Physical Assessment of newborn + respiratory system

1. General Assessment & Abdomen

  • Abdomen is concave at birth; may be distended as it fills with air.

  • Report visible or dilated veins.

  • Omphalocele.

  • Bowel sounds appear within the first hour after birth.

  • Doctor will palpate liver, spleen, and kidneys.

  • Nurse should palpate the inguinal area for hernia.

  • Umbilical hernia: associated with weakness in the abdominal wall. Ensure it's soft and not tight, as tightness can indicate strangulation of bowel.

  • Duodenal atresia: obstruction of the duodenum.

    • Symptoms: abdominal distension, absence of stool, jaundice, billous emesis.

    • X-ray would show a double bubble pattern.

  • Umbilical cord: bluish/white, 1 vein, 2 arteries, usually 30-90 centimeters.

    • A thin cord typically indicates potential vascular compromise in the fetus, which can be associated with various congenital abnormalities.

    • Discolored or foul-smelling cord can indicate infection.

    • If the umbilical cord is continually wet or oozing, evaluate the newborn for patent urachus. The urachus normally closes after birth, but if it remains patent, it can lead to urine leakage from the umbilicus, which may necessitate further evaluation and potential surgical intervention. This can increase the risk of bladder infections.

  • Most common abdominal wall defect is omphalocele. Other notable defects include gastroschisis.

    • Omphalocele: repaired by surgical intervention.

    • Gastroschisis: not covered by a membrane, typically to the right of the umbilicus.

    • Extrophy of the bladder: a congenital defect resulting in the bladder being exposed outside the body due to a failure of the abdominal wall to close properly. Occurs more with cleft palate / preterm birth.

  • It's important that the parents hold the newborn.

  • Nursing care for abdominal wall defects: Nurse should place saline sterile gauze or a plastic bowel bag. Put the baby on their side to prevent kinking. A nasal gastric tube should be placed.

2. Genitalia & Extremities

  • Newborn genitalia: whitish discharge is normal during the first week of life, and some blood is normal during the first couple of weeks.

  • Breech birth can lead to swollen genitalia.

  • Hypospadias: A congenital condition where the urethra opens on the underside of the penis, which may require surgical correction.

  • Testes descend around 28 weeks gestation.

  • Meconium is usually passed within the first day of life.

  • Examine the palm for a simian crease (a single crease across the entire palm), which may be a normal variant or a sign of Down syndrome.

  • Syndactyly: webbing (conjoined) fingers of the hands.

  • Suck blisters: found on hands, forearms.

  • Assess buttocks for dimples.

  • Assess feet for clubbing, which requires orthopedic consultation.

  • Congenital hip dysplasia: Evaluate the alignment of the gluteal folds, as asymmetric folds are symptomatic of hip dislocation.

  • Amniotic banding: a congenital condition where fibrous bands form in the amniotic sac, potentially causing limb deformities and constrictions in the neonate. Amnionic bands can lead to encircling or amputation of digits.

  • Inspect spinal alignment. Inspect the sacral area for the presence of pilonidal dimples, tufts of hair, or other abnormalities.

  • Myelomeningocele: a type of spina bifida that occurs when the spinal canal does not close completely, causing the spinal cord to protrude through an opening in the back, which can lead to severe disabilities and requires surgical intervention.

    • Nurse should cover the defect with a saline-moistened sponge to protect the exposed spinal tissue and prevent infection while preparing for surgical repair. Do not use wet gauze or latex to cover.

3. Neurological Assessment & Reflexes

  • Movement in a term newborn is smooth; in earlier gestational age newborns, movements appear jerkier.

  • Jitteriness in a newborn may be a symptom of hypoglycemia, hypocalcemia, or withdrawal from prenatal exposure to opiates, nicotine, or other electrolyte imbalances.

  • Seizure activity has a fast-slow rhythmic movement that cannot be stopped when the limb is held.

  • Moro reflex: A startle reflex that occurs when a baby feels a sensation of falling; it includes throwing back of the head, extending the arms and legs, and then pulling them back in.

  • Rooting reflex: Touch the newborn's cheek, and they should turn their head and suck. This reflex is crucial for feeding as it helps the newborn find the breast or bottle.

  • Babinski reflex: Stroke the lateral foot to the sole; toes should spread outward.

