Newborn Assessment


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Newborn Assessment

  1. 1. Maternal and Child Health NursingNewborn Assessment MATERNAL and CHILD HEALTH NURSING NEWBORN ASSESSMENT Lecturer: Mark Fredderick R. Abejo RN, MAN ______________________________________________________________________ Newborn AssessmentNewborn Assessment Abejo
  2. 2. Maternal and Child Health NursingNewborn AssessmentNewborn Assessment and Nursing Care  Tachypnea - respirations > 60  Persistent irregular breathing  Excessive mucus  Temperature - range 36.5 to 37 axillary  Persistant fine crackles  Common variations  Stridor o Crying may elevate temperature Stabilizes in 8 to 10 hours after Breathing ( ventilating the lungs) delivery  check for breathlessness o Temperature is not reliable indicator  if breathless, give 2 breaths- of infection ambu bag A temperature less than 36.5  1 yr old- mouth to mouth, pinch noseTemp: rectal- newborn – to rule out imperforate  < 1 yr – mouth to nose Anus  force – different between baby & - take it once only, 1 inch insertion child  infant – puffImperforate anus Circulation 1. atretic – no anal opening  Check for pulslessness :carotid- 2. agenetialism – no genital adult 3. stenos – has opening  Brachial – infants 4. membranous – has opening CPR – breathless/pulseless Earliest sign:  Compression – inf – 1 finger breath 1. no mecomium below nipple line or 2 finger breaths 2. abd destention or thumb 3. foul odor breath  CPR inf 1:5 4. vomitous of fecal matter  Adults 2:30 5. can aspirate – resp problem Mgt: Surgery with temporary colostomy  Blood Pressure - not done routinely Factors to consider Heart Rate Varies with change in activity level range 120 to 160 beats per minute Appropriate cuff size important for accurate Common variations reading  Heart rate range to 100 when sleeping 65/41 mmHg to 180 when crying  Color pink with acrocyanosis  General Measurements  Heart rate may be irregular with  Head circumference - 33 to 35 cm crying  Expected findings  Although murmurs may be due to  Head should be 2 to 3 cms larger than the transitional circulation-all murmurs chest should be followed-up and referred for  Abdominal circumference – 31-33 cm medical evaluation  Weight range - 2500 - 4000 gms (5 lbs. 8oz.  Deviation from range - 8 lbs. 13 oz.)  Faint sound  Length range - 46 to 54 cms (19 - 21 inches)  Normal length- 19.5 – 21 inch or 47.5 –Cardiac rate: 120 – 160 bpm newborn 53.75cm, average 50 cmApical pulse – left lower nipple  Head circumference 33- 35 cm or 13 – 14 “Radial pulse – normally absent. If present PDAFemoral pulse – normal present. If absent COA Hydrocephalus - >14” Chest 31 – 33 cm or 12 – 13” Respiration Abd 31 – 33 cm or 12 – 13” - range 30 to 60 breaths per minute Common variations  Bilateral bronchial breath sounds Signs of increased ICP Moist breath sounds may be present 1. abnormally large head shortly after birth 2. bulging and tense fontanel Signs of potential distress or deviations 3. increase BP and widening pulse pressure from expected findings 4. Decreased RR, decreased PR  Asymmetrical chest movements 5. projective vomiting- sure sign of cerebral  Apnea >15 seconds irritation  Diminished breath sounds 6. high deviation – diplopia – sign of ICP older  Seesaw respirations child  Grunting a. 4-6 months- normal eye deviation  Nasal flaring b. >6 months- lazy eyes  Retractions 7. High pitch shrill cry-late sign of ICP  Deep sighingNewborn Assessment Abejo
  3. 3. Maternal and Child Health NursingNewborn Assessment Head to Toe Newborn AssessmentCIRCULATORY UMBILICAL VEIN and DUCTUS VENOSUS constrict after cord id clampedSTATUS DUCTUS ARTERIOSUS constrict with establishment of respiratory function FORAMEN OVALE closes functionally as respirations established, but anatomic or permanent closure may take several months HEART RATE averages 140 b.p.m. BP 73/55 mmHg PERIPHERAL CIRCULATION acrocyanosis within 24 hours RBC high immediately after birth; falls after 1 st week ABSENCE/ NORMAL FLORA INTESTINE Vitamin KRESPIRATORY Adequate levels of surfactants (Lecithin and spingomyelin) ensure mature lungSTATUS function; prevent alveolar collapse and respiratory distress syndrome RR = 30-80 breaths /minutes with short periods of apnea (< 15 seconds) = assess for 1 full minute change noted during sleep or activity NOTE: Periodic apnea is common in preterm infants. Usually, gentle stimulation is sufficient to get the infant to breatheRENAL SYSTEM Urine present in the bladder at birth but NB