Head and Trunk – Physical Examination of the Newborn (Nursing)

by Jacquelyn McMillian-Bohler

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    00:01 Now, we're ready to talk about the head to toe assessment.

    00:04 We're going to move in a cephalocaudal progression so that we don't leave anything out.

    00:09 Let's begin with the head.

    00:11 When we look at the head, we want to observe the shape.

    00:15 And we also want to make sure that the eyes, the naris, the lips are all evenly lined up.

    00:21 If there are any abnormalities in alignment that may indicate that there is some sort of neurologic or other type of complication that exists.

    00:30 The nurse should also observe and palpate the anterior and posterior fontanelle.

    00:35 The anterior fontanelle is shaped like a diamond.

    00:39 Now, it should feel level.

    00:40 If it's sunken in, it may be an indication of dehydration, or if it's bulging, that may be an indication of bleeding or increased intracranial pressure.

    00:49 You also should not feel a pulse inside the anterior fontanelle.

    00:53 The posterior fontanelle is shaped like a triangle.

    00:56 It's located a little bit further back on the baby's head.

    00:59 Again, this should be level should not be sunk in, or even bulging.

    01:05 Now, sometimes you may find that these fontanelles are hard to feel because of the overlapping bones. And that's okay.

    01:11 We just want to note if we feel it and what they feel like.

    01:15 You also want to palpate the suture lines.

    01:17 So you can see in this graphic, our fontanelle anterior and posterior are present.

    01:22 But there are also some other lines.

    01:24 So these lines are here because that allowed the head to shape in order to make its way out of the vagina.

    01:30 So you want to note that the suture lines are either level, that they're separated, or that they're overriding.

    01:37 Recognizing that overriding suture lines may be normal the first few days after birth.

    01:42 Reassure the parents however, that over time, the suture lines will line up, they'll still have a soft spot, but they will go together.

    01:52 Next you want to palpate and observe the scalp.

    01:54 So knowing particularly if anything has happened during the delivery.

    01:58 So thinking about if a vacuum extraction was used, or a forcep, or perhaps during labor, and electronic fetal monitor was placed, a scalp electrode on the baby's head, you want to check and make sure that they're not any lacerations there.

    02:12 And this could be really important.

    02:14 So you want to not only look but to feel all around the baby's head for any lesions or lacerations.

    02:24 Now, let's talk about three additional conditions that the nurse should assess the head for during the newborn assessment.

    02:30 Caput succedaneum, cephalohematoma and subgaleal hematoma.

    02:36 First, let's look at caput succedaneum.

    02:39 What I want you to notice in this graphic is that the fluid is collecting underneath the skin layer of the scalp.

    02:46 You'll notice that the fluid is able to cross the suture line.

    02:51 Caput crosses the see. Caput, Captain...

    02:55 Get it? Now, let's look at cephalohematoma.

    02:59 In this case, you have a collection of blood that is collected underneath the periosteal layer of the scout.

    03:06 In this particular case, the blood is not able to cross the suture line.

    03:12 So it's contained and it creates sort of like a bump, a bump on the head.

    03:18 Now, let's look at the subgaleal hematoma.

    03:21 Now, the subgaleal hematoma is formed in a potential space.

    03:25 So it's not encapsulated.

    03:27 And the difficulty here is that because there's not an encapsulated space, the baby can continue to bleed, and bleed, and bleed.

    03:36 And they can lose significant amounts of their blood volume in a very short amount of time.

    03:41 So it's important that the nurse is able to distinguish between caput succadeneum, cephalohematoma, and subgeleal hematoma.

    03:52 Let's look at a picture to see if we can notice the difference between a hematoma and a caput succadeneum.

    04:00 What I want you to notice in this picture is this small ridge.

    04:04 Did you see that? That's the suture line.

    04:06 And adjacent to that suture line, you'll notice that there's a hump.

    04:11 Guess what type of abnormality this is.

    04:15 Exactly. This is a Cephalohematoma.

    04:17 And we know that because the fluid does not cross the suture line.

    04:22 Do you see that? Now, let's look at caput succedaneum.

    04:27 So what you'll notice here is that we still have an abnormally shaped head, but this fluid definitely crosses the suture line.

