Care Of The Newborn

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Care Of The Newborn

  1. 2. The 1 st 24 hours of Life The first 24 hours of life is a very significant and a highly vulnerable time due to critical transition from intrauterine to extrauterine life
  2. 3. Immediate Care of the Newborn <ul><li>A irway </li></ul><ul><li>B reathing </li></ul><ul><li>T emperature </li></ul>
  3. 4. Airway & Breathing <ul><li>Suction gently & quickly using bulb syringe or suction catheter </li></ul><ul><li>Starts in the mouth then, the nose to prevent aspiration </li></ul>051104 Neonatal Care
  4. 5. 051104 Neonatal Care
  5. 6. Airway & Breathing <ul><li>Stimulate crying by rubbing </li></ul><ul><li>Position properly- side lying / modified t-berg </li></ul><ul><li>Provide oxygen when necessary </li></ul>051104 Neonatal Care
  6. 7. Temperature <ul><li>Dry immediately </li></ul><ul><li>Place in infant warmer or use droplight </li></ul><ul><li>Wrap warmly </li></ul>051104 Neonatal Care
  7. 8. APGAR Scoring <ul><li>Standardized evaluation of the newborn </li></ul><ul><li>Perform 1 minute and 5 minutes after birth </li></ul><ul><li>Involves (5) indicators: </li></ul><ul><ul><li>Activity </li></ul></ul><ul><ul><li>Pulse </li></ul></ul><ul><ul><li>Grimace </li></ul></ul><ul><ul><li>Appearance </li></ul></ul><ul><ul><li>Respirations </li></ul></ul>051104 Neonatal Care
  8. 9. Care of the Newborn in the Nursery
  9. 10. Components <ul><li>A nthropometric Measurements </li></ul><ul><li>B athing – Oil bath/ warm water bath </li></ul><ul><li>C ord Care </li></ul><ul><li>D ressing/ Wrapping - mummified </li></ul><ul><li>E ye prophylaxis – Crede’s </li></ul><ul><li>F oot printing / Identification </li></ul><ul><li>G et APGAR score – 1 & 5 mins </li></ul><ul><li>H R, RR, Temp, BP </li></ul><ul><li>I njection of Vitamin K </li></ul>051104 Neonatal Care
  10. 11. Components <ul><li>Proper identification –tag/bracelet </li></ul><ul><li>Oil bath/ Warm water bath </li></ul><ul><li>Cord Care/ Dressing </li></ul><ul><li>Measurements </li></ul><ul><ul><li>Weight </li></ul></ul><ul><ul><li>Anthropometric measurements </li></ul></ul>051104 Neonatal Care
  11. 12. <ul><li>Crede’s Prophylaxis </li></ul><ul><li>Vitamin K Administration </li></ul><ul><li>Foot printing/ marking </li></ul><ul><li>Vital signs </li></ul><ul><li>Dressing/ wrapping </li></ul>051104 Neonatal Care
  12. 13. Proper Identification <ul><li>After delivery, gender should be determined </li></ul><ul><li>Pertinent records should be completed including the ID bracelet </li></ul><ul><li>Before transferring to nursery, ID tag should be applied. </li></ul>051104 Neonatal Care
  13. 14. Bathing <ul><li>Oil bath or complete warm water bath </li></ul><ul><li>From cleanest to dirties part </li></ul><ul><li>DO NOT remove vernix caseosa vigorously </li></ul>051104 Neonatal Care
  14. 15. Cord Care 051104 Neonatal Care
  15. 16. Weight/ Anthropometric Measurements 051104 Neonatal Care
  16. 17. 051104 Neonatal Care
  17. 18. Crede’s Prophylaxis 051104 Neonatal Care
  18. 19. Vitamin K Administration 051104 Neonatal Care
  19. 20. Foot Printing 051104 Neonatal Care
  20. 21. Vital Signs 051104 Neonatal Care
  21. 22. Dressing/ Wrapping <ul><li>“ Mummy” </li></ul><ul><li>Wrap in warm blanket </li></ul><ul><li>Cover head with stockinette cap </li></ul>051104 Neonatal Care
  22. 23. Daily Care <ul><li>Nutrition/ Feeding </li></ul><ul><li>Elimination </li></ul><ul><li>Weight </li></ul><ul><li>Bathing & Hygiene/ Grooming </li></ul><ul><li>Obtain vital signs </li></ul><ul><li>Rooming-in </li></ul><ul><li>Note for any abnormalities </li></ul>051104 Neonatal Care
  23. 24. NEWBORN ASSESSMENT Assessment of the newborn is essential to ensure a successful transition
  24. 25. Major Time Frames <ul><li>Immediately after birth </li></ul><ul><li>Within the 1 st 4 hours after birth </li></ul><ul><li>Prior to discharge </li></ul>051104 Neonatal Care
  25. 26. APGAR Scoring System <ul><li>A ctivity/ Muscle Tone </li></ul><ul><li>P ulse/ Heart Rate </li></ul><ul><li>G rimace/ Reflex Irritability/ Responsiveness </li></ul><ul><li>A ppearance/ Skin Color </li></ul><ul><li>R espiration/ Breathing </li></ul>051104 Neonatal Care 1 2 3 4 5
  26. 27. 051104 Neonatal Care APGAR Scoring System INDICATORS 2 1 0 Activity Active, spontaneous Some flexion of extremities No movement (flaccid, limp) Pulse >100 bpm < 100 bpm Absent Grimace Pulls away, sneezes, coughs Facial grimace only No response with stimulation Appearance Completely pink Acrocyanosis Bluish-gray or pale all over Respiration Good vigorous cry Slow, irregular Weak cry Absent
