Lecture ten

Care of the NewbornCare of the Newborn

Neonatal TransitionNeonatal Transition

Respiratory AdaptationsFetal lung developmentFetal breathing movements Initiation of breathingMechanical eventsChemical stimuliThermal stimuliSensory stimuli

Fetal Lung DevelopmentFetal Lung Development (681) (681)

Between 24-28 weeks Surfactant synthesis and storage begins to occur.

Surfactant (composed of a group of surface active phospholipids, lecithin and sphingomyelin, which are critical for aveolar stability.

The newborn born before the lecithin/sphingomyelin (L/S) ratio is 2:1 will have varying degrees of respiratory distress.

May need synthetic surfactant if born with respiratory distress.

Breathing Movements Breathing Movements (pg. 681-684)(pg. 681-684)

Breathing is a continuation of a process that began inutero.

Lungs convert from fluid filled to gas filled organs.Pulmonary ventilation must be established through

lung expansion following birth.A marked increase in pulmonary circulation must

occur.Mechanical events, chemical stimuli, thermal stimuli,

and sensory stimuli. Factors opposing the first breath: 1) aveolar surface

tension, 2) viscosity of lung fluid within the respiratory tract and 3) degree of lung compliance.

Cardiopulmonary PhysiologyCardiopulmonary Physiology

Cardio pulmonary adaptationOxygen transportMaintaining respiratory functionCharacteristics of newborn respiration

Transitional Physiology Transitional Physiology (pg. 686-(pg. 686-687)687)

1) Increased aortic pressure and decreased venous pressure:.

2) Increased systemic pressure and decreased pulmonary artery pressure.

3) Closure of the foramen ovale: venosus.

occurs due to increased pressure in the left atrium.

4) Closure of the ductus arteriosus.5) Closure of the ductus

Characteristics of Cardiac Characteristics of Cardiac Function Function (pg. 687-689)(pg. 687-689)

Heart rateBlood pressureHeart murmursCardiac workload

Heart rateHeart rate

The average resting heart rate for full term newborns is 120 to 160 (when the newborn cries the heart rate may exceed 180).

Apical pulses should be obtained by auscultation for a full minute, preferably while the newborn is asleep.

The heart rate should be evaluated fore abnormal rhythms or beats.

Blood PressureBlood Pressure

The newborn blood pressure tends to be higher immediately after birth.

Blood pressure is sensitive to the changes in blood volume that occur in the transition to newborn circulation.

Capillary refill should be less than 2 to 3 seconds when the skin is blanched.

Blood PressureBlood Pressure

Crying may cause an elevation in blood pressure.

Blood pressure should be taken while the newborn is in a quiet state.

Measurement of blood pressure is best accomplished by using the Doppler technique or a 1 to 2 inch cuff and a stethoscope over the brachial artery.

Heart MurmursHeart Murmurs

Murmurs are usually produced by turbulent blood flow.

90% of all murmurs are transient and not associated with anomalies.

Usually involve incomplete closure of the ductus arteriosis or foramen ovale.

Cardiac WorkloadCardiac Workload

Systemic blood volume and pulmonary blood volume are not equal in the neonate.

The right ventricle does most of the work prior to birth.

The left ventricle increases its workload after birth and gains in size and thickness.

Right sided heart defects appear better tolerated than left sided defects.

Hematological AdaptationsHematological Adaptations

Physiologic anemia of infancyDelayed cord clamping and normal shift of

plasma to extravascular spacesGestational agePrenatal or perinatal hemorrhageThe site of the blood sample

Temperature RegulationTemperature Regulation

Thermal neutral zone (TNZ)Heat loss: Convection, Radiation,

Evaporation and ConductionHeat production (Thermogenesis)Brown adipose tissue (BAT, brown fat)Response to heat

Hepatic AdaptationsHepatic Adaptations

Iron Storage and Red Blood Cell Production: 1) Iron is stored in the liver until needed for red

blood cell (RBC) production. 2) Newborn iron stores are determined by total

body hemoglobin content and length of gestation.

3) If the mother’s iron intake has been adequate, newborn iron stores will be stored to last until 5 month of age.

4) After about 6 months of age, foods containing iron or iron supplements may be given to prevent anemia.


Carbohydrate Metabolism:1) Neonatal carbohydrate reserves are relatively

low.2) Energy crunch occurs at birth with the removal

of maternal glucose supply and increased energy expenditure adjusting to extrauterine life.

3) Glucose is the main source of energy in the first 4 to 6 hours following birth.

4) Blood glucose level stabilizes at values of 50 to 60 mg/dL.

5) Glucose level is assessed by using a chemstrip method on admission to the nursery and at 4 hours of age.