  • Fencing reflex (also known as the tonic neck reflex): occurs when the infant's head is turned to one side, resulting in the arm and leg on that side extending while the opposite arm and leg flex.

4. Respiratory System & Pulmonary Function

  • Tidal volume: air that moves into and out of the lungs, 4-6 ml per kg; consistently increasing tidal volume may indicate improving condition.

  • Vital capacity: maximum volume of air inspired and expired.

  • Functional residual capacity (FRC): the volume of air remaining in the lungs after a normal expiration, which is essential for maintaining adequate oxygenation and preventing lung collapse. FRC is approximately 30-40 ml/kg, vital for maintaining adequate oxygen levels and preventing atelectasis.

  • Ventilator settings:

    • PIP: 20 cm H_2O

    • PEEP: adjusted to 5 cm H_2O

    • I:E: amount of time the breath cycle occurs. Inspiration approx 0.33 sec, expiration approx 0.44 seconds.

  • Oxygenation: for preterm is 21-30%, 21% for term babies, and establish as needed.

  • Lung compliance: Think of a balloon. If there's a lot of volume with little pressure, that means the lung is compliant. A patient with RDS needs much more pressure to inhale volume, and lungs collapse on exhalation.

  • Pulmonary vascular resistance: needs to drop to allow blood to flow effectively through pulmonary vessels, enabling adequate oxygenation and supporting the transition to normal respiratory function after birth.

  • Mean Airway Pressure (MAP): pressure transmitted to the airways throughout the entire respiratory cycle. A healthy lung has much lower MAP.

  • Gas trapping: occurs when gas is not fully exhaled, leading to overdistention of alveoli. This can happen with the presence of debris, meconium, PNA, or secretions in the airway, which occludes the airway and traps the gas. Inhalation/exhalation ratios used in mechanical ventilation can also contribute to gas trapping.

  • Maintaining Functional Residual Capacity: Maintaining PEEP allows some air to remain in the lungs at the end of expiration and permits the newborn's next breath cycle to begin from a higher lung volume, thus improving oxygenation and ventilation efficiency. If the FRC isn’t supported with adequate PEEP, the newborn may experience under- or overinflated symptoms, potential for an air leak such as a pneumothorax. Underinflated symptoms could be atelectasis.

  • For efficient gas exchange, the V/Q ratio should be 1 to 1, meaning the alveoli are in perfect contact with the capillaries.

  • V/Q ratio: relationship between alveolar ventilation (volume of air that is available for gas exchange) and blood supply to the alveoli.

    • V/Q mismatch: decreased ventilation with normal blood flow may be found with atelectasis or RDS.

    • Normal ventilation with decreased blood flow can be found with pulmonary hypertension; carbon dioxide cannot be released into the lung because the HTN causes decreased blood flow to the capillary.

  • Normal PaO_2 for a preterm neonate is 45-65 (higher levels can cause ROP).

  • Oxygenation: the amount of oxygen available at the tissue level and is dependent on oxygen delivery and oxygen consumption. This is dependent on cardiac output and oxygen carrying capacity of blood.

  • Oxyhemoglobin saturation: percentage of hemoglobin that is combined with oxygen.

  • The amount of oxygen available to use is dependent on the O_2 content of the blood, plus the effectiveness of the heart in circulating, e.g., cardiac output (CO).

  • Oxyhemoglobin dissociation curve: is not linear. It depends on the affinity of hemoglobin for oxygen, which is influenced by factors such as pH, temperature, and levels of 2,3-Bisphosphoglycerate (2,3-BPG) in the blood. This relationship is crucial for understanding how effectively oxygen is released to tissues during the physical assessment of newborns. It follows a 30-60-90 pattern.

  • Pulmonary hygiene: usually done by ciliary activity, a layer of mucus, and bronchial tree movement with respiration. However, neonates get secretions that impede the flow of air.

    • The immobilization of air flow promotes the accumulation of secretions, which predisposes newborns to atelectasis, infection, and PNA. Clear secretions to maintain a patent airway and prevent pulmonary infections/hydrostatic PNA from accumulated secretions.

  • Suctioning: should not be routine due to fluctuations. Can affect cerebral blood pressure, causing IVH.

    • Criteria for suctioning:

    • Vital signs: tachypnea, retractions, flaring of the nares, grunting, or apnea, alterations of vitals.

