[ ] Newborn

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Transcript [ ] Newborn

Nursing Care of
the Newborn
Immediate Baby Care
Airway - Clean mouth and nose
Thermoregulation - Warmth
Gross assessment
Bonding – safety against infection
Fetus to Newborn:
Respiratory Changes
• Initiation of respirations
• Chemical
surfactant reduces surface tension 34-36wks
decrease in oxygen concentration
• Thermal
sudden chilling of moist infant
• Mechanical
compression of fetal chest during delivery
normal handling
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
• Evaluation – rate 30-60, no distress
Fetus to Newborn:
Neurological adaptation:
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
Nonshivering thermogenesis
The distribution of brown adipose tissue (brown fat)
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
Increased oxygen need
Decreased surfactant production
Respiratory distress
Metabolic acidosis
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
• Assess for anomalies
• Head – anterior fontanelle closes 12-18 mo
posterior fontanelle closes 2-3 months
• Neck and clavicles
fracture of clavicle – large infant, lump, tenderness,
crepitus, decreased movement
• Cord
• Extremities
flexed and resist extension
assess fractures, clubfeet
vertebral column
Not crossing
suture line
Cephalhematoma is a collection of blood between the
surface of a cranial bone and the periosteal membrane.
suture line
Caput succedaneum is a collection of fluid (serum)
under the scalp.
A, Congenitally dislocated right hip
B, Barlow’s (dislocation) maneuver.
C, Ortolani’s maneuver
Weight – loss of 10% normal
Head and chest circumference
Normal VS
temp 97.7-99.5F axillary
apical pulse 120-160bpm
respirations 30-60/min
head larger
A, Measuring the head circumference of the newborn.
B, Measuring the chest circumference of the newborn.
Assessment of Cardio-respiratory
• History
• Airway
• Assess
q 30minX2hrs
breath sounds - moisture for 1-2 hrs
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
Axillary temperature measurement. The thermometer
should remain in place for 3 minutes.
Assessment of Hepatic Function
• Blood Glucose
Signs of hypoglycemia
respiratory difficulties
drop in temp
poor sucking
Tx- feed infant if glucose below 40-45 mg/dl
• Bilirubin
physiologic jaundice peaks 2-4 days of life
early onset may be pathologic
Hemolysis of excessive erythrocytes
Short red blood cell life
Liver immaturity
Lack of intestinal flora
Delayed feeding
Trauma resulting in bruising or
• Cold stress or asphyxia
Potential sites for heel sticks. Avoid shaded areas to
prevent injury to arteries and nerves in the foot.
Assessment of Neuro System
• Reflexes
• Babinski
Tonic neck reflex “fencing”
• Cry
• Infant response to soothing
Assessment of Gastrointestinal
Initial feeding
meconium – within 12-48 hours of birth
dark greenish black
breastfed – soft, seedy, mustard yellow
formula-fed – solid, pale yellow
Assessment of Genitourinary
Umbilical cord vessels
Urine – within 24 hours of birth
Voiding – 6 to 10 times a day after 2 days
female – edema normal, majora covers
minora, pseudomenstruation
male – pendulous scrotum, descended
testes by 36 wks gest., placement of meatus
Assessment of Integumentary System
Vernix – white covering
Lanugo – fine hair
Erythema toxicum – red blotchy with white
Mongolian spots – sacral area
Telangiectatic nevus “stork Bite” - blanches
Nevus flammeus “port wine stain”
- no blanching
Nevus vasculosus “strawberry hemangioma”
usually on head, disappears by school age
Port Wine Stain
Erythema toxicum
Fetus to Newborn:
Psychosocial adaptation
• Periods of Reactivity
active – 30-60 min
sleep – 2-4 hours
alert – 4-6 hours
• Behavioral States
quiet sleep
active sleep
drowsy state
quiet alert – best for bonding
active alert
crying state
Gestational Age Assessment
Assessment tool – Dubowitz, Ballard
Weeks from conception to birth
Used to identify high risk infants
Neuromuscular characteristics
Posture – more flexion
Square window – more pliable
Arm recoil - active
Popliteal angle - less
Scarf Sign – less crossing
Heel to ear – most resistance
Newborn maturity rating and classification
Gestational Age Assessment
• Physical characteristics
Skin- deep cracking, no vessels seen, post-leathery
Lanugo – less as age
Plantar creases – more with age
Breasts – larger areola
Eyes and Ears – stiff with instant recoil
Genitals – deep rugae, pendulous, covers minora
• Gestational Age & Size – may not correspond
small SGA <10% for weight
large LGA >90% for weight
appropriate AGA between 10-90%
Classification of newborns based on maturity and
intrauterine growth.