may not void doe 1st 12-24 hours Later pattern is 6-10 voidings/ day – indicative of sufficient fluid intake Urine is pale and straw colored – initial voidings may leave brick-red spots on diaper ( d/t passage of uric acid crystals in urine) Infant unable to concentrate urine for the 1st 3 monthsDIGESTIVE IMMATURE CARDIAC SPHINCTER – may allow reflux of food, burped,SYSTEM REGURGITATE- placed NB right side after feeding Newborn can’t move food from lips to pharynx. Insert nipple well to mouth FEEDING PATTERS vary - Newborns may nurse vigorously immediately afterbirth or may need as long as several days to suck effectively - Provide support and encouragement to new mothers during this time as infant feeding is very emotional doe most mothers NOTE: Distinguishing Neonatal Vomiting from Regurgitation Vomiting is usually sour, looks like curdled milk due to HCL, with a sour odor, while regurgitation has no sour odor or curdling of milk, or occurs during or immediately after feeding. IMPORTANT CONSIDERATIONS: Breastfeeding can usually begin immediately after birth; bottle-fed newborns may be offered few milliliters of sterile water or 5% dextrose 1 to 4 hours after birth prior to a feeding with formula An infant with gastrostomy tube should receive a pacifier during feeding unless contraindicated to provide normal sucking activity and satisfy oral needs. At age4-6 months, an infant should begin to receive solid food foods one at a time and 1 week apart. FIRST STOOL is MECONIUM - Black, tarry residue from lower intestine - Usually passed within 12-24 hours after birth If the amniotic fluid shows evidence of meconium staining, the physician most likely do immediately after delivery is to suction the oropharynx immediately after the head is delivered and before the chest is delivered. TRANSITIONAL STOOLS thin, brownish green in color After 3 days MILK STOOLS are usually passed a. MILK STOOLS for BF infant – loose and golden yellow b. MILK STOOLS for FORMULATED FED- formed and pale yellowNewborn Assessment Abejo
  4. 4. Maternal and Child Health NursingNewborn AssessmentHEPATIC Liver responsible for changing Hgb into conjugated bilirubin, which is further changed into conjugated (water soluble) bilirubin that can be excreted Excess unconjugated bilirubin can permeate the sclera and the skin, giving a jaundiced or yellow appearance to these tissuesTEMPERATURE HEAT PRODUCTION in newborn accomplished by: a. Metabolism of “ BROWN FAT” - A special structure in NB is a source of heat - Increased metabolic rate and activity Axillary temperature: 96.8 to 99F Newborn can’t shiver as an adult does to release heat Newborns are unable to maintain a stable body temperature because they have an immature vasomotor center, and unable to shiver to increase body heat. NB’s body temperature drops quickly after birth – after stress occurs easily Body stabilizes temperature in 8-10 hours if unstressed Cold stress increases o2 consumption – may lead to metabolic acidosis and respiratory distressIMMUNOLOGIC NB develops own antibodies during 1st 3 months but at risk for infection during the first 6 weeks Ability to develop antibodies develops sequentially Neonatal Physical Assessment Birth weight=2500-400 grams (5 lbs. 8oz. – 8 lbs. 13 oz.) Length= 45.7 – 55.9 cm. (18-22 inches)HEAD Head circumference = 33-35 cm (2-3 cm. Greater than chest circumference) Anterior fontanel (diamond shape) = closes 12-18 months Posterior fontanel (triangle shape)= closes 2-3 months NOTE: The posterior fontanel is located at the intersection of the sagittal and lambdoid suture is the space between the pariental bones; the lambdoid suture separates the two parietal bones and the occipital bone Molding- asymmetry of head as a result of pressure in birth canaNewborn Assessment Abejo
  5. 5. Maternal and Child Health NursingNewborn AssessmentEYES Blue/ gray d/t scleral thinness; permanent color established w/in 3-12 mos. Lacrimal glands immature at birth; tearless cry up to 2 months Absence of tears is common because the neonate’s tear glands are not yet fully developed Transient strabismus Doll’s eye reflex persist for about ten days Red Reflex: A red circle on the pupils seen when an ophthalmoscope’s light is shining onto the retina is a normal finding. This indicates that the light is shining onto the retina. CONVERGENT STRABISMUS (CROSS EYED) It is common during infancy until age 6 months because of poor oculomotor coordination NOTE : Congenital Glaucoma It is due to increased intraocular