NEWBORN : NEWBORN Physiologic Status of the NEWBORN : Physiologic Status of the NEWBORN Slide 3: CIRCULATORY STATUS
UMBILICAL VEIN and DUCTUS VENOSUS constrict after cord is clamped.
DUCTUS ARTERIOSUS constricts w/ establishment of respiratory function.
FORAMEN OVALE closes functionally as respirations are established, but anatomic or permanent closure may take several months.
HEART RATE averages 140 bmn
BP 73/55 mmHg
PERIPHERAL CIRCULATION acrocyanosis w/n 24H
RBC high immediately after birth; falls after 1st wk
ABSENCE /NORMAL FLORA INTESTINE vit K Slide 4: RESPIRATORY SYSTEM NORMAL RESPIRATORY RATE Chest and abdomen rise simultaneously.
- no SEE-SAW BREATHING LECITHIN & SPINGOMYELIN N/B are obligate nose breathers. Slide 5: Urine present in the bladder at birth, but NB may not void for 1st 12-24 hours.
Later pattern is 6-10 voidings/day
- indicative of sufficient fluid intake.
Urine is pale and straw colored.
- initial voidings may leave brick-red spots on
diaper (d/t passage of uric acid crystals in urine
Infant unable to concentrate urine for the 1st 3 mos RENAL SYSTEM Slide 6: DIGESTIVE SYSTEM
Hard palate should be intact, small raised white areas on the palate are normal. EPSTEIN’S PEARLS
Newborn can’t move food from lips to pharynx.
CIRCUMORAL PALLOR may appear while sucking.
capable of digesting simple CHO and simple CHON but fats
Immature Cardiac (esophageal) Sphincter
Stomach capacity caries= 50-60 ml
Feeding patterns Slide 7: FIRST STOOL is MECONIUM.
- black, tarry residue from lower intestine.
- usually passed within 12- 24 hours after birth.
- thin, brownish green in color
After 3 days MILK STOOLS are usually passed.
a. MILK STOOLS for BF-INFANT
- Loose and golden yellow
b. MILK STOOLS for FORMULA-FED
- Formed and pale yellow Slide 8: HEPATIC
hgb … unconjugated bilirubin (< 12mg/dl), …conjugated (water-soluble) bilirubin..excreted Slide 9: TEMPERATURE
HEAT PRODUCTION a. Metabolism of “BROWN FAT”
Axillary temperature: 96. 8 to 99ºF
NB can’t shiver as an adult does to release heat.
NB’s body temp drops quickly after birth.
- cold stress occurs easily.
Body stabilizes temp in 8-10 hours if unstressed.
Cold stress increases O2 consumption.
- may lead to metabolic acidosis and respi distress. Slide 10: IMMUNOLOGIC
IgG & Colostrum
NB develops own antibodies during 1st 3 mos, but at risk for infection during first 6 weeks.
Ability to develop antibodies develops sequentially. Slide 11: NEUROLOGIC / SENSORY
SIX STATES OF CONSCIOUSNESS
CRYING NEONATAL ASSESSMENT : NEONATAL ASSESSMENT Slide 13: WEIGHT
normal= 2500 - 4300 g (5.5 to 9.5 lbs) at term.
Initial loss of 5-10% of body weight
- normal for the first few days
- this should be regained in 1-2 weeks
Average 45.7-55.9 cm (18-22 in)
30-33 cm (12-13 inches)
should be equal to or 2-3 cm < head circumference Slide 14: 25% of the body length; circumference 33-37cm
Bones of the skull are not fused
Molding …Caput Succedaneum..Cephal Hematoma
Masses from birth trauma
*Re-measure after several days if significant
molding or caput succedaneum present
HEAD LAG HEAD Slide 15: EYES EARS NOSE MOUTH NECK Slide 16: CHEST Appears circular since AP and lateral diameters are about equal Respirations appear diaphragmatic Bronchial sounds heard on ausculation Nipples prominent and often edematus Milky secretion (Witch’s milk) common Clavicles need to be palpated to assess for fractures Slide 17: ABDOMEN UMBILICAL CORD
3. ANUS Slide 18: Pigmentation increases after birth
Skin may be dry.