  27. 28. 051104 Neonatal Care Score Interpretation Score Interpretation Nursing Interventions 7 to 10 Well baby Rarely needs resuscitation 4 to 6 At risk INFANT NEEDS INTENSIVE CARE Requires resuscitation Suction Dry immediately Ventilate until stable Careful observation 0 to 3 Sick baby PROGNOSIS FOR NB IS GRAVE Intensive resuscitation ET/ Ambu bag Ventilate with 100% O 2 CPR Maintain body temperature Parental support
  28. 29. General Guidelines <ul><li>Keep warm during examination </li></ul><ul><li>From general to specific </li></ul><ul><li>Least disturbing first </li></ul><ul><li>Document ALL abnormal findings & provide nursing care </li></ul>051104 Neonatal Care
  29. 30. GENERAL APPEARANCE
  30. 31. Posture <ul><li>Full term: </li></ul><ul><ul><li>Symmetric </li></ul></ul><ul><ul><li>Face turned to side </li></ul></ul><ul><ul><li>Flexed extremities </li></ul></ul><ul><ul><li>Hands tightly fisted with thumb covered by the fingers </li></ul></ul>051104 Neonatal Care
  31. 32. Special Concerns <ul><li>Asymmetric </li></ul><ul><ul><li>Fractured clavicle or humerus </li></ul></ul><ul><ul><li>Nerve injuries (Erb-Duchenne’s Paralysis) </li></ul></ul><ul><li>Breech Presentation </li></ul><ul><ul><li>Knees and legs straightened or in FROG position </li></ul></ul>051104 Neonatal Care
  32. 33. VITAL SIGNS
  33. 34. TEMPERATURE <ul><li>Site: Axillary NOT Rectal </li></ul><ul><li>Duration: 3 mins </li></ul><ul><li>Normal Range: 36.5 – 37.6 C </li></ul><ul><li>Stabilizes within 8-12 hrs </li></ul><ul><li>Monitor q 30 mins until stable for 2 hrs then q 8 hrs </li></ul>051104 Neonatal Care
  34. 35. Heat Loss Mechanisms <ul><li>Convection – the flow of heat from the body surface to cooler surrounding air </li></ul><ul><ul><li>Eliminating drafts such as windows or air con, reduces convection </li></ul></ul><ul><li>Conduction – the transfer of body heat to a cooler solid object in contact with the baby </li></ul><ul><ul><li>Covering surfaces with a warmed blanket or towel helps minimize conduction heat loss </li></ul></ul>051104 Neonatal Care
  35. 36. <ul><li>Radiation – the transfer of heat to a cooler object not in contact with the baby </li></ul><ul><ul><li>Cold window surface or air con; moving as far from the cold surface, reduces heat loss </li></ul></ul><ul><li>Evaporation – loss of heat through conversion of a liquid to a vapor </li></ul><ul><ul><li>From amniotic fluid; NB should be dried immediately </li></ul></ul>051104 Neonatal Care
  36. 37. Nursing Considerations <ul><li>Keep dry and well-wrapped </li></ul><ul><li>Keep away from cold objects or outside walls </li></ul><ul><li>Perform procedures in warm, padded surface </li></ul><ul><li>Keep room temperature warm </li></ul>051104 Neonatal Care
  37. 38. Pulse <ul><li>Awake: 120 – 160 bpm—120 – 140 bpm </li></ul><ul><li>Asleep: 90-110 bpm </li></ul><ul><li>Crying: 180 bpm </li></ul><ul><li>Rhythm: irregular, immaturity of cardiac regulatory center in the medulla </li></ul><ul><li>Duration: 1 full minute, not crying </li></ul><ul><li>Site: Apical </li></ul>051104 Neonatal Care
  38. 39. Nursing Considerations <ul><li>Keep warm </li></ul><ul><li>Take HR for 1 full minute </li></ul><ul><li>Listen for murmurs </li></ul><ul><li>Palpate peripheral pulses </li></ul><ul><li>Assess for cyanosis </li></ul><ul><li>Observe for CP distress </li></ul>051104 Neonatal Care
  39. 40. Special Concerns <ul><li>(+) Prominent radial pulse = CHD </li></ul><ul><li>(-) Femoral pulse = Coarctation of aorta </li></ul>051104 Neonatal Care
  40. 41. Respiration <ul><li>Characteristics: </li></ul><ul><li>Nasal breathers, gentle, quiet, rapid BUT shallow; may have short periods of apnea (<15 secs) and irregular without cyanosis—periodic respirations </li></ul><ul><li>Rate: 30-60 cpm </li></ul><ul><li>Duration: 1 full minute </li></ul>051104 Neonatal Care
  41. 42. Nursing Considerations <ul><li>Position on side </li></ul><ul><li>Suction PRN </li></ul><ul><li>Observe for respiratory distress </li></ul><ul><li>Administer oxygen via hood PRN and as prescribed </li></ul>051104 Neonatal Care
  42. 43. Silverman-Anderson Index <ul><li>Perform to observe for signs of respiratory distress </li></ul><ul><ul><li>Chest lag </li></ul></ul><ul><ul><li>Retractions </li></ul></ul><ul><ul><li>Nasal flaring </li></ul></ul><ul><ul><li>Expiratory grunting </li></ul></ul>051104 Neonatal Care
  43. 44. Silverman Scoring System 051104 Neonatal Care 0 1 2
  44. 45. Example 051104 Neonatal Care 0 1 2 Score: 5
  45. 46. Score Interpretation 051104 Neonatal Care Score Interpretation 0-3 No RDS 4-6 Moderate RDS 7-10 Severe RDS
