NORMAL NEWBORN

Fall 2011

Surfactant-

What is this? Why is it necessary? When is it formed?

Respiratory Changes

InitiationInitiation ofof BreathingBreathing

Mechanical

Chemical

Thermal

Sensory

Factors in Initial Respiration Mechanical – chest recoil Chemical- respiratory acidosis Thermal- decrease in

environmental temp Sensory- tactile, auditory, and

visual influences stimulate activation of the first breath

Fetal Circulation

Fetal Circulation (p246-247)

Ductus arteriosus- blood flow from pulmonary artery to aorta

Ductus venosus-blood flow from umbilical vein into the inferior vena cava

Foramen ovale- blood flow from right atrium to left atrium

Neonatal Circulation

Ductus arteriosus- closes after birth triggered by pressure changes and pO2

(transient murmurs normal in first 24 hours)

Ductus venosus- closes at clamping of umbilical cord

Foramen ovale- closes at first breath

Cardiovascular/Cardiopulmonary Adaptations Increased aortic pressure and decreased

venous pressure (clamping of cord)

Systemic pressure and pulmonary artery pressure (expanding of the lungs)

Closure of foramen ovale (atrial pressure changes) Closure of ductus arteriosus (PO2 triggers constriction of ductus arteriosus)

Closure of ductus venosus (clamping of cord)

Thermoregulation

Thermoregulation Contributing factors to neonatal

heat loss Size Loss of heat source Loss of glucose supply Metabolic rate

Temperature Regulation Convection Radiation Evaporation Conduction

How does the NB maintain body temperature?

Neonatal methods of producing heat Basal metabolic rate Muscular activity Non-shivering thermogenesis (NST)

Why is heat regulation vital to the neonate’s survival?

What nursing interventions assist the neonate to maintain adequate thermoregulation? Drying Swaddling (blankets) Cap Skin to skin contact (cuddling)

Hematopoietic System

Lifespan of neonatal RBC:

80-100 days (2/3 lifespan of adult’s RBC)

Factors effecting blood volume:Delayed cord clamping

Shift of plasma to extra-vascular spaces

Gestational age

Prenatal or postnatal hemorrhage

Neonatal Lab Values (p498)

Hemoglobin 14-20g/dl Hematocrit 48-69% WBC 10,000 – 30,000mm3 Glucose 40-60mg/dl first 24 hr

then 50-90mg/dl Low blood sugar 40-45mg/dl

requires treatment

Clinical judgment:

Why is Vitamin K AquaMEPHYTON ®

administered to the newborn?

GI Function: What is the significance of

meconium?

What is the priority nursing intervention regarding GI assessment?

Presence of bowel sounds and patency of the anus

Hepatic Function What is the function of the liver in the neonate?

What is physiologic jaundice?

What is the difference between conjugated and unconjugated bilirubin?

What is the long-term consequence of elevated bilirubin levels?

Normal Lab Values

Bilirubin levels for a term NB<3mg/dl

Elevated bilirubin levels depend on NB’s age- peak levels reached between day 3 and 5 in the term infant.

Toxic levels approximately – 20mg/dl

Nursing Interventions: to decrease physiologic jaundice

Maintain NB’s core temperature

Monitor stool frequency and characteristics

Encourage early feeding

Encourage bowel elimination

Prevent dehydration

Urinary System of the NB What is the normal number of

voids in a 24 hour period? For first 48 hours- 1 or 2 daily Following 48 hours- 6 times daily

What is brick-dust staining?

Immunologic Adaptations: Active acquired immunity- the

mother forms antibodies in response to illness or immunization

Passive acquired immunity- transfer of immunoglobulins to the fetus in utero (IgG production begins at 20 weeks gestation) or to the infant via breastmilk

Behavioral States of the NBp. 665 & 872 CHART

Sleep States: Deep or quiet sleep Active or REM sleep

Alert States: Drowsy Wide awake Active awake Crying

Critical thinking…

Which of the behavioral states is optimal for maternal-infant bonding?