    • Breath sounds that are decreased, audible, or wet.

    • Secretions in the nares or tubes.

    • Behavioral changes: may set off a high-pressure alarm on the vent.

    • Color changes: PIP might need to be increased.

  • Nasopharyngeal suctioning: suction mouth before nose. Suctioning can be traumatic to very small nares; never force the suction catheter through the nares.

    • Nasopharyngeal suctioning may result in bradycardia caused by vasovagal stimulation. Provide oxygenation throughout the procedure. Set higher FiO_2 if the newborn is on NCPAP.

5. Lung Conditions

  • Respiratory Distress Syndrome (RDS):

    • Immature lung anatomy and physiology, diffuse alveolar insufficiency with deficient surface area for gas exchange, predominantly caused by surfactant deficiency.

    • Affects 51% of neonates born less than 1,000 grams and typically occurs in newborns less than 34 weeks.

    • RDS should be anticipated for any preterm neonate, and care should be planned accordingly. May appear in term neonates born to diabetic people.

    • RDS risk factors:

    • Males are affected more commonly than females for RDS.

    • C-section.

    • Prematurity.

    • Diabetic mom (too much insulin inhibits breakdown of glycogen, which is needed to make surfactant).

    • Second-born twin.

    • Perinatal hypoxia.

RDS

insufficient surfactant

alveoli and pulmonary capillary beds are too immature to support oxygenation and ventilation. 

three factors occur due to diffuse alveolar atelactasis, pulmonary edema, and lung cell injury

FRC is decreased or lost

alteration in ventilation to perfusion ratio

uneven ventilation in the lungs 

the neonate may not be able to create enough inspiratory pressure to open alveoli. retractions become more severe and less volume is inspired. 

Nothing in the body works well when there is acidosis. the blood flow to the alveoli becomes decreased due to increasing PVR ( the vessel constrict to not take more of its O2) further exacerbating hypoxemia and leading to further respiratory distress in the newborn. This leads to decrease surfactant production. Endothelial and alveolar damage allow proteins to leak into the alveoli inhibiting surfactant production. 

The epithelial cells of the aiway become nectrotic if the lung cant clear the fluid. 

Surface area for gas exchange is decreased , ductus arteriosus may remain patent due to the hypoxemia and acidemia. 

Long term ventilation complication 

  • O2 toxicity 

  • increased water content and serum proteins causing pulm edema 

  • inflamation and edema 

Despite increased respiratory rate, the the tidal volume become smallergrunting on expiration an attemp to maintain FRC. Flaring of the nares Retractions are the result of the very pliant chest wall. Pallor or cyanosis is found with increasing hypoxemia. Decreased breath sounds are heard as alveoli collapse. Fine crackles may be ausculated. Decreased capillary refill. and acidosis. 

Perform ABG analysis. PaO2 less than 50 with FiO2 of 60% or more. PcO2 greated than 50 with pH of 7.25 or less. 

Should receive surfactant 

Survanta - 4ml/kg via et tube 

Infasurf

3ml/kg divided into two aliquots.

Curosurf 2.5 ml/kg with subsequent doses of 1.25 ml/kg 

After administration its important to monitor neonate closely as the dynamics of the respiratory system may change dramatically after surfactant therapy 

Can be given prophalactically  to high-risk infants, particularly those born prematurely, to reduce the incidence of respiratory distress syndrome (RDS) and improve overall lung function.

Can cause desaturation and changes in cerebral blood flow- after administration FiO2 should be adjusted. suctioning the lung fields should be avoided for 1 hour post-surfactant treatment to allow for the medication to be absorbed. 

Rapid changes in lung compliance increases the risk of air leaks and pulmonary hemorrhage (the open alveoli can rupture the cappillaries also PDA shuntes blood to pulmonary artery over perfusing them.

LISA technique - places fine catheter in trachea (while baby is breathing spontaneously) 

MIST technique -  a non-invasive method that utilizes a thin catheter for delivering medication directly to the lungs, helping to improve lung function and reduce the need for mechanical ventilation. 

INSURE method - intubation then surfactant administration then PPV extubation to cpap 

    increases risk of BPD 

ENSURE integrates respiratory care principles that include  the use of non-invasive techniques, timely administration of surfactant, and supportive ventilation strategies to optimize the respiratory status of the newborn while minimizing complications such as bronchopulmonary dysplasia (BPD). . also to avoid delivery of large tidal volumes and high peak pressures. 

