Comprehensive Review of Systems for Term Newborn with Multiple Conditions
A comprehensive review of systems for a term newborn with neonatal jaundice, ABO incompatibility, respiratory distress syndrome, and ventricular septal defect must include systematic assessment of all major organ systems, with particular focus on the cardiovascular, respiratory, and hepatobiliary systems.
General Assessment
- Vital signs: Temperature, heart rate, respiratory rate, blood pressure
- Overall appearance: Activity level, tone, posture, color (degree of jaundice)
- Weight, length, head circumference and trends
Cardiovascular System
- Heart rate and rhythm
- Heart sounds: Presence of murmurs (location, intensity, timing, radiation)
- Peripheral pulses (brachial, femoral, pedal)
- Capillary refill time
- Blood pressure in all four extremities (to assess for coarctation)
- Signs of heart failure: Hepatomegaly, edema, respiratory distress
- Signs of right ventricular failure: Tricuspid regurgitation, hepatomegaly 1
- Cyanosis (central vs. peripheral)
- Oxygen saturation measurements (pre- and post-ductal)
Respiratory System
- Work of breathing: Retractions, nasal flaring, grunting
- Breath sounds: Air entry, crackles, wheezes
- Respiratory rate and pattern
- Oxygen requirements and delivery method
- Signs of PPHN (persistent pulmonary hypertension of the newborn) 1
- Chest wall movement and symmetry
Hepatobiliary/Gastrointestinal System
- Extent and progression of jaundice (cephalocaudal progression) 1, 2
- Liver size and consistency
- Spleen size
- Abdominal distension
- Feeding tolerance
- Stool color and frequency (pale stools may indicate biliary obstruction)
- Urine color (dark urine may indicate conjugated hyperbilirubinemia)
- Assessment of hydration status
Hematologic System
- Skin color (pallor, plethora, jaundice)
- Petechiae or purpura
- Bleeding from puncture sites
- Hepatosplenomegaly (may indicate hemolysis)
- Signs of anemia or polycythemia
Neurological System
- Level of consciousness
- Tone and posture
- Reflexes (Moro, grasp, suck, rooting)
- Irritability or lethargy
- Signs of bilirubin encephalopathy: Hypertonia, arching, retrocollis, opisthotonos 1
- Seizure activity
- Fontanelle assessment (bulging or depressed)
Fluid/Electrolyte Balance
- Hydration status: Skin turgor, mucous membranes, fontanelle
- Urine output (number of wet diapers)
- Weight changes
- Edema
Integumentary System
- Extent and pattern of jaundice
- Skin integrity
- Edema
- Perfusion
Feeding Assessment
- Breastfeeding frequency (should be 8-12 times per day) 1, 2
- Feeding quality and duration
- Signs of adequate intake (wet diapers, stools)
- Weight trends
Special Considerations for Each Condition
For Neonatal Jaundice/ABO Incompatibility
- Time of onset of jaundice (icterus praecox suggests hemolytic disease) 3, 4
- Rate of bilirubin rise (>0.5 mg/dL/hour suggests pathologic jaundice)
- Response to phototherapy 1, 2
- Signs of anemia from hemolysis
- Family history of hemolytic disorders (G6PD deficiency) 2
For Respiratory Distress Syndrome
- Oxygen requirements and changes
- Response to surfactant (if administered)
- Signs of air leaks (pneumothorax)
- Ventilator settings if intubated
For Ventricular Septal Defect
- Signs of increased pulmonary blood flow
- Evidence of heart failure
- Feeding difficulties or failure to thrive 5
- Exercise tolerance (in older infants)
Laboratory and Diagnostic Assessment Documentation
- Total and direct bilirubin levels and trends 1, 2
- Complete blood count with peripheral smear
- Blood type and Rh of mother and infant
- Direct Coombs' test results 3
- Reticulocyte count
- Arterial blood gases
- Chest radiograph findings
- Echocardiogram results (VSD size, location, hemodynamic significance) 5
Common Pitfalls to Avoid
- Failing to distinguish between physiologic and pathologic jaundice
- Missing signs of acute bilirubin encephalopathy
- Overlooking signs of hemodynamic compromise from VSD
- Underestimating the severity of respiratory distress
- Inadequate monitoring of bilirubin levels in ABO incompatibility (can rise rapidly) 3, 4
- Failing to assess adequacy of breastfeeding in jaundiced infants 1, 2
- Not recognizing PPHN which can complicate both respiratory distress syndrome and congenital heart disease 1
This comprehensive review of systems will ensure thorough assessment and monitoring of this complex neonate with multiple conditions requiring specialized care.