General Appearance – Initial Assessment of the Newborn (Nursing)

by Jacquelyn McMillian-Bohler

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    00:01 Now, let's move on to our general survey.

    00:04 So just as our general survey works in our adults, we're going to just take a look at the baby.

    00:09 We're going to look at every part of their skin and just see what they look like.

    00:13 One of the first things you will notice is the baby's color.

    00:17 So often when a baby's first born, their central area will be pink or normal color.

    00:24 But you'll notice that they may have blue hands and feet.

    00:27 We call that acrocyanosis.

    00:30 And acro meaning edges or extremities, and cyanosis, meaning blue, so not well oxygenated.

    00:37 And so this is a normal response because in utero, well, we don't need oxygen going to hands and feet, we're not going to waste that.

    00:45 So when we're born, it takes a while for all that oxygen to get out to our hands and feet.

    00:49 It may take a few days.

    00:51 And so you want to reassure the parents that this is a normal finding.

    00:55 And they will not be Smurfs for the rest of their life.

    00:58 This is just temporary, but it's called acrocyanosis.

    01:02 Next, you want to look at the baby's tone.

    01:05 So we think about flexion.

    01:06 And we talked about this a little bit when we discussed APGARs.

    01:10 So is the baby lying sort of like this baby is really chilling like a villain just everything is very loose.

    01:16 Or does the baby look like this.

    01:18 So you'll notice with the term baby, the arms are sort of in a muscle position, the legs are pulled up. So this all refers to tone.

    01:26 So do we have good tone? Or do we have sort of a flatted tone, the way we would note with a preterm baby that would be expected for them.

    01:36 The next thing we might notice is something called vernix caseosa.

    01:40 So if you look at this baby, you'll notice there's this white sort of cream cheese like substance that's all over the baby.

    01:47 And this actually comes from sebaceous gland secretions.

    01:51 And this is there to protect the baby.

    01:53 To think about maybe when you've taken a bath or been in the shower a little bit too long.

    01:58 And when you get out your fingertips and your toes are all wrinkly.

    02:02 Well, most babies when they're born, even though they're swimming in water for months, and months, they're not all wrinkly on their fingers.

    02:09 And that's because they have vernix caseosa all over them to protect the skin.

    02:14 So it's sort of white, and it's greasy.

    02:18 And it's definitely protective.

    02:20 And you'll find it mostly in the creases.

    02:23 So anywhere where the skin folds, you'll find more vernix caseosa.

    02:28 You do not need to remove it.

    02:30 In fact, if we could collect this and bottle it, it would be the best moisturizer ever.

    02:36 But we don't do that.

    02:37 Because I don't know, that would just be weird.

    02:39 But just to reminder, you don't have to do anything with it, you can rub it in. It's wonderful.

    02:44 And the way I remember this is it looks like a case of cheese.

    02:48 So vernix case of cheese, then you'll remember this is what it looks like.

    02:53 Now, let's talk about another skin issue that you may see that's completely normal. And it's called lanugo.

    02:59 So lanugo refers to that baby fine hair.

    03:02 So around 12 to 20 weeks, you're gonna see a lot of lanugo.

    03:06 So if you were able to transport yourself inside the uterus, you would see a baby covered with all of this baby fur.

    03:14 And this fur does just what any fur does, it helps to keep the baby warm.

    03:19 So as the baby gets to around 28 weeks, however, we know that birth is going to be coming sooner.

    03:25 And so we may notice that some of the fur begins to fall out.

    03:29 So if you have a baby that's born around 28 weeks, they won't be completely covered with fur, they'll have spots that are perhaps missing that.

    03:37 Once the baby gets to term, there's going to be lots less lanugo or if you have a baby that's post term, there may not be any lanugo at all.

    03:46 So remember, lanugo refers to that baby fine hair that's there to keep the baby warm.

    03:52 You may find it on the tops of the ears and on the back, sometimes even on the face.

    03:57 But assure the parents that this will all fall out eventually and they won't have a baby with a hairy face.

    04:04 That's not what's going to happen.

    04:07 Now, let's talk about some other sort of skin changes that you may notice with a newborn.

    04:11 The first one we'll talk about is erythema toxicum also known as the newborn rash.

    04:18 So it looks like the baby has acne.

    04:21 But babies don't have acne. So that's not what it is.

