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Lecture ten



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  • 1. Care of the NewbornCare of the Newborn
  • 2. Neonatal TransitionNeonatal TransitionRespiratory AdaptationsFetal lung developmentFetal breathing movementsInitiation of breathingMechanical eventsChemical stimuliThermal stimuliSensory stimuli
  • 3. Fetal Lung DevelopmentFetal Lung Development (681)(681)Between 24-28 weeks Surfactant synthesis andstorage begins to occur.Surfactant (composed of a group of surfaceactive phospholipids, lecithin and sphingomyelin,which are critical for aveolar stability. The newborn born before thelecithin/sphingomyelin (L/S) ratio is 2:1 will havevarying degrees of respiratory distress.May need synthetic surfactant if born withrespiratory distress.
  • 4. Breathing MovementsBreathing Movements (pg. 681-684)(pg. 681-684) Breathing is a continuation of a process that beganinutero. Lungs convert from fluid filled to gas filled organs. Pulmonary ventilation must be established throughlung expansion following birth. A marked increase in pulmonary circulation mustoccur. Mechanical events, chemical stimuli, thermal stimuli,and sensory stimuli. Factors opposing the first breath: 1) aveolar surfacetension, 2) viscosity of lung fluid within therespiratory tract and 3) degree of lung compliance.
  • 5. Cardiopulmonary PhysiologyCardiopulmonary PhysiologyCardio pulmonary adaptationOxygen transportMaintaining respiratory functionCharacteristics of newborn respiration
  • 6. Transitional PhysiologyTransitional Physiology (pg. 686-(pg. 686-687)687)1) Increased aortic pressure anddecreased venous pressure:.2) Increased systemic pressure anddecreased pulmonary artery pressure.3) Closure of the foramen ovale:venosus.occurs due to increased pressure inthe left atrium.4) Closure of the ductus arteriosus.5) Closure of the ductus
  • 7. Characteristics of CardiacCharacteristics of CardiacFunctionFunction (pg. 687-689)(pg. 687-689)Heart rateBlood pressureHeart murmursCardiac workload
  • 8. Heart rateHeart rateThe average resting heart rate for fullterm newborns is 120 to 160 (when thenewborn cries the heart rate may exceed180). Apical pulses should be obtained byauscultation for a full minute, preferablywhile the newborn is asleep. The heart rate should be evaluated foreabnormal rhythms or beats.
  • 9. Blood PressureBlood PressureThe newborn blood pressure tends to behigher immediately after birth.Blood pressure is sensitive to the changesin blood volume that occur in thetransition to newborn circulation.Capillary refill should be less than 2 to 3seconds when the skin is blanched.
  • 10. Blood PressureBlood PressureCrying may cause an elevation in bloodpressure.Blood pressure should be taken while thenewborn is in a quiet state.Measurement of blood pressure is bestaccomplished by using the Dopplertechnique or a 1 to 2 inch cuff and astethoscope over the brachial artery.
  • 11. Heart MurmursHeart MurmursMurmurs are usually produced byturbulent blood flow.90% of all murmurs are transient and notassociated with anomalies.Usually involve incomplete closure of theductus arteriosis or foramen ovale.
  • 12. Cardiac WorkloadCardiac WorkloadSystemic blood volume and pulmonaryblood volume are not equal in theneonate.The right ventricle does most of thework prior to birth.The left ventricle increases its workloadafter birth and gains in size andthickness.Right sided heart defects appear bettertolerated than left sided defects.
  • 13. Hematological AdaptationsHematological AdaptationsPhysiologic anemia of infancyDelayed cord clamping and normal shift ofplasma to extravascular spacesGestational agePrenatal or perinatal hemorrhageThe site of the blood sample
  • 14. Temperature RegulationTemperature RegulationThermal neutral zone (TNZ)Heat loss: Convection, Radiation,Evaporation and ConductionHeat production (Thermogenesis)Brown adipose tissue (BAT, brown fat)Response to heat
  • 15. Hepatic AdaptationsHepatic AdaptationsIron Storage and Red Blood Cell Production: 1) Iron is stored in the liver until needed for redblood cell (RBC) production.2) Newborn iron stores are determined by totalbody hemoglobin content and length ofgestation. 3) If the mother’s iron intake has beenadequate, newborn iron stores will be stored tolast until 5 month of age. 4) After about 6 months of age, foods containingiron or iron supplements may be given toprevent anemia.