  46. 47. Blood Pressure <ul><li>NOT routinely measured UNLESS </li></ul><ul><li>in distress or CHD is suspected </li></ul><ul><li>At birth: 80/46 mmHg* </li></ul><ul><li>After birth: 65/41 mmHg* </li></ul><ul><li>Using Doppler UTZ </li></ul>051104 Neonatal Care
  47. 48. ANTHROPOMETRIC MESUREMENTS
  48. 49. Body Measurements <ul><li>Weight : </li></ul><ul><ul><li>5.5 to 9.5 lbs (2500-4300 gms) </li></ul></ul><ul><ul><ul><li>Caucasian: 7 lbs </li></ul></ul></ul><ul><ul><ul><li>Filipinos: 6.5 lbs </li></ul></ul></ul><ul><ul><li>70-75% TBW is water </li></ul></ul><ul><ul><li>LBW = below 2500 gms; regardless of AOG </li></ul></ul>051104 Neonatal Care
  49. 50. <ul><li>Length : </li></ul><ul><ul><li>45 to 55 cm (18-22 inches) </li></ul></ul><ul><ul><li>Average: 50 cm </li></ul></ul><ul><ul><li>Techniques: using tape measure </li></ul></ul><ul><ul><ul><li>Supine with legs extended </li></ul></ul></ul><ul><ul><ul><ul><li>Crown to rump </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Head to heel </li></ul></ul></ul></ul>051104 Neonatal Care
  50. 51. <ul><li>Head Circumference (HC) : </li></ul><ul><ul><li>33 to 35.5 cm (13-14 inches) </li></ul></ul><ul><ul><li>Technique: using tape measure </li></ul></ul><ul><ul><ul><li>From the most prominent part of the OCCIPUT to just above the EYEBROWS </li></ul></ul></ul>051104 Neonatal Care
  51. 52. <ul><ul><li>1/3 the size of an adult’s head </li></ul></ul><ul><ul><li>Disproportionately LARGE for its body </li></ul></ul><ul><ul><li>HC should be = or 2cm > CC </li></ul></ul>051104 Neonatal Care
  52. 53. <ul><li>Chest Circumference (CC) : </li></ul><ul><ul><li>30 to 33 cm (12-13 inches) </li></ul></ul><ul><ul><li>Technique: using tape measure </li></ul></ul><ul><ul><ul><li>From the lower edge of the SCAPULAS to directly over the NIPPLE LINE anteriorly </li></ul></ul></ul><ul><ul><li>CC should be = or < 2 cm than HC </li></ul></ul>051104 Neonatal Care
  53. 54. SKIN
  54. 55. Nursing Considerations <ul><li>Under natural light </li></ul><ul><li>Assess for: </li></ul><ul><ul><li>Color </li></ul></ul><ul><ul><li>Hair distribution </li></ul></ul><ul><ul><li>Turgor/ Texture </li></ul></ul><ul><ul><li>Pigmentation/ Birthmarks </li></ul></ul><ul><ul><li>Other skin marks </li></ul></ul>051104 Neonatal Care
  55. 56. Skin Color <ul><li>Velvety smooth and puffy esp. at the legs, dorsal aspects of hands & feet and in the scrotum or labia </li></ul><ul><li>Pinkish red (light skinned) to pinkish brown to yellow (dark skinned) </li></ul><ul><li>“ Ruddy” or reddish due to increased RBC concentration and decreased subQ tissues </li></ul>051104 Neonatal Care
  56. 57. 051104 Neonatal Care
  57. 58. Skin Color <ul><li>Cyanosis/ Acro cyanosis </li></ul><ul><li>Pallor </li></ul><ul><li>Jaundice </li></ul><ul><li>Meconium Staining </li></ul>051104 Neonatal Care
  58. 59. Acro cyanosis <ul><li>Bluish discoloration of palms of hands & soles of feet </li></ul><ul><li>Due to immature peripheral circulation </li></ul><ul><li>Exacerbated by cold temperatures </li></ul><ul><li>Normal within 1 st 24 hrs </li></ul>051104 Neonatal Care
  59. 60. Pallor/ Cyanosis <ul><li>May indicate hypothermia, infection, anemia, hypoglycemia, cardiac, respiratory or neurological problems </li></ul>051104 Neonatal Care
  60. 61. Jaundice <ul><li>Under natural light </li></ul><ul><li>Blanch skin over the chest or tip of the nose </li></ul>051104 Neonatal Care
  61. 62. <ul><li>Physiologic </li></ul><ul><ul><li>FT: after the 1 st 24 hrs (2-7 days) </li></ul></ul><ul><ul><li>PT:after the 1 st 48 hrs </li></ul></ul><ul><ul><li>Peaks at 5-7 days & disappears by the 2 nd week </li></ul></ul><ul><ul><li>Due to immaturity of liver </li></ul></ul><ul><ul><li>Usually found over the face, upper body and conjunctiva of eyes </li></ul></ul>051104 Neonatal Care
  62. 63. <ul><li>Pathologic </li></ul><ul><ul><li>Within 1 st 24 hrs </li></ul></ul><ul><ul><li>May indicate early hemolysis of RBC or underlying disease process </li></ul></ul><ul><ul><li>Duration: </li></ul></ul><ul><ul><ul><li>FT: 1 wk </li></ul></ul></ul><ul><ul><ul><li>PT: 2 wks </li></ul></ul></ul>051104 Neonatal Care
  63. 64. Management of Jaundice <ul><li>Monitoring serum bilirubin levels </li></ul><ul><ul><li>Physiologic: not more than 5 mg/dl per day </li></ul></ul><ul><ul><li>Pathologic: more than 15-20 mg/dl (critical levels) </li></ul></ul><ul><li>Maintain hydration </li></ul><ul><li>Place in bilirubin lights as needed </li></ul><ul><li>Provide emotional support to parents </li></ul>051104 Neonatal Care
  64. 65. Phototherapy units 051104 Neonatal Care
