GUIDE SHEET

INTRODUCTION

Life begins at conception about 9 months before delivery.Maternal health and events during pregnancy
have profound effect on well being of baby. Newborn physical examination is a means to assess the
health and wellbeing of the neonate.

DEFINITION:

A detailed and systemic whole body examination of a stabilized newborn during the early hours
of life.

PURPOSE:

1. To determine the normalcy of different body systems for healthy adaptation to extrauterine life.
2. To detect significant medical problems for immediate management.
3. To detect any congenital problems for early management and parent education

SPECIAL POINTS:
1. Friendly approach to the newborn and to the informant is important.
2. Information to be recorded clearly and orderly immediate after the collection.
3. Complaints to be written in informants own words rather than medical terms.
4. System review should be done to exclude any missing problem of any system.

PRINCIPLE OF ASSESSMENT:

1. Physical examination is the head to foot examination of an individual along with examination
of different system to exclude the abnormalities present in them
2. It includes anthropometric examination.
3. Method used for physical examination is inspection, palpation, manipulation, percussion and
auscultation.

ARTICLES REQUIRED:

ARTICLES PURPOSES
A. A tray containing:
1. Articles for temperature taking 1. To ascertain temperature.

2. A tape measure 2. To measure length, head, and chest

circumference.
3. A torch 3. To inspect mouth, eyes, ears and nose.

4. A stethoscope 4. To auscultate the chest and abdomen.

5. Articles for napkin changing 5. To change wet/soiled napkin.

 6. Baby clothing, linen and 6. To wrap the baby and to maintain warmth
blanket (in winter)

B. Weight machine B. To measure the weight.

C. Good light C. To examine under the good exposure of light.

D. Two buckets D. To discard solid napkin and linen separately.

E. Examination table covered E. To examine easily and accurately.

with mackintosh and sheet

F. Pencil/pen and paper F. To record the finding and to use during

examination.

PREPARATION OF ARTICLES:

1. Collect all the articles and set up the tray.

2. Ensure good light source.
3. Examination table to be kept ready in the examination room or in the treatment room.
Examination may also be done in the bed in very sick or in emergency.
4. If special examination done by the doctor, then special physical examination tray to be kept
ready with appropriate size of necessary equipment for the children.

GENERAL INSTRUCTIONS:

1. The newborn must be stabilized before starting the assessment procedure, i.e. normal body
temperature and colour.
2. The newborn should be protected from harmful processes such as chilling or nosocomial
infection.
3. Examination should be done systematically.

PREPARATION OF THE NEWBORN:

1. Strategies to be followed to gain co-operation.

2. Change napkin if necessary
3. Position the baby as required.
4. Maintain privacy and warmth.
5. Allow the parent to be with the baby or in nearest place.
6. Explain the procedure to the parent.

POSITION FOR PHYSICAL EXAMINATION OF THE NEWBORN:

1. For examination of the head and neck put the child on mother to hold the newborn firmly, or
use mummy restraint.
 2. For examination of the chest and abdomen use modified mummy restraint exposingthe chest
and abdomen or have the babylie on the bed, steadying him/her with your hands.
3. For examination of arms, leg-restraints can be use or continue to lie on the bed.
4. For examination the back-place the neonate in prone position.

PROCEDURE:

NURSING ACTION RATIONALE

1. Explain the procedure to the
parents
2. Collect the articles at the
examination table and place
conveniently.
1.
2. To have easy reach to the articles during
the procedure.
3. To prevent cross infection.

3. Wash hand and dry. 4. To examine the baby thoroughly and

easily.
4. Place the baby on the examination 5. To provide comfort to the baby.
table.
5. Check the napkin and change if 6. To assess the weight gain or loss, thus to
necessary. detect any deviation.
6. Take weight. hight

7. Check vital signs

HEAD TO FOOT EXAMINATION:

Steps Rationale
Face
To assess presence or absence of facial palsy
Symmetry /swelling Or injury

Eyes

Discharge –presence or absence

To assess presence of infection
Sclera: white/yellowish/redish/blue discolouration
To assess jaundice or sub conjunctival
 Conjunctiva: clear/ presence of redness haemorrhage
 Iris: dark black/grey/blue
 Pupils: equal bilaterally and reactive to light)
 Cornea: clear/hazy
 Blink reflex: reactive (responds to bright light
 Eyelids :normal / ptosis or edema

 Doll-eye response (with infant in supine To assess neurological status

position, turn head from one side to the other:
eyes move to opposite side from which head is
 turned) To assess chromosomal abnormality

 Eye position: distance between two eyes

normal /abnormal
Nose

Discharge- present/not
To assess presence of infection
Nares: bilaterally present/absent
To assess patency of nasal passage
Nasal passage: patent /not
Nasal flaring –present/absent
Ears

 Position: ears in straight line eyes; vertical

angle that is greater than straight vertical line;
 Skin tags: absent
To assess chromosomal abnormality
 Cartilage formation: well-curved pinna, sturdy,
stiff cartilage, instant recoil To assess maturity
 Neonate or snapping fingers; or moro reflex and
startle reflex

Oral cavity
To assess hydration level
 Mucous membranes: moist/dry
Pink/pale
 Chin shape and size in proportion with face
 Palate: without arching intact (determine by
palpating)
To assess congenital anomaly
Cleft lip/palate-present/absent.
 Tongue: size in proportion with mouth
 Tongue: midline/tongue tie is present
 Uvula: midline rises with crying/not

