what are the two key steps in delivery room assessments
- drying and warming
-drying the infant skin, removing wet linens and wrapping baby in prewarmed blankets prevent heat loss
-cold stress increases oxygen consumption and impedes effective resuscitation - clearing the airway
-baby not breathing, gasping, poor tone. check airway obstruction, if secretions obstructing airway, meconium stained fluid suction or PPV
- suction mouth first then nose with bulb syringe
-suction catheter -80- -100
what are the two critical assessments that need to be addressed in the delivery room
- mecronium stained amniotic fluid: fetal distress (meconium aspiration syndrome)
-vigorus newborn:
*good respiratory effort and muscle tone, HR>100bpm doesn’t require intervention
*can stay with mother
*bulb syringe
-non vigorus newborn: depressed respirations/poor muscle tone
*place under radient warmer
*bulb syringe
*PPV if not breathing or HR< 100 - provide stimulation
-no strong cry
-effective methods: flicking bottom of feet, rubbing back and drying with towel
-warming ,stimulation, clearing airways should occur 30 sec after birth to support spontaneous breathing
when should gestational age and size assessment be performed? what is measured? and what 3 factors are looked at to determine gestational age?
performed before first 12hrs
measured: length, weight,and head circumference
3 factors:
1.gestational duration on menstrual cycle (nageles rule)
-delivery date=date of menstrual period+7 months+7 days
2. prenatal ultrasound evaluation
-length of femur bone and size of fetal skull
3.postnatal findings: physical and neurological examination
define the APGAR assessment
- performed @ 1 min and then @ 5 mins to evaluate newborns transition to extra uterine life
- 5 key assessments:
1. appearance (0-2 pts)
-pale/blue (0), blue/pink torso(1), pink (2)
2. pulse (0-2)
-none(0),<100(1), >/=100 (2)
3. grimance (0-2)
-no respon(0),weak grimance when stimu(1), cries or pulls away when stimulated (2)
4.activity (0-2)
-none(0), some flexion of arms(1), arms flexed legs resist extension (2)
5. respirations (0-2)
-none(0), weak irregular or gasping (1), strong cry (2)
total out of 10 pts
-(0-3)=critically low (resuscitate)
-(4-6) fairly low( stimulate,warm,admin O2)
- (7-10) normal (monitor, routine care)
what characteristics help distinguish preterm from full term infants
- vernix caseosa: gray cheese like substance present in full term infants
- abundance in vernix: found in preterm infants
- lanugo: fine hair that covers premature infants (back,shoulder and forehead)
- weight, length, head circumference
-low weight: </= 2500g
-very low: </=1500g
-extremely low: </= 1000g - gestation age
-appropriate for gestational age (AGA): 10th and 90th percentiles
-large (LGA): above 90th percentile
-small (SGA): below 10th percentile
what are the 3 vital signs assessed
- HR
-normal: 120-170
-bradycardia: <80-90
-tachycardia: >180 - RR
-newborn: 40-60
-newborn-6m: 30-60
-6m-12m: 24-30
-1-5 yrs: 20-30
-6-12yrs: 12-20 - temp
-97.6F/ 36.4 C axillary
-99.6F/37.5C rectal
what to look for during a general inspection
1.body and symmetry at rest and during muscular activity
2.skin - intravascular volume and perfusion status
-good circulation=pink
-poor perfusion=pale
3.perfusion
4. capillary refill
-pressing sole of infants foot or palms
-good perfusion=pink, less than 3 sec
define the different types of skin color and appreances: motting, meconium stained, jaundice, ruddy complexion
motting:
-irregular areas of dusky skin alternating with areas of pale skin
-extremely pale or mottled suggest hypotension or anemia
meconium stained:
-yellow green staining of skin
-concern for mecornium aspiration syndrome (MAS)
jaundice
-hyperbillirubinermia
-yellow skin and sclea
-phototherpy for high levels
ruddy complexion
-high hematocrit/polythermia
-hyper viscosity syndrome ( hematocrit> 65%)
define what you are looking for during the physical exmaination of the respiratory function
- transient tachypnea for new born
-RR> 60 but normalize over several hrs
-caused by retained fluid - irregular breathing pattern
-70-80 breaths for 10-20 seconds, followed by 20-30 breaths for a short time
3.periodic breathing
-common in premature infants
-irregular pattern of intermittent respiratory pattern long than 5 seconds
4.apnea of the newborn
-breathing ceases for >20 secs
-associated with cyanosis,bradycardia, pallor, hypotonia
what are two signs indicating respiratory distress in newborns
1.nasal flaring :
-during inspiration when muscles of nasal passage contracts resulting in flaring