  65. 66. 051104 Neonatal Care Nursing Responsibilities: -cover eyes and sex organ
  66. 67. Meconium Staining <ul><li>Over the skin, fingernails & umbilical cord </li></ul><ul><li>Due to passage of meconium in utero r/t fetal hypoxia </li></ul>051104 Neonatal Care
  67. 68. Lanugo <ul><li>Found after 20 weeks of gestation on the entire body except the palms & soles </li></ul><ul><li>Fine downy hair that covers the shoulders, back & upper arms </li></ul>051104 Neonatal Care
  68. 69. Nursing Considerations: <ul><li>More mature, less lanugo </li></ul><ul><li>May disappear within 2 weeks </li></ul><ul><li>Preterm: woolly patches of lanugo on skin and head </li></ul><ul><li>Post term: parchment-like skin w/o lanugo </li></ul>051104 Neonatal Care
  69. 70. Vernix Caseosa <ul><li>Protective cheesy-like, gray-white fatty substance </li></ul><ul><li>FT: skin folds under the arms and in the groin under the scrotum or in the labia </li></ul><ul><li>Nursing Considerations: </li></ul><ul><ul><li>Use baby oil </li></ul></ul><ul><ul><li>DO NOT attempt to remove vigorously </li></ul></ul>051104 Neonatal Care Vernix Caseosa
  70. 71. Desquamation <ul><li>Dryness/ peeling of the skin </li></ul><ul><li>Usually occurs after 24-36 hours </li></ul><ul><li>Marked scaliness & desquamation = signs of postmaturity </li></ul>051104 Neonatal Care
  71. 72. Milia <ul><li>Multiple, yellow or pearly white papules approx. 1 mm wide </li></ul><ul><li>Due to enlarged or clogged sebaceous gland </li></ul><ul><li>Usually found on the nose, chin, cheeks, eyebrows and forehead </li></ul>051104 Neonatal Care
  72. 73. 051104 Neonatal Care <ul><ul><li>                                                               </li></ul></ul>
  73. 74. Birthmarks
  74. 75. Mongolian Spots <ul><li>Blue - green or gray pigmentation </li></ul><ul><li>Lower back, sacrum & buttocks </li></ul><ul><li>Disappears by 4 years of age </li></ul>051104 Neonatal Care
  75. 76. 051104 Neonatal Care
  76. 77. Salmon Patches <ul><li>Seen commonly in NB </li></ul><ul><li>More on Caucasian </li></ul><ul><li>AKA: Naevus simplex, &quot;angel kisses&quot; (when on the forehead or eyelids), and &quot;stork bites&quot; (over the nape of the neck) </li></ul><ul><li>midline malformations consisting of ectatic capillaries in the upper dermis with normal overlying skin. </li></ul>051104 Neonatal Care
  77. 78. Stork bites <ul><li>Telangiectatic Nevi </li></ul><ul><li>Flat red or purple lesions </li></ul><ul><li>Back of neck, lower occiput, upper eyelid and bridge of the nose </li></ul><ul><li>After 2 years of age </li></ul>051104 Neonatal Care
  78. 79. Strawberry marks <ul><li>Nevus Vasculosus or Capillary Hemangioma </li></ul><ul><li>Dark red , raised lobulated tumor </li></ul><ul><li>Head, neck trunk & extremities </li></ul><ul><li>After 7 to 9 years of age </li></ul>051104 Neonatal Care                                          
  79. 80. 051104 Neonatal Care
  80. 81. 051104 Neonatal Care Large capillary hemangioma
  81. 82. 051104 Neonatal Care Cavernous Hemangioma
  82. 83. Port-wine stain <ul><li>Nevus Flammeus or Capillary Angioma </li></ul><ul><li>capillary malformation </li></ul><ul><li>Flat Red to purple , sharply demarcated dense areas beneath the capillaries </li></ul><ul><li>Face </li></ul><ul><li>Does not fade with time </li></ul><ul><li>Associated with Sturge-Weber syndrome </li></ul>051104 Neonatal Care                                        
  83. 84. Sturge-Weber syndrome <ul><li>PWS involving the forehead (V1 area of the trigeminal nerve), eye abnormalities (choroidal vascular abnormalities, glaucoma), and leptomeningeal and brain abnormalities (vascular malformations, calcification, or cerebral atrophy) </li></ul>051104 Neonatal Care
  84. 85. Other Skin Marks
  85. 86. Mottling <ul><li>Cutis marmorata </li></ul><ul><li>reticulated pattern of constricted capillaries and venules due to vasomotor instability in immature infants </li></ul><ul><li>Bluish mottling or marbling of skin in response to chilling, stress or overstimulation </li></ul>051104 Neonatal Care
  86. 87. 051104 Neonatal Care
  87. 88. Erythema toxicum <ul><li>Newborn rash </li></ul><ul><li>Small, white, yellow, or pink to red papular rash </li></ul><ul><li>Trunk, face & extremities </li></ul><ul><li>Within 48 hrs </li></ul>051104 Neonatal Care
  88. 89. 051104 Neonatal Care                                                             
  89. 90. Petechiae <ul><li>Pinpoint hemorrhages on skin </li></ul><ul><li>Due to increased vascular pressure, infection or thrombocytopenia </li></ul><ul><li>Within 48 hrs </li></ul>051104 Neonatal Care
