Professional Documents
Culture Documents
TH ND TH ND
TH ND TH ND
GENERAL MEASUREMENTS a. Age b. Weight c. Length d. Apgar Score II. HEAD MEASUREMENT a. Shape Round symmetrical may have molding--> overriding sutures. Slight asymmetry. 33-35 cm 2 cm> chest circ Term = start of 38th wk. end of 42nd week. 6.5-7.75 lbs 18-20.5 in 45-52.3 cm 7-10 <7 Textbook Information
Infant Observation
preterm = before end of 37th wk. posterm = after end of 42nd wk. <6 lbs >9 lbs
Textbook Information Sutures, palpable slight pulsation Soft 3-4 cm long 2-3 cm wide diamond shape 1-2 cm triangular
Possible Major Deviations and Complications Full bulging, large, depressed Closed sutures
Infant Observation
Grayish blue or gray brown iris. Blue white sclera. Random, jerky, uneven. Focus momentarily. Follows to midline. Pupils equal in size, round and reactive to light. May turn toward soft light. Without or occasionally. Focuses and follows by 15 min of age. See above, reaction to light.
Jaundiced sclera. Gross nystagmus Constant Strabimus Dolls eyes > 10 d. Pupils unequal, restricted, dilated, fixed Discharge Does not respond to light, focus or follow.
c. Reaction to Light
Assessment f. Eyelids
Textbook Information Size and movement symmetric. Blink reflex. Edema from prophylaxis. Eyes on a parallel plane.
Possible Major Deviations and Complications Does not respond to light, focus, or follow.
Infant Observation
IV. EARS a. reaction to noise Startle reflex to loud noise. Attends to sound. By 15 min. of age may move eyes in direction of sound. Responds to crooning by relaxation. Line drawn through inner and outer canthi of eye comes to top notch of ear (where it connects with scalp.) Symmetrical. Evidence of hearing. Reaction to noise. Midline Clear Infants obligatory nose breathers. Sneezing is common. Copius drainage Cyanosis at rest. Flaring or nares. Absence of reaction.
b. Position
Low placement
Infant Observation
See Section XXI. REFLEXES Symmetrical Presence of gag and swallowing Hard & soft palate in tact Epsteins Pearls Mouth drawls to one side
Clefts VII. NECK a. Length b. Mobility Short, thick, surrounded by skin folds. Head held midline. Free movement from side to side. Full flexion and extension. Cannot move head past shoulder. Webbing Rigid. Restricted movement. Head held at angle. Without head control. VIII. CHEST a. Size b. Breast tissue 1-2 cm <head circ. 30-33 cm 3-10 mm breast nodule Nipples prominent <30 cm Lack of breast tissue
Possible Major Deviations and Complications Bulging of chest. Retractions. Bowel sounds in chest.
Infant Observation
IX.
RESPIRATIONS a. Rate b. Rhythm c. Breath Sounds 30-60/min Shallow. Irregular when infant awake. No sounds heard without stethoscope. Bronchial. Loud, clear, near. d. Muscular activity involved Simultaneous rise and fall of chest and abdomen. Diaphragmatic and abdominal breathing. Tachypnea > 60/min Bradypnea < 25/min Labored breathing. Grunting, rales, rhonchi, wheeze (with or without stethoscope) Apnea > 15 sec. Subcostal and substernal retractions. Flaring of nares. Chin tug.
X.
PULSE a. Rate 120-160/min. 180 with crying 100/min. if asleep May be irregular for brief periods especially after crying. Persistent tachycardia-- > 170 Bradycardia-- < 120 Persistent irregular rhythm.
b. Rhythm
Assessment c. Peripheral circulation XI. ARMS AND HANDS a. Length b. Movements c. Muscle tone
Textbook Information Femoral pulses palpable, equal, strong. Sluggish peripheral circulation.
Infant Observation
Arms equal in length. Arms longer than legs. Spontaneous. Full range of motion. Generally flexed. Fist often clenched with thumb under finger.
Anelia, phocomelia Limited movements. Asymmetry of movements. tonicity Asymmetric contour. Poor tone/floppy. + scarf sign.
d. Fingers 1. Number 2. Webbing e. Position XII. ABDOMEN a. Contour Rounded, protruding Abd. distended. Scaphoid. Correct Without Fists often clenched with thumb under finger. Absence of or additional. Short. Polydactyl Syndactyl Rigid flexion. Persistent fists.
Assessment b. Musculature
Textbook Information Not fully developed. Bowel sounds audible 1-2 hours after birth.
Infant Observation
XIII.
UMBILICAL CORD a. Number of vessels at birth b. Appearance 2 arteries 1 vein Clear, gelatin. Odorless. Drying. 1 artery Bleeding or oozing. Drainage or redness.
XIV.
GENITAL-URINARY a. Female 1. Labia a. Size b. Appearance 2. Vaginal discharge a. Color b. Type Smegma under labia. May be blood tinged. Mucoid/white Usually edematous Covers labia minora May have pigment. Symmetric in size. Majora widely separated Minora prominent. Absence of vaginal orifice. Fecal discharge. Ambiguous genitals
Textbook Information
Infant Observation
Palpable each side. Large. Rugge. Cremasteric. Correct position. Prepuce covers glans. Not easily retractable. Yes or no. By day 2 white exudate may cover glans penis.
