N106 Nursing Care of the Newborn

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N106Nursing Care of the Newborn
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Immediate Baby Care

• Airway - Clean mouth and nose
• Thermoregulation - Warmth
• APGAR
• Gross assessment
• Identification
• Bonding safety against infection
• Medications

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Fetus to Newborn Respiratory Changes

• Initiation of respirations
• Chemicalsurfactant reduces surface tension
  34-36wksdecrease in oxygen concentration
• Thermalsudden chilling of moist infant
• Mechanicalcompression of fetal chest during
  delivery normal handling

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Nursing Process for Respirations

• Assess for respiratory distress
• Plan Maintain patent airway
• Interventions- Positioning infant head lower
• - Suction secretions bulb, keep near head,
  mouth first, avoid trauma to membranes
• Evaluation rate 30-60, no distress

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Fetus to Newborn Neurological adaptation
Thermoregulation

• Methods of heat loss
• Evaporation wet surface exposed to air
• Conduction direct contact with cool objects
• Convection- surrounding cool air - drafts
• Radiation transfer of heat to cooler objects
  not in direct contact with infant

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Convection
Radiation
Evaporation
Conduction
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Nonshivering thermogenesisThe distribution of
brown adipose tissue (brown fat)
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Nursing Care Cold Stress

• Preventing heat loss radiant warmer
• Providing immediate care - dry quickly, cover
  head with cap, replace wet blankets
• Providing on going prevention - safety
• Restoring thermoregulation if becoming chilled
  - intervene

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Effects of Cold Stress

• Increased oxygen need
• Decreased surfactant production
• Respiratory distress
• Hypoglycemia
• Metabolic acidosis
• Jaundice

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APGAR

• Heart rate above 100
• Respiratory Effort spontaneous with cry
• Muscle tone flexed with movement
• Reflex response active, prompt cry
• Color pink or acrocyanosis
• 0-3 infant needs resuscitation
• 4-7 Gentle stimulation Narcan
• 8-10 no action needed

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Early Assessments

• Assess for anomalies
• Head anterior fontanelle closes 12-18 mo
  posterior fontanelle closes 2-3 months
• Neck and claviclesfracture of clavicle large
  infant, lump, tenderness, crepitus, decreased
  movement
• Cord
• Extremitiesflexed and resist extensionassess
  fractures, clubfeethipsvertebral column

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Not crossing suture line
Cephalhematoma is a collection of blood between
the surface of a cranial bone and the periosteal
membrane.
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Crossing suture line
Caput succedaneum is a collection of fluid
(serum) under the scalp.
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A, Congenitally dislocated right hip
B, Barlows (dislocation)
maneuver. C, Ortolanis maneuver
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Measurements

• Weight loss of 10 normal
• Length
• Head and chest circumference
• Normal VStemp 97.7-99.5F axillaryapical pulse
  120-160bpm respirations 30-60/min

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head larger
A, Measuring the head circumference of the
newborn. B, Measuring the chest circumference
of the newborn.
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Assessment of Cardio-respiratory Status

• History
• Airway
• Assessrateq 30minX2hrssymmetrybreath sounds -
  moisture for 1-2 hrs

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Assessment of Thermoregulation

• Check soon after birth
• Set warmer controls
• Take temp q 30 min until stable
• Rectal for first temp
• Insert only 0.5 inch
• Axillary route rest of time

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Axillary temperature measurement. The thermometer
should remain in place for 3 minutes.
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Assessment of Hepatic Function

• Blood GlucoseSigns of hypoglycemia
  jitteriness respiratory difficulties drop in
  temp poor suckingTx- feed infant if glucose
  below 40-45 mg/dl
• Bilirubinphysiologic jaundice peaks 2-4 days of
  lifeearly onset may be pathologic

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Jaundice

• Hemolysis of excessive erythrocytes
• Short red blood cell life
• Liver immaturity
• Lack of intestinal flora
• Delayed feeding
• Trauma resulting in bruising or cephalhematoma
• Cold stress or asphyxia

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Potential sites for heel sticks. Avoid shaded
areas to prevent injury to arteries and nerves in
the foot.
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Assessment of Neuro System

• Reflexes
• BabinskiGraspMoroRootingSteppingSuckingTonic
  neck reflex fencing
• Cry
• Infant response to soothing

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Assessment of Gastrointestinal System

• Mouth
• Suck
• Abdomen
• Initial feeding
• Stoolsmeconium within 12-48 hours of birth
  dark greenish blackbreastfed soft, seedy,
  mustard yellowformula-fed solid, pale yellow

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Assessment of Genitourinary System

• Umbilical cord vessels
• Urine within 24 hours of birth
• Voiding 6 to 10 times a day after 2 days
• Genitaliafemale edema normal, majora covers
  minora, pseudomenstruationmale pendulous
  scrotum, descended testes by 36 wks gest.,
  placement of meatus

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Assessment of Integumentary System