  90. 91. Ecchymosis <ul><li>Bruises </li></ul><ul><li>As a result of rupture of blood vessels </li></ul><ul><li>May appear over the presenting part as a result of trauma during delivery </li></ul><ul><li>May also indicate infection or bleeding problems </li></ul>051104 Neonatal Care                                        
  91. 92. Harlequin Sign <ul><li>When on side, dependent side turns red and upper side/ half turns pale </li></ul><ul><li>Due to gravity and vasomotor instability or immature circulation </li></ul><ul><li>Skin resembles a CLOWN’S SUIT </li></ul>051104 Neonatal Care CLOWN’S SUIT
  92. 93. Café-au-lait spots <ul><li>Tan or light brown macules or patches </li></ul><ul><li>NO pathologic significance, if <3cm in length and <6 in number </li></ul><ul><li>If > 3 or 6 = Cutaneous neurofibromatosis </li></ul>051104 Neonatal Care
  93. 94. Neurofibromatosis 051104 Neonatal Care
  94. 95. HEAD
  95. 96. What to assess <ul><li>For symmetry, shape, swelling, movement </li></ul><ul><ul><li>Soft, pliable, moves easily </li></ul></ul><ul><ul><li>With some molding (if VSD); round & well-shaped (if CS) </li></ul></ul><ul><li>Measure HC; HC = or > CC </li></ul>051104 Neonatal Care
  96. 97. <ul><li>Fontanelles “soft spot” </li></ul><ul><ul><li>BAD (12-18 mos) </li></ul></ul><ul><ul><li>LPT (2-3 mos or 8-12 wks) </li></ul></ul><ul><ul><li>Bulging or sunken </li></ul></ul><ul><li>Sutures </li></ul><ul><ul><li>Overriding or separated </li></ul></ul>051104 Neonatal Care
  97. 98. <ul><li>Head lag </li></ul><ul><ul><li>Common when pulling newborn to a sitting position </li></ul></ul><ul><ul><li>When prone, NB should be able to lift the head slightly and turn head from side to side </li></ul></ul>051104 Neonatal Care
  98. 99. Caput Succeedaneum <ul><li>Swelling of soft tissues of the scalp </li></ul><ul><li>Due to pressure </li></ul><ul><li>Crosses the suture lines </li></ul><ul><li>Presenting part </li></ul><ul><li>3 days after birth </li></ul>051104 Neonatal Care
  99. 100. Cephalhematoma <ul><li>Subperiosteal hemorrhage with collection blood </li></ul><ul><li>Due to rupture of capillaries as a result of trauma </li></ul><ul><li>Does not crossed suture lines </li></ul><ul><li>Several weeks </li></ul>051104 Neonatal Care
  100. 101. Molding <ul><li>Overlapping of skull bones </li></ul><ul><li>Due to compression during labor and delivery </li></ul><ul><li>Disappears in few days </li></ul>051104 Neonatal Care
  101. 102. 051104 Neonatal Care
  102. 103. Forcep Marks <ul><li>U –shaped bruising usually on the cheeks after forcep delivery </li></ul>051104 Neonatal Care
  103. 104. Craniotabes <ul><li>Localized softening of the cranial bones </li></ul><ul><li>Can be indented by pressure of fingers </li></ul><ul><li>MOST common among 1 st born babies, pathological in older child—metabolic disorder </li></ul><ul><li>Caused by pressure of the fetal skull against the mother’s pelvic bone in utero </li></ul>051104 Neonatal Care
  104. 105. Craniosynostosis <ul><li>Premature closure of the fontanelles </li></ul>051104 Neonatal Care
  105. 106. Face/Eyes/Ears/ Nose /Mouth
  106. 107. What to Assess <ul><li>Facial movement & symmetry </li></ul><ul><li>Symmetry, size, shape and spacing of eyes, nose and ears </li></ul>051104 Neonatal Care                    
  107. 108. Eyes <ul><li>Color: </li></ul><ul><ul><li>white sclera </li></ul></ul><ul><ul><li>Slate gray, brown or dark blue </li></ul></ul><ul><ul><li>Final eye color: after 6-12 months </li></ul></ul><ul><li>Symmetrical </li></ul><ul><li>Pupils equal, round, reactive to light </li></ul><ul><li>(+) Blink reflex </li></ul>051104 Neonatal Care
  108. 109. <ul><li>(+) transient strabismus due to weak EOM </li></ul><ul><li>Able to move and fixate momentarily </li></ul><ul><li>(+) Red reflex – if (-), cataract </li></ul><ul><li>(+) Edema on eyelids r/t pressure during delivery or effects of medication </li></ul><ul><li>(-) Tear formation (begins @ 2-3 mos) </li></ul>051104 Neonatal Care
  109. 110. 051104 Neonatal Care                                                                                                                            
  110. 111. Nursing Considerations <ul><li>Administer eye medication within 1 hr after birth to prevent Ophthalmia neonatorum </li></ul><ul><li>DOC: Erythromycin 0.5% </li></ul><ul><ul><ul><li>Tetracycline 1% </li></ul></ul></ul><ul><ul><ul><li>Silver Nitrate 1% </li></ul></ul></ul><ul><li>From inner to outer canthus of the eye (conjunctival sac) </li></ul>051104 Neonatal Care
