrinkled Lanugo No lanugo lanugo lanugo Lanugo Bald areas Mostly bald No vessels Heel- toe Heel- toe Anterior Skin – largest organ in the body Plantar 40-50 mm > 50 mm Faint red transverse Creases Creases over surface marks anterior 2/3 entire sole <40 = 2 No crease crease only Stratum corneum outer layer of epidermis Stippled Raised . Begins to develop after 21 weeks Im- Barely Flat areola areola areola Full areola Breast perceptible perceptible no bud 1-2 mm bud 3-4 mm bud 5-10 mm bud . 28 to 30 weeks is a few cell layers thick Lids fused: Lids open Slightly Well-curved pinna Formed Thick Eyes / Loosely: -1 Pinna flat curved pinna and firm cartilage . By term is 10 to 20 cell layers thick ears Soft but Tightly: -2 Stays folded Soft slow Instant recoil Ear stiff recoil ready recoil Before epidermis and stratum corneum develop, Scrotum Testes in Testes Testes Male Scrotum empty upper canal descending Testes down pendulous flat, smooth skin is transparent and thin Genitals Faint rugae Rare rugae Few rugae Good rugae Deep rugae Prominent Prominent Majora and Clitoris clitoris clitoris Majora large Majora cover Female prominent minora clitoris and Genitals Small labia Enlarging equally Minora small minora Labia flat minora minora prominent © K. Karlsen 2013 © K. Karlsen 2013 The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 2 Physical Assessment of the Newborn: Part 1 -1 0 1 2 3 4 5 -1 0 1 2 3 4 5 Superficial Parchment Superficial Parchment Sticky Gelatinous Smooth Cracking Leathery Sticky Gelatinous Cracking Leathery peeling Deep Smooth pink peeling Deep Friable Red pink Pale areas Cracked Friable Red Pale areas Cracked and/or rash cracking Visible veins and/or rash cracking Transparent Translucent Visible veins Rare veins Wrinkled Transparent Translucent Rare veins Wrinkled Few veins No vessels Few veins No vessels –1 0 1 2 © K. Karlsen 2013 © K. Karlsen 2013 -1 0 1 2 3 4 5 -1 0 1 2 3 4 5 Parchment Parchment Sticky Gelatinous Superficial Cracking Leathery Sticky Gelatinous Superficial Cracking Leathery Smooth pink peeling Deep Smooth pink peeling Deep Friable Red Pale areas Cracked Friable Red Pale areas Cracked Visible veins and/or rash cracking Visible veins and/or rash cracking Transparent Translucent Rare veins Wrinkled Transparent Translucent Rare veins Wrinkled Few veins No vessels Few veins No vessels 3 4 © K. Karlsen 2013 © K. Karlsen 2013 -1 0 1 2 3 4 5 -1 0 1 2 3 4 Parchment Sticky Gelatinous Superficial Cracking Leathery No lanugo Sparse Abundant Thinning Bald areas Mostly bald Smooth pink peeling Deep Friable Red Pale areas Cracked Visible veins and/or rash cracking Transparent Translucent Rare veins Wrinkled Few veins No vessels Fine, downy hair that begins to appear 24 to 25 weeks Abundant across shoulders and upper back by 28 weeks 5 With increasing gestation lower back area thins first bald areas appear over lumbo-sacral area By term, minimal to no lanugo present on back Amount and location may vary with nutritional status, ethnicity, hormonal and metabolic factors © K. Karlsen 2013 © K. Karlsen 2013 The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 3 Physical Assessment of the Newborn: Part 1 -1 0 1 2 3 4 -1 0 1 2 3 4 No lanugo Sparse Abundant Thinning Bald areas Mostly bald No lanugo Sparse Abundant Thinning Bald areas Mostly bald 1 -1 0 © K. Karlsen 2013 © K. Karlsen 2013 -1 0 1 2 3 4 -1 0 1 2 3 4 No lanugo Sparse Abundant Thinning Bald areas Mostly bald No lanugo Sparse Abundant Thinning Bald areas Mostly bald 1 2 3 4 © K. Karlsen 2013 © K. Karlsen 2013 -1 0 1 2 3 4 -1 0 1 2 3 4 Heel–toe Anterior Creases Heel–toe Anterior Creases > 50 mm Faint red Creases > 50 mm Faint red Creases 40 – 50 mm transverse over entire 40 – 50 mm transverse over entire No crease marks anterior 2/3 No crease marks anterior 2/3 < 40 = – 2 crease only sole < 40 = – 2 crease only sole Prior to foot