ASSESSMENT OF THE NEWBORN ed 2019.pptx.pdf

Pemeriksaan newborn

1. ASSESSMENT OF THE NEWBORN

Dr. dr. Ekawaty Lutfia Haksari, MPH, Sp.AK
dr. Setya Wandita, M.Kes., Sp.AK
dr. Tunjung Wibowo, M.Kes., MPH., Sp.AK
dr. Alifah Anggraini, M.Sc., Sp.AK
dr. Elysa Nur Safrida, M.Sc., Sp.A
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

2. General Examination of The Newborn
•Should be done on a radiant warmer with sufficient
lighting
?????? unless there are signs of overheated.
•Keep communicate with the mother while
examining the baby
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

3. General Examination of The Newborn
•Directly after birth
•APGAR score
•Vital sign
•Anthropometry (birth weight, birth length, head
circumference)
•Estimating Gestational Age (Dubowitz score)

Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

4. APGAR SCORE
•Not for determining resuscitation of neonates

•To examine a neonate’s condition
•Show prognosis of neonate


Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

5. APGAR SCORE
0 1 2
Heart rate per
minute
absent <100 >100
Respiratory effortabsent Slow, irregular Good, crying
Muscle tone limp Some flexion Active motion
Response to
stimulation
No response grimace Good response
Color Blue or pale Pink body, blue
extremities
Completely pink
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

6. Expanded-APGAR SCORE
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

7. Body temperature
•Normal axilla temperature in neonate ranges from 36.5
o
C
to 37.5
o
C.
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

8. Respiratory rate
•Normal :
- 40 – 60 breaths per minute, no chest indrawing,
no grunting on expiration.
- small baby might have mild chest indrawing.
- periodically stop breathing for a few second.
- count respiratory rate during a full minute.




Mild chest indrawing (MMBBL,Depkes,IDAI,MNH-JPEIGO 2004)

Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

9. Heart Rate
» determined using a neonatal/infant stethoscope
•Normal heart rate : 100 -160 beats per minute
•It is not uncommon for the heart rate to be more than 160
beats per minute for short period of time during the first few
days of life, especially if the baby is distressed.

NOTICE
Heart rate consistently more than 160 or less than 100 beats
for minute.
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

10. Birth Weight
•Normal birth weight : 2500 – 4000 g

•Low birth weight: <2500 g
•Very low birth weight: 1000 - <1500 g
•Extremely low birth: <1000 g

•Large birth weight: >4000 g
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

11. Clinical Estimation of Gestational Age
DUBOWITZ SCORE

A. Neurologic signs
B. External signs
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

12. A. Neurologic sign
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

13. B. External sign
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

14. Examples
❖Skin
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada
Very thin gelatinous
uniformly pink
Numerous veins and venule seen

15. ❖Ear









(Depkes & IDAI, 2007) (Depkes & IDAI 2007)
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada
Incurving of part of edge of pinna.
Pinna soft easily folded slow recoil
Well-defined incurving whole of
upper pinna. Pinna firm cartilage to
edge instant recoil

16. ❖Breast

















(RSUP Dr. Sardjito, 2019) (Depkes&IDAI,2007)
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada
Nipple well defined, areola smooth and flat; no
breast tissue palpable
Areola stippled edge raised; breast tissue on
both sides

17. ❖Female Genital


















Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada
Labia majora widely separated, labia
minora protruding (RSUP Sardjito, 2019)
Labia majora almost cover labia minora
Labia majora completely cover labia
minora (Depkes & IDAI,2007)

18. ❖Male Genital















Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada
Neither testis in scrotum
(Depkes & IDAI, 2007)
At least one testis right down
(Depkes &IDAI,2007)

19. ❖Plantar Dermatoglify














(Depkes & IDAI, 2007)
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada
No skin creases
Faint red marks over anterior half of sole
Definite deep indentation
over more than anterior 1/3

20. Example of Clinical Estimation of
Gestational Age in Medical Record
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada
(Rekam medik RSUP Dr Sardjito, 2019)

21. Clinical Estimation of Gestational
Age
Estimated gestational age :
(0.2642 x (total score)) + 24.595







Regression graph of Dubowitz score
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

22. Intrauterine Growth Chart (Lubchenko, 1963)
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

23. Intrauterine Growth Chart (Lubchenko, 1963)
cont..
•If small for gestational age, symmetric? Or Asymmetric type?
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

24. Local Growth
Charts
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

25. Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

26. Classification of intrauterine growth
•Appropriate
•Small
•Symmetrical
•Asymmetrical
•Large/high
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