  111. 112. Nose <ul><li>Small & narrow </li></ul><ul><li>Flattened, midline </li></ul><ul><li>Nasal breathers </li></ul><ul><li>(+) Periodic sneezing </li></ul><ul><li>Reactive to strong odors </li></ul><ul><li>(+) Flaring = respiratory distress </li></ul><ul><li>(+) Low nasal bridge = Down’s syndrome </li></ul>051104 Neonatal Care
  112. 113. Ears <ul><li>Soft and pliable; with firm cartilage Pinna should be at the level of outer canthus of the eye </li></ul><ul><li>(+) Low set ears = renal or chromosomal abnormalities </li></ul><ul><li>May be congested and hear well after few days </li></ul>051104 Neonatal Care
  113. 114. 051104 Neonatal Care Low set ears
  114. 115. 051104 Neonatal Care Accessory tragus: remnant of 1 st branchial arch Congenital preauricular sinus: ends blindly risk for infection <ul><ul><ul><ul><li>                                                  </li></ul></ul></ul></ul>
  115. 116. Mouth <ul><li>Pink, moist gums </li></ul><ul><li>Intact soft & hard palates </li></ul><ul><ul><li>(+) Epstein’s pearls </li></ul></ul><ul><li>Uvula midline </li></ul><ul><li>Tongue moves freely, symmetrical with short frenulum </li></ul><ul><li>(+) Extrusion & Gag reflexes </li></ul>051104 Neonatal Care
  116. 117. <ul><li>Small mouth or large tongue = chromosomal problems </li></ul><ul><li>(+) white patches on tongue or side of the cheek = Oral thrush </li></ul>051104 Neonatal Care
  117. 118. Neck <ul><li>Short, thick, in midline </li></ul><ul><li>Able to flex and extend but cannot support the full weight of head </li></ul><ul><li>Creased with skin folds </li></ul><ul><li>Trachea midline </li></ul><ul><li>Thyroid gland not palpable </li></ul><ul><li>Intact clavicle </li></ul>051104 Neonatal Care
  118. 119. Chest <ul><li>CC = or < 2cm than HC </li></ul><ul><li>Cylindrical; equal AP:T diameters </li></ul><ul><li>Symmetrical </li></ul><ul><li>Abdominal breathers </li></ul>051104 Neonatal Care
  119. 120. <ul><li>(+) Bronchial sounds </li></ul><ul><li>(+) Breast engorgement ; subsides after 2 wks </li></ul><ul><li>(+)Prominent/ edematous nipple </li></ul><ul><li>(+) Accessory nipples </li></ul><ul><li>(+) “Witch Milk” </li></ul>051104 Neonatal Care
  120. 121. Abdomen <ul><li>Umbilical Cord </li></ul><ul><ul><li>2 arteries; 1 vein </li></ul></ul><ul><ul><li>White & gelatinous immediately after birth </li></ul></ul><ul><ul><li>Begins to DRY between 1-2 hrs following birth </li></ul></ul><ul><ul><li>Blackened or shriveled between 2-3 days </li></ul></ul><ul><ul><li>Dried & gradually falls off by 7 days </li></ul></ul>051104 Neonatal Care
  121. 122. Daily Cord Care <ul><li>Keep cord dry and clean & clamp secured </li></ul><ul><li>Apply 70% isopropyl alcohol to the cord with each diaper change and at least 2-3x a day. </li></ul><ul><li>DO NOT cover with diaper </li></ul><ul><li>Note for any signs of bleeding or drainage from the cord and other abnormalities </li></ul><ul><li>Sponge bath until cord falls off. </li></ul>051104 Neonatal Care
  122. 123. <ul><li>GIT: </li></ul><ul><ul><li>Capacity: 90 ml, with rapid intestinal peristalsis ( 2 ½ to 3 hrs) </li></ul></ul><ul><ul><li>Bowels sounds; (+) within 1-2 hrs after birth </li></ul></ul><ul><ul><li>Presence of mass, distention depression or protrusion </li></ul></ul><ul><ul><li>(+) Scaphoid = diaphragmatic hernia </li></ul></ul><ul><ul><li>(+) Distended = LGIT obstruction/ mass </li></ul></ul>051104 Neonatal Care
  123. 124. <ul><li>Anus </li></ul><ul><ul><li>Check patency </li></ul></ul><ul><ul><li>First stool (Meconium) – within 1 st 24 hrs </li></ul></ul><ul><ul><ul><li>Sticky, tarlike, blackish-green, odorless material </li></ul></ul></ul>051104 Neonatal Care
  124. 125. 051104 Neonatal Care
  125. 126. Transitional Stool <ul><li>Within 2- 10 days after birth </li></ul><ul><li>Breastfed: </li></ul><ul><ul><li>golden yellow, mushy, more frequent 3-4x and sweet smelling </li></ul></ul><ul><li>Bottlefed: </li></ul><ul><ul><li>Pale yello, firm, less frequent 2-3x, with more noticeable odor </li></ul></ul>051104 Neonatal Care
  126. 127. Nursing Considerations <ul><li>Breastfeeding can usually begin immediately after birth </li></ul><ul><li>Bottlefeeding may be started with sterile water to 4 hrs after birth prior to formula feeding </li></ul><ul><li>Burp during and after feeding </li></ul><ul><li>Position properly during and after feeding </li></ul>051104 Neonatal Care
  127. 128. Genitals <ul><li>Female: </li></ul><ul><ul><li>Labia: edematous </li></ul></ul><ul><ul><li>Clitoris: enlarged </li></ul></ul><ul><ul><li>(+) Smegma </li></ul></ul><ul><ul><li>Pseudomenstruation possible </li></ul></ul><ul><ul><li>Visible “hymen tag” </li></ul></ul><ul><ul><li>First voiding within 24 hrs </li></ul></ul>051104 Neonatal Care