Undescended. Scrotum smooth. Not at tip of penis. Adherent prepuce. Excessive bleeding, swelling or discharge.
c. Voidings 1. Color 2. Amount 3. Frequency 4. Specific gravity XV. RECTUM a. Patency Good sphincter tone of anus. Good wink reflex. Clear, light yellow. Well saturated diapers By 24 hrs after delivery. At least 3-4 times/day 1.008-1.010
Assessment b. Stools 1. Number 2. Color 3. Consistency 4. Frequency XVI. HIPS a. Symmetry b. Femur heads XVII. BACK a. Appearance b. Turns head from side to side in prone position.
Textbook Information
Infant Observation
Meconium by 24 hrs. after birth. Depends on age of infant and type of feeding she is receiving. See your book for specifics.
Failure to pass meconium. Abd. distention. Diarrheacurdy, green, large water ring, forceful.
Straight, easily flexed. Yes Can raise head momentarily. Limitation of movement. Pigmented nevus with tuft of hair located at base of spine. Spina bifida.
XVIII. LEGS AND FEET a. Appearance May appear to have bowed legs.
Textbook Information
Possible Major Deviations and Complications Different temps. Unequal Hypermobility. Lack of leg movement. Club foot.
Infant Observation
Legs of equal length. Shorter than arms. Full ROM Foot in straight line. May appear to turn in but easily rotated externally. General flexion Feet flat. Well lined over 2/3 of surface. Correct Without General flexion. Most often see legs drawn up against abd.
Assessment b. Textures
Textbook Information Smooth, soft. Flexible.May have dry peeling hands and feet. Without edema. Teleangiectases Mongolian spots. Transient hyperpigmentation of areolas, genitals.
Possible Major Deviations and Complications Thinner or thicker texture. Fish scale skin. Hemangiomas
Infant Observation
c. Birthmarks
d. Characteristics 1. Milia 2. Lanugo 3. Vernix caseosa 4. Ecchymosis 5. Hair Distended sebaceous glands particularly on nose and cheeks. Over shoulder, pinnias, forehead, back. White, cheesy, odorless. In creases and folds. Peteciae over presenting part. Ecchymosis from forceps. Amount varies. Silky, growth pattern toward face and neck. Absent or excessive. Absent of excessive. Yellow, green or foul odor. Over other areas. Fine, woolly. Coarse, brittle. Unusual growth pattern.
Assessment 6. Nails 7. Peeling XX. TEMPERATURE a. Normal b. Temperature regulatory mechanism c. Heat Loss XXI. REFLEXES a. Local 1. Blink
Textbook Information Present, extended beyond fingertips. Of hands and feet at about day 3.
Possible Major Deviations and Complications Absence. Generalized cracking and/or peeling.
Infant Observation
97.6-98.6 axillary Shivering mechanism undeveloped. Brown fat. From evaporation, conduction, convection, radiation.
<97 Ax. >99 Ax. Temp not stabilized by 10 hrs after birth. Swings of > 2 F from one reading to the next.
Response to light stimulus. Tap on forehead, bridge of nose, maxilla when eyes openblink first 4-5 times. Response to light is equal. Round. Pupil constricts.
2. Pupillary
Textbook Information When head is turned, eye movement lags behind. Turns head in direction of stimulus, opens mouth. Follows rooting. Takes hold, sucks ad obtains fluids. Safety reflex. Do not try to elicit. Spontaneous. Finger curl around examiners finger. Toes turn downward. Hyperextension of all toes with dorsiflexion of big toe when one side of sole is stroked from heel across ball of foot to toe.
Infant Observation
Absent.
Textbook Information
Infant Observation
Symmetric abduction and extension of arms. Finger may fan with forefinger and thumb forming a C. Arms then adduct in embracing motion and return to relaxed flexion. When head is turned to one side, extremities on same side extend and on opposite side flex. when held upright with one foot touching a flat surface, will stimulate walking. Will step alternately. While on abdomen, will make crawling movements with arms or legs. Asymmetry of stepping.
3. Dance/Walking
4. Crawling c. Assess the newborn for: 1. Presence or absence of each reflex. 2. Strength of each reflex. 3. Infants response to your assessment.
Absent.
Textbook Information
Infant Observation
Individual, 15-20 min q. 24 hrs to 2 hrs q. 24 hrs. Lusty, strong. Moderate pitch.
Unconsolable
Touch, massaging, warmth--> soothing Low pitch voice--> relaxation. Responds with quietness and increased alertness and cuddling, voice. Unconsolable
c. Parent-infant interaction
Turns head and focuses when No focus on person handling. interested. Coordinates body movement to parents voice and body movement. Variations in interest/ hunger. Usually feeds well within 24 hrs. Wakeful periods about q. 3-4 hours. Lethargy
d. Eating-Sleeping patterns