Small amounts of lanugo and vernix caseosa still seen
May develop “NEONATAL RASH”
- (ERYTHEMA TOXICUM NEONATORUM)
HARLEQUIN SIGN SKIN COLOR Slide 19: Testes descended or in inguinal canal.
Rugae cover scrotum.
Meatus at tip of penis. BREASTS Nodule of tissue present in breasts. FEMALE GENITALIA Vernix seen between labia
Pseudomenstruatrion MALE GENITALIA Slide 20: Predominantly flexed.
Occasional transient tremors of mouth & chin.
Newborn can turn head from side to side in prone position.
Needs head supported when held erect or lifted. LEGS Bowed
No click or displacement of head of femur observed when hips flexed and abducted. FEET Flat
Soles covered with creases in fully mature infant. MUSCLE TONE Slide 21: BIRTHMARKS Slide 22: TELANGIECTATIC NEVI (STORK BITES) NEVUS FLAMMEUS (PORT-WINE STAIN) NEVUS VASCULOSUS (STRAWBERRY MARK) MONGOLIAN SPOTS REFLEXES PRESENT at BIRTH : REFLEXES PRESENT at BIRTH ROOTING REFLEX : ROOTING REFLEX PALMAR-PLANTAR GRASP REFLEX : PALMAR-PLANTAR GRASP REFLEX Newborn’s fingers curl around the examiner’s fingers and the newborn’s toes curl downward.
Palmar response lessens within 3-4 months
Plantar response lessens within 8 months DARWINIAN REFLEX : DARWINIAN REFLEX MORO REFLEX : MORO REFLEX BAINSKI REFLEX : BAINSKI REFLEX SLEEPING OR WALKING REFLEX : SLEEPING OR WALKING REFLEX CRAWLING REFLEX : CRAWLING REFLEX Place the newborn on the abdomen
The newborn begins making crawling movements with the arm and legs
Reflex usually disappears after 6 weeks TONIC NECK/FENCING REFLEX : TONIC NECK/FENCING REFLEX CRY : CRY Loud and vigorous.
Heard when infant is hungry, disturbed or uncomfortable. GESTATIONAL AGE ASSESSMENT : GESTATIONAL AGE ASSESSMENT Slide 34: Direct examination of the infant leads to an accurate assessment of maturity. SKIN thickens with gestational age may be dry/peeling if postmature LANUGO disappears as pregnancy progresses SOLE (PLANTAR) CREASES increase with gestational age (both depth & no.) Slide 35: AREOLA OF BREAST at term, 5-10 mm in diameter EAR CARTILAGES Cartilage stiffens, recoil increases, and curvature of
pinna increases with advancing gestational age. GENITALIA Female, look for the labia majora to cover the labia minora and clitoris Male, check for descended testicles & scrotal rugae Slide 36: NEUROMUSCULAR ASSESSMENT - best done after 24 hours RESTING POSTURE Relaxed posture (extension) seen in the premature; Flexion increases with maturity SQUARE WINDOW ANGLE Flex hand onto underside of forearm, identify angle at which you feel resistance. Angle decreases with increasing gestational age. Slide 37: ARM RECOIL Flex infant’s arms, extend for 5 sec., then release. Note angle formed as arms recoil. Decreases with increasing gestational age. POPLITEAL ANGLE Place infant on back, extend one leg and measure angle at point of resistance. Angle becomes more acute as gestation progresses. Flex infant’s arms, extend for 5 sec., then release. Note angle formed as arms recoil. Decreases with increasing gestational age. Place infant on back, extend one leg and measure angle at point of resistance. Angle becomes more acute as gestation progresses. Slide 38: SCARF’S SIGN Draw one arm across chest until resistance is felt; note relation of elbow to midline of chest. Resistance increases with advancing gestational age. HEEL TO EAR Attempt to raise foot to ear, noting point at which foot slips from your grasp. Resistance increases with gestational age. INITIAL CARE OF THE NEWBORN : INITIAL CARE OF THE NEWBORN Slide 43: Observe and assist with initiation of respirations
Assess Apgar score
Note characteristics of cry
Monitor for nasal flaring, grunting, retractions and abnormal respirations
Obtain vital signs.
