Assesment, Physical

Examination, Nursing Diagnose,

and Intervention of the
Newborn
Retnayu Pradanie
Clinical assessment of the newborn (General
Examination)
• Examine skin for prematurity or dismaturity

Thin,
transparent skin
in preterm
infants

Pale pink skin

of a term
infant (hair
shaved to site
Wrinkled peeling skin of
IV line)
dysmaturity in an IUGR infant
Skin: some common normal findings
• Vernix caseosa: a cream/white cheesy material
on the skin at birth which cleans off easily with
oil.
• Lanugo; fine downy hairs seen on the back and
shoulders especially in preterm infants.
• Milia: pinpoint whitish papules
on nose and cheeks due to
blocked sebaceous glands.
• Capillary heamangiomas (“stork bite” naevi):
red flat patches which blanch with gentle
pressure.
Commonly occur on
upper eyelids,
forehead and
nape of the neck.
 Skin: some common normal findings

• Mongolian blue spots: grey/bluish pigment patches seen in the

lumbar area, buttocks and extremities in dark skinned babies.They
usually disappear by one year.
• Erythema toxicum: small white/yellow papules or pustules on a red
base seen on face, trunk and limbs. Develop 1 – 3 days after birth and
usually disappear by one week.
Colour
• Note palor or plethora
• Cyanosis: the baby should be uniformly pink
• Blueness of the hands and feet (peripheral
cyanosis) may be due to cold extremeties.
• Blueness of the mucous membranes and tongue is
central cyanosis and is usually due to lung or heart
problems

• Bruising (ecchymosis) is common after birth

trauma. Unlike cyanosis, bruising does not
blanch on gentle pressure.
Jaundice
• Jaundice is common in the first week
of life and may be missed in dark
skinned babies
• Blanch the tip of the nose or hold
baby up and gently tip forward and
backward to get the eyes to open.
• Teach mother to do the same at
home in the first week and report to
hospital if significant jaundice is
observed.

Jaundice within 24 hours of birth is

pathological jaundice; jaundice after 24 hours
is probably physiological jaundice.
After general examination
• After these general observations, examine the
infant starting with the head and moving down
the body (Head to toe examination)
• Count the respiratory rate
• normal 30 – 40 breaths/min in term infants
• faster in preterms.
• > 60 / minute abnormal
After general examination…
Measure:
• Weight
• normal 2.5 – 3.99 kg
• Length
• normal 48 – 52 cm

• Occipitofrontal
circumference (OFC)
• normal 33 – 37 cm
Infants at Risk
• gagging --> turning blue (esp. after feeding)
• generalized cyanosis
• weak cry
• grunting or respiratory distress
• decreased or absent movements
• excessive twitching or trembling
Nursing Diagnosis:
• Ineffective Airway Clearance R/T excessive
oropharyngeal mucus
• Ineffective Thermoregulation R/T newborn
transition to extrauterine life
• High Risk for infection R/T maturational factors,
immature immune system
• PC: Hypoxemia
• PC: Hyperbilirubinemia
• (W) Beginning Integration of NB into Family Unit
Nursing care of the newborn
The major elements of routine care:
• Cord care
• Thermal control
• 24 hour rooming in
• Feeding
• Immunization
• Maternal education on hygiene
Cord Care
• The umbilical stump needs particular attention
as there are risks of bleeding and infection.

• Good cord care includes:

• Cutting cord with sterile equipment or a new razor
blade depending on the setting
• Ligation with a sterile plastic clamp or clean thread
• Keeping cord stump exposed, clean (with 70%
alcohol, 4% chlorhexidine or simple soap and water)
and dry
Cord Care and Research
• 1,811 NB’s- 2 groups - one receiving
cord care with alcohol and one
group not:
• equal # infections in infants who
received and did not receive cord
care
• cord separation ~ alcohol use: 9.8
days and no alcohol use: 8.16 days
Thermal Control
The causes of heat loss at birth:
1. Evaporation: the lost of heat through
moisture (a major cause).
2. Radiation: the lost of heat to cooler solid
objects in the environment that are not in
direct contact with the infant.
3. Conduction: loss of heat from the body
because of direct contact of skin with a
cooler solid object
4. Convection is similar to conduction, except
that heat loss is aided by surrounding air
currents; as direct flow of air from air
conditioner vent.
Measures to prevent hypothermia include:

• Delivery in a warm environment

• Immediate drying of the infant to
minimize heat loss by evaporation
• Bath after temperature is stable
• Keep out of drafts
• Skin to skin contact with mother
• Proper clothing and wrapping up with
A well dressed baby
linen including use of booties and
bonnets
• Regular feeds
Rooming In
refers to the practice of nursing babies with their
mothers rather than keeping them in a separate
nursery

Advantages:
Promotes bonding
Makes exclusive breastfeeding easy
Mother is able to keep a close watch on her infant. She
should be encouraged to report any concerns that she
has to the health care staff.
Feeding
Breast feeding remains the best method of
feeding the newborn and has the following
advantages:
• Breastmilk is nutritionally balanced
• It reduces the risk of infection especially in
unhygienic situations
• Protects against diarrhoea and other infections in
infancy
• Promotes mother-child bonding
• It is readily available
• It helps in child spacing
Immunization
Example of an immunisation schedule
• At birth BCG, Oral polio & HBV1
• 6 weeks DPT1, Oral polio & HBV2
• 10 weeks DPT2, Oral polio
• 14 weeks DPT3, Oral polio & HBV3
• 9 months Measles, yellow fever
Hygiene and prevent infection
• Hand washing.
• A common practice in many newborn nurseries is the
use of cover gowns to prevent infection.
• Eye care, umbilical care, bathing, care of the
circumcision.
• Vitamin K is administered to protect against
hemorrhage.
• Proper identification.
• No tub baths until cord off and healed
• clean around organs of elimination and mouth after
soiling to prevent skin break down
• fold diapers away from umbilicus
Questions and
Discussions
Thank You