    04:36 Remember, caput crosses.

    04:39 Here's another example of caput succedaneum.

    04:43 Again, we noticed the head is abnormally shaped, but the fluid definitely crosses the suture line.

    04:51 I hope you have those differences down now.

    04:55 Now, let's move on to the spine.

    04:57 It's important to remember that when we observe the spine and when we palpate the spine, we palpate down the entire length of the spine to make sure we don't miss one single area.

    05:07 What we're looking for is symmetry to make sure everything on the left and the right are balanced.

    05:12 We want to make sure the spine doesn't curve to the right or left.

    05:15 We're looking for any lesions that may be along the link of the spine, or palpate for any masses that might be located there, or any tags, any skin tags, and they may look like a pedunculated mole somewhere down the length of the spine.

    05:30 Next, we want to look at the neck. So, well -- Next we want to look at the neck.

    05:36 So we'll position the baby and make sure that the head doesn't lean to one side or the other.

    05:42 And that may indicate that there may be an issue with birth or nerve damage.

    05:46 So we want to hold the head midline and make sure that it's possible to keep the head that way.

    05:50 We want to move through a full range of motion of the head from side to side, and front to back.

    05:57 We also want to check the clavicles and so the nurse will palpate the clavicles and make sure that they do not feel like crepitus.

    06:04 And you may have learned about crepitus in your adult assessment.

    06:08 And it feels like rice krispies.

    06:11 So rice crispy if you've ever had a rice krispies treat, yummy, yummy, but not yummy if you've got it on your neck.

    06:17 So we're going to feel for any signs of crepitus, which might indicate a broken clavicle or any lumps or any other masses.

    06:25 Next for the eyes.

    06:26 Again, we're looking for symmetry. Are they even? Are they evenly spaced? Is the outer canthus of the eye in line with the pinna or the upper part of the ear? These are all indicators that there may be something neurologically, or genetically abnormal about the newborn.

    06:46 The nurse should also make sure that the red reflex is present.

    06:50 So this may be using either a penlight or an otoscope.

    06:55 And we can actually just shine a light and make sure that the red shows through from the retina.

    07:00 So this is a very easy procedure.

    07:02 And this is something that the nurse can do.

    07:06 Now, let's look at the nose.

    07:08 So on the nose, we want to look for any signs of drainage from the naris or any signs of nasal flaring, where you see the edges of the naris sort of moving as a result of difficulty in breathing or respiration.

    07:22 You may have also noticed these little white spots that are all over the baby in this particular graphic.

    07:27 Right on the nose, you see those? Those are clogged sebaceous glands, also known as Milia.

    07:33 And you might find them located on the nose or the chin or the forehead.

    07:37 They usually disappear in about two to four weeks, and they are completely benign.

    07:42 So reassure the parents that this is totally fine.

    07:46 Now, as we look inside the baby's mouth, we may notice several things that are different, but completely normal.

    07:53 One of the first things a nurse might notice are Epstein's pearls, and this is a result of retained epithelial tissue that's right on the roof of the mouth.

    08:02 And that can be found on the palate, up at the roof, could be have found all along the gum lines.

    08:08 So this is going to be something that you might notice.

    08:11 They might be white, or they might look a little yellow, but they're all the same.

    08:15 These are Epstein's pearls.

    08:17 And again, they are completely benign and normal and typically disappear in two to four weeks.

    08:22 They are not teeth, they are just retained epithelial tissue.

    08:27 These, however, are teeth.

    08:30 These are natal teeth.

    08:31 And so very rarely does happen that babies are born with natal teeth.

    08:36 These teeth are not baby teeth, they will fall out.

    08:39 They do pose a choking hazard.

    08:41 So the nurse needs to make sure that if natal teeth are present, they let someone know.

    08:48 Now, let's talk about another variation called the cleft lip or cleft palate.

    08:53 If a newborn has a cleft lip, this is something the nurse will notice clearly because this is going to be an external abnormality.

    09:00 And so they'll see an opening between the lips and the mouth.

    09:03 You'll be able to see straight into the baby's mouth when their lips are closed.