Observe NB for signs of hypothermia or hyperthermia. ASSESSMENT Slide 44: Suction mouth, then nares with bulb syringe.
Dry baby and stimulate crying by rubbing.
Maintain temperature stability.
Keep newborn with mother to facilitate bonding.
Place newborn at mother’s breast if breastfeeding is planned or place on mother’s abdomen.
Place newborn in a warmer.
Position newborn on the side or abdomen or in modified Trendelenburg position to facilitate drainage of mucus.
Ensure proper NB ID
Footprint NB & fingerprint mother on ID sheet/ agency’s policies & procedures
Place matching ID bracelets on mother & NB NURSING INTERVENTION Slide 45: APGAR SCORING SYSTEM Perform and record Apgar score at 1 min & at 5 mins. If the score is less than 7 at 5 mins., the Apgar score shld be perform at 10 mins. A score of 7-10 indicates a healthy newborn. A score of 3-6 is considered moderately depressed. A score of 0-2 is severely depressed. PRETERM NEWBORN : PRETERM NEWBORN respirations are irregular with periods of apnea
body temp. is below normal
poor suck and swallow reflexes
diminished bowel sounds
extremities thin w/ minimal creasing on soles & palms
extends extremities & does not maintain flexion
Lanugo present in wooly patches
skin thin, with visible bld. vessels & minimal SQ fat pads
skin may appear jaundiced
testes undescended in boys
labia narrow in girls CLINICAL FINDINGS POSTTERM NEWBORN : CLINICAL FINDINGS
Parchment-like skin (dry & cracked) w/o lanugo
Fingernails long & extended over ends of fingers
profuse scalp hair
body is long & thin
extremities show wasting of fat & muscle
meconium-staining may be present on nails & umbilical cord POSTTERM NEWBORN SMALL FOR GESTATIONAL AGE : SMALL FOR GESTATIONAL AGE CLINICAL FINDINGS
Lowered or elevated body temperature
Signs of polycythemia
- ruddy appearance
Signs of infection
Signs of aspiration of meconium LARGE FOR GESTATIONAL AGE : LARGE FOR GESTATIONAL AGE CLINICAL FINDINGS
Birth trauma or injury
Hypoglycemia HYPOGLYCEMIA : HYPOGLYCEMIA Abnormally low level of glucose in the blood (less than 30 mg/dl in the first 72 hours or below 45 mg/dl after the first 3 days of life
Normal: 40-60 mg/dl in 1-day-old neonate
50-90 mg/dl in neonate older than 1 day
Twitching, nervousness, or tremors
Cyanosis NB OF DIABETIC MOTHER : NB OF DIABETIC MOTHER CLINICAL FINDINGS
Excessive size and weight
Edema or puffiness in the face & cheeks
hypocalcemia, hyperbilirubenemia, hypoglycemia
Signs of respiratory distress such as:
- nasal flaring Slide 52: Tachypnea (RR >60 bpm) & increased apical pulse
Flaring nares & expiratory grunting
Retractions & chin lag
Decreased activity level & elevated CO2 level in ABG
Decreased breath sounds
Pallor & cyanosis
Hypothermia & Poor muscle tone
X-rays show atelectasis & high density in alveoli RESPIRATORY DISTRESS SYNDROME (RDS) Slide 53: HYPERBILIRUBINEMIA
BRONCHOPULMONARY DYSPLASIA (BPD)
- damage to alveolar epithelium of the lungs related to high O2 concentrations and positive ventilation.