pressure caused by an abnormal outflow or manufacturing of normal eye fluid. Unequal size should be reported immediately.NOSE Nose breathers for first few months of lifeMOUTH Scant saliva with pink lips Epstein’s Pearls - small shiny white specks on the neonate’s gums and hard palate which are normalEARS Incurving of pinna and cartilage depositionNECK Short and weak with deep fold of skinCHEST Characterized by cylindrical thorax and flexible ribs NOTE: appears circular since anteroposterior and lateral diameters are about equal Respirations appear diaphragmatic Nipples prominent and often edematous Milky secretion (witchs milk) common ( effect of estrogen)Newborn Assessment Abejo
  6. 6. Maternal and Child Health NursingNewborn AssessmentABDOMEN Cylindrical with some protrusion; scaphoid appearance indicates diaphragmatic hernia Umbilical cord is white and gelatinous with two arteries and one vein and begins to dry within 1-2 hours after delivery NOTE: Umbilical cord Three vessels, two arteries and one vein, in cord; if fewer than three vessels are noted notify the physician Small, thin cord may be associated with poor fetal growth Assess for intact cord, and ensure that damp is cured Cord should be clamped for at least the first 4 hours after birth; clamp can be removed hen the cord is dried and occluded Umbilical clamp can be removed after 24 hoursGENITALIA MALE: includes rugae on the scrotum and testes descended into the scrotum Urinary meatus: Hypospadias (ventral surface) Epispadias (dorsal surface) NOTE: Meatus at tip of penis Testes descended but may retract with cold Assess for hernia or hydrocele First voiding should occur within 24 hours FEMALE: labia majora cover labia minora and clitoris Pseudomenstruation possible (blood-tinged mucus) effect of estrogen First voiding should occur within 24 hoursEXTREMITIES All neonates have bowlegged and flat feet NOTE NORMAL FEATURES: Major gluteal folds even Creases on soles of feet Assess for fractures (especially clavicle) or dislocations (hip) Assess for hip dysplasia; when thighs are rotated outward, no clicks should be heard Some neonates may have abnormal extremities: Polydactyl (more than 5 digits on extremity) Syndactyl (two or more digits fused together)Newborn Assessment Abejo
  7. 7. Maternal and Child Health NursingNewborn Assessment Polydactyl SyndactylSPINE Should be straight and flat Anus should be patent without any fissure Dimpling at the base is associated with spina bifida A degree of hypotonicity or hypertonicity is indicative of central nervous system (CNS damage)SKIN Assessment for Jaundice The #1 technique is to blanch the skin over the bony prominence such as the forehead, chest or tip of the nose. NOTE: Jaundice starts at the head first, spreads to the chest, then the abdomen, then the arms and legs, followed by the hands and feet, which are the last to be jaundiced. Jaundice in the first 24 hours after the birth is a cause for concern that requires further assessment. Possible causes of early jaundice are blood incompatibility, oxytocin induction, and severe hemolytic process. Mongolian Spots Gary, blue or black marks that are frequently found on the sacral area, buttocks, arms shoulders or other areas. Harlequins Sign Occurs on one side of the body turns deep red color. It occurs when blood vessels on one side constrict, while those on the other side of the body dilate.Newborn Assessment Abejo
  8. 8. Maternal and Child Health NursingNewborn Assessment Erythema toxicum  Is an eruption of lesions in the area surrounding a hair follicle that are firm, vary in size from 1-3 mm, and consist of a white or pale yellow papule or pustule w/ an erythematous base.  It is often called “newborn rash” or “flea-bite” dermatitis  The rash may appear suddenly, usually over the trunk and diaper area and is frequently widespread.  The lesions do not appear on the palms of the hands or soles of the feet.  The peak incidence is 24-48 hours of life.  Cause is unknown and no treatment necessary Acrocyanosis versus Central Cyanosis  Acrocyanosis involves the extremities of the neonate, for example bluish hands and feet due to neonates being cold or poor perfusion of the blood to the periphery of the body.  Central cyanosis, which involves the lips, tongue and trunk indicating HYPOXIA which needs further assessment by the nurse. . Milia are blocked sebaceous glands located on the chin and the nose of the infant. VERNIX CASEOASA Should not be removed by oil or hand lotion, because it is a protective layer of the neonate after birth, and it disappears after birth. Never remove it with alcohol or cotton balls, unless meconium skinned.Newborn Assessment Abejo