  • 16. Hepatic AdaptationsHepatic AdaptationsCarbohydrate Metabolism: 1) Neonatal carbohydrate reserves are relativelylow. 2) Energy crunch occurs at birth with the removalof maternal glucose supply and increased energyexpenditure adjusting to extrauterine life. 3) Glucose is the main source of energy in the first4 to 6 hours following birth. 4) Blood glucose level stabilizes at values of 50 to60 mg/dL. 5) Glucose level is assessed by using a chemstripmethod on admission to the nursery and at 4hours of age.
  • 17. Hepatic AdaptationsHepatic AdaptationsConjugation of Bilirubin: 1) Conjugation of bilirubin is the conversion of yellow lipidsoluble pigment into water soluble pigment. 2) Unconjugated (indirect) bilirubin is a breakdown productderived from hemoglobin that is released primarily fromdestroyed red blood cells. 3) Unconjugated bilirubin is not in an excretable form andis 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, theninto the common duct and duodenum. The direct(conjugated) bilirubin then progresses down the intestineswhere bacteria transform it into urobilinogen. This productis not reabsorbed but is excreted as a yellow-brownpigment in the stools.
  • 18. Hepatic AdaptationsHepatic AdaptationsPhysiologic Jaundice: Physiologic jaundice is caused by accelerated destruction of fetalRBCs, 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 ofbilirubin are delivered to the liver, 2) Defective uptake of bilirubinfrom the plasma, 3) Defective conjugation of the bilirubin, 4) Defectin 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 exhibitphysiologic jaundice on the second or third postpartum day. There appears a characteristic yellow color that results fromincreased levels of unconjugated bilirubin and a temporary inability toeliminate bilirubin. The signs of physiologic jaundice occur after 24 hours afterbirth. Breast milk jaundice is controversial and difficult to distinguish fromprolonged jaundice.
  • 19. Hepatic AdaptationsHepatic AdaptationsCoagulation:Coagulation factors II, VII, IX, and X areactivated under the influence of vitamin Kand are considered vitamin K dependant.The absence of normal intestinal floraneeded to synthesize vitamin K in thenewborn gut results in low levels ofvitamin K.Although newborn bleeding problems arerare, an injection of vitamin K(AquaMEPHYTON) is given prophylacticallyon admission to the nursery to combatpotential clinical bleeding problems.
  • 20. Gastrointestinal AdaptationsGastrointestinal Adaptations(pg.697-698)(pg.697-698) By 36 to 38 weeks gestation, the gastrointestinal tract isadequately mature: 1) enzymatic activity present, 2) ableto transport nutrients. Lactose is the primary carbohydrate in the breastfeedingnewborn and is usually easily digested and well absorbed. By birth the newborn has experienced swallowing, gastricemptying, and intestinal propulsion. The newborn’s stomach has a capacity of 50 to 60 mls. The cardiac sphincter is immature, as is neural control ofthe stomach, so some regurgitation may be noted. Term newborns normally pass meconium (dark green toblack) within 8 to 24 hours of life and almost always by 48hrs. Transitional (thinner brown to green) stools are passed forthe 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.
  • 21. Urinary AdaptationsUrinary Adaptations (pg. 698-699)(pg. 698-699) Full term newborns are less able than adults to concentrateurine (reabsorb water back into the blood) due to shorterand narrower tubules. Concentrating and dilutional limitations of renal functionare important considerations in monitoring fluid therapy toavoid dehydration and overhydration. Many newborns void immediately after birth. A newbornwho has not voided by 48 hours should be assessedfor inadequate fluid intake, bladder distention,restlessness, and symptoms of pain. The first two days of birth the newborn voids two to sixtimes 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 ofmaternal hormones) may be seen as blood on the newbornfemale’s diaper.
  • 22. Immunologic AdaptationsImmunologic Adaptations Limitations in the newborn’s inflammatory response results infailure to recognize, localize, and destroy invasive bacteria. The signs and symptoms of infection are often subtle andnonspecific 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 thenewborn. Passive acquired immunity : transfer of antibodies (IgG) fromthe mother to the fetus in utero. Newborns have maternally induced immunity to tetanus,diphtheria, smallpox, measles, mumps, poliomyelitis, and avariety of other bacterial and viral disease. Immunity against common viral infections such as measles maylast 4 to 8 months; whereas immunity to certain bacteria maydisappear within 4 to 8 weeks. Colostrum, the forerunner of breast milk is very high inimmunoglobulin IgA which may provide some passive immunityto the breastfeeding newborn.