• Vernix white covering
• Lanugo fine hair
• Milia
• Erythema toxicum red blotchy with white
• BirthmarksMongolian spots sacral
  areaTelangiectatic nevus stork Bite - blanches
• Nevus flammeus port wine stain - no
  blanchingNevus vasculosus strawberry
  hemangioma usually on head, disappears by
  school age

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Port Wine Stain
Erythema toxicum
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Fetus to Newborn Psychosocial adaptation

• Periods of Reactivityactive 30-60 minsleep
  2-4 hoursalert 4-6 hours
• Behavioral Statesquiet sleepactive sleepdrowsy
  statequiet alert best for bondingactive
  alertcrying state

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Gestational Age Assessment

• Assessment tool Dubowitz, Ballard
• Weeks from conception to birth
• Used to identify high risk infants
• Neuromuscular characteristicsPosture more
  flexionSquare window more pliableArm recoil -
  activePopliteal angle - lessScarf Sign less
  crossing Heel to ear most resistance

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Newborn maturity rating and classification
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Gestational Age Assessment

• Physical characteristicsSkin- deep cracking, no
  vessels seen, post-leatheryLanugo less as
  agePlantar creases more with ageBreasts
  larger areola Eyes and Ears stiff with instant
  recoilGenitals deep rugae, pendulous, covers
  minora
• Gestational Age Size may not correspondsmall
  SGA lt10 for weight large LGA gt90 for
  weightappropriate AGA between 10-90

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Classification of newborns based on maturity and
intrauterine growth.
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Classification of newborns by birth weight and
gestational age.
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Ongoing Assessment and Care

• Bathing
• Cord care
• Cleansing diaper area
• Assisting with feedings
• Protecting infantidentifying infantpreventing
  infant abduction alert to unusualpreventing
  infection
• Review beige cue cards in center of book for teach

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One method of swaddling a baby.
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Common Breastfeeding Positions
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Infant in good breastfeeding position
tummy-to-tummy, with ear, shoulder, and hip
aligned.
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LATCH was created to provide a systematic method
for breastfeeding assessment and charting.
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Infant teaching checklist is completed by the
time of discharge.
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Circumcision

• Most common neonatal surgical procedure
• Reasons for choosing
• Reasons for rejecting hypospadias, epispadias
• Pain relief
• Methods
• Nursing care

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Circumcision using a circumcision clamp.
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Circumcision using the Plastibell.
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Other Concerns

• ImmunizationsHepatitis B begin vaccine at
  birth
• Screening testsHearingPhenylketonuria by law

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Further Assessments

• Complications r/t poorly functioning
  placentahypoglycemiahypothermiarespiratory
  problems
• Complications r/t LGA infanthypoglycemiabirth
  injury due to size

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Shoulder Dystocia

• Risk factorsdiabetes macrosomic
  infantobesityprolonged second stageprevious
  shoulder dystocia
• Morbidity- fracture of clavicle or
  humerus,brachial plexus injury
• Management generous episiotomy

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Neonatal morbidity by birth weight and
gestational age.
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High Risk Infants

• Preterm before 38 weeks gestation
• IUGR full term but failed to grow normally
• SGA -
• LGA
• Infants of Diabetic mothers
• Post mature babies
• Drug exposed

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Preterm infants

• Survive - Weight 1250 g -1500 g 85-90500-600g
  at birth 20 survive
• Ethical questions
• Characteristics frail, weak, limp, skin
  translucent, abundant vernix lanugo
• Behavior easily exhausted, from noise and
  routine activities, feeble cry

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Nursing Care of Preterm Infants

• Inadequate respirations
• Inadequate thermoregulation
• Fluid and electrolyte imbalance dehydration
  sunken fontanels lt1ml/kg/hr or over hydration
  bulging, edema and urine output gt3ml/kg/hr
• Signs of pain high-pitched cry, gtVS
• Signs of over stimulation - gtP, gtRR, stiff
  extended extremities, turning face away
• Nutrition signs of readiness to nippleresp
  lt60/m, rooting, sucking, gag reflex

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Measuring gavage tube length.
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Auscultation for placement of gavage tube.
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Complications of Preterm Infants

• Respiratory Distress Syndrome -RDS
• Bronchopulmonary dysplasia chronic lung disease
• Periventricular-Intraventricular Hemorrhage30
  infants lt32 wk gest or lt1500 g
• Retrolenthal fibroplasia visual impairment or
  blindness from O2 ventilator
• Necrotizing Enterocolitis (NEC) distention,
  increased residual, Tx - rest bowel

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Respiratory Distress Syndrome

• RDS also know as hyaline membrane disease
• Cause besides preemie, C/S, diabetic mothers,
  birth asphyxia interfere with surfactant
• S S tachypnea - over 60/min retractions-
  sternal or intercostal
• nasal flaring cyanosis- centralgrunting-
  expiratoryseesaw respirationsasymmetry

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Evaluation of respiratory status using the
Silverman-Andersen index.
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Therapeutic Management of RDS