RDS management - least invasive mode should be considered first. 

The FiO2 should be kept as low as possible to minimize toxicity. these newborns have lower MAP. low - dose dopamine may be giiven to increase systolic BP. 

Trancutaneous CO2 monitoring via skin brobe may assist in the assessment and care of the newborn with increased ven support. 

Low stress environment - decrease lighting and noise. Group noxious interventions such as heel sticks and tracheal suctioning to avoid IVH. 

Acute complications include air leaks, pulmonary hemorrhage and PDA. 

Chronic complications for preterm neonates includes ROP, Intrachranial hemorrhage and nec enterocolitis, hyperbilrubinemia and anemia. 

Increased risk for major neurological deficits, such as cerebral palsy, hydrocephalus, seizure activity, and developmetal delay within the first year of life. 

Air leak syndrome as a complication of RDS- air escapes from the alveoli or airway into places it dose not belong. (alveoli popping,  leading to a pneumothorax or pneumomediastinum, can further compromise the infant's respiratory status and require immediate medical intervention.

diagnosed- by increase work of breathing. - uneven breath sounds. transillmination - point it up under the skin - the skiin will glow a lot more. 

pneumomediastinum - resolves on its own. 

Pleura - air in it is the  pleural space, which can lead to complications such as pleural effusion or tension pneumothorax, both of which may necessitate drainage to relieve respiratory distress.

They can do a needle thoracenthesis - needle to suck out air. Remove the needle. Sometimes removing the air. works right away. The air is still leaking afterwards most of the time. Chest tube- midaxillary line. - once the air is out you can put chest tube to water seal. 

You want to lower the pressure to the alveoli. 

Cessation of breathing for more than 20 seconds. Occurs more often in neonates. Apneic events with no causative medical condition : apnea of prematurity. 

Central apnea - absence of airflow and repiratory effort 

Obstructive apnea - absence of airflow despite respiratory effort - blockage d/t macroglossia or micrognathis or hyperextenion or flextion of neck. 

Combination of central apnea and obstructive apnea with obstruction at the level of the pharynx. (in 50-60% of apneic episodes. 

Within the first 24-48 hours of life up to the first week. Immaturity of the brainstem. 

Apnea occurs more often during REM or active sleep.

Babies under 32 weeks spend 80% of their time sleeping. 

Why babies experience apnea -Minute ventilation is drecreased leading to hypoxemia - causing short periods of increased breathing, followed by apnea. Respiratory muscles also get fatigued. during sleep chest wall movement may be out of phase adn could result in a collapse of the rib cage with abdominal distension. 

primary apnea - cessasion of respiratory movements after a period of rapid respiratory effort due to hypoxia during the birth. Stimulation with or without oxygen typically will induce spontaneous respirations. 

Secondary apnea- response to a disease entity or after a period of deep gasping respirations, fall in BP and HR, usually brought on by prolonged hypoxic event that may be associated with birth. 

Desaturation drives bradycardia because the vagus nerve says slow down to save oxygen. 

As the nurse you do not wait 20 seconds you begin stimulation as soon as you confirm apnea also when SpO2 or HR begin to fall with no visible respiratory effort. within 10-15 seconds before bradycardia develops .

Majority etology of secondary apnea 

RDS
CNS hemorrhage and seizures

Central depression in sepsis

PDA 

latrogenic

reflex apnea. 

Documenting episode of apnea - duration - time - if it occured during activit, position of the neonate when the apneic episode occured, precense of of bradycardia or heart rate changes - and length of time it took to recover. , cchange in neonates color or the presence of oxygen desaturation, type os stimulation performed to resolve the episode- self- resolved, gentele , or vigorous tactile stimulation, administration of oxygen, need for bag-and-mask ventilation. 

Apnea in term babys - evaluate glucose, ABGs, chest- xray, r/o IVH, Obtain CBC with differential, C-reactive protein and blood cx. 

Treatment - provide gentle stimulation first, position the neck to make sure its neutral position, can place neonate in prone position , minimize noxious environmental stimuli, provide gentele tactile stimulation. bradycardia and cyanosis are evident after approximately 20 seconds. Start FiO2 10%-20% obove of what was required before apnea episode. 

newborn does not reach SpO2 of 90% until up to 10 minutes. 