  • 23. Neurological andNeurological andSensory/PerceptualSensory/PerceptualFunctioningFunctioning Intrauterine factors influencing newborn behavior:maternal nutrition and extrauterine environment (noise). Characteristics of newborn neurological function: partiallyflexed extremities, eye movements are observable, mayfixate on faces, or geometric objects, cry is lusty andvigorous, knee jerk is brisk, plantar flexion is present. Periods of reactivity: First Period of reactivity, Period ofInactivity to sleep phase, Second period of reactivity. Behavioral states of the newborn: Sleep states and Alertstates. Behavioral and sensory capacities of the newborn:Habituation, Orientation, Self-quieting ability, auditorycapacity, olfactory capacity, taste and sucking, and tactilecapacity.
  • 24. Nursing Assessment of theNursing Assessment of theNewbornNewbornAssessment of the newborn is a continuousprocess used to evaluate development andadjustments to extrauterine life.Assess immediately after birth: r/oresuscitation and allow bonding.Assessment within 1 to 4 hours after birth:progress of newborns adaptation, gestationalage, ongoing assessment of high-riskproblems.Assessment procedures in the first 24 hoursor prior to discharge.
  • 25. Nursing Assessment of theNursing Assessment of theNewbornNewborn
  • 26. Estimation of Gestational AgeEstimation of Gestational AgeMust be established in the first four hoursof birth.Ballard and Dubowitz.Include external physical characteristicsand neurological or neuromusculardevelopment evaluations.Some maternal conditions may affectcertain gestational age assessmentcomponents. (PIH, Diabetes, analgesia).
  • 27. Estimation of Gestational AgeEstimation of Gestational Age(pg 707- 714)(pg 707- 714)PHYSICAL CHARACTERISTICS: Resting posture: assessed undisturbed on a flatsurface Skin: thin, opaque, peeling Lanugo: decreases as gestational age increases Sole (plantar) creases: increase with gestational age Areola and breast bud tissue: increases with age. Ear form and cartilage distribution: Cartilage givesshape. Pinna is firm at term. Male genitals: Size of scrotal sac, the presence ofrugae, and descent of the testicles. Female genitals: size of labia majora and minora. Vernix: None in the post term infant. More seen withprematurity. Hair: Preterm patchy, term silky. Skull firmness: increases as the fetus matures. Nails: long may be a sign of postmaturity.
  • 28. Estimation of Gestational AgeEstimation of Gestational Age(pg 707- 714)(pg 707- 714)NEUROMUSCULAR CHARACTERISTICS The square window sign: elicited by flexing the baby’shand toward the ventral forearm until resistance is felt (theangle formed at the wrist is measured). Recoil: test of flexion development. Lower extremities aretested first. Popliteal angle: degree of knee flexion, angle is increasedin the preterm infant. Scarf sign: elicited by placing the newborn in supineposition and drawing an arm across the chest toward thenewborn’s opposite shoulder. The location of the elbow isnoted in relation to the midline of the chest. Heel to ear extension: with advancing age greaterresistance 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 degreeof flexion in the arms and legs are noted. Major reflexesevaluated.
  • 29. Physical AssessmentPhysical Assessment General appearance: Headlarger than body Weight and measurements:average birth weight is 7lbs,8oz, average length is 18 -22inches. Temperature: assessed byaxillary method after initialrectal temp. 97.7 to 98.6. Skin characteristics: (719) Head: 12.5 to 14.5 inches,approximately 2 cms largerthan the chest circumference.Cephalohemotoma, caputsuccedenum Face: blue or dark. Chemicalconjunctivits, subconjunctivalhemorrhages. Epsteins pearlsor thrush. Neck looks short, creasedwith skin folds. Fracturedclavicle. Chest:engorged breasts Cry: strong and of mediumpitch Respiration: 30 to 60respiratory rate Heart: 120 -160 HR Abdomen: appears prominent Umbilical cord: white andgelatinous, bleeding isuncommon, umbilical cordhernia abnormal. Genitals: may have vaginaldischarge in the first week oflife (white, thick) Anus: check for imperforateanus or atresia (donevisually) Extremities: check forabnormalities, polydactyly,Erb’s palsy.
