10.03 Body System Assessments

Overview

  1. Various assessments and interventions are necessary during the newborn phase
  2. Educate parents/support system about what you’re doing and why it is necessary, before you do it

Nursing Points

General

  1. Always keep the newborn warm during assessments and procedures
  2. Observe, assess,and then intervene
  3. Provide or facilitate appropriate screening
    1. Hearing exam
      1. Electrodes watch brain waves with noise
      2. Some fail and need re-screen because of fluid on their ears
    2. Metabolic screening or newborn screening
      1. State regulated
      2. Used to be called PKU test for phenylketonuria but now the screen tests for many more then just PKU
      3. Blood sample
      4. Must be eating successfully for 24 hrs before screening to appropriately assess
      5. Looking for around 26 metabolic disorders
        1. PKU
        2. Maple syrup urine disease
        3. Cystic fibrosis
        4. Galactosemia
    3. Bilirubin
      1. Jaundice/ yellow color
      2. Build up from broken down RBCs-ie: bruising
      3. Excreted in stool
    4. Congenital heart defects
      1. Pre (Right hand) and post (any other extremity) pulse oximeter
      2. Saturation should be over 94% and no more than 4 apart
        1. Ie: 95% and 97%=ok
        2. Ie: 100% and 95%= not ok

Assessment

  1. Nervous
    1. Assess temp at least q30 minutes for 2 hours then per hospital policy
      1. Can’t thermoregulate
        1. Prevent cold stress: divert calories,burn up blood sugar, increasing O2 consumption, to try to increase their temp, which can impair essential growth
        2. Cannot shiver to produce heat
    2. Observe reaction to stimuli – is the appropriate response noted?
      1. Check fontanels and head size – proportional?
      2. Check reflexes
    3. Cardiac
      1. Auscultate heart sounds, note abnormalities
        1. Assess O2 sat if in distress or cyanosis present
        2. Murmurs normal in first 24 hours
        3. Check pulses
        4. Check heart rate (120-160 BPM at rest)
          1. If abnormal, listen longer to see if it sustains
    4. Respiratory
      1. Observe respiratory pattern, effort, and rate before auscultation
      2. Only suction as needed, not routinely
        1. Bulb syringe
        2. Mouth first, nares second
        3. Compress bulb, insert, slowly release as you remove it
    5. Hepatic
      1. Jaundice
        1. Pathological jaundice – within the first 24 hours and fast rise, something pathological ie: blood incompatibility
        2. Physiological jaundice – immature liver to excrete broken down RBCs, normal day 2-3
        3. Breast milk jaundice – not getting enough hydration to excrete bilirubin
        4. Total bilirubin lab, possibly a retic count
      2. Vitamin K
        1. Necessary to prevent hemorrhagic issues
        2. Coags made in liver depend on this
        3. Not naturally made in liver until intestinal microflora present
    6. Renal
      1. 5-10% weight loss expected during week 1
        1. Even a bottle fed baby
      2. Might require supplementation/increase in nutritional requirements if over 10% weight loss
      3. Weight newborn every day and diapers if necessary (NICU)
        1. 1 g diaper = 1 mL urine
        2. Must know weight of dry diaper
      4. Circumcision
        1. Make sure baby voids post-procedure
    7. Integumentary
      1. Assess thoroughly and document abnormalities
      2. Provide appropriate cord care
        1. Clamp can only be removed if it is dry, occluded and free from bleeding (typically after 24 hours)
          1. Dry cord care
          2. Watch for infection signs
          3. Cord falls off in 7-10 days

Therapeutic Management

  1. Assess body systems systematically so you do not forget anything
    1. Head to toe
  2. Keep newborn dry and warm during assessment
  3. Pacify for comfort
  4. Heal warmer on infant for better blood draw

Nursing Concepts

  1. Human Development
  2. Clinical Judgment

Patient Education

  1. What the newborn screen is looking for
  2. Bilirubin
    1. Increase feedings
  3. How many voids to expect
  4. Cord care
    1. Dry cord care
    2. Only sponge bath until it falls off at 7-10 days
    3. Do not pull it off even if it is hanging

