Nb Assessment

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  • Topic: Intracranial pressure, Blood pressure, Esophageal atresia
  • Pages : 8 (2574 words )
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  • Published : March 21, 2013
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Table 21-2 SUMMARY OF NEWBORN ASSESSMENT *MCH pages 479-473| NORMAL| ABNORMAL (POSSIBLE CAUSES)| NURSING CONSIDERATIONS| Initial AssessmentAssess for obvious problems first. If infant is stable and has no problems that require immediate attention, continue with complete assessment.| Vital Signs|

TemperatureAxillary: 36.5– 37.5°C (97.7 – 99.5°F).Axilla is preferred site.| Decreased (cold environment, hypoglycemia, infection, CNS problem). Increased (infection, environment to warm).| Decreased: Institute warming measures and check in 30 minutes. Check blood glucose.Increased: the excessive clothing. Check for dehydration.Decreased or increased: look for signs of infection. Check radiant warmer or incubator temperature setting. Check thermometer for accuracy if skin is warm or cool to touch. Report abnormal temperature to physician.| PulsesHeart rate 120 – 160 BPM. (100 sleeping, 180 crying).Rhythm regular.PMI at 3rd-4th intercostal space lateral to mid-clavicular line.Brachial, femoral, and pedal pulses present and equal bilaterally.| Tachycardia (respiratory problems, anemia, infection, cardiac conditions). Bradycardia (asphyxia, increased intracranial pressure). PMI to right (dextrocardia-heart situated to right of body, pneumothorax). Murmurs (normal or congenital heart defects). Dysrhythmias. Absent or unequal pulses (coarctation of the aorta).| Note location of murmurs. Refer abnormal rates, rhythms and sounds, pulses.| RespirationsRate 30 -60 (AVG 40 -49) BrPM.Respirations irregular, shallow, unlabored.Chest movements symmetric.Breath sounds present and clear bilaterally.| Tachypnea, especially after the first hour (respiratory distress).Slow respirations (maternal medications). Nasal flaring (respiratory distress). Grunting (respiratory distress syndrome). Gasping (respiratory depression). Periods of apnea more than 20 seconds or with change in heart rate or color (respiratory depression, sepsis, cold stress). Asymmetry or decreased chest expansion (pneumothorax). Intercostal, xiphoid, supraclavicular retractions or see-saw (paradoxical) respirations (respiratory distress). Moist, coarse breath sounds (crackles, rhonchi) (fluid in the lungs). Bowel sounds in chest (diaphragmatic hernia).| Mild variations require continued monitoring and usually clear early hours after birth.If persistent or more than mild, suction, give oxygen, call physician, and initiate more intensive care.| Blood Pressure Varies with age, weight, activity, and gestational age. Average systolic 65-95 mm Hg, average diastolic 30-60 mm Hg.| Hypotension (hypovolemia, shock, sepsis).BP 20 mm Hg or higher in arms than legs (coarctation of the aorta).| Refer abnormal blood pressures. Prepare for intensive care and very low.| Measurements|

Weight2500-4000 g (5 lbs. 8 oz. to 8 lbs. 13 oz.).Weight loss up to 10% in early days.| High (low gestational age LGA, maternal diabetes). Low (small for gestational age SGA, preterm, multifetal pregnancy, medical conditions and mother that affected fetal growth). Weight loss above 10% (dehydration, feeding problems).| Determine causeMonitor for complications common to cause.| Length48-53 cm (19-21 inches)| Below normal (SGA, congenital dwarfism). Above normal (LGA, maternal diabetes).| Determine causeMonitor for complications common to cause.| Head Circumference32-38 cm (12.5-15 inches). Head and neck are approximately ¼ of infants body surface.| Small (SGA, microcephaly, anencephaly-absence of large part of brain or skull). Large (LGA, hydrocephalus, increased intracranial pressure).| Determine causeMonitor for complications common to cause.| Chest Circumference30-36 cm (12-14 inches). Is 2 cm less than head circumference.| Large (LGA). Small (SGA).| Determine causeMonitor for complications common to cause.| Posture Flexed extremities move freely, resist extension, return quickly to flexed state. Hands usually clenched. Movements symmetric. Slight tremors on crying....
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