• Surfactant replacement therapy
• Installed into the infants trachea
• Improvement in breathing occurs in minutes
• Doses repeated prn
• Other treatmentmechanical ventilationcorrection
  of acidosisIV fluids

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Post Term Infants

• Born after 42 weeks
• Increase risk of meconium aspiration
• Hypoglycemia
• Loss of subcutaneous fat
• Skin peeling, vernix sparse, lanugo absent,
  fingernails long
• Focus on prevention due date
• Attention to thermoregulation feeding

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Meconium Aspiration Syndrome

• Occurs most often post term infants, decreased
  amniotic fluid /cord compression
• Meconium enters lung obstruction
• S S vary from mild to severe respiratory
  distress tachypnea, cyanosis, retractions, nasal
  flaring, grunting
• Tx suction at birth, may need warmed,
  humidified oxygen, or ventilators

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Hyperbilirubinemia

• Pathologic jaundice occurs within first 24
  hours
• Bilirubin levels gt12 in term or 10-14 preterm
• May lead to kernicterus brain damage
• Most common cause blood incompatibility of
  mother and fetus, Rh or ABO only occurs with
  mother negative Rh or O blood
• Treatment focus on prevention, assess coombs,
  monitor bilirubin levels, most common treatment
  is phototherapy, blood transfusions

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Conjugation of bilirubin in the newborn.
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Phototherapy for Hyperbilirubinemia

• Phototherapy bilirubin on skin changes into
  water-soluble excreted in bile urine
• Bili lights placed inside warmer, need patches
  over eyes, infant wearing only diaper or
  fiberoptic phototherapy blanket against skin
• Side effects of phototherapy freq, loose, green
  stools, skin changes
• Can use at home

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Other interventions for hyperbilirubinemia

• Exchange transfusions if lights not working
• Maintain neutral thermal environment not too
  hot or too cold
• Provide optimal nutrition hydrate
• Protecting the eyes from retinal damage
• Enhance therapy by expose as much skin as
  possible to light, remove all clothing except
  diaper, turn frequently

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Infant of a Diabetic Mother

• Macrosomia face round, red, body obese, poor
  muscle tone, irritable, tremors
• High risk for trauma during birth, congenital
  anomalies, RDS, hypocalcemia
• Hypoglycemia occurs 15-50 of timelt40-45 mg/dl,
  test right after birth, q 2hX4,then q 4 hrX6
  until stable
• Most frequent symptom jitteriness or tremors
• Tx fed, gavage or IV if needed

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Hypoglycemia

• Serum glucose is below 40 mg/dL
• Tx feed infant formula or breast milk and retest
  until glucose stable
• S S jitteriness, lethargy, poor feeding,
  high-pitched cry, irregular respirations,
  cyanosis, seizures
• Risk factors DM, PIH, preterm, post term, LGA,
  cold stress, maternal intake of ritodrine or
  terbutaline

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Large for Gestational Age

• Infants weight is in the 90th for neonates same
  gestational age, may be pre, post, or full term
  infants
• LGA does not mean post term
• Most common cause maternal diabetes
• Infant at risk birth injuries, hypoglycemia, and
  polycythemia - macrosomia

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Small for Gestational Age

• Infant whose wt is at or below the 10th
• Results from failure to thrive
• Is a high risk condition
• SGA does not mean premature.
• Causes anything restricting uteroplacental blood
  flow, smoking, DM, PIH, infections
• Complications hypoglycemia, meconium aspiration,
  hypothermia, polycythemia

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Mother with Substance Abuse

• Use of alcohol or illicit drugs
• Tobacco and alcohol are most frequent
• Prenatal alcohol exposure is the most commons
  preventable cause of mental retardation
• Signs of maternal addition wt loss, mood swings,
  constricted pupils, poor hygiene, anorexia, no
  prenatal care

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Drug Withdrawal in Infants

• Signs of drug exposureopiates 48-72
  hourscocaine 2-3 daysalcohol within 3-12
  hours
• Symptoms irritable, hyperactive muscle tone,
  high-pitched cry
• High risk for SGA, preterm, RDS, jaundice
• Obtain infant mec and urine sample for test

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Nursing Care of Drug-Exposed Infant

• Feeding more difficult may need to gavage
• Rest keep stimulation to minimum, reduce noise
  and lights, calm, slow approach
• Promote bonding
• Teach measures for frantic crying rock, coo,
  dark room, avoid stimulation

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Phenylketonuria - PKU

• Genetic disorder causes CNS damage from toxic
  levels of amino acid phenylalanine
• caused by deficiency of the enzyme phenylalanine
  hydroxylase
• Signs- digestive problems, vomiting, seizures,
  musty odor to urine, mental retardation
• Tx low phenylalanine diet start within 2
  months
• Screening before 24-48 hours needs to be repeated
  for accuracy

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Signs Bonding Delayed

• Using negative terms describing infant
• Discussing infant in impersonal terms
• Failing to give name check culture
• Visiting or calling infrequently
• Decreasing length of visit
• Refusing to hold infant
• Lack of eye contact with infant