Methylxanthines such as caffeine, theophylline, aminophylline

    increase CO2 sensitivity 

    serum levels should be closely monitored (not for caffeine). 

    the doctor should be notified if HR reaches above 180 BPM. 

    Caffeine is typically the medication of choice because its administration once a day , earlier onset of action. 

Each apnea episode should be documented. 

If increased apnea occurs - sepsis should be ruled out. 

Respiratory equipment 

    

BELOW IS TO REVIEW LATER - STOPPED AT RESPIRATORY EQUIPMENT 

TTN

is obstructive 

Less than 24-48 hours 

breathing is 60-120 x per minute

What labs show? -

Resolves after 72 hours. 

Treatment - o2 

Until RR is less than 60 adequate fluid intake should be give. 
Sepsis work up may be performed, and abx may initiated if its suspected to be sepsis. 

Pneuomonia 

Common organisms that cause neonate pneumonia 

bacterial 

community aquired viral infections. 

congenital pna (present at birth)

bacterial pna -within days to weeks 

nosocomial caused in the hospital

viral pna- dont involve alveoli mostly bronchi - cannot remove secretions from the airway. stasis of mucus leads to obstruction and atelactasis. most common  viral infection that causes early-onset pna is HSV. 

Fungal PNA. 

Labs - CBC with differential - abdnormal I/T ratio

meds- ampicillin and gentamicin.

MAS - term and posterm babies 

Meconium stained amniotic fluid is in 8-29% of all births

MAS is in 3-12%

Can lead to decrease surfactant 

Can lead to PPHN - 

newborn might have yellow/green skin 

Diagnosis - prolonged expiratory phase - to reduce air trapping. 

PPHN - diagnosed with ecchocardiography. 

use of inhailed iNO. 

Pneumothorax occurs in 10-30% of neonates with MAS.

have needle aspiration kit readily available. 

PPHN 

Normally the PVR decreases. But increases with these newborns d/t autonomic response

Vasospasms can occur. 

acidosis contribute to pulmonary vasoconstriction. 

2% of preterm newborns. 

With right to left shunting, pre and post ductal saturation monitoring is warranted. Differences of atleast 10% can be found. 

Active precordium 

Hypotension

presence of pulmonic systolic ejection clicks. 

loud , split second heart sound

systolic heart murmur. 

diagnosis - administer 100% O2 - observe PaO2 for increase . preductal and post ductal values. 

pressors are used to decrease right to left shunting. 

Inotrope - 

Dopamine is usally to be given by umbilical catheter

Inhaled iNO is a vasodialater. can be given via nasal prongs. 

sildenafil - 

CDH- congenital diaphragmatic hernia is a condition where there is an abnormal opening in the diaphragm, which allows abdominal organs to move into the chest cavity, potentially affecting respiratory function in newborns.. 

Baby should be transferred at a high level NICU with surgical capabilities. - if newborn receves PPV would further increase bowel size. OG tube should be placed. 

Oxygen delivery. 

should be warmed and humidified. - blender should be attached to delivery system. 

High flow nasal cannula - more than 1L/min - may be same effect of CPAP. 

Apply protectant under the tape. 

Massage nasal to help circulation. 

Bubble CPAP induces chest wall vibrations that assist with gas exchange similar to high -frequency ventilation. 

Best practive is alternating the prongs and mask every 6 hours to prevent pressure injury. The CPAP device is usually set at 5-8 cm H2O but can be lower for smaller g age. 

CPAP should be considered when paO2 cannot reach 60 mmHg. FiO2 in CPAP usually stay under 50-60%. 

Complications of NCPAP - gaseous distension of bowel. OG tube for decompression. 

Atleast every 3-4 hours the prongs or mask should be gently moved to inspect and clean the nares and the ptongs cleared of any secretions as needed. 

Put hydrocolloid layer before tape to secure cpap. 

FiO2 shoudl maintain PaO2 at 60-80 mm Hg. humidity shoudl be greater than 90%

In CPAP only PEEP is set. 

extreme neonates may reach a pH of 7.2

NOrmal is 7.3-7.45 (7.5 for term)

HCO3 19-26 in capillary anx 22-26 in arterial 

Kidneys - retain or excrete HCO3 

babies tend to excrete HCO3. normal is 22-26

Kidneys excrete/reabsorb Hydrogen ions and excrete/  reabsorb HC3 back to blood. 