- may be difficult to wean infant from ventilator, but most recover & have normal x-rays at 6 months to 2 years.
NECROTIZING ENTEROCOLITIS SEQUELA OF RDS Slide 54: Monitor for color, RR, degree of effort in breathing.
Monitor ABG and O2 sat. levels q2-4H.
Assess retinal damage.
Position on side or back, w/ neck slightly hyper-extended
CPAP or PEEP may be used
Encourage as much parental participation in NB care
Maintain infant temp @ 97.6’F (36.2’C) NURSING INTERVENTIONS HYPERBILIRUBINEMIA : HYPERBILIRUBINEMIA NURSING INTERVENTIONS
Monitor for presence of jaundice.
- examine the newborn’s skin color in natural light.
- press fingers over bony prominence or tip of nose to press out capillary blood from the tissues
- jaundice starts from head, chest abdomen arms & legs then hands and feet
Keep newborn well hydrated to maintain bld. volume
Facilitate early, frequent feeding.
- hasten passage of meconium and encourage excretion of bilirubin
Report jaundice to MD any signs of jaundice in the first 24 hours and any abnormal S/S.
Prepare for phototherapy & monitor closely during treatment. PHOTOTHERAPY : Expose newborn’s skin as much as possible.
Cover genital area & monitor for skin irritation/breakdown.
Cover the eyes with eye shields or patches.
Measure the quantity of light q8H
Monitor skin temp closely.
Increase fluids for compensate for water loss.
Expect loose green stools & green urine.
Monitor the skin color w/ florescent light turned off q4-8H
Monitor for BRONZE BABY SYNDROME
Monitor for signs of hyperbilirubinemia PHOTOTHERAPY ERYTHROBLASTOSIS FETALIS : ERYTHROBLASTOSIS FETALIS Destruction of RBCs that result from Ag-Ab rxn
hemolytic anemia/ hyperbilirubinemia
ABO incompatibility RH INCOMPATIBILTY : RH INCOMPATIBILTY In each pregnancy, an Rh(-) mother who carries an Rh (+) fetus receives Rhogam if both the mother and infant is (-) to both direct & indirect Coombs’ test.
If mother is has been sensitized:
anti-Rh(+) Ab are present
- Rhogam is not indicated
Rhogam must be injected into unsensitized mother’s system within 72 hours of delivery of Rh(+) infant ABO INCOMPATIBILTY : ABO INCOMPATIBILTY Reaction less severe than Rh incompatibility
First born may be affected
- mother may have anti-A & anti-B Ab even before pregnancy
Fetal RBCs w/ A, B, or AB Ag evoke less severe reaction on part of mother
- fewer anti-A, anti-B or anti-AB Ab are produced
Observe for hemolysis & jaundice ERYTHROBLASTOSIS FETALIS : NURSING INTERVENTIONS
Determine blood type and Rh early in pregnancy.
Determine results of direct Coomb’s test early in pregnancy & again at 28 week’s.
Determine results of direct Coomb’s test on cord blood.
- type & Rh, Hgb, Hct
Implement phototherapy/exchange transfusion. ERYTHROBLASTOSIS FETALIS ERYTHROBLASTOSIS FETALIS : NURSING INTERVENTIONS
Administer Rh0 (D) immune globulin to the mother during the first 72 hrs. after delivery if the Rh(-) mother delivers an Rh (+) fetus but remains unsensitized
Assist with exchange transfusion as prescribed.