creases appearing, for very preterm infants, measure foot length from tip of great toe to back of heel Foot crease begins to appear on ball of foot between 28 and 30 weeks gestation As infant approaches term, creases should cover entire plantar surface -1 0 1 © K. Karlsen 2013 © K. Karlsen 2013 The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 4 Physical Assessment of the Newborn: Part 1 -1 0 1 2 3 4 -1 0 1 2 3 4 Heel–toe Anterior Creases Stippled Raised Full areola > 50 mm Faint red Creases Im- Barely Flat areola 40 – 50 mm transverse over entire areola areola 5–10 mm No crease marks anterior 2/3 perceptible perceptible no bud < 40 = – 2 crease only sole 1–2 mm bud 3–4 mm bud bud As gestation advances, breast tissue is stimulated to grow by maternal estrogen 4 Evaluate size of areola and presence of any stippling Palpate breast tissue and estimate diameter in millimeters . 36 weeks 1 to 2 mm nodule of breast tissue 3 palpable 2 . By term 10 mm nodule of breast tissue usually palpable © K. Karlsen 2013 © K. Karlsen 2013 -1 0 1 2 3 4 -1 0 1 2 3 4 Stippled Raised Full areola Stippled Raised Full areola Im- Barely Flat areola areola areola Im- Barely Flat areola areola areola perceptible perceptible no bud 5–10 mm perceptible perceptible no bud 5–10 mm 1–2 mm bud 3–4 mm bud bud 1–2 mm bud 3–4 mm bud bud -1 2 0 3 1 4 © K. Karlsen 2013 © K. Karlsen 2013 -1 0 1 2 3 4 -1 0 1 2 3 4 Slightly Well-curved Formed Slightly Well-curved Formed Lids fused: Lids open Thick Lids fused: Lids open Thick curved pinna pinna and firm curved pinna pinna and firm Loosely: -1 Pinna flat cartilage Loosely: -1 Pinna flat cartilage Soft slow Soft but Instant Soft slow Soft but Instant Ear stiff Ear stiff Tightly: -2 Stays folded recoil ready recoil recoil Tightly: -2 Stays folded recoil ready recoil recoil Cartilage content increases as infant matures -2 Palpate for cartilage thickness, then fold pinna toward face and release it evaluate speed pinna 0 springs back If pinna remains folded, evaluate whether eyelids are fused or whether one or both eyelids are open If eyelids loosely or partially fused, assign a number of minus one (-1) © K. Karlsen 2013 © K. Karlsen 2013 The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 5 Physical Assessment of the Newborn: Part 1 -1 0 1 2 3 4 -1 0 1 2 3 4 Slightly Well-curved Formed Scrotum Testes in Testes Testes Testes Lids fused: Lids open Thick Scrotum curved pinna pinna and firm empty upper canal descending down pendulous Loosely: -1 Pinna flat cartilage flat, smooth Soft slow Soft but Instant Faint rugae Rare rugae Few rugae Good rugae Deep rugae Ear stiff Tightly: -2 Stays folded recoil ready recoil recoil Testes . Begin to descend from peritoneal cavity between 2 28 to 30 weeks 3 . Both palpated in lower inguinal canals by end of 4 rd th 1 33 to 34 week / scrotal skin thickens . Completely descended by 40 weeks Rugae (creases over scrotum) . Extremely preterm scrotum flat and smooth . By 40 weeks, scrotum covered with numerous thickened rugae and scrotum pendulous © K. Karlsen 2013 © K. Karlsen 2013 -1 0 1 2 3 4 -1 0 1 2 3 4 Scrotum Testes in Testes Testes Testes Prominent Prominent Majora and Majora Majora Scrotum Clitoris empty upper canal descending down pendulous clitoris clitoris minora large cover flat, smooth prominent Faint rugae Rare rugae Few rugae Good rugae Deep rugae Small labia Enlarging equally Minora clitoris and Labia flat minora minora prominent small minora 0 Assess with hips abducted to 45 1 Extremely preterm labia flat, clitoris very prominent 2 3 As fetus matures, clitoris less prominent, labia minora becomes more prominent 4 Closer to term clitoris and labia minora enveloped by enlarging labia majora Labia majora contains fat – size affected by intrauterine nutrition correlate findings with assessment of growth (small, average or large for gestational age) © K.