  128. 129. <ul><li>Male: </li></ul><ul><ul><li>Prepuce covers glans penis </li></ul></ul><ul><ul><ul><li>(+) adherent foreskin = Phimosis </li></ul></ul></ul><ul><ul><li>Scrotum: edematous </li></ul></ul><ul><ul><ul><li>(+) enlarged = Hernia </li></ul></ul></ul><ul><ul><li>Meatus: central </li></ul></ul><ul><ul><ul><li>(+) ventral/ dorsal = Hypo/epispadias </li></ul></ul></ul><ul><ul><li>Testes: descended </li></ul></ul><ul><ul><ul><li>(+) undescended = Cryptorchidism </li></ul></ul></ul>051104 Neonatal Care
  129. 130. 051104 Neonatal Care <ul><li>                                </li></ul>
  130. 131. Back <ul><li>Spine </li></ul><ul><ul><li>Straight, posture flexed </li></ul></ul><ul><ul><li>Supports head momentarily </li></ul></ul><ul><ul><li>Arms & legs flexed </li></ul></ul><ul><ul><li>Chin flexed on upper chest </li></ul></ul><ul><ul><li>Check for protrusion, excessive or poor muscle contractions = CNS damage </li></ul></ul>051104 Neonatal Care
  131. 132. Extremities <ul><li>Flexed, full ROM, symmetrical </li></ul><ul><li>Clenched fists; flat soles </li></ul><ul><li>With 10 fingers and toes in each hand </li></ul><ul><li>Legs bowed </li></ul><ul><li>Even gluteal folds </li></ul>051104 Neonatal Care
  132. 133. <ul><li>(+) Creases on soles of feet </li></ul><ul><ul><li>(-) Creases = prematurity </li></ul></ul><ul><li>Check for hip fractures or dysplasia </li></ul><ul><ul><li>(+) Ortolani’s click & uneven gluteal folds = Hip dysplasia </li></ul></ul>051104 Neonatal Care click !
  133. 134. 051104 Neonatal Care                                                                                                     
  134. 135. 051104 Neonatal Care                                                              
  135. 136. <ul><li>(+) inward turning of the foot = club foot or talipes equinovarus </li></ul>051104 Neonatal Care
  136. 137. <ul><li>(+) extra digits = Polydactyly </li></ul><ul><li>(+) web fingers = Syndactyly </li></ul>051104 Neonatal Care <ul><ul><li>                                               </li></ul></ul>
  137. 138. Neurologic System
  138. 139. Reflexes
  139. 140. Sucking/ Rooting <ul><li>Touch the lip, cheek or corner of the mouth </li></ul><ul><li>Turns head toward the nipple, opens mouth, takes hold of the nipple and sucks </li></ul><ul><li>Disappears after 3-4 mos up to 1 year </li></ul>051104 Neonatal Care
  140. 141. Extrusion <ul><li>Anything place on the anterior portion of the tongue will be “spit out’ </li></ul><ul><li>To prevent swallowing of inedible substances </li></ul><ul><li>Disappears after 4 months </li></ul><ul><li>Disappearance indicates readiness for semi-solid to solid foods </li></ul>051104 Neonatal Care
  141. 142. Swallowing <ul><li>Occurs spontaneously after sucking and obtaining fluids </li></ul><ul><li>NEVER disappear </li></ul><ul><li>Newborn swallows in coordination with sucking without gagging, coughing or vomiting </li></ul>051104 Neonatal Care
  142. 143. Tonic Neck/ Fencing <ul><li>While the baby is falling asleep or sleeping, gently and quickly turn the head to one side </li></ul><ul><li>As the baby faces the left side, the left arm and leg extend outward while the right arm or leg flex and vice-versa </li></ul><ul><li>Disappears within 3-4 mos </li></ul>051104 Neonatal Care
  143. 144. Palmar(Grasping)/ Plantar <ul><li>Place a finger in the palm of the baby’s hand, then place a finger at the base of the toes </li></ul><ul><li>Fingers will curl or grasp the examiner’s finger and the toes will curl downward </li></ul><ul><li>Palmar: fades within 3-4 mos </li></ul><ul><li>Plantar: fades within 8 mos </li></ul>051104 Neonatal Care
  144. 145. Moro <ul><li>Hold baby in a semi sitting position then allow the head and trunk to fall backward to at least a 30-degree angle </li></ul><ul><li>Symmetrically abducts and extends the arms; fans the fingers out and forms a C with the thumb and the forefinger; and adducts the arms to an embracing position & returns to a relaxed state </li></ul>051104 Neonatal Care
  145. 146. <ul><li>Present at birth; complete response at 8 weeks </li></ul><ul><li>MOST significant singular reflex indicative of CNS problem (>6 mos) </li></ul><ul><li>Disappears after 4-5 mos. </li></ul>051104 Neonatal Care
  146. 147. Startle <ul><li>Best elicited if baby is 24 hrs old </li></ul><ul><li>Make a loud noise or claps hands </li></ul><ul><li>Baby ‘s arms adduct while elbows flex with fists clenched </li></ul><ul><li>Disappears within 4 mos </li></ul>051104 Neonatal Care