The baby’s blood is replaced with Rh(-) blood to stop the destruction of the baby’s RBC
- the Rh (-) blood is replaced with the baby’s own blood gradually
Reassure the mother that the newborn will suffer no untoward effects from the condition ERYTHROBLASTOSIS FETALIS SEPSIS : SEPSIS NURSING INTERVENTIONS
Assess for periods of apnea or irregular respirations
If apnea is present, stimulate by gently rubbing chest or foot
Administer oxygen as prescribed.
Monitor vital signs.
Maintain warmth in an isolette.
Provide isolation as necessary.
Assess for fever.
Monitor for I&O and obtain daily weight.
Monitor for diarrhea.
Assess feeding & sucking reflex which may be poor
Assess for jaundice
Assess for irritability and lethargy.
Administer antibiotics as prescribed and monitor for toxicity. TORCH SYNDROME : TORCH SYNDROME TOXOPLASMOSIS : TOXOPLASMOSIS CHARACTERISTICS
Produces no serious effects in the mother
Can be transmitted to the fetus
Can result in severe physical and development abnormalities
Common carriers include cat feces and raw beef RUBELLA : RUBELLA CHARACTERISTICS
Systemic viral infection
Causes congenital rubella syndrome which includes congenital heart disease, cataracts, growth retardation, and pneumonia if the mother becomes infected within the trimester
Deafness and some learning disabilities can occur if the mother becomes infected during the first trimester CYTOMEGALUS : CYTOMEGALUS CHARACTERISTICS
A viral infection that persists in the body indefinitely, with periods of reactivation without symptoms
Can infect the fetus or infant during delivery or after birth through breastmilk, blood transfusions or contact with infected secretions
May cause microcephaly, blindness, deafness, mental and motor retardation. HERPES SIMPLEX : HERPES SIMPLEX CHARACTERISTICS
Sexually transmitted disease caused by a virus
Periods of reactivation
Neonate is commonly infected during delivery by direct contact with lesions in the genital tract
Can cause neurological impairment or death. SYPHILIS : SYPHILIS Sexually transmitted disease
Congenital syphilis can result in premature delivery, skin lesions, abnormal skeletal development
Treponema pallidum, a spirochete, is able to cross the placenta throughout pregnancy and infect the fetus usually after 18 weeks’ gestation
Risks include preterm birth, stillbirth, and low birth weight
Congenital effects are irreversible and may include CNS damage and hearing loss. SYPHILIS : SYPHILIS CLINICAL FINDINGS
CSF changes SYPHILIS : NURSING INTERVENTION
Monitor for signs of syphilis
Monitor for palmar rash and snuffles
Prepare newborn for serological testing if prescribed.
Administer antibiotic therapy as prescribed.
Use universal (standard) precautions and drainage/ secretion precautions with suspected congenital syphilis
Wear gloves when handling neonate until 24 hours of antibiotic therapy has been administered. SYPHILIS THE ADDICTED NEWBORN : THE ADDICTED NEWBORN ADDICTING DRUGS
cocaine THE ADDICTED NEWBORN : CLINICAL FINDINGS
Irritability, tremors, hyperactivity & hypertonicity
Excessive sucking fists
Convulsions THE ADDICTED NEWBORN THE ADDICTED NEWBORN : NURSING INTERVENTIONS
Monitor respiratory & cardiac status frequently
Monitor temperature & V/S
Hold during feeding & when giving care.
Initiate seizure precautions (pad side rails)
Provide small frequent feedings & allow longer period of feeding.
Administer IV hydration if prescribed.
Protect skin from injury that can be caused by the constant rubbing from hyperactive jitters THE ADDICTED NEWBORN THE ADDICTED NEWBORN : NURSING INTERVENTIONS
Place newborn in a quiet room & reduce stimulation.
Administer medications as ordered.
- may use Phenobarbital or Paragoric
Allow mother to ventilate feelings of anxiety & guilt.
