3/21/2018 Outcomes Newborn Assessment • Understand newborn history • Discuss APGAR scoring Dr. Susan Ward PhD, RN, LCCE • Discuss newborn vital signs, weight and Lee Ann Caracciolo RN measurement • Examine newborn medications • Explore newborn assessment • Practice newborn assessment test questions History History Antepartum/OB Intrapartum • Para/gravida • Maternal age • Prenatal care • Prenatal care • Spontaneous/induction • Previous preterm • Pre-existing medical births/complications • Medications conditions such as • Medications - Rx, • Membranes ruptured? infertility, chronic illicit, over-the- • Meconium stained? counter, tobacco or hypertension… • alcohol use • High risk factors such Type of delivery • EDC as GDM, clotting or • Apgar scores seizure disorders • Antenatal testing Apgar Scoring (not predictive of neonatal mortality or morbidity) • Performed at 1 and 5 minutes of age • If the Apgar score is less than 7 at 5 minutes of age, the Neonatal Resuscitation Program guidelines state that the assessment should be repeated every 5 minutes for up to 20 minutes • Reflects status of infant and response to resuscitation 1 3/21/2018 Newborn Vital Signs (37to 41 weeks) Other assessment questions Vital Signs • Temperature - is the baby overwrapped, just • Temperature finished nursing or was he snuggling with • Normal axillary is 97.7-99.3 degrees F • Heart Rate mom? • Normal range 100-160 beats per • HR- is the baby awake? HR can decrease to 70 minute bpm while sleeping. Does the HR increase • Respiratory Rate with stimulation? • Normal range 30-60 beats per minute • RR - what is the baby’s color? and non-labored *Count HR and RR for one full minute Weight and Measurement Medications • Use a growth chart to determine SGA, AGA, LGA Vitamin K (phytonadione) • Weight (average 3405 gm or 7 lbs 8 oz) • Every newborn receives a single parenteral dose (IM) of natural Vitamin K1 (phytonadione) 0.5 to 1 mg • Less than 2748 grams (6 lbs) small for gestational age or preterm, greater than 4050 grams (9 lbs) large for gestational • Prophylaxis and treatment of Vitamin K deficiency age or infants of diabetic mothers bleeding (VKDB) • Coagulation factors (II, VII, IX, & X) formed in the • Chest circumference • Measure at level of nipples after exhalation liver • 30-35 cm (12-14 inches) • Requires Vitamin K for final synthesizes. • Sterile intestinal flora does not allow for Vitamin K • Head circumference • Measure just above eyebrows and around to occipital synthesis prominence in back of skull • Administer shortly after birth • 32 to 37 cm (12.5 to 14.5 inches) • Oral administration has not shown to be as effective • Length for prevention of late hemorrhagic disease • Measure top to head to heel • 48 to 52 cm (18 to 22 inches) Hepatitis B Vaccination Eye Prophylaxis • Hepatitis B is a contagious liver disease caused by the hepatitis B virus • Erythromycin 0.5% ointment is the most effective prophylaxis medication for vaginal and cesarean • All medical stable babies receive the first vaccine of hepatitis B deliveries against Gonococcal Ophthlamia vaccine before they leave the hospital Neonatorum and Chlamydia • The vaccine acts as a protectant, reducing the newborn’s risk of • Administration of eye prophylaxis is required in all acquiring the disease from the mother or family members who states may not know they are infected with Hepatitis B Virus • The administration of the ointment may be delayed • B Vaccine (Engerix-B, Recombivax HB) - the 1st dose of 10 mcg is until after initial breastfeeding in the delivery room given IM in vastus lateralis • The eye ointment should reach all parts of the • Hepatitis B Immuno-globulin (HBIG) - 0.5ml given IM if the conjunctival sac. After one minute the excess mother’s HBsAg status is positive or unknown, within 12 hours of medication can be wiped away with a sterile cotton birth swab or gauze AAP & ACOG (2012, p. 295) 2 3/21/2018 Techniques of Physical Assessment Newborn Assessment Assessment Skills Basic Principles • Observation • First hours of life • Auscultation • Subtle signs/symptom(s) – one • Palpation sign or a combination of • Percussion signs • Translumination • Review history for (scrotal sac) potential clues • Quiet environment • Calm and warm infant Physical Assessment Skin Assessment • Head to toe assessment – Count umbilical vessels Skin Color and Variations • Two arteries, one vein • Pink, warm and dry are the standard indicators that • Report a two vessel cord verify a newborn’s overall health status – Apgar scoring – Vital signs • All healthy newborns have a pink tinge to their skin – Weight and measurements – Medications • The pigment, melanin, is passed on to a newborn by – Skin his/her parents and determines skin tone, which can – Head and neck darken overtime