27. How to Assess Newborn
•Birthweight
•Gestational Age
•Intrauterine growth
•Delivery method
•Other conditions
•Example:
•Normal birth, term, appropriate for gestational age (AGA), spontaneous
delivery, asphyxia.
•Low birth weight, preterm, AGA, C-section due to antepartum hemorrhage,
asphyxia, hypovolemic shock
•Very low birth weight, preterm, small for gestational age (SGA), asymmetric,
C-section due to eclampsia, pneumonia
•Large birth weight, term, large for gestational age (LGA), Vacuum extraction,
infant of diabetic mother, respiratory distress syndrome.
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

28. General Examination of The Newborn
Before the baby is undressed :
•Emergency sign!!
•Examine :
a. Color
b. Respiratory rate
c. Posture
d. Movement
e. Reaction to stimuli
f. Obvious abnormality
g. Pain
•Weight the baby and record the weight (if he/she has not been weighed
yet).




Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

29. Skin Color
•At term appear paler than preterm.
•Look for :
a. Jaundice (yellowish skin)





Jaundice (Depkes & IDAI, 2007) “Kramer” grade of jaundice(Depkes & IDAI, 2007)


Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

30. Skin Color
b. Cyanosis




Acrocyanosis dan Central Cyanosis (Perinasia,2006)

c. Pallor
d. Plethorhea, very red skin.
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

31. Pale Plethorea
Icteric
Cyanotic
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

32. Respiration
•Important signs :
a. Respiratory rate consistently more than 60 or less
than 30.
b. Grunting on expiration
c. Chest indrawing
d. Apnea
•No Breathing within 20 seconds or more, OR
•Less than 20 seconds, With
•Cyanosis OR
•bradycardia

Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

33. DOWNES SCORE
Parameter 0 1 2
Respiratory
rate/minute
<60 60-80 >80
Cyanosis none Cyanosis dissolves
with O2
supplementation
Cyanosis is
persistent even
though oxygen is
applied
Retraction none Mild retraction Severe retraction
Breathing sound Good breathing
sound in both lungs
Decrease breathing
sound in both lungs
No breathing sound
in both lungs
Grunting none Can be heard with
stethoscope
Can be heard
without
stethoscope.
Downes Score of Clinical Respiratory Distress
Score ≤ 3 = Mild
4-5 = Moderate
≥ 6 = severe
To asses the severity of distress
respiration clinically
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

35. Posture and Movement
Posture of normal neonate
Posture of small neonate
(MMBBL,Depkes,IDAI,MNH-JPEIGO 2004)

Posture of neonate with breech presentation
(MMBBL,Depkes,IDAI,MNH-JPEIGO 2004)

Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

36. Posture and Movement
•Look for
1. Opisthotonus
2. Irregular, jerky movements of the body, limbs, or
face (convulsion or spasm).
3. Jitteriness
Opisthotonus
(MMBBL,Depkes,IDAI,MNH-JPEIGO 2004)
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

37. Reaction to stimulation (muscle tone and level of
alertness)
The normal newborn baby ranges from quiet and alert and is
consolable when upset. The baby is arousable when quiet
or asleep.
Important sign
•Lethargy
•Floppiness
•Irritability
•Drowsiness (sluggish)
•Reduced activity
•Unconsiousness
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

40. Obvious abnormality
A. SKIN
Considered normal as long as the baby’s general condition
is normal.
- Milia
- Erythema toxicum
- Exfoliation of the skin in the body, back and
abdomen after the first day.
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

41. Obvious abnormality
Abnormality :
- Redness or swelling of the skin or soft tissues
- Pustule or blister
- Cut or abrasion
- Bruise
- Thrush
- Birth mark or skin tag
- Loss of elasticity

Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

43. Obvious abnormality
B. UMBILICUS
Normal ?????? white-bluish on day 1. It then begins to dry and shrink and
falls off after 7 to 10 days.

Abnormal ?????? red, swollen, draining pus or foul smelling. The skin
surrounding the umbilicus is red and hardened. There might be bleeding
from umbilicus.





Omphalitis (Depkes & IDAI, 2007)


Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

44. •Umbilical granuloma




•Umbilical hernia
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

46. Obvious abnormality
C. HEAD AND FACE
Baby’s head may be moulded from a vertex birth, this will
resolve spontaneously over a period of three to four weeks.




Moulage (MMBBL, Depkes RI, IDAI, MNH-JPEIGO 2004)

Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

47. Cephalhematoma
Caput Succedaneum
Subgaleal hemorrhage with skull fracture
Extracranial injury
Basic neonatal care, 2006)

48. Obvious abnormality
Look for :
-Hidrocephalus
-Bulging of the anterior fontanelle
-Sunken fontanelle
-Swelling on scalp thet is not restricted to the area over the
fontanelles.
-Face paralysis
-Unable to breastfeed without dribbling milk.

