Newborn Nursery Observation Sheet

NEWBORN NURSERY OBSERVATION SHEET Describe Birth Date:

Skin

Color: inspect and palpate: inspect seminaked newborn in well-lit, warm area without drafts; natural daylight best (when quiet and alert)

Evidence of jaundice Texture : inspect and palpate for intactness, smoothness, texture, edema, pressure points

Posture & Body Movement

Sex:

Textbook Information:

Infant Observations:

Complete PRIOR to clinical

Completed in nursery day of clinical

Birth Weight:

Observe for birthmarks or bruises: Inspect a nd palpate for location, size, distribution, characteristics, color, if obstructing airway or oral cavity Normal Variations: Mongolian spot (bruising on back at buttocks) in AA, Asian, and NA. Variations/Possible Problems: Capillary hemangiomas; Nevus flammeus: portwine stain; Nevus vasculosus: strawberry hemangioma; Cavernous hemangioma AVG Findings: Generally pink varying with ethnic origin; Acrocyanosis (blue extermities) Normal Variations: Mottling (blotches), Harlequin sign, Plethora, Telangiectases, Erythema toxicum neonatorum, Milia, Petechiae, Ecchymoses, Birthmark Variations/Possible Problems: Dark red (preterm, polycythemia), Gray (hypotension, poor perfusion), Pallor (CV problem, CNS damage, blood dyscrasia, blood loss, twin-to-twin transfusion, infection), Cyanosis (hypothermia, infection, hypoglycemia, cardiopulmonary diseases, neurologic, or respiratory malformations), Gen. Petechiae (clotting factor deficiency, infections), Gen. Ecchymoses (hemorrhagic disease) AVG Findings: None at birth Normal Variations: Present in up to 60% of term infants in 1 st week of life Variations/Possible Problems: Present within 1 st 24hrs (increased hemolysis, Rh isoimmunization, ABO incompatibility) AVG Findings: Eyelid edema, Opacity Normal Variations: Slightly thick, superficial cracking, peeling of hands or fee t, Some fingernail scratches Variations/Possible Problems: Edema on hands/feet, Pitting over tibia, periorbital (overhydration, hydrops), Texture thin, smooth, or of medium thickness; rash or superficial peeling visible (preterm, posterm), Texture thick (posterm), Skin tags, webbing, Papules, pustules, vesicles, ulcers, maceration (impetigo, candidiasis, herpes, diaper rash) AVG Findings: Vertex: arms, legs in moderate flexion; fists clenched; Resistance to having extremities extended for examination or measurement, crying possible when attempted; Cessation of crying when allowed to resume curled-up fetal position (lateral); Normal spontaneous movement bilaterally asynchronous (legs flex and extend in a lternating fashion) but equal extension in all extremities Normal Variations: Frank Breech: legs straighter and stiff, newborn assuming intrauterine position in repose for a few days; Prenatal pressure on limb or shoulder possibly causing temporary facial asymmetry or resistance to extension of extremities Variations/Possible Problems: Hypotonia, relaxed posture while awake (preterm or hypoxia in utero, maternal medications, neuromuscular atrophy); Hypertonia (CNS disorder, chemical dependent); Limitation of motion in any of extremities

Describe





- Asleep

Newborns readily assumes in utero position – refer to maternal chart for fetal presentation

- Quiet alert

Smile, vocalize, move in synchrony with speech, watch their parents’ faces, and respond to people talking to them

- Crying

Signal hunger, discomfort, pain, desire for attention, or fussiness. Duration is highly variable. 5min-2hrs

Eyes

- Color

- Coordination

- Ability to see

Vital Signs

Check for placement on face: AVG Finding – eyes and space between eyes each 1/3 the distance from outerto-outer canthus Normal Variations - Epicanthal folds in some ethnicities Variations/Possible Problems - Epicanthal folds when present with other signs (Downs, cri-du-chat) Check for symmetry in size/shape Check eyelids for size, movement, blink: AVG Finding – blink reflex Normal Variations – edema if eye prophylaxis instilled Assess for discharge: AVG Finding - None, No tears Normal Variations – Some discharge or tears Variations/Possible Problems – purulent discharge (infection); chemical conjunctivitis from eye med is common, requires no tx Normal Variations: subconjunctival hemorrhage.