  • 30. 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)
  • 31. Assessment of NeurologicalAssessment of NeurologicalStatusStatusTonic neck reflexGrasping reflexMoro reflexRooting reflexSucking reflexBabinski reflexTrunk incurvation (Galant reflex)
  • 32. Newborn BehavioralNewborn BehavioralAssessmentAssessmentHabituationOrientation to inanimate and animatevisual and auditory assessment stimuli.Motor activityVariations in quiet alert states, statechanges and color changes.Self quieting activity assessment on howoften and how quickly newborns quietthemselves.Cuddliness or social behaviors.
  • 33. Nursing DiagnosisRisk for ineffective breathing patternAltered nutrition: less than bodyrequirementsAltered urinary eliminationRisk for infectionKnowledge deficitAltered family processes
  • 34. Nursing Plan andNursing Plan andImplementationImplementation (pg. 762-772)(pg. 762-772)Maintenance of cardiopulmonary functionMaintenance of a neutral thermalenvironmentPromotion of adequate hydration andnutritionPromotion of skin integrityPrevention of complications andpreventing safetyEnhancing parent-newborn attachment
  • 35. Maintenance of CardiopulmonaryMaintenance of CardiopulmonaryFunctionFunctionAssess vital signs every 6 to 8 hrs or moredepending on the newborn’s status.“Back to Sleep” , side lying to preventaspiration and facilitate drainage of mucus.Keep bulb syringe readily available.Vigorous fingertip stroking of the spinefrequently stimulates respiratory activity.Cardiac/respiratory monitor may be required.At-risk indicators: pallor, cyanosis, ruddycolor, and apnea.
  • 36. Maintain the newborn’s temperature within thenormal range.Make certain the infant is dressed and bundledappropriately. Small caps may be used for theLBW or premature infant.Newborns use calories for warmth rather thangrowth.Chilling increases the affinity of serum albuminfor bilirubin.Chilling increases oxygen use and may causerespiratory distress.Overheating will increase respiratory rate andactivity in an attempt to cool the body, alsoincreasing insensible fluid loss.
  • 37.  Weigh at the same time each day. Weight loss of up to 10% is considered normal duringthe first week of life. Birth weight should be regained by the 2ndweek oflife. The nurse records voiding and stooling patterns. The first void should occur within the first 24 hoursand passage of stool in the first 48 hours. Assess for abdominal distention, bowel sounds,hydration, fluid intake, voiding pattern, andtemperature stability. Excessive handling may cause an increase in thenewborn’s metabolic rate, calorie use and fatigue.
  • 38. Promotion of Skin IntegrityPromotion of Skin Integrity (pg(pg764-765)764-765)Bathing is important for health, appearance,and infect5ion control in the nursery.Ongoing skin care includes cleansing of thebuttocks and perineal area with water and amild soap with diaper changes.Assess the umbilical cord for signs ofbleeding or infection: 1) apply triple dye onadmission to nursery and 2) alcohol aftereach diaper change.Cord care with each diaper change.Eye and skin care related to phototherapy.Skin care following circumcision.
  • 39. Prevention of Complications and PromotingPrevention of Complications and PromotingSafetySafety (pg 765-767)(pg 765-767) Pallor may be an early sign of hemorrhage. Circumcision is assessed for signs of hemorrhage andinfection. Initial scrub for 2-3 minutes when direct contact withthe newborn is anticipated. Handwashing between each client contact and contactwith floor, face, or any soiled surface. Encourage parents to wash hands prior to holding theinfant and wear a gown over street clothes. Teach parents to limit visitors who may have acommunicable disease. Check namebands with each encounter with theparents. Instruct clients in security measures in place toprevent infant abduction.
  • 40. Enhancing Parent-Newborn AttachmentEnhancing Parent-Newborn Attachment(pg. 767)(pg. 767)Involve the entire family in newborn careInfant massage may be encouragedIncrease skin to skin contactRead to or play music for the newbornEncourage cuddling and talking to theinfant
  • 41. Discharge Planning andDischarge Planning andPreparationPreparation (pg. 767-773)(pg. 767-773)Parent teachingGeneral instructions for newborn careNasal and oral suctioningWrapping the newbornSleep and activitySafety considerationsNewborn screening and immunizationProgram
  • 42. Community-Based NursingCommunity-Based NursingCare for the NewbornCare for the Newborn (pg. 773-776)(pg. 773-776)The family should have access to thebirthing unit and physician phonenumbers.The client should be made aware offollow-up programs such as PRS, earlyintervention and high-risk referral.Referral to the public health department.Hospital phone follow-up.
  • 43. Thanks for attentionThanks for attention