Refer mother for treatment of substance abuse. THE ADDICTED NEWBORN FETAL ALCOHOL SYNDROME : FETAL ALCOHOL SYNDROME CLINICAL FINDINGS
Short palpebral fissures
Short upturned nose
Thin upper lip
Low nasal bridge FETAL ALCOHOL SYNDROME : CLINICAL FINDINGS Abnormal palmar creases Respiratory distress (apnea, cyanosis) Congenital heart disorders Irritability, hypersensitivity to stimuli Tremors Poor feeding Seizures Abnormal palmar creases Respiratory distress (apnea, cyanosis) Congenital heart disorders Irritability, hypersensitivity to stimuli Tremors Poor feeding Seizures FETAL ALCOHOL SYNDROME FETAL ALCOHOL SYNDROME : NURSING INTERVENTIONS Monitor for respiratory distress. Keep resuscitation equipment at the bedside. Monitor for hypoglycemia. Assess suck & swallow reflex. Administer small feedings & burp well. Suction as necessary. Monitor I&O. Monitor weight & head circumference. Decrease environmental stimuli. FETAL ALCOHOL SYNDROME PHENYLKETONURIA(PKU) : PHENYLKETONURIA(PKU) - Done when the infant is about 6 weeks old - test urine with PHENISTIX - Done after infant has ingested CHON for a minimum of 24H Initial screening is done via GUTHRIE TEST SECOND screening PHENYLKETONURIA(PKU) : PHENYLKETONURIA(PKU) CLINICAL FINDINGS
Phenylalanine levels greater than 8 mg/dl
- are diagnostic of PKU.
Newborn appears normal but may be fair with decreased pigmentation.
Untreated PKU may result in:
- failure to thrive
By about 6 months, signs of brain involvement evident if left untreated. PHENYLKETONURIA(PKU) : PHENYLKETONURIA(PKU) Restrict CHON intake.
Substitute a low-phenylalanine formula (Lofenalac) for either mothers’s milk or formula.
Provide special food lists for parents. NURSING INTERVENTIONS NECROTIZING ENTEROCOLITIS (NEC) : An ischemic attack to the intestine resulting in thrombosis & infarction of the affected bowel, mucosal ulcerations, pseudomembrane formation, & inflammation.
Bacterial action (E.coli or Klebsiella) complicates the process causing SEPSIS.
May be precipitated by any event in which blood is shunted away from the intestine to the heart & brain.
- Fetal distress
- low Apgar score
- neonatal shock & asphyxia NECROTIZING ENTEROCOLITIS (NEC) NECROTIZING ENTEROCOLITIS (NEC) : NECROTIZING ENTEROCOLITIS (NEC) Average onset: 4 days
NEC more encountered more frequently due to reasons that more severely ill infants are surviving.
May ultimately cause bowel perforation.
Correction of acidosis & fluid and electrolyte imbalances
Surgical removal of diseased intestine NECROTIZING ENTEROCOLITIS (NEC) : NECROTIZING ENTEROCOLITIS (NEC) CLINICAL FINDINGS History indicating high risk group Findings related to sepsis - temperature instability - apnea, labored respirations - cardiovascular collapse - lethargy or irritability NECROTIZING ENTEROCOLITIS (NEC) : Gastrointestinal symptoms
- abdominal distention
- vomiting or increased gastric residual
- poor feeding
- (+) Hematest for stools
- X-rays showing air in the bowel wall, adynamic ileus, & bowel wall thickening NECROTIZING ENTEROCOLITIS (NEC) NECROTIZING ENTEROCOLITIS (NEC) : NECROTIZING ENTEROCOLITIS (NEC) NURSING INTERVENTIONS
Carefully assess infants at risk for early recognition of symptoms.
D/C oral feedings. Insert NGT.
Prevent trauma to abdomen by avoiding diapers & planning care for minimal handling.
Maintain acid-base balance
Administer antibiotics as ordered.
Stroke infant’s hands & head and talk to the infant as much as possible.
Provide auditory & visual stimulation.
Inform parents of progress & support them in expressing their fears & concerns.