Most caucasions are born with blue, to blue brown color...if they are going to stay blue, they will be lighter blue at birth...darker blues usually go to hazel or green, and brown are usually VERY dark grey...almost brown underneath...to go to just brown!!! (but again, it d epends on ethnic background) By 6-12 months eyes will take their pigment on. This only an average. Possible problems: lens opacity or absence of red reflex (congenital cataracts, possibly from rubella, retinoblastoma [cat’s eye reflex]); Lesions: coloboma, absence of part of iris (congenital); pink color of iris (albinism); jaundiced sclera (hyperbilirubinemia) AVG Findings: Random, jerky, uneven focus possible briefly, following to midline Normal Variations: Transient strabismus or nystagmus until 3-4 months Variations/Possible Problems: Persistent strabismus, Doll’s eyes (increased intracranial pressure), Sunset (increased intracranial pressure) AVG Findings: Blink Reflex; PERRLA Variations/Possible Problems: Edema if eye prophylaxis drops or ointment instilled; Pupils unequal, constricted, dilated, fixed (intracranial pressure, medications, tumor) Term Newborns: 2.5ft, sensitive to light, open eyes wide in dark, eyes will follow light…5 Days: black/white patterns…2 Months: Color Peripheral Pulses: femoral, brachial, popliteal, posterior tibial AVG Finding: equal and strong Variations/Possible Problems: Weak or absent (decreased CO, thrombus, possible coarctation of aorta if weak on left and strong on right); Bounding

Describe

- Temperature

- Heart Rate

- Respirations

- Rate





AVG Findings: Axillary: 37C, stabilized by 8-10hr of age Normal Variations: 36.5-37.2C, Heat loss from evaporation, conduction, convection, radiation Variations/Possible Problems: Subnormal (preterm birth, infection, low environmental temp, inadequate clothing, dehydration), Increased (infection, high environmental temp, excessive clothing, proximity to heating unit or in direct sunlight, chemical dependence, diarrhea and dehydration), Temp not stabilized by 6-8hr after birth (if mother received mag sulfate, newborn less able to conserve heat by vasoconstriction; maternal analgesics possibly reducing thermal stability in newborn) AVG Findings: Visible pulsations in left midclavicular line, 5 th intercostal space, Apical pulse in 4 th intercostal space 120-140 bts/min, Quality – S1 and S2 sharp and clear Normal Variations: 80-100 bts/min (sleeping) to 180 bts/min (crying); possibly irregular for brief periods, especially af ter crying; Murmur, especially over base or at left sternal border in interspace 3-4 Variations/Possible Problems: Tachycardia: persistent >180 bts/min (RDS; pneumonia), Bradycardia: persistent <80 bts/min (congenital heart block, maternal lupus); Murmur; Arrhythmias: irregular rate; Sounds: distant, poor quality, S3, S4; Heart on right side of chest (dextrocardia), often accompanied by reversal of intestines AVG Findings: 40 breaths/min; tendency to be shallow and irregular in rate, rhythm, and depth when infant is awake; Crackles may be heard after birth; No adventitious sounds audible on insp/exp; Breath sounds, bronchial: loud, clear Normal Variations: 30-60 breaths/min; Short periodic breathing episodes and no evidence of resp. distress or apnea (>20sec); periodic breathing; First Period: 50-60 breaths/min; Second Period: 50-70 breaths/min; Stabilization (1-2 days): 30-40 breaths/min; Crackles (fine) Variations/Possible Problems: Apneic episodes: >20 sec (preterm infant: rapid warming or cooling of infant; CNS or blood glucose instability); Bradypnea: <25 breaths/min (maternal narcosis from analgesics or ane sthetics, birth trauma); Tachypnea: >60 breaths/min (RDS, transient tachypnea of the newborn, congenital diaphragmatic hernia); Breath sounds: Crackles (course), rhonchi, wheezing, Expiratory grunt (narrowing of bronchi); Distress evidenced by nasal flaring, grunting, retractions, labored breathing; Stridor (upper airway occlusion) AVG: 40 breaths/min Normal Variations: 30-60 breaths/min Variations/Possible Problems: Apneic: >20 sec (preterm, CNS or blood glucose instability; Bradypnea: <25 breaths/min (maternal narcosis from analgesics, birth trauma); Tachypnea: >60 breaths/min (RDS, cong diaphragmatic hernia