  9. 9. Maternal and Child Health NursingNewborn Assessment BIRTH MARKS Telangiectatic nevi (stork bites)  Appear as pale pink or red spots and are frequently found on the eyelids, nose, lower occipital bone and nape of the neck  These lesions are common in NB w/ light complexions and are more noticeable during periods of crying. These areas have no clinical significance and usually fade by the 2nd birthday Hemangioma is benign vascular tumor that may be present on the newborn 3 types Hemangiomas 1. Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. NEVER disappear. Can be removed surgically 2. Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal area. Enlarges, disappears at 10 yo. 3. Cavernous hemangiomas – communication network of venules in SQ tissue that never disappear with age. Nevus Flammeus (port-wine stain)  A capillary angioma directly below the epidermis, is a non-elevated, sharply demarcated, red-to-purple area of dense capillaries.  Macular purple  The size & shape vary, but it commonly appears on the face. It does not grow in size, does not fade in time and does not blanch. The birthmark maybe concealed by using an opaque cosmetic cream.  If convulsions and other neurologic problem accompany the nevus flammeus,---- 5th cranial nerve involvement. Nevus vasculosus (strawberry mark)  A capillary hemangioma, consists of newly formed and enlarged capillaries in the dermal and subdermal layers.  It is a raised,clearly delineated, dark-red, rough-surfaced birthmark commonly found in the head region.  Such marks usually grow starting the second or third week of life and may not reach their fullest size for 1 to 3 months; disappears at the age of 1 yr. but as the baby grows it enlarges.  Providing appropriate information about the cause and course of birthmarks often relieves the fears and anxieties of the family. Note any bruises, abrasions,or birthmarks seen on admission to the nursery.Newborn Assessment Abejo
  10. 10. Maternal and Child Health NursingNewborn Assessment GESTATIONAL ASSESSMENTPARAMETER NURSING ‘TERM’ born between ‘PRETERM’ born before 37 weeks ACTION 37-42 weeks gestation gestationEAR Fold the pinna Pinna recoils (springs Pinna opens slowly or stays folded (auricle) forward back) in very premature infantsBREAST TISSUE Measure it 3 mm Less than 3 mmFEMALE GENITALIA Observe Labia majora cover Labia minora are more prominent; labia minora vaginal opening can be seenMALE GENITALIA Observe Scrotal sac very Fewer shallow rugae on the scrotum wrinkledHEEL CREASES Observe Extend 2/3 of the way Soles are smoother, creases extend from the toes to the heel less than 2/3 of the way from the toes to the heel NEWBORN REFLEXES Immature central nervous system (CNS) of newborn is characterized by variety of reflexes o Some reflexes are protective, some aid in feeding, others stimulate interaction o Assess for CNS integration Protective reflexes are blinking, yawning, coughing, sneezing, drawing back from pain Rooting and sucking reflexes assist with feeding“What reflexes should be present in a newborn? Reflexes are involuntary movements or actions. Some movementsare spontaneous, occurring as part of the babys usual activity. Others are responses to certain actions. Reflexeshelp identify normal brain and nerve activity. Some reflexes occur only in specific periods of development. Thefollowing are some of the normal reflexes seen in newborn babies””PALMAR GRASP  Newborn’s fingers curl around the examiner’s fingers and the newborn’s toesREFLEX curl downward.  The palmar grasp reflex is elicited by placing an object in the palm of a neonate; the neonates fingers close around it. This reflex disappears between ages 6 and 9 months. Palmar response lessens within 3-4 months Palmar response lessens within 8 monthsROOTING  The rooting reflex is elicited by stroking the neonates cheek or stroking nearREFLEX the corner of the neonates mouth.  The neonate turns the head in the direction of the stroking, looking for food.  This reflex disappears by 6 weeks.SUCKING  The sucking reflex is seen when the neonates lips are touchedREFLEX  Lasts for about 6 monthsNewborn Assessment Abejo