Conjugation of Bilirubin: 1) Conjugation of bilirubin is the conversion of yellow lipid

soluble pigment into water soluble pigment. 2) Unconjugated (indirect) bilirubin is a breakdown product

derived from hemoglobin that is released primarily from destroyed red blood cells.

3) Unconjugated bilirubin is not in an excretable form and is a potential toxin.

4) Total serum bilirubin is the sum of conjugated (direct) and unconjugated (indirect) bilirubin.

5) Total bilirubin at birth is less than 3mg/dL. 6) Direct bilirubin is excreted into the tiny bile ducts, then

into the common duct and duodenum. The direct (conjugated) bilirubin then progresses down the intestines where bacteria transform it into urobilinogen. This product is not reabsorbed but is excreted as a yellow-brown pigment in the stools.


Physiologic Jaundice: Physiologic jaundice is caused by accelerated destruction of fetal

RBCs, impaired conjugation of bilirubin, and increased bilirubin re-absorption from the intestinal tract.

A normal biologic response of the newborn. Six factors give rise to physiologic jaundice: 1) Increased amounts of

bilirubin are delivered to the liver, 2) Defective uptake of bilirubin from the plasma, 3) Defective conjugation of the bilirubin, 4) Defect in bilirubin excretion, 5) Inadequate hepatic circulation, and 6) Increased re-absorption of bilirubin from the intestines.

About 50% of full term and 80% of pre-term newborns exhibit physiologic jaundice on the second or third postpartum day.

There appears a characteristic yellow color that results from increased levels of unconjugated bilirubin and a temporary inability to eliminate bilirubin.

The signs of physiologic jaundice occur after 24 hours after birth.

Breast milk jaundice is controversial and difficult to distinguish from prolonged jaundice.


Coagulation:Coagulation factors II, VII, IX, and X are

activated under the influence of vitamin K and are considered vitamin K dependant.

The absence of normal intestinal flora needed to synthesize vitamin K in the newborn gut results in low levels of vitamin K.

Although newborn bleeding problems are rare, an injection of vitamin K (AquaMEPHYTON) is given prophylactically on admission to the nursery to combat potential clinical bleeding problems.

Gastrointestinal Adaptations Gastrointestinal Adaptations (pg.697-698)(pg.697-698)

By 36 to 38 weeks gestation, the gastrointestinal tract is adequately mature: 1) enzymatic activity present, 2) able to transport nutrients.

Lactose is the primary carbohydrate in the breastfeeding newborn and is usually easily digested and well absorbed.

By birth the newborn has experienced swallowing, gastric emptying, and intestinal propulsion.

The newborn’s stomach has a capacity of 50 to 60 mls. The cardiac sphincter is immature, as is neural control of

the stomach, so some regurgitation may be noted. Term newborns normally pass meconium (dark green to

black) within 8 to 24 hours of life and almost always by 48 hrs.

Transitional (thinner brown to green) stools are passed for the next day or two then they become completely fecal.

The stools of the breastfed infant are yellow, more liquid , and more frequent than formulas fed infants.

Urinary Adaptations Urinary Adaptations (pg. 698-699)(pg. 698-699)

Full term newborns are less able than adults to concentrate urine (reabsorb water back into the blood) due to shorter and narrower tubules.

Concentrating and dilutional limitations of renal function are important considerations in monitoring fluid therapy to avoid dehydration and overhydration.

Many newborns void immediately after birth. A newborn who has not voided by 48 hours should be assessed for inadequate fluid intake, bladder distention, restlessness, and symptoms of pain.

The first two days of birth the newborn voids two to six times a day, thereafter 5 to 25 times a day.

First voiding frequently appears cloudy, occasionally pink “brick dust” may be observed.

Pseudomenstruation (related to the withdrawal of maternal hormones) may be seen as blood on the newborn female’s diaper.

Immunologic AdaptationsImmunologic Adaptations

Limitations in the newborn’s inflammatory response results in failure to recognize, localize, and destroy invasive bacteria.

The signs and symptoms of infection are often subtle and nonspecific in the newborn.

The newborn has a poor hypothalamic response to pyrenogens, therefore fever is not a reliable indicator of infection.

Hypothermia is a more reliable indicator of infection in the newborn.

Passive acquired immunity : transfer of antibodies (IgG) from the mother to the fetus in utero.

Newborns have maternally induced immunity to tetanus, diphtheria, smallpox, measles, mumps, poliomyelitis, and a variety of other bacterial and viral disease.

Immunity against common viral infections such as measles may last 4 to 8 months; whereas immunity to certain bacteria may disappear within 4 to 8 weeks.

