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N106 Nursing Care of the Newborn. Immediate Baby Care. Airway - Clean mouth and nose Thermoregulation - Warmth APGAR Gross assessment Identification Bonding – safety against infection Medications. Fetus to Newborn: Respiratory Changes. Initiation of respirations

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immediate baby care
Immediate Baby Care
  • Airway - Clean mouth and nose
  • Thermoregulation - Warmth
  • APGAR
  • Gross assessment
  • Identification
  • Bonding – safety against infection
  • Medications
fetus to newborn respiratory changes
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
nursing process for respirations
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
fetus to newborn neurological adaptation thermoregulation
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

slide6

Convection

Radiation

Evaporation

Conduction

nursing care cold stress
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
effects of cold stress
Effects of Cold Stress
  • Increased oxygen need
  • Decreased surfactant production
  • Respiratory distress
  • Hypoglycemia
  • Metabolic acidosis
  • Jaundice
apgar
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
early assessments
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
slide12

Not crossing suture line

Cephalhematoma is a collection of blood between the surface of a cranial bone and the periosteal membrane.

slide13

Crossing suture line

Caput succedaneum is a collection of fluid (serum) under the scalp.

slide14

A, Congenitally dislocated right hip B, Barlow’s (dislocation) maneuver. C, Ortolani’s maneuver

measurements
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
slide16

head larger

A, Measuring the head circumference of the newborn. B, Measuring the chest circumference of the newborn.

assessment of cardio respiratory status
Assessment of Cardio-respiratory Status
  • History
  • Airway
  • Assessrateq 30minX2hrssymmetrybreath sounds - moisture for 1-2 hrs
assessment of thermoregulation
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
assessment of hepatic function
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
jaundice
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
slide22

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

assessment of neuro system
Assessment of Neuro System
  • Reflexes
  • BabinskiGraspMoroRootingSteppingSuckingTonic neck reflex “fencing”
  • Cry
  • Infant response to soothing
assessment of gastrointestinal system
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
assessment of genitourinary system
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
assessment of integumentary system
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

slide27

Port Wine Stain

Erythema toxicum

fetus to newborn psychosocial adaptation
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
gestational age assessment
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
gestational age assessment31
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 <10% for weight large LGA >90% for weightappropriate AGA between 10-90%
ongoing assessment and care
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
slide40

LATCH was created to provide a systematic method for breastfeeding assessment and charting.

circumcision
Circumcision
  • Most common neonatal surgical procedure
  • Reasons for choosing
  • Reasons for rejecting – hypospadias, epispadias
  • Pain relief
  • Methods
  • Nursing care
other concerns
Other Concerns
  • ImmunizationsHepatitis B – begin vaccine at birth
  • Screening testsHearingPhenylketonuria – by law
further assessments
Further Assessments
  • Complications r/t poorly functioning placentahypoglycemiahypothermiarespiratory problems
  • Complications r/t LGA infanthypoglycemiabirth injury due to size
shoulder dystocia
Shoulder Dystocia
  • Risk factorsdiabetes; macrosomic infantobesityprolonged second stageprevious shoulder dystocia
  • Morbidity- fracture of clavicle or humerus,brachial plexus injury
  • Management – generous episiotomy
high risk infants
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
preterm infants
Preterm infants
  • Survive - Weight 1250 g -1500 g – 85-90%500-600g 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
nursing care of preterm infants
Nursing Care of Preterm Infants
  • Inadequate respirations
  • Inadequate thermoregulation
  • Fluid and electrolyte imbalance – dehydration sunken fontanels <1ml/kg/hr or over hydration bulging, edema and urine output >3ml/kg/hr
  • Signs of pain – high-pitched cry, >VS
  • Signs of over stimulation - >P, >RR, stiff extended extremities, turning face away
  • Nutrition – signs of readiness to nippleresp <60/m, rooting, sucking, gag reflex
complications of preterm infants
Complications of Preterm Infants
  • Respiratory Distress Syndrome -RDS
  • Bronchopulmonary dysplasia – chronic lung disease
  • Periventricular-Intraventricular Hemorrhage30% infants <32 wk gest or <1500 g
  • Retrolenthal fibroplasia – visual impairment or blindness from O2 & ventilator
  • Necrotizing Enterocolitis (NEC) – distention, increased residual, Tx - rest bowel
respiratory distress syndrome
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

therapeutic management of rds
Therapeutic Management of RDS
  • Surfactant replacement therapy
  • Installed into the infant’s trachea
  • Improvement in breathing occurs in minutes
  • Doses repeated prn
  • Other treatmentmechanical ventilationcorrection of acidosisIV fluids
post term infants
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
meconium aspiration syndrome
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
hyperbilirubinemia
Hyperbilirubinemia
  • Pathologic jaundice – occurs within first 24 hours
  • Bilirubin levels >12 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
phototherapy for hyperbilirubinemia
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
other interventions for hyperbilirubinemia
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
infant of a diabetic mother
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 time<40-45 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
hypoglycemia
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
large for gestational age
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
small for gestational age
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
mother with substance abuse
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
drug withdrawal in infants
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
nursing care of drug exposed infant
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
phenylketonuria pku
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
signs bonding delayed
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
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