  11. 11. Maternal and Child Health NursingNewborn AssessmentMORO REFLEX  Symmetric & bilateral abduction & extension of arms and hands  Thumb & forefinger form a C  “EMBRACE” reflex  Present at birth, complete response may occur up to 8 weeks  A persistent response lasting more than 6 months may indicate the occurrence of brain damage during pregnancy A normal reflex in a young infant caused by a sudden loud noise. It results in drawing up the legs, an embracing position of the arms, and usually a short cry.BABINSKI’ SIGN  Beginning at the heel of the foot, gently stroke upward along the lateral aspect of the sole; then the examiner moves the fingers along the ball of the foot  The newborn’s toes hyperextend while the big toe dorsiflexes  Absence of this reflex indicates the need for a neurological examination  The Babinski reflex is elicited by stroking the neonates foot, on the side of the sole, from the heel toward the toes.  A neonate will fan his toes, producing a positive Babinski sign, until about age 3 monthsSTEPPING OR  The newborn simulates walking, alternately flexing and extending the feetWALKING  The reflex is usually present 3-4 monthsREFLEXTONIC NECK  While the newborn is falling asleep or sleeping, gently and quickly turn the headREFLEX to one side  As the newborn faces the left side, the left arm & leg extend outward while the right arm & leg flex  When the head is turned to the right side, the right arm & leg extend outward while the left arm & leg flex  Usually disappears within 3-4 monthsNewborn Assessment Abejo
  12. 12. Maternal and Child Health NursingNewborn AssessmentCRAWLING Place the newborn on the abdomen The newborn begins making crawling movements with the arms and legs The reflex usually disappears after about 6 weeks BASIC TEACHING NEEDS OF NEW PARENTSCORD CARE Cleanse the cord with alcohol and sometimes triple dye once a day Keep the area clean and dry Keep the newborn’s diaper below the cord to prevent irritation Signs of infection: redness, drainage, swelling, odor Notify physician for signs of infection NOTE: Note any bleeding or drainage from the cord Triple dye may be applied for initial cord care because it minimizes microorganisms and promotes drying; use a cotton-tipped applicator to paint the dye, one time, on the cord on 1 inch of surrounding skin Application of 70% isopropyl alcohol to the cord with each diaper change and at least two r three times a day to minimize microorganisms and promote drying. NOTE: The skin is surrounded with alcohol which promotes drying and cleans the area. The umbilical cord dries and falls off about 14 days. Peroxide and lanolin promote moisture, which can inhibit drying and allow growth of bacteria. Water doesn’t promote drying. It is best to care for the neonate’s umbilical cord area by cleaning it with cotton pledgets moistened with alcohol. The alcohol promotes drying and helps decrease the risk of infection. An antibiotic ointment maybe used instead of alcohol, because there are a lot of bacteria which is resistant against some bacteria. Other agents such as wipes, sterile water and soap & water are not as effective as alcohol.CIRCUMCISION Observe for bleeding, first urinationCARE Apply diaper loosely to prevent irritation Notify physician for signs of infectionBONDING Encourage parent to talk to, hold, and sing to infant Promotes skin-to-skin contact between parent and infant Feedings are opportunities for parent-infant bonding Notify physician for signs of infection NOTE: Sense of Touch The most highly developed sense at birth that is why, neonates responds well to touch.Newborn Assessment Abejo
  13. 13. Maternal and Child Health NursingNewborn Assessment PRE TERM INFANT ( PREMATURE INFANT)Definition PRE TERM INFANT  A neonate born before 38 weeks age of gestationSynonym Low birth weightContributing factors  Low socioeconomic level  Poor nutritional status  Lack of pre natal care  Multiple pregnancy  Prior previous early birth  Race (non whites have a higher incidence of prematurity than whites)  Cigarette smoking  The age of the mother ( the highest incidence is in mother’s younger than age 20.)  Order of birth ( early termination is highest in first pregnancies and in those beyond the forth )  Closely spaced pregnancies  Abnormalities of the reproductive system such as intrauterine septum  Infections ( specially urinary tract infections)  Obstetric complications such as premature rupture of membranes or premature separation of the placenta  Early induction of labor  Elective cesarian birth  Appears small and underdevelopedCardinal signs  The head is disproportionately large ( 3 cm or more greater than chest size)  Skin is thin with visible blood vessel and minimal subcutaneous fat pads  Vernix caseosa is absent  Both anterior and posterior fontanelles are smallAbnormal laboratory values  Decreased RBC’s  Decreased serum glucose  Increased concentration of indirect bilirubin  Decreased serum albumin  NOTE: The normal range of urine output for a preterm baby is 1 to 2ml/kg/day. The normal specific gravity for a preterm baby is 1.020. The normal range for blood glucose level in a preterm baby is 40 to 60 mg/dl.Best procedure  Resuscitation NOTE: resuscitation becomes important for infant who fails to take first breath or difficulty maintaining adequate respiratory movements on his own.Newborn Assessment Abejo