- Regularity

AVG Finding: Tendency to be shallow and irregular in rate, rhythm, and depth when infant is awake

Best observed by:

Observing at rest

Describe Anterior fontanel

Posterior fontanel Are they open? Head circumference Chest circumference

Umbilical cord

Circumcision Stools Moro reflex (startle): with infant on flat surface, make a loud, abrupt noise

Tonic neck reflex: with infant in supine neutral position, turn head to one side





AVG Findings: 5cm diamond increasing as molding resolves Normal Variations: Variation in fontanel size with degree of molding; Difficulty in feeling fontanels possible because of molding Variations/Possible Problems: Full, bulging (tumor, hemorrhage, infection); Large, flat, soft (malnutrition, hydrocephaly, delayed bone age, hypothyroidism); Depressed (dehydration) AVG Findings: Triangle, smaller than anterior Normal Variations: Same as Anterior Variations/Possible Problems: Same as Anterior

Yes AVG Findings: ¼ of Body of Length, Molding Normal Variations: Slight asymmetry from intrauterine position; Lack of molding (preterm, breech presentation, cesarean birth) Variations/Possible Problems: Severe molding (birth trauma); I ndentation (fracture from trauma) Head and Chest are the same for first 1-2 days after birth AVG Finding: 33-35cm Normal Variations: 32-36.8cm Variations/Possible Problems: circumference less than or equal to 4cm less than head = infection AVG Findings: 2 arteries, 1 vein; whitish gray; demarcation between cord and skin; no intestinal structures within cord; dry around base, drying; odorless; cord clamp in place for 24hr Normal Variations: Reducible umbilical hernia Variations/Possible Problems: 1 artery (renal anomaly); Meconium stained (intrauterine distress); Bleeding/oozing (hemorrhagic disease); Redness/drainage (infection); Hernia: herniation of abd contents through cord opening; defect covered with thin, friable membrane, possibly extensive Check for bleeding, if so apply pressure. Within 24 hrs becomes covered with yellow exudate. Normal/not infection! Use only water to c lean. AVG Findings: meconium followed by transitional and soft yellow stool Variations/Possible Problems: No stool (obstruction), Frequent/watery (infection, phototherapy) Characteristic Response: Symmetric abduction and extension of arms, fingers fan out and form a C with thumb and forefinger, arms are adducted in embracing motion and return to relaxed flexion and movement, followed by cry. Legs may follow similar pattern. Response is present at birth-8wks. Asymmetric response may connote injury to brachial plexus, clavicle, or humerus. Persistent response after 6mo indicates possible neurologic abnormality such as CP. Characteristic Response: With infant facing left side, arm and leg on that side extend; opposite arm and leg flex. (turn head to right and extremities assume opposite position. Responses in leg are more consistent. Response disappears by 3-4mo After 6wk, persistent response is sign of an abnormality

Describe Stepping reflex: hold infant vertically under arms or on trunk, allowing one foot to touch table surface





Characteristic Response: Infant will simulate walking, alternating flexion and extension of feet. Term-walk on soles, Preterm-walk on toes Response is normally present for 3-4wk. Palmar: place finger in palm in ha nd Characteristic Response: fingers curl around examiner’s fingers

Grasp reflex

Molding of the head

Plantar: place finger at base of toes Characteristic Response: toes curl downward Face appears small in relation to the skull. The skull appears large and heavy. AVG finding. Normal Variations: No molding (preterm, cesarean, breech) Variations/Possible Problems: Severe molding (birth trauma); I ndentation (fracture from trauma)

Caput succedaneum

Edematous area of scalp (fr om vacuum extraction)

Milia

Milk bumps

Mongolian spots

Bluish black areas of pigmentation commonly found on back or buttocks. Frequently noted in ethnic origins.

Erythema toxicum

Transient rash last approx. 3wks, Requires no tx

Acrocyanosis

Bluish color in extremities (arms, legs). Normal and appears intermittently over the first 7-10 days, especially with exposure.

