a. Physical Assessment Vital Signs: T= 37.2 oC Height: 42 cm Weight: 2.

2 kg Body Appearance GENERAL SURVEY Length Head circumference Chest circumference Abdomen circumference Weight VITAL SIGNS Temperature Respiratory Rate Pulse Rate Inspection and palpation Techniques Normal Findings Actual Findings Interpretation Analysis PR= 152bpm RR= 62cpm

Inspection and palpation

46-54 cm 33-34 cm

42 cm 30 cm

32-33 cm

29 cm

A B N O R M A L

32-33 cm

25.5cm

Small for gestational age describing a baby that is significantly below the birth weight or size is expected for its gestational age. Reference: the bantam medical dictionary 6th edition

2.4-3.5 kg

2.2 kg ABNORMAL (Respiratory and pulse rate) Tachypnea occurs to the babies either premature or full term because their lungs are not fully developed. Newborns who are at higher risk of TTN include those who are:

36.5-37.5 C 30-60 cpm 120-140 bpm

37.2 C 62 cpm 152 bpm

 SYSTEM OF ASSESSMENT Skin Inspection and palpation In young babies, the skin is soft, smooth, and velvety in texture and warm to touch Pigmentations vary in children, depending on race, and will change as the child gets older. Smooth; warm to touch; has good skin turgor; presence of lanugo most prominent on the shoulder and back; superficial skin peeling ; yellowish skin color in face and chest (physiologic jaundice) Normal

Delivered by csection Born to mothers who smoked during pregnancy Born to mothers with diabetes Small at birth

Newborn babies have higher than normal number of red blood cells. Because the baby has more RBC which is being break down more quickly, more bilirubin is made. Your babys liver removes the bilirubin from their blood. But the liver is a complicated organ and, despite a baby being full term, it can take a few days to work properly. So, bilirubin builds up in the blood and it causes babies to be jaundiced. Reference:

Head

Inspection and palpation

Eyes

Inspection

A babys head maybe asymmetrical because of pressure during pregnancy and delivery. The suture lines of the skull maybe felt to override as a result of the pressure applied when contractions occurred during labor, this is usually most marked between the frontal and the parietal bone where the coronal suture is located. The fontanels are soft and flat Eyes are grey or blue. The Sclera is navy blue due to its thinness.

Anterior fontanel diamond shaped; Posterior fontanel triangular, not bulging and not sunken; hair is silky and soft and black in color; presence of caput succedaneum

Normal presence of caput succedaneum

Caput succedaneum is a temporary swelling of the soft parts of the head of a newly born infant that occurs during labor, due to the compression of the muscles of the cervix of the uterus and it resolves after delivery. It does not usually cause complications and usually resolves over the first few days. Reference: the bantam medical dictionary 6th edition

Ears

Inspection and palpation

Symmetrical in size and shape; eyebrows are distinct (not connected in midline) The pinna tends to Ears are well bend easily. formed and The level of the complete; top part of the symmetrical and is

Normal

Normal

Nose

Inspection

external ear should be on a line drawn from the inner canthus to the outer canthus of the eye and back across the side of the head. A Newborns nose tends to appear large for the face.

aligned to the outer canthus of the eye; pinna recoiled when folded

Mouth

Inspection

Neck

Inspection

Chest

Inspection

Symmetrical; both nostrils open to air flow; presence of milia on the tip of the nose Tongue should be Mouth, gums and in the midline tongue are pinkish; position. tongue is in The infants midline position; tongue and mouth soft and hard are pinkish in palate are intact; color. Uvula is in uvula in midline midline. The neck of a (flat red mosquito newborn is short like bites) and often chubby with creased skin folds. The head should rotate freely on it. Nipples would Almost circular, appear along a barrel shape line extending thorax, nipples from the anterior everted and

Normal

Normal

Normal

Meaning of telangectasia or storks big mark. It blanches on pressure; although it doesnt fade. Not noticeable as it becomes covered by hair.

Normal

Abdomen

Inspection, Auscultation and palpation.

Genitalia (Male)

Inspection and palpation

axillary line through the normal nipple down toward the symphysis pubis The contour of a newborn abdomen looks slightly protuberant. Bowel sounds should be present within one hour after birth. The edge of the liver is usually palpable one to two centimeter below the left costal margin. Presence of two arteries and one vein. There should be no bleeding on the cord site. The wrinkles or rugae are more developed as the child grows older. The foreskin may adhere to the glans for the first few years of life. It is

aligned; stippled areola that is 12mm

Umbilical cord is whitish gray in color, odorless and has 2 arteries and 1 vein; sigmoid , loop colostomy on the left lower quadrant and has slight swelling

A B N O R M A L

Sigmoid loop colostomy is a surgical procedure cutting the intestines and bringing the two ends outside of the body, usually on the left side of the body. The ends are turned inside out like a sleeve and stitched to the abdomen. This leaves two neat donut-like protrusions The upper stoma is where your baby will defecate from now on. Reference:

Testes within scrotal sac; few rugae on scrotum; prepuce not retractable; meatus at the tip of the penis;

Normal

Anus

Inspection

not necessary for the parents to stretch the skin by retraction. The meatus may be positioned off center. Presence of anus. Passage of meconium stool within 24 hours.

Imperforated anus; absence of sphincter A B N O R M A L

Imperforated anus is a condition discovered at birth, wherein the anus is not developed normally in the embryo. If the anal fails to develop, the rectum ends blindly above the muscles of the perineum. imperforate anus usually requires immediate surgery to open a passage for feces (colostomy). reference: http://www.ask.com/wiki/ imperforated_anus/

Back

Extremities

Inspection

Spine appears flat in the lumbar and sacral areas. Arms and legs appear short. The hands are plump and clenched into fists. Fingernails are soft and smooth

Presence of lanugo. Correct number and formation of fingers; flexion, has good muscle tone; bilateral movement of extremities; legs

Normal

Normal

Reflexes

Babinski

Gallant (trunk incurvation)

Grasp

Moro

usually long enough to extend over the fingertips. Newborn legs are bowed as well as short. When the side of the sole of the foot is stroke in an inverted J curve from the heel upward. A newborn fans the toes. When newborns lie in a prone position and are touch along the paravertebral area by a proving finger, they flex their trunk and swing their pelvis toward the touch. Newborn grasp an object placed in their palm by closing their fingers on it. Newborn abduct and extend their arms and legs

equal in length; normal position of the feet; presence of faint, red marks

Toes flare with dorsiflexion of the big toe.

Normal

Entire trunk flexes toward the side stimulated Normal

Fingers curl tightly, toes curl forward Normal Sharp extension and abduction of the arms with the

Normal

when a newborn hears a loud noise. Rooting The babys mouth will open and the head will turn toward the side stimulated. This reflex is marked during the early weeks of life Normally the baby responds by lifting the knees and hip into a flexed position and moving the opposite leg forward- making a series of stepping movements When a newborn lips are touched, the baby makes a sucking motion. Food that reaches the posterior portion of the tongue is automatically Swallowed. The arm and legs on the side to

thumbs and forefingers in C position Infant turn to the side touched Normal

Stepping

Infant lifts alternate feet as if walking Normal

Sucking

The infant begins to suck Normal Infant swallows fluid and is coordinated with sucking

Swallowing

Normal

Tonic neck

The arm and leg on the side toward

which the head is turned will extend, whereas those on the other side will flex

which the head turns extend, and the opposite arm and leg contract.

Normal