N106 Nursing Care of the Newborn Immediate Baby Care

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

• 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 membranes

• Evaluation – rate 30-60, no distress

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

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

• Hypoglycemia

• Metabolic acidosis

• Jaundice

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

• 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 hips vertebral column

Measurements

• Weight – loss of 10% normal

• Length

• Head and chest circumference

• Normal VS temp 97.7-99.5F axillary apical pulse 120-160bpm respirations 30-60/min

Assessment of Cardio-respiratory Status

• History

• Airway

• Assess rate q 30minX2hrs symmetry 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

Assessment of Hepatic Function

• Blood Glucose Signs of hypoglycemia jitteriness 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

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

Assessment of Neuro System

• Reflexes

• Babinski Grasp Moro Rooting Stepping Sucking Tonic neck reflex “fencing”

• Cry

• Infant response to soothing

Assessment of Gastrointestinal System

• Mouth

• Suck

• Abdomen

• Initial feeding

• Stools meconium – within 12-48 hours of birth dark greenish black breastfed – soft, seedy, mustard yellow formula-fed – solid, pale yellow

Assessment of Genitourinary System

• Umbilical cord vessels

• Urine – within 24 hours of birth

• Voiding – 6 to 10 times a day after 2 days

• Genitalia 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

• Milia

• Erythema toxicum – red blotchy with white

• Birthmarks 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

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

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%

Ongoing Assessment and Care

• Bathing

• 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.

Circumcision

• Most common neonatal surgical procedure

• Reasons for choosing

• Reasons for rejecting – hypospadias, epispadias

• Pain relief

• Methods

• Nursing care

Other Concerns

• Immunizations Hepatitis B – begin vaccine at birth

• Screening tests Hearing Phenylketonuria – by law

Further Assessments

• Complications r/t poorly functioning placenta hypoglycemia hypothermia respiratory problems

• Complications r/t LGA infant hypoglycemia birth injury due to size

Shoulder Dystocia

• Risk factors diabetes; macrosomic infant obesity prolonged second stage previous shoulder dystocia

• Morbidity- fracture of clavicle or humerus, brachial plexus injury

• Management – generous episiotomy

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

• 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

Complications of Preterm Infants

• Respiratory Distress Syndrome -RDS

• Bronchopulmonary dysplasia – chronic lung disease

• 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 asymmetry

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

• 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

• 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

• 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 – 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

• 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

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

• 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 retardation

• 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 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

• 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

• 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