Transcript Newborn Assessment and Care (chapter twelve) power

The Normal Newborn
ASSESSMENT AND CARE
Three transition phases
 Phase One: the first hour
 Phase Two: from one to three hours
 Phase Three: from two to 12 hours
Priorities in first hour
 Cardiovascular assessment and support
 Thermoregulation
 Assessment and support of blood glucose
 Identification
 Observing urinary/meconium passage
 Observing for major anomalies and for apparent
gestational age concerns
APGAR ASSESSMENT
 One and five minutes
 Meant to identify the need for neonatal resucitation
APGAR SCORE
APGAR SCORE
Criteria
0
1
2
Color
Blue or pale
Acro-cyanotic
CompletelyPink
Heart Rate
Absent
Slow
(< 100/min)
>100/min
Reflex irritability
No response
Grimace
Cough, sneeze,
cry
Muscle tone
Limp
Some flexion
Active motion
Respirations
Absent
Slow, irregular
Good, crying
Additional signs of respiratory distress
 Persistant cyanosis
 Grunting respirations
 Flaring of the nostrils
 Retractions
 Respiratory rate >60
 Heart rate >160 or <110
Maintaining thermoregulation
 Referred to as maintaining a neutral thermal
environment
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Heat loss is minimal
Oxygen consumption needs are at their lowest
 Hypothermia can cause
 Hypoglycemia
 Increased oxygen needs
Four mechanisms of heat loss
and corresponding interventions
 Evaporation
 Dry infant immediately
 Conduction
 Place on mothers body skin to skin
 Convection
 Cover with a blanket, wear a cap
 Radiation
 Keep away from cold windows and cold objects
Mechanisms of heat loss
Vital Sign Normals
 97.7-98.6 F (36.5-37 C)
 110-160
 A soundly sleeping baby can go to 80 bpm
 A crying baby may be as high as 180
 30-60
Voids and Stools
 Document from the moment of birth
 Urination sometimes missed in early minutes
 Generally expect both within the first 24 hours
 One really wet diaper per day of age until milk is
fully in.
Observation for Gestational Age
 Thorough assessment with Ballard Scale done later
 A quick assessment is done in the delivery room
 This enables infants earlier admission to the nursery
and anticipatory intervention to the problems of pre
and post term infants
Quick Assessment of Gestational Age
 Skin
 Vernix
 Hair
 Ears
 Breast tissue
 Genitalia
 Sole Creases
 Resting Posture
Cracked Skin
Abundant Lanugo
Ear of a preterm infant
Areola and increased lanugo
Sole creases
Female genitalia, very preterm
Preterm and Term Genitalia
Male Genitalia
Comparison of resting posture
Preterm and Term Male Genitalia
Hypoglycemia
 Criteria vary from source to source
 LPN book says <40
 RN book says <36 but a threapuetic objective of 45
mg/dl or greater
 The brain is dependent on a steady supply of glucose
for its metabolism
Infants at Increased Risk for Hypoglycemia
 Preterm/postterm
 Infants of diabetic mothers
 Large for gestational age
 Small for gestational age
 Infants with Intrauterine growth retardation
 Asphyxiated infants
 Infants who are cold stressed
 Infants whose Moms took ritodrine or tgerbutaline
to stop preterm labor
Symptoms of Hypoglycemia
 Jitteriness
 Poor suck
 Poor muscle tone
 Feeding difficulties
 Sweating
 High pitched cry
 Respiratory difficulty
 Weak cry
 Apnea
 Lethargy
 Low temperature
 Seizures
Hypoglycemia protocol
 Low risk infants have a serum glucose drawn only if
symptomatic
 High risk infants will have one per a hospital
protocol
 Protocol typically at birth and q 1 hour x 3
Routine Medications
 Erythromycin Eye
Ointment
 Aquamephyton
(vitamin K)
 First Hepatitis B
vaccine
 HBIG if Mother is
Hep B surface
antigen positive
Physical Characteristics
DURING PHASES TWO AND THREE
Nervous System: Reflexes
 Head lag
 Rooting reflex
 Moro reflex
 Suck
 Rooting
 Hand and foot grasp
 Tonic Neck reflex
 Babinski
 Dancing reflex
 Trunk incurvation
 Magnet reflex
 Observe for symmetry
Head Lag
Moro Reflex
Tonic Neck Reflex
Dancing Reflex
Suck Reflex
Hand Grasp
Foot Grasp
Head
 Head circumference
 Molding
 Caput succedaneum
 Cephalohematoma
 Fontanelles
 Anterior closes between 12-18 months
 Posterior closes by the end of the 2nd month
Molding
Cehpalhematoma
Caput Succedaneum and Cephalhematoma
Eyes
 Eye placement
 Epicanthal folds
 Blink reflex
 Discharge
 Pupil reaction
 Follows to midline
Hearing
 Check overall response to sudden sound
 Moro reflex
 Check for placement of ears
 Low set ears may indicate a congenital anomaly
 Most infants receive hearing screening within the
first week of life
Respiratory and Cardiovascular
 Ongoing assessment of cardio respiratory status that
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has occurred since birth
More thorough heart assessment
Murmur may be present until fetal openings have
completely closed however they must be carefully
verified by pediatrician
Femoral and brachial pulses
Abdominal breathing; nose breathers
Femoral Pulses
Brachial Pulses
Assessment of Respiratory Status
Musculoskeletal
 Symmetry!!