Colostrum, the forerunner of breast milk is very high in immunoglobulin IgA which may provide some passive immunity to the breastfeeding newborn.

Neurological and Neurological and Sensory/Perceptual Sensory/Perceptual FunctioningFunctioning

Intrauterine factors influencing newborn behavior: maternal nutrition and extrauterine environment (noise).

Characteristics of newborn neurological function: partially flexed extremities, eye movements are observable, may fixate on faces, or geometric objects, cry is lusty and vigorous, knee jerk is brisk, plantar flexion is present.

Periods of reactivity: First Period of reactivity, Period of Inactivity to sleep phase, Second period of reactivity.

Behavioral states of the newborn: Sleep states and Alert states.

Behavioral and sensory capacities of the newborn: Habituation, Orientation, Self-quieting ability, auditory capacity, olfactory capacity, taste and sucking, and tactile capacity.

Nursing Assessment of the Nursing Assessment of the NewbornNewborn

Assessment of the newborn is a continuous process used to evaluate development and adjustments to extrauterine life.

Assess immediately after birth: r/o resuscitation and allow bonding.

Assessment within 1 to 4 hours after birth: progress of newborns adaptation, gestational age, ongoing assessment of high-risk problems.

Assessment procedures in the first 24 hours or prior to discharge.

Nursing Assessment of the Nursing Assessment of the NewbornNewborn

Estimation of Gestational AgeEstimation of Gestational Age

Must be established in the first four hours of birth.

Ballard and Dubowitz.Include external physical characteristics

and neurological or neuromuscular development evaluations.

Some maternal conditions may affect certain gestational age assessment components. (PIH, Diabetes, analgesia).

Estimation of Gestational Age Estimation of Gestational Age (pg 707- 714)(pg 707- 714)PHYSICAL CHARACTERISTICS:Resting posture: assessed undisturbed on a flat

surfaceSkin: thin, opaque, peelingLanugo: decreases as gestational age increasesSole (plantar) creases: increase with gestational ageAreola and breast bud tissue: increases with age.Ear form and cartilage distribution: Cartilage gives

shape. Pinna is firm at term.Male genitals: Size of scrotal sac, the presence of

rugae, and descent of the testicles.Female genitals: size of labia majora and minora.Vernix: None in the post term infant. More seen with

prematurity.Hair: Preterm patchy, term silky.Skull firmness: increases as the fetus matures.Nails: long may be a sign of postmaturity.

Estimation of Gestational Age Estimation of Gestational Age (pg 707- 714)(pg 707- 714)NEUROMUSCULAR CHARACTERISTICS

The square window sign: elicited by flexing the baby’s hand toward the ventral forearm until resistance is felt (the angle formed at the wrist is measured).

Recoil: test of flexion development. Lower extremities are tested first.

Popliteal angle: degree of knee flexion, angle is increased in the preterm infant.

Scarf sign: elicited by placing the newborn in supine position and drawing an arm across the chest toward the newborn’s opposite shoulder. The location of the elbow is noted in relation to the midline of the chest.

Heel to ear extension: with advancing age greater resistance an smaller angle is noted.

Ankle dorsiflexion: flexing the ankle on the shin. Head lag: Full term may support head momentarily. Ventral suspension: position of the head, back, and degree

of flexion in the arms and legs are noted. Major reflexesevaluated.

Physical AssessmentPhysical Assessment

General appearance: Head larger than body

Weight and measurements: average birth weight is 7lbs, 8oz, average length is 18 -22 inches.

Temperature: assessed by axillary method after initial rectal temp. 97.7 to 98.6.

Skin characteristics: (719) Head: 12.5 to 14.5 inches,

approximately 2 cms larger than the chest circumference. Cephalohemotoma, caput succedenum

Face: blue or dark. Chemical conjunctivits, subconjunctival hemorrhages. Epsteins pearls or thrush.

Neck looks short, creased with skin folds. Fractured clavicle.

Chest:engorged breasts Cry: strong and of medium

pitch Respiration: 30 to 60

respiratory rate Heart: 120 -160 HR Abdomen: appears prominent Umbilical cord: white and

gelatinous, bleeding is uncommon, umbilical cord hernia abnormal.

Genitals: may have vaginal discharge in the first week of life (white, thick)

Anus: check for imperforate anus or atresia (done visually)

Extremities: check for abnormalities, polydactyly, Erb’s palsy.

