Examination of the Newborn: A Practical Guide


Record active movements against gravity as none, minimal, moderate, or strong. Record the angle formed at the knee by the upper and lower leg for Left and Right leg. Upper Extremity Reflexes and Face Scarf sign: Gently push the elbow across the chest so that the arm comes across the neck like a scarf. Record the point on the chest to which the elbow moves easily prior to significant resistance. Forearm resistance and recoil: Record amount of forearm resistance and speed and amount of recoil.

Power of Active Arm Movements: Record response as none, turn away from, weak, full or exaggerated head turn toward stimulated side. Record response as none, weak, strong or prolonged. Lift the infant a few inches above the surface of the crib so that the buttocks do not touch the surface. Record the tone of the trunk as no tone, some tone, good tone or exaggerated tone.

As infant is pulled to sit, observe if there is muscular resistance to stretching the neck and if the infant attempts to right head into a position that is in midline of the trunk and parallel to the body. Hold the infant upright with both hands under the arms and around the chest.

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Lift the infant so that the top of the foot is stroked and gently pressed downward against an edge on the crib or tabletop. Repeat with the other foot. Let the soles of the feet touch the surface and move the infant forward as stepping occurs. Record response as none, some, clear or exaggerated stepping.

Examination of the Newborn

If stepping was not elicited, note if infant can support weight, legs stiffen or if feet cross in a scissoring pattern. Slowly tap or stroke a line with the side of your thumb a few centimeters from the vertebrae, downward from the shoulder to the buttocks. Repeat on the other side. Record response of trunk as it flexes laterally in a concave curve on the stimulated side as none, weak, fully developed or exaggerated.

With infant prone, place head in midline and arms near the head, palms down. If infant does not crawl spontaneously, stimulate the response by gently pressing your palms on the soles of the feet. Record response as none, weak, coordinated or prolonged crawling and whether stimulation was applied. Head Raise in Prone: From above position, record lifting of the head as none, head turning, brief lift, sustained lift, or exaggerated response such as hyperextended neck. Pick up Infant Cuddle in Arm: Hold the infant in a cuddled position in your arms.

Do not rock or talk to infant. Facilitate cuddling only if there is no active participation from the infant. Hold the infant in a cuddled position on your shoulder. Then, slowly move the ball horizontally from one side to the other.

Physical Exam Documentation Example Newborn Template – bolstergroup.com

If the eyes and head follow to at least one side, move the ball vertically and in an arc to see if the infant will continue to follow. Inanimate Visual and Auditory: Slowly move the rattle horizontally from one side to the other. If the eyes and head follow to at least one side, move the rattle vertically and in an arc to see if the infant will continue to follow. Slowly move from one side to the other. If the eyes and head follow to at least one side, move your face vertically and in an arc to see if the infant will continue to follow.

Animate Visual and Auditory: Repeat so there are two trials on each side. Use your fingers to support the base of the head. Rotate your trunk in a half circle. Rotate in the other direction. Infant Supine in Crib Defensive Movements: Wait for the infant to settle and make a postural adjustment. Over the crib, hold the infant supine in your hands with one hand under the head and the other hand supporting the back and buttocks.

While continuing to support the head, quickly lower the infant. Summary Items Throughout the exam, observe and record the following: Bestsellers in Neonatal Medicine. Neonatology Tricia Lacy Gomella. Eyes Without Sparkle Elaine Hanzak. Oxford Handbook of Paediatrics Robert J. Essential Neonatal Medicine Sunil Sinha.

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Oxford Handbook of Neonatology Grenville Fox. Neonatology at a Glance Tom Lissauer. Newborn Carole Arsenault. Echocardiography for the Neonatologist Susan M. Nutritional Care of Preterm Infants R. Workbook in Practical Neonatology Richard A. Unofficial Guide to Paediatrics: Nursing the Neonate Maggie Meeks. Engaging Infants Frances Thomson-Salo. The Si Solution Kavitha Krishnan. Physical Assessment of the Newborn Ellen P. Atlas of Procedures in Neonatology Jayashree Ramasethu. Examination of the Newborn Heather Durward.

Back cover copy "Examination of the Newborn: If not, use 2 or 3 pillows. Remember that although assessment of pulse and blood pressure are discussed in the vital signs section they are actually important elements of the cardiac exam. The evaluation of the cardiovascular system focuses on the heart, but should also include an assessment for disease in the arterial system throughout the body. Atherosclerosis, the most common cardiovascular ailment in the western world, is a systemic disease.