    04:24 So this results from eosinophils that are reacting to the environment.

    04:28 So before the baby's born, they're in a wonderful protective sac.

    04:32 They don't have all of these pollutants and things in the air, but the minute they're exposed to the air, their skin goes, "Ah! What is this?" And we get erythema toxicum.

    04:42 Now, this is going to be common on the face, maybe on the trunk, maybe on the legs.

    04:46 But you can reassure the parents that this is benign meaning it's not a problem that it happens.

    04:53 It may look kind of strange, but it is really okay and as the baby adjust to the external environment, this will go away.

    05:00 The next skin condition are telangiectatic nevi, also known as stork bites, which is much easier to say.

    05:08 But telangiectatic nevi are caused by a collection of immature red blood vessels.

    05:14 And it's really important that you let the parents know about this because whenever the baby gets upset, or the baby cries, they may notice these reddened areas.

    05:23 And it may happen on the back of the neck where a stork, "would bite the baby", or they may notice it on the eyelids, or maybe on the lips.

    05:32 So letting the parents know is really helpful in terms of anticipatory guidance.

    05:37 This will disappear at about one year of age.

    05:41 Next, I want to talk to you about melanocytosis.

    05:45 Now, back in the old days, this used to be called Mongolian spots.

    05:49 But we recognize that that is not a correct term. It's not inclusive.

    05:53 And so the term that is correct, the term you should use now is melanocytosis.

    05:59 And this refers to this sort of darkened area that you might notice over the buttocks or over the legs.

    06:04 Now, what's interesting about melanocytosis is that if you were to blanch it, meaning you touch the skin and sort of remove the blood flow for just a second, it will blanch just like regular skin.

    06:16 Because if you look closely, this looks awfully like a bruise.

    06:20 And so you might wonder, how would you tell the difference? Well, bruises don't blanch.

    06:25 Melanocytosis does.

    06:28 And why do you want to know the difference? Because if I saw a baby that came into the emergency department with something that looked like this, I might suspect child abuse or some sort of trauma or accident.

    06:39 So it's very important that if the nurse notes this on an assessment that this is charted, because there have been cases of parents that are pursued by child protective services because of abuse, because this has not been recorded.

    06:51 So melanocytosis blanches, bruises do not.

    06:56 The next one I want to talk about is Strawberry hemangiomas.

    07:00 So it looks like a strawberry which is why it's called that.

    07:03 These will disappear usually by the age of two or three, but may go all the way up to the age of 10.

    07:10 So they're not permanent but they will be noticeable.

    07:12 And they can occur anywhere on the body but usually around the trunk section.

    07:17 And the final skin condition we'll talk about is the Port Wine Stain.

    07:21 So one of the major differences between the Port Wine Stain and a strawberry hemangioma is the fact that the strawberry hemangioma is going to go away.

    07:29 The Port Wine Stain however, will not.

    07:31 So this baby will have this particular mark for the entirety of their life.

    07:36 The other thing you may notice with a port wine stain is that it's flat and the strawberry hemangioma is usually raised.

    07:42 So you'll see that sort of three dimensional characteristic there of the hemangioma.

    About the Lecture

    The lecture General Appearance – Initial Assessment of the Newborn (Nursing) by Jacquelyn McMillian-Bohler is from the course Newborn Assessment (Nursing).

    Included Quiz Questions

    1. Blue hands and feet
    2. A small amount of lanugo
    3. White, greasy, cottage cheese substance covering the body
    4. Blue trunk
    5. Rash on the entire body
    1. It is white, greasy, and cottage-cheese like.
    2. It should not be removed initially.
    3. It protects the newborn client and should remain intact.
    4. It should be removed by the nurse immediately.
    5. It is a sign of intrauterine infection.
    1. The area blanches and should be documented as a normal finding in the nurse's assessment.
    2. Notify the physician about the bruise
    3. Document that potential abuse might be occurring in the household
    4. Document an abnormal finding in the chart
    1. A port-wine stain will not go away.
    2. A port-wine stain is flat.
    3. A strawberry hemangioma will eventually go away.
    4. A port-wine stain is raised.
    5. A port-wine stain will go away.

    Author of lecture General Appearance – Initial Assessment of the Newborn (Nursing)

     Jacquelyn McMillian-Bohler

    Jacquelyn McMillian-Bohler

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