Respiratry acidosis is the most common 

    RDS

    pneumothorax 

    airway obstrucion 

    severe apnea.

    Recommended fluid bolus is 10ml/kg given over 30 minutes

Most common cause of metabolic acidosis -

    decrease tissue pefusion 

    sepsis

    CHF 

    renal fx

    dhiarrea

caused by increased lactic acid production .

Metabolic alkalosis 

    gastric suction 

    vomitting 

    diuretic therapy. 

Compensated blood gasses - normal PH

    takes a long time days or weeks to happen 

Cold stress causes metaboic acidosis because the tissues produce lactic acid because of anaerobic metabolism. 

diuretics can cause metabolic alkalosis (you pee it out)

Air leak include pneumos 

its rupture of overdistended alveoli

may be caused by air trapping. incidence is 16-36%

transillumination may show of pneumo

Usually good lung down for better perfusion - but for PIE good lung is up because compress it with gravity to make it harder to inflate to rest it, 

Pulmonary hemorrhage - increased pumonary capillary pressure

BPD aka CLD - Bronchopulmonary Dysplasia, a chronic lung disease commonly seen in premature infants, is characterized by inflammation and scarring in the lungs which can lead to respiratory distress and requires supportive care including oxygen and mechanical ventilation.

Can occur from oxygen toxicity 

barotrauma volutrauma

baby does not have enough antioxidants - no free radicals.

It starts with the primary lng disease. 

Volutrauma - high ventilatory presures. 

Injury triggers leukocytes - neutropholes - macrophages (inhibit surfactant) free radicals , 

Neonate still requires respiratory support after 36 weeks PMA

Gavage feed is tupically over 15-20 minutes. for example every 3 hours. 

120 kcal/kg/day 

Albuterol - relaxation of pulmonary smooth muscle. 

Postnatal steriods - has been associated with neurological effects. 

Most neonates recover and do well- may take years to overcome damage. 

Cardiovascular sytem.

The heart is the first organ to form and function

Heart beat is in third week of gestation (rythmic peristalsis).

There is SR at 4 months.

At birth - closure of the fetal patheways - Foramen ovale, ductus arteriosus, and ductus venosus), Increase in blood flow to the lungs, decrease PVR and increase SVR.

CO= stroke volume x heart rate which is blood it ejects in 1 minute.

Stroke volume - In neonates its 1.5ml per kg. effected by preload, cardiac contractility, and afterload

Preload in neonates is influenced by volume coming into ventricals (frank staling law) heart adjusts its force of contraction in reponse to changes in venous return.

Hypovolemia causes decrease preload.

Neonates have less compliant muscle fibers- heart muscle is stretched close to its maxiumum d/t minimal function in newborns

Over the first weeks of life the ventricular output decreases and left wall begins to hypertrophy.

Dopamine increrases contractility.

What effects its- hyperkalemia and hypocalcemia also hypoglycemia.

Afterload - resistance heart has to overcome to be ejected.

If the PVR is increased the blood flow to lungs will be reduced and if SVR is high the blood flow to aorta will be reduced.

Dysrhytmias

depolirazion - more positive as sodium enters the cell causing it to move. also calciume enters to maintain contraction . the repolirization the sodium pumps back out.

Tachy and brady is usually benign in newborns - if its prolonged obtain a 12 lead ECG.

COmmon newborn dysrithmia.

PACs are common(originiate somehwere other than the SA node in the atria)- can be caused by a CVC that is too deep.

PVCs are also common in newborns

SVT- sustained over 220 BPM. can be associated with wolff parkinson white, ebstein anamoly, cardiolyopathy, and myocarditis.

most are self liminiting and terminate spontaneously.

vagal maneuvers such as knee-chest position or placing a bag of ice over newborns face, if these dont work IV adenosine shouldl be give,

Babies can get pacemakers for type 2 and 3 block. Can be associated with infection of pregnant person with lupus.

afib and aflutter are very rate.

CHD - is 9.4/1000

50% of Trosomy 21 have endocardical cushion defects and VSD.