Face Paralysis (MMBBL, Depkes RI, IDAI, MNH-JPEIGO 2004)
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

49. Hidocefalus Anencafali
Myelomeningochele Bibir sumbing

50. Paralisis N. Facialis Strabismus
Microcephal
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

52. Obvious abnormality
D. EYE
Notice
-Pus draining from eye
-Red or swollen eyelids
-Subconjuctival bleeding






Suppurative eyes (Depkes & IDAI 2007) Gonococcus (RSUP Dr.Sardjito, 2016)
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

53. Obvious abnormality
E. Mouth and Nose
Mouth examination must carefully inspect for ;
- Cleft lip
- Cleft palate
- Thrush
- Central cyanosis
- Profuse nasal discharge
- Dry tongue and mucous membrane
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

54. Obvious abnormality
F. ABDOMEN AND BACK
Look for :
- Abdominal distension
- Gastroschisis
- Spina bifida





Abdominal Distension (MMBL, Depkes RI, MNH-JPEIGO 2004)
Spina bifida (Depkes, 2004) Omphalocele (RSUP Dr.Sardjito, 2006)Gastroschisis (RSUP Dr.Sardjito, 2006)
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

55. Obvious abnormality
G. LIMBS
Abnormalities :
- Abnormal position and movement of limbs
- Baby’s arms or legs move asymmetrically
- Baby cries when his/her leg, arm or shoulder is
touched or moved.
- Club foot
- Extra finger (s) or toe (s)

Erb palsy (MMBL, Depkes RI, MNH-JPEIGO 2004)


Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

56. PAIN ?????? should be assessed in every sick neonates
Neonatal Infant Pain Scale (NIPS)
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

57. Other pain score
Instrumen Indikator fisiologisIndikator perilaku Sumber nyeri
PIPP: Premature Infant Pain
Profile
HR, SpO2 Kerutan dahi, mata terpejam rapat,
kerutan nasolabial lebih dalam
Nyeri prosedural, post
operatif
CRIES: Crying, Requires Oxygen
Saturation, Increased Vital
Signs, Expression,
Sleeplessness
HR, SpO2 Menangis, ekspresi wajah, tidur
nyenyak
Nyeri post operatif
NIPS: Neonatal Infant Pain ScaleCorak respirasi Ekspresi wajah, menangis, gerak
lengan dan tungkai, state arausal
Nyeri prosedural
N-PASS: Neonatal Pain Agitation
and Sedation Scale
HR, RR, TD, SpO2 Menangis, iritable, tonus ekstremitas,
perilaku
Nyeri akut dan yang
sedang berlangsung,
penggunaan sedasi
NFCS: Neonatal Facing Coding
System
Tidak ada Gerakan otot wajah Nyeri prosedural
PAT: Pain Assessment Tool RR, HR, TD, SpO2 Postur, tonus, corak tidur, ekspresi,
wana, menangis
Nyeri akut
SUN: Scale for Use in NewbornsStatus SSP, RR, HR, TDGerakan, tonus, wajah Nyeri akut
EDIN: Echelle de la Douleur
Inconfort Nouveau-Ne’
(Neonatal Pain and
Discomfort Scale)
Tidak ada Aktivitas wajah, gerakan tubuh,
kualitas tidur, kualitas kontak
Nyeri berkelanjutan
BPSN: Bernese Pain Scale for
Neonates
HR, RR, TD, SpO2 Ekspresi wajah, postur, gerakan, Nyeri akut

58. Urine and Stool
•Normal condition :
- have 6-8 watery stools per day.
- Vaginal bleeding in female newborn during the first week
of life.

Notice
•Passes urine less than six times per day after day 2
•Diarrhea
•Has not passed meconium within 24 hours of birth.
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

59. Breast Feeding
•Baby has fed well at birth but is now feeding poorly or has
stopped feeding.
•Baby has not fed well since birth
•Baby is not gaining weight (proven or suspected)
•Mother has not been able to breastfeed successfully
•Baby is having difficulty feeding and is small or a twin.
•Baby is vomiting forcefully, regardless of the method of
feeding after every feeding, or is vomiting bile or blood.

Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

60. Primitive Reflex
How to examine…..
1.Moro reflex
2.Palmar and plantar grasping reflex
3.Tonic neck reflex
4.Rooting and sucking reflex
5.Swallowing reflex
6.Babinski reflex
7.Automatic reflex
Skills Laboratory, 2019
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada

64. QUESTION ?

65. Thank You