-widen nostrils and reduces airway resistance
2.grunting:
-audible expiratory noice caused by closure of the glottis during expiration in an attempt to increase PEEP
define the meaning of retractions of chest in infants
indicate increased WOB
- occur in suprasternal, substernal, subcoastal, and intercostal regions
-indicate reduced lung compliance or obstruction of the airways with normal lung compliance
-abdominal and thoracic respiratory muscle normally move in parallel
-paradoxical respiratory (see-saw) thoracic and abdominal are not synchronized indicates severe respiratory distress
define the slivermans score
- used to evaluate the severity of respiratory distress in newborns
- 5 physical signs
1. upper chest movement
2.lower chest movement
3.xiphoid retract
4.nares dialtion
5. expiratory grunt
each category 0-2 total 10
0= no respiratory distress
moderate or 1 mild respiratory distress
-lag in movement, slight retractions min nasal flaring
score of 2= severe respiratory distress
why is auscultation hard in newborns
- chest wall small and sounds transmit from one lung region to another
-abdominal sounds transmit to the lungs (diaphragmatic hernia)
-compare breath sounds from R-L
what is examined during the chest and cardiovascular system assessment
- chest of newborn=head circumference
-two notable chest wall abnormalities:
1. pectus carinatum: pigeon chest
2. pectus excavatum: funnel chest-sunken sternum
-bulging/asymmetry of the chest- important pathologic conditons: fluid accumulation, mass effect, musculoskeletal
define the physical assessment of heart
- important to listen for: cardiac murmur: soft -loud harsh sound similar to forcible exhalation with open mouth
(turbulent blood flow=Patent ductus arteriosus)
-heart size, shape, thoracic position assess congenital heart disease
pulse indications:
-weak pulse=low Cardiac output, hypoplastic leftside heart syndrome
-bounding pulse- patent ductus arteiosus or left-right shunting
-brachial and femoral pulse, equal intensity and felt simultaneously
-delayed or weak femoral pulse= coarctation of aorta (narrowing aorta restricts blood flow to body)
why is pre and post ductal saturation important to assess during physical examination
-assess right to left ductal level shunting
-detect persistent pulmonary hypertension
-determine abnormal blood flow that by passes lungs
-right arm will have higher saturation
-post ductal site will have lower saturation then pre ductal saturation: 5-10%
what should be observed when examining the abdomen of newborn
- calm and quiet infant
- observe the contour of the abdomen-flat or slightly rounded is normal
- scaphoid: belly appears sunken or hallowed=diaphragmatic hernia
-flat
-distended: bowel obstruction - auscultate and palpate all 4 quadrants
absent or reduced bowel sounds: elias necrotizing enterocolities
high pitched: bowel obstruction
what 3 conditions of congenital and musculature defects can be identified at birth
- prune belly syndrome
- congential lack of abdominal musculature
-gives abdomen wrinckled or prune like appearance - omphalocele
-protrusion of membranous sac that encloses abdominal contents through an opening in the abdominal wall into the umbilical cord
-as
3.gastroschisis
-defect in the abdominal wall lateral to the midline with protrusion of intestines
define the normal formation of the skull of infant after birth
during birth head may show evidence of brusing and molding as result of pressure during birth
molding of skull with overlapping cranial bones is common
fontanels are nonossified areas bw cranial bones that make up skull should not bulge
-anterior; closes bw 12-18 mon
-posterior: closes 2-3 months
-should be soft and flat
define subgaleal hemorrhage
- tearing of the emissary veins
-edema from blood loss can extend from the eyes-nape of neck
-blood loss may occur daily, rapidly, may cause hypovolemic shock
define the eyes of newborn
-swollen
-assess eyes for excessive spacing and unusual slant
-antibiotic ointment applied to prevent infection
-pupils should be round and regular and react to light
how to examine the nares of a newborn
-natural nose breathers
-occulde each side and list to breath sounds to assess patency of each nastril
define what bilater choanal atresia is
- imcomplete opening into the nasopharynx as result of membranes or bony structures
what are some congenital conditions affecting the head and neck
microstomia-trisomy 18 (edward syndrome)
-small mouth seen in chromosomal defect
trisomy 13
-midfacial cleft, cleft lip and palate
pierre robin syndrome
-characterized by cleft palate