Skin CharacteristicsSkin Characteristics

Acrocyanosis Mottling Harlequin Sign Jaundice Erythema Toxicum Milia Skin turgor Vernix caseosa Forceps or Vacuum extractor marks Telangiectatic Nevi (stork bites) Mongolian spots Nevus flammeus (port wine stain) Nevus Vasculosis (strawberry mark)

Assessment of Neurological Assessment of Neurological Status Status

Tonic neck reflexGrasping reflexMoro reflexRooting reflexSucking reflexBabinski reflexTrunk incurvation (Galant reflex)

Newborn Behavioral Newborn Behavioral AssessmentAssessment

HabituationOrientation to inanimate and animate

visual and auditory assessment stimuli.Motor activityVariations in quiet alert states, state

changes and color changes.Self quieting activity assessment on how

often and how quickly newborns quiet themselves.

Cuddliness or social behaviors.

Nursing DiagnosisRisk for ineffective breathing patternAltered nutrition: less than body

requirementsAltered urinary eliminationRisk for infectionKnowledge deficitAltered family processes

Nursing Plan and Nursing Plan and Implementation Implementation (pg. 762-772)(pg. 762-772)

Maintenance of cardiopulmonary functionMaintenance of a neutral thermal

environmentPromotion of adequate hydration and

nutritionPromotion of skin integrityPrevention of complications and

preventing safetyEnhancing parent-newborn attachment

Maintenance of Cardiopulmonary Maintenance of Cardiopulmonary FunctionFunction

Assess vital signs every 6 to 8 hrs or more depending on the newborn’s status.

“Back to Sleep” , side lying to prevent aspiration and facilitate drainage of mucus.

Keep bulb syringe readily available.Vigorous fingertip stroking of the spine

frequently stimulates respiratory activity.Cardiac/respiratory monitor may be required.At-risk indicators: pallor, cyanosis, ruddy

color, and apnea.

Maintain the newborn’s temperature within the normal range.

Make certain the infant is dressed and bundled appropriately. Small caps may be used for the LBW or premature infant.

Newborns use calories for warmth rather than growth.

Chilling increases the affinity of serum albumin for bilirubin.

Chilling increases oxygen use and may cause respiratory distress.

Overheating will increase respiratory rate and activity in an attempt to cool the body, also increasing insensible fluid loss.

Weigh at the same time each day.Weight loss of up to 10% is considered normal during

the first week of life.Birth weight should be regained by the 2nd week of

life.The nurse records voiding and stooling patterns. The first void should occur within the first 24 hours

and passage of stool in the first 48 hours.Assess for abdominal distention, bowel sounds,

hydration, fluid intake, voiding pattern, and temperature stability.

Excessive handling may cause an increase in the newborn’s metabolic rate, calorie use and fatigue.

Promotion of Skin Integrity Promotion of Skin Integrity (pg (pg 764-765)764-765)

Bathing is important for health, appearance, and infect5ion control in the nursery.

Ongoing skin care includes cleansing of the buttocks and perineal area with water and a mild soap with diaper changes.

Assess the umbilical cord for signs of bleeding or infection: 1) apply triple dye on admission to nursery and 2) alcohol after each diaper change.

Cord care with each diaper change.Eye and skin care related to phototherapy.Skin care following circumcision.

Prevention of Complications and Promoting Prevention of Complications and Promoting

SafetySafety (pg 765-767)(pg 765-767)

Pallor may be an early sign of hemorrhage.Circumcision is assessed for signs of hemorrhage and

infection. Initial scrub for 2-3 minutes when direct contact with

the newborn is anticipated.Handwashing between each client contact and

contact with floor, face, or any soiled surface.Encourage parents to wash hands prior to holding the

infant and wear a gown over street clothes.Teach parents to limit visitors who may have a

communicable disease.Check namebands with each encounter with the

parents. Instruct clients in security measures in place to

prevent infant abduction.

Enhancing Parent-Newborn AttachmentEnhancing Parent-Newborn Attachment

(pg. 767)(pg. 767)

Involve the entire family in newborn careInfant massage may be encouragedIncrease skin to skin contactRead to or play music for the newbornEncourage cuddling and talking to the

infant

Discharge Planning and Discharge Planning and Preparation Preparation (pg. 767-773)(pg. 767-773)

Parent teachingGeneral instructions for newborn careNasal and oral suctioningWrapping the newbornSleep and activitySafety considerationsNewborn screening and immunization

Program

Community-Based Nursing Community-Based Nursing Care for the Newborn Care for the Newborn (pg. 773-776)(pg. 773-776)

The family should have access to the birthing unit and physician phone numbers.

The client should be made aware of follow-up programs such as PRS, early intervention and high-risk referral.

Referral to the public health department.Hospital phone follow-up.

Thanks for attentionThanks for attention

Lecture ten

Health & Medicine

Transcript of Lecture ten