  14. 14. Maternal and Child Health NursingNewborn Assessment  Suctioning NOTE: allows removing mucus and prevents aspiration of any mucus and amniotic fluid present in the mouth and nose of the newborn to establish clear airway.  Intubations NOTE: head of the infant in neutral position with towel under shoulder.Best position  Positioning the infant on the back with the head of the mattress elevated approximately 15 degrees to allow abdominal contents to fall away from the diaphragm affording optimal breathing space. Best position for suctioning:  Infant on the back and slide a folded towel or pad under shoulders to rise, head is in neutral position.Complications  Anemia of prematurity  Hyperbilirubinemia/ kernicterus  Persistent patent ductus arteriosus  Periventricular / intraventricular hemorrhage  Respiratory distress syndrome  Retinopathy of prematurity Retrolental fibroplasias are a complication that occurs if the infant is overexposed to high oxygen levels.  Necrotizing enterocolitisBedside equipment  Preterm size laryngoscope  ET tube  Suction catheter with synthetic surfactant  Isolettes (incubator)Drug study 1. Naloxone (Narcan) Nature of the drug:  Narcotic antagonist Side effects:  Hypertension, irritability, tachycardia 2. Surfactan ( Survanta) Nature of the drug:  Lung surfactant to improve lung compliance Side effect:  Transient bradycardia, rales 3. Vitamin K (Aquamephyton)  Use for prophylaxis to treat hemorrhagic disease of the newborn. Side effects:  Hyperbilirubinuria 4. Eye prophylaxis (Erythromycin 0.5% Ilotycin, Tetracycline 1% Silver Nitrate 1% ( not already used – causes chemical conjunctivitis)  Prophylactic measure to protect against Neisseria gonorrhoeae and Chlamydia trachomatis Side effects:  Silver nitrate can cause chemical conjuctivitisNursing diagnosis 1. Impaired gas exchange related to immature pulmonary functioning 2. Risk for fluid volume deficit related to insensible water loss at birth and small stomach capacityNewborn Assessment Abejo
  15. 15. Maternal and Child Health NursingNewborn Assessment 3. Risk for aspiration related to weak or absent gag reflex a nd/or administration of tube feedings 4. Hypothermia related to lack of subcutaneous and brown fat deposits, inadequate shiver response, immature thermoregulation center, large body surface area in relation to body weight, and/or lack of flexion of extremities toward the body. 5. Risk for infection related to immature immune response, stasis of respiratory secretions, and/ or aspiration 6. Imbalanced nutrition: less than body requirements related to lack of energy to suck and/or weak or absent sucking reflexNursing intervention The nurse’s first priority in preparing a safe environment for a preterm newborn with low Apgar scores is to prepare respiratory resuscitation equipment. Airway maintenance is the first priority. Give the mother oxygen by mask during the birth to provide the preterm infant with optimal oxygen saturation at birth ( 85-90%). Keeping maternal analgesia and anesthesia to a minimum also offers the infant the best chance of initiating effective respiration. Bedside larngyoscope, endotracheal tube, suction catethers and synthetic surfactant to be administered by the endotracheal tube. Infant must be kept warm during resuscitation procedures so he or she is not expending extra energy to increase the metabolic rate to maintain body temperature. Observe for changes in respirations, color and vital signs Check efficacy of Isolette: maintain heat, humidity and oxygen concentration, administer oxygen only if necessary Maintain aseptic technique to prevent infection Adhere to the techniques of gavage feeding for safety of infant Observe weight-gain patterns Determine blood gases frequently to prevent acidosis. Institute phototherapy when hyperbilirubinemia occurs Support parents by letting them verbalize and ask questions to relieve anxiety. Provide liberal visiting hours for parents, allow them to participate in care. Arrange follow-up before and after discharge by a visiting nurse.Newborn Assessment Abejo