    09:08 However, a cleft palate can be something that's hidden.

    09:11 You can have a cleft palate of your hard palate, which would be right on the front of the mouth.

    09:15 Or it could be a cleft that goes all the way through to the soft palate, which is in the very back of the mouth.

    09:21 So the nurse really needs to do a thorough job of making sure that they palpate all the way back to the soft palate in order to make sure there's not a hole located there.

    09:32 So hard or soft palate cleft, or lip cleft or baby could have a combination of all of the above.

    09:40 Now, let's look at the chest.

    09:41 Again, looking for shape, size, and symmetry.

    09:45 This is going to be a theme as we go through this assessment, making sure that everything on the left and the right are exactly the same.

    09:52 In addition for noticing a diminished tissue around the breast area, the nurse should also notice the position of the nipples.

    09:59 Are they even? Is one nipple higher than the other? There's also the possibility of supernumerary tissue.

    10:06 So if the nurse examines down the inframammary ridge, they may notice additional tissue.

    10:12 Now, the tissue might look like a breast or it may look like a small mole.

    10:16 Any of those indications are going to be supernumerary tissue.

    10:20 So take a look.

    10:22 We also want to notice on the chest any signs of any sort of respiratory distress.

    10:28 So if there is any accessory muscles use if there any retractions in the chest, this is going to be something that the nurse needs to note.

    10:37 We want to make sure that the baby is continuing to transition well.

    10:42 Moving down to the abdomen.

    10:44 Again, shape and symmetry.

    10:46 Is the abdomen protuberant meaning it's sticking out.

    10:49 It's like a gravid uterus, or is it sunken in.

    10:53 So normally, babies have a little bit of a PUJ.

    10:55 But a tight abdomen is an indication that there may be something that is abnormal that's happening.

    11:01 Or an abdomen that sunken in may also be an indication that something else is going on.

    11:08 We want to make sure that if you were asked to palpate for the liver, which is not something nurses really do anymore, that you know how to do this because you can cause damage.

    11:18 But if you are to palpate, then you want to make sure you're palpating for the liver, and the spleen, and typically the kidneys.

    11:26 Now again, if this is not something that the nurse has been trained or is expected to do, this will not be part of the normal assessment, but you do need to make sure that it is done by the provider.

    11:37 While the provider is palpating for the kidneys, and the liver, and spleen, they may also notice any tenderness that the baby's feeling during that assessment.

    11:46 Now, when you assess the abdomen, one of the things you want to make sure is that you're hearing bowel sounds in all four quadrants.

    11:53 So let's think back to when we would do this assessment before we palpate for the liver, spleen, kidneys, or after? Before, exactly right.

    12:04 In fact, when you're listening for respiratory sounds, when you do your vital sign assessment, it's a good idea to go ahead and listen to the bowel sounds while you have your stethoscope out and the baby's quiet.

    12:15 So just as you would listen for bowel sounds in all four quadrants on an adult, we'll do the same thing for the baby.

    12:22 Then we can look at the umbilicus.

    12:24 So if we are able to visualize the cord and it's right after delivery, you will still note two arteries and a vein.

    12:33 So you'll see all three of those vessels.

    12:35 Every now and then you'll notice that there may only be one artery and one vein.

    12:39 This is an abnormality, and you would want to chart that.

    About the Lecture

    The lecture Head and Trunk – Physical Examination of the Newborn (Nursing) by Jacquelyn McMillian-Bohler is from the course Newborn Assessment (Nursing).

    Included Quiz Questions

    1. Pulse upon palpitation of fontanelles
    2. Sunken fontanelles
    3. Bulging fontanelles
    4. No pulse upon palpitation of fontanelles
    5. Symmetry
    1. Fluid collects under the skin layer of the scalp.
    2. Lesions on the scalp.
    3. It is formed in a potential space.
    4. Bleeding can continue without hindrance.
    1. Curve to left
    2. Curve to right
    3. Skin tags
    4. Symmetry
    5. Balance

    Author of lecture Head and Trunk – Physical Examination of the Newborn (Nursing)

     Jacquelyn McMillian-Bohler

    Jacquelyn McMillian-Bohler

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