Assessment for distention of the right Internal Jugular vein IJ is a difficult skill. Its importance lies in the fact that the IJ is in straight-line communication with the right atrium. This in turn is an important marker of intravascular volume status and related cardiac function. A discussion of the a, c and v waves that make up the jugular venous pulsations can be found elsewhere.

Background

These are quite difficult to detect for even the most seasoned physician. Why is JVD so hard to assess?

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Newborn babies are examined at around 6 to 72 hours after their birth to rule out major congenital abnormalities and reassure the parents that their baby is. Newborn babies are examined within the first 6 to 72 hours after their birth to rule out major congenital abnormalities and reassure the parents that their baby is.

The IJ lies deep to skin and soft tissues, which can provide quite a bit of cover. Additionally, this blood vessel is under much lower pressure then the adjacent, pulsating carotid artery. It therefore takes a sharp eye to identify the relatively weak, transmitted venous impulses. A few things to remember: The right IJ runs between the two heads sternal and clavicular of the sternocleidomastoid muscle SCM and up in front of the ear.

This muscle can be identified by asking the patient to turn their head to the left and into your hand while you provide resistance to the movement. The two heads form the sides of a small triangle, with the clavicle making up the bottom edge. You should be able to feel a shallow defect formed by the borders of these landmarks. Note, you are trying to identify impulses originating from the IJ and transmitted to the overlying skin in this area.

You can't actually see the IJ. The External Jugular EJ runs in an oblique direction across the sternocleidomastoid and, in contrast to the IJ, can usually be directly visualized. If the EJ is not readily apparent, have the patient look to the left and valsalva. This usually makes it quite obvious.

EJ distention is not always a reliable indicator of elevated CVP as valves, designed to prevent the retrograde flow of blood, can exist within this vessel causing it to appear engorged even when CVP is normal. It also makes several turns prior to connecting with the central venous system and is thus not in a direct line with the right atrium. Look at the area in question for several minutes while the patient's head is turned to the left. The carotid artery is adjacent to the IJ, lying just medial to it. If you are unsure whether a pulsation is caused by the carotid or the IJ, place your hand on the patient's radial artery and use this as a reference.

The carotid impulse coincides with the palpated radial artery pulsation and is characterized by a single upstroke timed with systole. The venous impulse at least when the patient is in sinus rhythm and there is no tricuspid regurgitation has three components, each associated with the aforementioned a, c and v waves. When these are transmitted to the skin, they create a series of flickers that are visible diffusely within the overlying skin. In contrast, the carotid causes a single up and down pulsation.

Furthermore, the carotid is palpable. The IJ is not and can, in fact, be obliterated by applying pressure in the area where it emerges above the clavicle. Search along the entire projected course of the IJ as the top of the pressure wave which is the point that you are trying to identify may be higher then where you are looking. In fact, if the patient's CVP is markedly elevated, you may not be able to identify the top of the wave unless they are positioned with their trunk elevated at 45 degrees or more else their will be no identifiable "top" of the column as the entire IJ will be engorged.

After you've found the top of the wave, see what effect sitting straight up and lying down flat have on the height of the column. Sitting should cause it to appear at a lower point in the neck, while lying has the opposite effect. Realize that these maneuvers do not change the actual value of the central venous pressure.

They simply alter the position of the top of the pulsations in relation to other structures in the neck and chest. Shine a pen light tangentially across the neck. This sometimes helps to accentuate the pulsations. If you are still uncertain, apply gentle pressure to the right upper quadrant of the abdomen for 5 to 10 seconds. This elicits Hepato-Jugular Reflux which, in pathologic states, will cause blood that has pooled in the liver to flow in a retrograde fashion and fill out the IJ, making the transmitted pulsations more apparent.

Make sure that you are looking in the right area when you push as the best time to detect any change in the height of this column of blood is immediately after you apply hepatic pressure. Once you identify JVD, try to estimate how high in cm the top of the column is above the Angle of Louis.

The angle is the site of the joint which connects the manubrium with the rest of the sternum. First identify the supra-sternal notch, a concavity at the top of the manubrium. Then walk your fingers downward until you detect a subtle change in the angle of the bone, which is approximately 4 to 5 cm below the notch. This is roughly at the level of the 2nd intercostal space. The vertical distance from the top of the column to this angle is added to 5cm, the rough vertical distance from the angle to the right atrium with the patient lying at a 45 degree angle.