Reference Links

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Video Transcript

In this lesson I will explain the pieces to the newborn body system assessments and your role for doing this.
So what is all this about? There are a few special assessments that will be done while the baby is in the hospital.. So first before any of these assessments are done the baby must be kept warm! You as the nurse will either perform or help facilitate the screening. The hearing exam is done to assess babies hearing. You can see in this image how electrodes are placed and the machine makes noises and detects brain activity to see if they hear the noises. Now some babies fail this and it is ok a lot of time there is just fluid still in their ears so they just need a rescreen. There is also the metabolic screening or newborn screening and this used to be called PKU test for phenylketonuria but now the screen tests for many more then just PKU but in case you’ve heard it called PKU that is why. We are still trying to get used to the name change! This is state mandated and a blood sample is taken after the baby is 24 hours old. That is important! They must be eating successfully for 24 hrs before screening since it is looking for metabolic disorders. The test looks for around 26 different metabolic disorders. The main ones are PKU, Maple syrup urine disease, Cystic fibrosis and Galactosemia but there are many more. The baby will also have a bilirubin level drawn to assess for jaundice. Jaundice is that yellow color they get when the bilirubin is high. Bilirubin builds up from broken down red blood cells so if the baby had a lot of bruising at delivery it is going to be higher. The more the baby poops the quicker it will come down since bilirubin is excreted in the stool. The congenital heart screen is done after the baby is 24 hours old and a Pre and post oxygen level is taken. Pre is always the right hand so it is the blood prior to enter the heart and post is any other extremity, which is the blood post heart.) The saturation should be over 94% and no more than a 3 percent difference. So for example a 95% and 97% is ok because we are above 94% and only 2 apart. 100% and 95% is not ok. Yes we are above 94% but we are greater than 3 percent apart. So this baby will either need a retry or cardiac consult.
Ok let’s look at these different systems and what we expect to assess and find if there is a concern. So first the nervous system. We will be assessing the baby’s temperature frequently in the beginning. Usually every 30 minutes for first two hours of life then per the hospital policy. Newborns have a limited ability to thermoregulate which can quickly put them into cold stress. When they become cold they divert calories,burn up their blood sugar and increase their oxygen consumption so this becomes a disaster! I once was carrying for a preterm baby who was 30 hours old, needed a bath, and the temp was stable. I gave it a bath then an hour later the mother called to tell me she thought he felt cold. Well he was! His temperature was 96.8 ℉ so I took him to the nursery and put him under the radiant warmer. His blood sugar was undetectable because it was so low so our machines this means under 10! The nurses all jumped in and started getting my supplies because I knew I was going to have to give a dextrose IV bolus as I called the doctor for orders. As I’m on the phone I hear a nurse shout my name and I look and he is blue and apneic so I dropped the phone and gave PPV. He came back quickly and we got the IV in and bolused. He then went to the NICU and come to find out a week later they discovered he was born diabetic which is extremely rare but all of this shows what goes on with cold stress. So do whatever you can to keep your babies warm! Another important factor for you to remember is that newborns cannot shiver to produce heat like we do. So they burn up their sugar and fat to warm up. You will see the tremors and parents will think it means their cold but those are just normal tremors that babies do not shivers. Checking reflexes is also key for the nervous system. You can refer to the lesson on reflexes for more on that. The cardiac system will be checked for good heart sounds and no murmurs. Murmurs are normal in the first 24 hours as the ductus closes so we are not concerned in the first 24 hours. Also check pulses to ensure they are strong and equal. Respiratory wise we will observe the pattern, effort, and rate to identify any concerns. We expect not labored and 30-60 breaths per minutes.
Ok so now a few more systems to cover. The hepatic system might have signs of jaundice. That is yellowing skin color and a bilirubin level will be drawn on every baby prior to discharge or if they look yellow early on. Refer to the hyperbilirubinemia lesson for more about this. Vitamin K is given at delivery and is necessary to prevent hemorrhagic issues. This is needed for clotting and the baby isn’t born with this. With the renal system the babies should be voiding 1 void for every 24 hours old that they are. They might go more but that shows us they are getting hydrated. All babies have weight loss but we are worried when that goes over 10%. So yes even a bottle fed baby will lose weight but no baby should be over 10%. If they are then supplementation might be necessary. If you care for a male that is circumcised then you want to ensure there is a void post procedure. The Integumentary system should just be checked thoroughly and document any abnormalities that are found. The umbilical cord will be clamped after delivery and should be removed once the cord is dry. The cord should be kept dry so it can fall off and should fall off in 7-10 days. Just keep an eye on the cord for any oozing or smell because they can be infected.
For our management there are a few important things. Assessment needs to be systematically so you do not forget anything so stay in order and go head to toe. We need to keep newborn dry and warm during assessment to prevent cold stress. Pacify the baby for comfort during procedures like newborn screening and hearing screen so they stay quiet. And a heal warmer can be used to warm the heal and get a better blood draw which means it is also quicker for the baby and you won’t have to squeeze as hard to get blood out so better for everyone!

So if there is a problem detected then there will be more education for those patients but just our basic education on this will be the things we are doing. So what the newborn screen is looking for. You just tell them “we are looking for some different metabolic disorders and it is send to the state lab and the results will go to your pediatrician.” You will explain why you are checking the bilirubin. So either it is being checked as a standard prior to discharge or that the baby is a little jaundice so we need to check the level. If it is a little elevated we can encourage them to increase feedings because bilirubin is excreted in stool. They need to know that voids are important, right?! So we expect to see 1 for every 24 hours and this shows the baby is hydrated. And cord care should be dry cord care, nly sponge bath until it falls off at 7-10 days and it will be tempting to pull of but do not pull it off even if it is hanging.

Concepts for this will be human development because it is the body systems. Clinical Judgment because we have to assess and make clinical judgments on what is found to properly intervene and patient education because we will provide education on what we are doing and what is found.
Let’s review our key points to remember. The body system assessments are tools used to assess a specific system. The main ones are hearing screening, bilirubin for jaundice, and newborn screening, which tests for around 26 metabolic disorders. Using these screening tools allow us to catch problems earlier and treat properly.
Make sure you check out the resources attached to this lesson and review the different assessment tests that are done. Now, go out and be your best selves today. And, as always, happy nursing.

Read more

  • Question 1 of 6

A nurse is teaching the parents of a newborn about bathing the infant and caring for the cord. Which of the following information is most appropriate to give to the parents about cord care?

  • Question 2 of 6

A nurse is educating new parents on the care of the umbilical stump of their newborn. Which information should be included? Select all that apply.

  • Question 3 of 6

When should the newborn metabolic screening be completed?

  • Question 4 of 6

A newborn is undergoing the congenital heart screening. What results would warrant further assessment?

  • Question 5 of 6

A newborn undergoes their hearing test at 10 hours of life and fails on the right side. What is the most likely reason for this?

  • Question 6 of 6

A nurse is drawing labs for newborn screening. Which of the following tests would be included in this screening?

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