Cephalhematoma

Collection of blood between a skull bone and its periosteum that does not cross a cranial suture line (from forceps)

Subconjunctival hemorrhage

Red blotch on sclera

Ear cartilage resilience

Term: Nodule approx 6mm, Nipples prominent, well formed, symmetrically placed. Normal Variations: Nodule approx. 3-10mm, secretion of witch’s milk Variations/Possible Problems: Lack of breast tissue; Nipples: supernumerary along nipple line; Malpositioned or widely spaced Term: Pinnia is firm, stands away from head and springs back quickly. Soft and flat, slightly curved with slow recoil. Curves over time and become thick cartilage.

Sole creases

Well lined (wrinkled). Over 2/3 of foot in term infants.

Breast tissue

Nails

Neonates-no nails. Post-term-past fingertip

Describe





inspect newborn before disturbing for assessment. Refer to maternal chart for fetal presentation, position, and type of birth (vaginal, surgical), since newborn readily assumes in utero position.

AVG Findings: Vertex: arms, legs in moderate flexion; fists clenched. Resistance to having extremities extended for examination or measurement, crying possible when attempted. Cessation of crying when allowed to r esume curled-up fetal position (lateral). Normal spontaneous movement bilaterally asynchronous (legs flex and extend in a lternating fashion) but equal extension in all extremities. Normal Variations: Frank breech: legs straighter and stiff, newborn assuming intrauterine position in repose for a few days. Prenatal pressure on limb or shoulder possibly causing temporary facial asymmetry or resistance to extension of extremities. Possible Problems: Hypotonia, relaxed posture while awake (preterm or hypoxia in utero, maternal medications, neuromuscular disorder such as spinal muscular atrophy); Hypertonia (chemical dependence, central nervous system [CNS] disorder); Limitation of motion in any of extremities.

Scarf sign

Elbow crosses the chest to the opposite shoublder midline without any resistance.

Posture:

Testes: palpable on each side Normal Variation: Bulge palpable on inguinal canal Variations/Possible Problems: Undescended (preterm)

Testes, scrotum

Labia, clitoris

Rugae (wrinkles):large, edematous, pendulous in term, covered with rugae. Normal Variation: Scrotal edema and ecchymosis if breec h birth; Hydrocele, small, noncommunicating Variations/Possible Problems: Scrotum smooth and testes undescended (preterm, cryptorchidism); Bifid scrotum; Hydrocele; Inguinal hernia Clitoris: edematous. Normal Variations: Increased pigmentation by pregnancy hormones Variations/Possible Problems: Ambiguous genitalia (not well distinguished from enlarged clitoris); Virilized female-extremely enlarged clitoris; Enlarged clitoris with urinary meatus on tip, absent scrotum, micropenis, fused labia Labia majora: edematous, covering labia minora Normal Variations: Edema and ecchymosis after breech birth Variations/Possible Problems: Widely separate and labia minora prominent (preterm); absence of vaginal orifice Labia minora: protrusion over labia majora Normal Variations: Blood-tinged discharged; Some vernix caseosa between labia possible

Head lag

Ankle & wrist

Total head lag normal in newborn. Full range of motion, symmetric contour Normal variations: feet appearing to turn in but can be easily rotated externally, positional defects tending to correct while infant is crying Possible Problems: increased tonicity, clonus, prolonged tremors (CNS disorder)

Describe Lanugo Estimate gestational age Describe any





AVG Finding: Over shoulders, pinnae of ears, forehead Normal Variations: Variation in amount Variations/Possible Problems: Absent (postterm); Abundent (preterm)

Circle which one you think fits Weeks:

abnormalities observed in newborn nursery

Labs:

Hgb.

14-24 g/dl

Hct.

44-64%

Blood Glucose

Term Newborn: 50-60 mg/dl 3 Days: 60-70 mg/dl

Serum Bilirubin

5 mg/dl = jaundice (jaundice beyond 7-10days requires further investigation)

Blood Type/RH

90%+

10-90%

-10%

LGA

AGA

SGA

Newborn Nursery Observation Sheet

Recommend Documents