 Five finger and five toes!!!
 Clavicles
 Movement of arms
 Hips for developmental hip dysplasia
 Lower legs/feet for “club foot”
 Back: curvatures, cysts or dimples
Hip Check
Hip Check Skin Folds
GenitoUrinary
 Male or female
 Male
 Testes descended
 Proper placement of meatus
 Female
 Teach parents about pseudomenstruation
 Always watch for and record voids!!!
Gastrointestinal
 Passage of meconium
 Placement and patency of anus
 Abdomen should be soft and non tender
 Round but not distended
 Bowel sounds are present after first hour of birth
 Umbilical cord inspection
Skin, many normal findings
 Acrocyanosis
 Desquamation
 Epstein’s Pearls
 Erythema toxicum
 Harlequin Color
 Milia
 Mongolian Spots
 Port Wine Stains *
The Normal Newborn
CARE MEASURES FOR THE
NORMAL NEWBORN PLUS A
LITTLE MORE.
Jaundice
 Yellow coloring of an infants skin
 Common and is caused by the natural breakdown of
RBCs in the infant after birth
 Is never considered normal in the first 24 hours.
Physiologic Jaundice
 Most jaundice in newborns is physiologic
 It peaks between 48-72 hours
 Usually disappears within a week
 Usually benign
 Can become elevated to a point of concern for the
baby
Significance of Jaundice
 Bilirubin is toxic to the brain.
 Bilirubin is prevented from entering the brain by
blood brain barrier under normal circumstances.
 However the blood brain barrier isn’t well developed
in the newborn. Unconjugated bilirubin (lipid
soluble) could cross to the newborn and would cause
encephalopathy. (Kernicterus)
Physiologic Jaundice
 Infants have extra RBCs due to fetal life
 They need to be broken down by the body
 Bilirubin is a component of the degradation of the
RBCs.
 The liver is immature and does not conjugate and get
rid of the bilirubin fast enough.
More data on Physiologic Jaundice
 RBC/Hgb level is higher than required
 Neonatal RBC: 4.8-7.1 Infant: 4.2-5.2
 Neonatal Hbg 14-24 Infant 11-17
 Cells containing fetal hemoglobin have a shorter life
span
Bilirubin Nomogram
Phototherapy Nomogram
Other factors that will exacerbate physiologic
jaundice
 Drugs
 Hypoglycemia
 Bruises
 Hypothermia
 Caput
 Poor feeding
 Cephalohematoma
 Delayed passage
 Fetal hypoxia
meconium
 Trisomy 21
 Polycythemia
Care to prevent hyperbilirubinemia
 Early feeding
 Frequent feeding
 Neutral thermal environment
 Prevention of hypoglycemia
 Prevention of hypoxia
Causes of Pathologic Jaundice
 Excessive hemolysis
 Rh incompatibility
 ABO incompatibility
 G6PD defficiency
 Infection
 Metabolic/endocrine abnormalities
 Delayed defecation/intestinal obstruction
 Liver/biliary disease
 Spleen pathology
 Polycythemia
PHOTOTHERAPY
Care of Infant on Phototherapy
 Risk of injury to eyes
 Risk of injury to gonads
 Risk of impaired skin integrity
 Risk for fluid volume deficiency
 Risk for hyperthermai or hypothermia
 Risk of neurological injury
 Imbalance nutrition
 Parental anxiety
Exchange Transfusion
Isn’t he lovely?
Other Newborn Care issues
 Bulb suctioning: RN 731 LPN 286
 Umb cord care: RN 733 LPN 219
 Heel Sticks: RN 741-43 LPN219
 Circumcision: RN 755 See patient teaching page 757
LPN 290