  147. 148. Babinski <ul><li>Gently stroke upward along the lateral aspect of the sole, starting at the heel of the foot to the ball of the foot </li></ul><ul><li>Dorsiflexion of big toe and fanning of little toes </li></ul><ul><li>Disappears starts a 3 mos to 1 year </li></ul><ul><li>Disappearance indicates maturity of CNS </li></ul>051104 Neonatal Care
  148. 149. Stepping/ Walking/ Dancing <ul><li>Hold baby in a standing position allowing one foot to touch a surface </li></ul><ul><li>Simulates walking by alternately flexing and extending feet </li></ul><ul><li>Disappears after 3-4 mos </li></ul>051104 Neonatal Care
  149. 150. Assessment of Gestational Age <ul><li>Dubowitz Maturity Scale </li></ul><ul><ul><li>Gestational rating scale </li></ul></ul><ul><ul><li>NB are observed and tested according to the criteria </li></ul></ul><ul><ul><li>Help determine whether the NB needs immediate high-risk nursery intervention </li></ul></ul>051104 Neonatal Care
  150. 151. Usher’s Criteria 051104 Neonatal Care FINDINGS 0-36 WKS 37-38 WKS 39 WKS AND OVER Sole creases Anterior transverse crease only Occl creases in ant 2/3 Sole covered with creases Breast nodule diameter (mm) 2 4 7 Scalp hair Fine and fuzzy Fine and fuzzy Coarse and silky Ear lobe Pliable; no cartilage Some cartilage Stiffened by thick cartilage Testes and scrotum Testes in lower canal; scrotum small; few rugae Intermediate Testes pendulous, scrotum full; extensive rugae
  151. 152. Ballard’s Scoring <ul><li>Completed in 3-4 min </li></ul><ul><li>2 portions: physical maturity and neuromuscular maturity </li></ul>051104 Neonatal Care
  152. 153. 051104 Neonatal Care Physical maturity
  153. 154. 051104 Neonatal Care Neuromuscular Maturity
  154. 155. 051104 Neonatal Care Scoring
  155. 156. 051104 Neonatal Care Physical maturity 19
  156. 157. 051104 Neonatal Care Neuromuscular Maturity 17
  157. 158. 051104 Neonatal Care Scoring 19+17=36 36 39
  158. 159. Other Nursing Responsibilities <ul><li>Identification band </li></ul><ul><li>Birth Registration </li></ul><ul><li>Birth record and </li></ul><ul><li> documentation </li></ul>051104 Neonatal Care
  159. 160. Newborn Screening <ul><li>The Newborn Screening Reference Center (NSRC) is an office under the National Institutes of Health (NIH), University of the Philippines Manila created under RA 9288– The Newborn Screening Act of 2004 </li></ul><ul><li>Performed after 24 hours of life up to 3 days except for patient in intensive care, must be tested by 7 days </li></ul>051104 Neonatal Care
  160. 161. <ul><li>Congenital Hypothyroidism (CH) </li></ul><ul><li>Congenital Adrenal Hyperplasia (CAH) </li></ul><ul><li>Galactosemia (GAL) </li></ul><ul><li>Phenylketonuria (PKU) </li></ul><ul><li>Glucose-6-Phosphate-Dehydrogenase Deficiency (G6PD Def) </li></ul>051104 Neonatal Care
  161. 162. 051104 Neonatal Care Disorder Screened If not screened If screened Congenital Hypothyroidism Severe mental retardation Normal Congenital Adrenal Hyperplasia Death Alive and Normal Galactosemia Death or Cataracts Alive and normal PKU Severe mental retardation Normal G6PD Deficiency Severe Anemia, Kernicterus Normal
  162. 163. Infant Care Skills <ul><li>Holding the baby </li></ul><ul><ul><li>Football Hold </li></ul></ul><ul><ul><li>Cradle Hold </li></ul></ul><ul><ul><li>Shoulder Hold </li></ul></ul>051104 Neonatal Care
  163. 164. Football Hold <ul><li>Purpose: to carry on one hand free </li></ul><ul><li>A holding technique in bathing a baby </li></ul><ul><li>Use for small babies </li></ul><ul><li>Procedure: </li></ul><ul><li>1. slide forearm under his back </li></ul><ul><li>2. support neck and head with your hand </li></ul><ul><li>3. press his arm firmly against your side </li></ul><ul><li>4. his head faces you </li></ul><ul><li>5. infant’s feet tucked under your elbow </li></ul>051104 Neonatal Care
  164. 165. Cradle Hold <ul><li>Purpose: use for feeding and cuddling a baby </li></ul><ul><li>  </li></ul><ul><li>Procedure: </li></ul><ul><li>support head in the crook of your arm </li></ul><ul><li>encircle the body with your arm </li></ul><ul><li>press baby firmly against your side </li></ul><ul><li>use other hand to support bottom and thigh </li></ul>051104 Neonatal Care
  165. 166. Shoulder Hold <ul><li>Purpose: use for burping </li></ul><ul><li>  </li></ul><ul><li>Procedure: </li></ul><ul><li>draw baby towards your chest with one forearm </li></ul><ul><li>bracing his back and your hand cradling his head </li></ul><ul><li>support your baby’s bottom and thighs with your other arm </li></ul><ul><li>gently press his head against shoulder </li></ul>051104 Neonatal Care
  166. 167. The end 081007 Neonatal Care

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