The sum is an estimate of the CVP. However, if you can simply determine with some accuracy whether JVD is present or not, you will be way ahead of he game! Normal is cm. Bony Structures of the Chest. Finding the Angle of Louis: The wooden Q-tips highlight the different slopes of the sternum and manubrium. The point at which the Q-tips cross is the Angle of Louis. Determining the CVP Video of patient with markedly elevated central venous pressure. Video simulation and discussion of central venous pressure. Take some time to look across the left chest and try to identify the transmitted impulse caused by ventricular contraction, which may be apparent when contractions are particularly vigorous.

There are several sources of tension relating to the physical exam in general, which are really brought to the fore during the chest examine. Keys to performing a sensitive yet thorough exam: Ask pt to remove bra prior you can't hear the heart well thru fabric Expose left side of chest to extent needed Enlist patient's assistance, asking them to raise their breast to a position that enhances your ability to listen to and palpate the heart Don't rush, act in a callous fashion, or cause pain PLEASE The palm of your right hand is placed across the patient's left chest so that it covers the area over the heart.

The heel should rest along the sternal border with the extended fingers lying below the left nipple. Focus on several things: If so, where is it located? After identifying the rough position with the palm of your hand, try to pin down the precise location with the tip of your index finger. The normal sized and functioning ventricle will generate a penny sized impulse that is best felt in the mid-clavicular line, roughly at the 5th intercostal space. If the ventricle becomes dilated, most commonly as the result of past infarcts and always associated with ventricular dysfunction, the PMI is displaced laterally.

In cases of significant enlargement, the PMI will be located near the axilla. Occasionally, the PMI will not localize to any one area, which does not necessarily indicate ventricular enlargement or dysfunction. Obesity and COPD may also limit your ability to identify its precise location. Palpating while the patient is in the left lateral decubitus position can make the PMI more obvious. What is the duration of the impulse?

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In the setting of hypertension or any other state of chronic pressure overload, the ventricle hypertrophies and the PMI becomes sustained i. This is actually pretty subjective and can be tough to detect. Note that hypertrophy and dilatation are not synonymous. They can exist separately or in conjunction with one another. How vigorous is the transmitted impulse? Processes associated with ventricular hypercontractility e.

Do you feel a thrill, a vibratory sensation produced by turbulent blood flow that is usually secondary to valvular abnormalities? The feeling is similar to that produced when you squeeze on a garden hose, partially obstructing the flow of water. The location of the thrill will depend on the involved valve e. If a loud murmur is detected during auscultation, you may then go back and reassess for the presence of a thrill.

In general, thrills are an uncommon finding.

Cardiovascular Exam

Make sure that you tell that patient what you are about to do and why before actually performing this maneuver. Remember that with age tissue turgor often declines, causing the breasts to hang below the level of the heart. This is of greatest value during the assessment of aortic valvular and out flow tract disease see below and should thus be performed after auscultation so that you know whether or not these problems exist prior to palpation.

However, for the sake of completeness it will be described here.

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Reduced accommodative function is seen in a large proportion of children with cerebral palsy. Palpating while the patient is in the left lateral decubitus position can make the PMI more obvious. Furthermore, examinations that assess both physical and neuromuscular characteristics may be complex for clinicians and stressful for newborns, which may limit their utility [ 8 ]. Abstract Congenital hypothyroidism, occurring in 1: Data are available on the Additional file 1 submitted together with the manuscript. The exact underlying etiology for most cases of thyroid dysgenesis remains unknown. These studies provide insight into molecular mechanisms related to newborn neurobehavior that could have long term implications for behavioral development 30, 44, 45 including the development of mental health disorders.

The carotids can be located by sliding the second and third finger of either hand along the side of the trachea at the level of the thyroid cartilage i. The carotid pulsation is palpable just lateral to the groove formed by the trachea and the surrounding soft tissue. The quantity of subcutaneous fat will dictate how firmly you need to push.

The pulsations should be easily palpable. Diminution may be caused by atherosclerosis, aortic stenosis, or severely impaired ventricular performance. Do not push on both sides simultaneously as this may compromise cerebral blood flow.