Senses in the Neonate: Visual Auditory Olfactory Taste Tactile

Apgar Scoring

Sign 0 1 2Heart rate Absent Slow-below

100Above 100

Respiratory effort

Absent Slow- irregular

Good Crying

Muscle tone

Flaccid Some flexion of

extremities

Active motion

Reflex irritability

None Grimace Vigorous cry

Color Pale blue Body pink, blue

extremities

Completely pink

Apgar Score: assigned at 1 & 5 minutes.

A score below 8 may require resuscitative efforts.

0-3 poor condition

4-6 fair condition

7-10 positive (good condition)

Quick review! What measures should the nurse take

to ensure a patent airway in the NB?

Why is it important to maintain a neutral thermal environment?

What nursing interventions assist to maintain the NB’s core temp? (prevent cold stress)

Assessment of the Neonate

Vital Signs: Pulse Respirations

Signs of Respiratory Distress Temperature Blood pressure

Average size for term Weight Length FOC

Assessment of NB skull/scalp Fontanells

Anterior Posterior

Suture lines Frontal Coronal Sagittal Lamdoidal

Assessing the Head:

Molding

Caput succedaneum

Cephalhematoma

Assessing the Face:

EyesEarsMouthWhat is the significance of

variations? (nursing interventions)

Assessment of the NB’s Eyes: Color Size Reaction to light/blink Conjunctival hemorrhages Transient strabismus or nystagmus

Assessment of the NB’s ears: Level Shape/ malformation Flexibility What body system must the nurse

carefully monitor if anomalies occur with the ears?

Assessment of the NB’s mouth: Lips Palate Hydration Reflexes Additional normal findings:

Epstein’s pearls Precocious teeth Short fernulum of tongue

Why is it important to assess the umbilical stump? How many vessels will you find in

the umbilical cord? ___ Arteries ___ Veins

What is Wharton’s jelly? (p. 246)

Assessment of the Abdomen What is the general shape What is the ratio of FOC to

abdominal size? What organs must be assessed in

the abdomen?

Extremities:

Upper Hands

Lower Hips Feet

Neurological Assessment/ Reflexes Moro or Startle

Palmer grasp

Rooting

Sucking

Step

Babinski

Plantar grasp

Tonic neck

Assessing the genitalia of the NB: Female

Labia Clitoris Vaginal opening

Hymeneal tag Secretions

Anal opening

Male Penis

Penial raphe Urethral meatus

Scrotum Testes Rugae

Skin Assessment: Color and thickness Birthmarks Harlequin sign Jaundice

Assessment of NB skin Acrocyonosis Mottling Erythema toxicum Vernix caseosa Telangiectatic nevi Mongolian spots- Why is it important

to carefully document these birth marks?

Gestational Age: Neuromuscular and physical maturity Newborn Maturity Rating &

Classification (P. 525-530)

Dubowitz tool Ballard Score

Posture, reflexes, size, skin characteristics and fat distribution

Neonatal Medications Administered within 1 to 2 hours of

birth AquaMEPHYTON ®- vitamin K Erythromycin ointment When is best time to administer?

Newborn Identification Footprints

Identification bands Newborn Mother Designated “other”

What would you include in a transfer of care report for the neonate to the transition nursery?

What would you include in a transfer of care report for the neonate to the transition nursery?

Apgar scores Resuscitative efforts Time of birth, weight and length Labor analgesia or anesthetic L&D history Maternal history

Circumcision: (p 549)

What factors are involved in the parent’s decision to have their male newborn circumcised?

What methods of pain relief may be implemented?

What assessments must the nurse include after circumcision?

Circumcision Instruments

Circumcision Care: pre-op & post -op Informed consent Comfort measures Risk of ______? Infection prevention Parent teaching and discharge

planning

Discharge teaching for the NB: Safety Elimination Genitalia care General Feeding Signs of illness NB behavior Immunization schedule Return appointment schedule

Required Newborn Screening for Texas: www.dshs.state.tx.us/lab/nbsHCRes.shtm

Early detection and treatment of inborn metabolic disorders (29 conditions)

Two screening times 24-48 hours after birth 1-2 weeks of age

Hearing screening

Nursing interventions for screening the neonate: Obtain specimen

Preparation of neonate Comfort measures

Inform parents Provide information for obtaining

results