Classification of newborns by birth weight and
gestational age.
Ongoing Assessment and Care
Cord care
Cleansing diaper area
Assisting with feedings
Protecting infant
identifying infant
preventing infant abduction – alert to unusual
preventing infection
• Review beige cue cards in center of book for teach
One method of swaddling a baby.
Common Breastfeeding Positions
Infant in good breastfeeding position : tummy-to-tummy,
with ear, shoulder, and hip aligned.
LATCH was created to provide a systematic method for
breastfeeding assessment and charting.
Infant teaching checklist is completed by the time of
• Most common neonatal surgical procedure
• Reasons for choosing
• Reasons for rejecting – hypospadias,
• Pain relief
• Methods
• Nursing care
Circumcision using a circumcision clamp.
Circumcision using the Plastibell.
Other Concerns
• Immunizations
Hepatitis B – begin vaccine at birth
• Screening tests
Phenylketonuria – by law
Further Assessments
• Complications r/t poorly functioning placenta
respiratory problems
• Complications r/t LGA infant
birth injury due to size
Shoulder Dystocia
• Risk factors
diabetes; macrosomic infant
prolonged second stage
previous shoulder dystocia
• Morbidity- fracture of clavicle or humerus,
brachial plexus injury
• Management – generous episiotomy
Neonatal morbidity by birth weight and gestational age.
High Risk Infants
Preterm – before 38 weeks gestation
IUGR – full term but failed to grow normally
Infants of Diabetic mothers
Post mature babies
Drug exposed
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
• 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 nipple
resp <60/m, rooting, sucking, gag reflex
Measuring gavage tube length.
Auscultation for placement of gavage tube.
Complications of Preterm Infants
• Respiratory Distress Syndrome -RDS
• Bronchopulmonary dysplasia – chronic lung
• Periventricular-Intraventricular Hemorrhage
30% 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
• 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- central
grunting- expiratory
seesaw respirations
Evaluation of respiratory status using the
Silverman-Andersen index.
Therapeutic Management of RDS
Surfactant replacement therapy
Installed into the infant’s trachea
Improvement in breathing occurs in minutes
Doses repeated prn
Other treatment
mechanical ventilation
correction of acidosis
IV fluids
Post Term Infants
Born after 42 weeks
Increase risk of meconium aspiration
Loss of subcutaneous fat
Skin –peeling, vernix sparse, lanugo
absent, fingernails long
• Focus on prevention – “due date”
• Attention to thermoregulation & feeding
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
• Pathologic jaundice – occurs within first 24
• 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
Conjugation of bilirubin in the newborn.
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
• 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
• 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
• 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
• 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
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
• Use of alcohol or illicit drugs
• Tobacco and alcohol are most frequent
• Prenatal alcohol exposure is the most
commons preventable cause of mental
• Signs of maternal addition: wt loss, mood
swings, constricted pupils, poor hygiene,
anorexia, no prenatal care
Drug Withdrawal in Infants
• Signs of drug exposure
opiates – 48-72 hours
cocaine – 2-3 days
alcohol – 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
• Feeding – more difficult may need to
• Rest – keep stimulation to minimum,
reduce noise and lights, calm, slow
• Promote bonding
• Teach measures for frantic crying: rock,
coo, dark room, avoid stimulation
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
• Screening before 24-48 hours needs to be
repeated for accuracy
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