Neck

 Shape: symmetrical/asymetrical T o assess chromosomal abnormality

Head: turn from side to side equally, full range
of joint motion To assess range of movement
 Size: short/ with excessive skin fold
Thyroid: midline
 Lymph nodes: palpable/ not palpable
 Presence of mass/No masses

Chest
  Shape and size: Round/Barrel shaped To identify any abnormality
To assess maturity
 Chest circumference: To assess respiratory status of the new born
 Ribs: Symmetric/asymmetric
 Breast tissue : nipple spacing on the line
without extra nipples To assess presence of respiratory infection
 Areola: raised and without discharge
 Respiratory effort: easy, unlabored /difficult
 Respiratory rate
 Rhythm; regular/ irregular, but
 Chest movement-Bilateral symmetrical or
not
 Breath sound: normal/grunting/wheezing/
 Heart rate;
 Rythm: regular/irregular
 Murmurs: present/absent To assess caediac function
(initially may hear slight murmur until
ductus arteriosus closes)
 Apical pulse at fourth or fifth intercostals
space, mid clavicular line, left anterior chest
/on right side.
 Thrill: present/not To assess normal location of heart.

Abdomen

 Abdomen: rounded, contoured, symmetrical

 Umbilical cord: 3 vessels (2 arteries, 1 To assess presence of any congenital anomaly
vein)Bluish white
 Abdominal musculature: strong
 No visible peristaltic waves
 Bowel sounds: present

Upper extremities
 Length: in proportion to each other extremities
and body symmetrical To assess range of movement
 Full range of joint motion
 Scarf sign: elbow short of midline (grasp
infant’s hand and gently pull hand around neck
To assess gestational maturity
toward the opposite shoulder; observe position
of elbow to chest; grade position according to
gestational chart)
 Arm recoil: (quickly fled neonate’s forearms for To assess gestational maturity
5 seconds, next pull them to full extension, then
release; recoil time is graded)
  Palm: creases
 Nails: extend beyond nail beds
 Nail beds: pink, brisk capillary refill (<3
seconds, equal bilaterally
To assess congenital anomaly
Fingers: 10 digits/oligodactile/syndactile/polydactile

Genitalia
(Female)

 Labia majora: Present and extend beyond labia

minora To assess gestational maturity
 Labia minora : present and well-formed
To assess any congenital anomaly
 Clitoris: present, may be enlarged
 Urethral meatus: present in front of vaginal
orifice
 Vagina: patent with or without white discharge
 Genitalia: distinguishable as female or
Perineum: smooth
 Anus: midline, patent (test by inserting small
finger)
 Anal wink: present (light stroking of anal area
produces constriction of sphincter
(Male)
 Penis: straight; proportionate to body (length:
2.8-4.3 cm) To assess any congenital anomaly
 Urinary meatus: midline and at tip of glans (if
neonate is uncircumcised, gently retract the
foreskin; if circumcised, also check for edema
or bleeding)/epispedias/hypospedius
 Urinary stream: straight from penis (first void
should occur no later than 24 hours postnatally)
 Testes and scrotum: full, numerous rugae
Darkly pigmented
 Perineum; smooth
 Anus: midline, patent (Test by inserting
catheter or small finger)
 Anal wink: present (light stroking of anal area
produces constriction of sphincter)
 Testes descended on at least one side
To assess gestational maturity

Hips:
without clicks and full range of motion To assess hip dislocation
(Ortolani’smaneuver: flex newborn’s hips and
knees, then abduct and adduct hip to detect a
slipping of the hip out of the acetabulum or an
even motion unilaterally;
  Barlow’s maneuver: flex newborn’s hips and
knees, then place finger on the femur and
trochanter, put hip through full range of joint
motion and listen for audible click)
Lower extremities

 Length in proportion to body and equal

bilaterally; limb straight To assess any congenital anomaly
 10 toes and without webbing; equal spacing
 Feet: straight/club foot distortion
 Ankle dorsiflexion: 0 degree angle (foot is
flexed back on ankle, then angle between foot
and ankle is measured)
 Popliteal angle: < 90 degrees (flex newborn’s
leg, then flex thigh; next releases and extend
leg; measure angle of knee)
 Heel-to-ear maneuver (gently pull leg to ear
without forcing; heel will not reach ear but only
near shoulder area in full-term infant) To assess gestational maturity
 Nails: extend to end of nail bed
 Nailbeds: pink; brisk capillary refill (<3
seconds)
 Planter creases: cover the sole of foot

Back To assess any congenital anomaly

Spinal column: straight/kyphosis/scoliosis

No visible deviations or defects spina bifida/spina

occulta/menningocele/menningomyelocele

To assess neurological status and gestational

maturity
Reflexes
 Rooting
 Sucking
 Swallowing
 Glabellar tap
 Moro reflex
 Tonic neck reflex
 Babinski
ADVICE TO MOTHER OR CARE GIVER

In following aspects

1. Exclusive Breast feeding upto six months

2.preventiion of hypothermia

3.Prevention of infection

4.Immunization

5. Follow up

6. Explanation about newborns danger signs

Impression:
 Baby is active, alert
 Vitals are normal
 Anthropometric measurements are normal
 Reflexes are normal
 No congenital anomalies
 Feeding well

CONCLUSION:

So a simple rapid quick assessment of newborn help to find the path to manage the neonatal
complications,assure mother of baby’s normalcy and prevent medicolegal problem
PROCEDURE GUIDESHEET
ON
NEWBORN EXAMINATION

Submitted to
Madam M. Roy
Senior lecturer
Govt College of Nursing, Burdwan

Submitted by
Anupama Jash
M. Sc Nursing Final year
Govt College of Nursing, Burdwan