based on genetic disposition – Respiratory system – Cardiovascular system • Ruddy skin color is due to the increased red blood cell – Abdomen concentration in the blood vessels and limited – Musculoskeletal system subcutaneous fat deposits (plethora) – Genitourinary system – Neurologic system Acrocyanosis (bluish color of hands and feet and might be present in first 24 hours of life) Skin Assessments and Variations • Assess for meconium staining • Inspect the newborn’s back for a closed vertebral column and for any abnormalities (closed” spina bifida or called Spina Bifida Occulta - causes no problems) • Dimpling Circumoral Cyanosis (cyanosis around the mouth) • Tuft of hair • Masses • Assess turgor (hydration status) • Skin should be elastic and should return rapidly to its original shape 3 3/21/2018 Vernix Caseosa Lanugo • Fine “downy” hair • A protective layer or covering (in utero it protects the • Part of gestational age assessment newborn that is surrounded by amniotic fluid) • At term, Lanugo is only present on shoulders, forehead and pinna of • Cheese-like, thick, whitish, substance fused to epidermis ears • Vernix Caseosa is visible in the skin folds, creases, • Lanugo in Postmature newborns axillary and genital areas is absent • Lanugo in Premature newborns • The actual amount found is effected by gestational age is long and thick on the back • Note the color – green (meconium stained), yellow (Rh and/or shoulders blood incompatibility), foul smell may indicate intrauterine infection that could be passed on to the newborn Mottling Skin Color and Variations • Cutis Marmorata or Skin Mottling is a “lacy pattern” on the skin and occurs as a result of general circulation Jaundice (physiological or Icterus fluctuations. It can last several hours to several weeks. Neonatorum) results from the accumulation Mottling may also be related to chilling, prolonged apnea, sepsis or hypothyroidism of bile pigments and associated with an • Capillary refill is > 3 seconds is abnormal – provides excessive amount of bilirubin in the blood. Is information about the infant’s cardiac perfusion worsened by ecchymosis – forcep marks, severe caput, cephalohematomas, bruising due to trauma. Seen in 30-50% of all normal term newborns Skin Color and Variations Skin Color and Variations • Hyperbilirubinemia • Administer phototherapy (the level of bilirubin determines if – Occurs within the first 24 hours of life the newborn is placed under single, double or triple – The Total Serum Bilirubin (TSB) increases by 0.5 mg/dL per phototherapy). Side effects of phototherapy are loose hour or 5mg/dL per day watery stools, diaper rash and dehydration – The diagnosis is made when the TSB concentrations climb ≥ • Fiber optic systems (Bili Blanket) can also deliver 12.9 mg/dL in a term infant and ≥ 15/mg/dL in a preterm phototherapy in a blanket form placed under or around the infant newborn – Visual observation is first noticed in the head and gradually • During phototherapy cover the newborn’s eyes and genital progresses to the thorax, abdomen and extremities area to prevent retinal and tissue damage. Remove the mask during feedings and shut off the lights – Use the Transcutaneous bilirubinometry (TcB) which is non invasive way to get a more accurate then visual reading of • Monitor the newborn’s temperature closely for hypothermia the infant’s bilirubin level • Excess bilirubin is excreted through the stools 4 3/21/2018 Mongolian Spot Harelequin Sign (Congenital Dermal Melanocytosis) Difference in color of half of the face or body (Harlequin’s sign) generally related to immature hypothalamic center The most common pigmented lesion in newborns Flushing occurs on dependent side (this Mistaken for a bruise due to newborn was placed on right side before gray/green color the current supine position) Location is the buttocks, flanks, or shoulders May fade over time Milia - raised white Epstein Pearls - Forcep Mark spots on the face and whitish-yellow cysts nose that form on the gums • Pressure marks are typically red or and roof of the mouth bruised areas from the use of forcep on the face, scalp, and/or cheeks • Examine the infant thoroughly or note other complications such as skull fracture, fractured clavicle, facial palsy Bohn’s Nodules - grayish white lesions in this newborn's mouth that resolve spontaneously Accessory Nipple(s) Erythema Toxicum Neonatorum • Accessory or supernumerary nipple(s) can be single or Newborn rash (cause unknown) –a multiple, flat, tan or brown spots along the “milk line” below and medial to the true nipple(s) pale yellow colored papule or pustules that vary in size from 1 to 3 • Often darken at puberty millimeters • Diagnosed when dimpling occurs when adjacent skin is stretched away from the nipple(s) Most commonly