  16. 16. Maternal and Child Health NursingNewborn Assessment POST TERM INFANT Definition POST TERM INFANT  A neonate born after 42 weeks age of gestation  Low socioeconomic level Contributing factors  Poor nutritional status  Lack of pre natal care  Multiparous mother’s  Cigarette smoking  The age of the mother (the highest incidence is in mother’s younger than age 20.)  Mother’s with diabetes mellitus  Congenital abnormalities such as omphalocele.  Body is covered with lanugo  Old man facies Classic signs  Intrauterine weight loss, dehydrations and chronic hypoxia “old man faces’  Long & thin with cracked skin which is loose, wrinkled and strained greenish yellow, with no vernix nor lanugo  Long nails with firm skull  Wide eyed alertness of one month old baby Abnormal laboratory  Increased total no. of RBC’s values  Increased hematocrit level  Decreased serum glucose Screening test  Sonogram  Resuscitation Best procedure NOTE: resuscitation becomes important for infant who fails to take first breath or difficulty maintaining adequate respiratory movements on his own.  Suctioning NOTE: allows removing mucus and prevents aspiration of any mucus and amniotic fluid present in the mouth and nose of the newborn. To establish clear airway.  Intubations NOTE: head of the infant in neutral position with towel under shoulder.  Positioning the infant on the back with the head of the mattress Best position elevated approximately 15 degrees to allow abdominal contents Complications  Meconium aspiration syndrome  Respiratory distress syndrome NOTE: Post mature neonates have difficulty maintaining glucose reserves. Other common problems include Meconium aspiration syndrome, polycythemia, congenital anomalies, seizure activity and cold stress. NOTE: The infant who are exposed to high blood-glucose levels in utero may experience rapid and profound hypoglycemia after birth because of the cessation of a high in-utero glucose load. The small-for- gestational-age infant has use up glycogen stores as a result of intrauterine malnutrition and has blunted hepatic enzymatic response with which to carry out gluconeogenesis.Newborn Assessment Abejo
  17. 17. Maternal and Child Health NursingNewborn Assessment NOTE: The patient with post-term pregnancy is at high risk for decreased placental functioning, therefore increasing the risk of inadequate oxygen circulation to the fetus Bedside equipment  ET tube  Suction catheter Drug study 1. Vitamin K (Aquamephyton)  Use for prophylaxis to treat hemorrhagic disease of the newborn Side effects:  Hyperbilirubinuria 2. Eye prophylaxis (Erythromycin 0.5% Ilotycin, Tetracycline 1% Silver Nitrate 1%  Prophylactic measure to protect against Neisseria gonorrhoeae and Chlamydia trachomatis Side effects:  Silver nitrate can cause chemical conjuctivitis Nursing diagnoses 1. Ineffective airway breathing 2. Risk for fluid volume deficit related to insensible water loss at birth 3. Ineffective infant feeding pattern Nursing interventions  Assess newborn’s respiratory rate, depth and rhythm. Auscultate lung sound. Note: Meconium stained syndrome of POST MATURE neonates Aspiration of meconium is best prevented by suctioning the neonate’s nasopharynx immediatelt after the head is delivered and before the shoulders and chest are delivered. As long as the chest is compressed in the vagina, the infant will not inhale and aspirate meconium in the upper respiratory tract. Meconium aspiration blocks the air flow to the alveoli, leading to potentially life threatening respiratory complications.  Suction every 2 hours or more often as necessary  Position newborn on side or back with the neck slightly extended  Administer O2, anticipate the need for CPAP or PEEP  Continue to assess the newborn’s respiratory status closely.  Encourage as much parental participation in the newborn’s care as condition allows  Administer IV fluids after birth to provide Glucose to prevent hypoglycemia, monitor closely the infusion rate.  Kept the infant under a radiant heat warmer to preserve energy  Monitor baby’s weight, serum electrolytes and ensure adequate fluid intake  Measure urine output by weighing diapers  Check for blood stools to evaluate for possible bleeding from intestinal tract.  Keep a restful environment.  Anticipate the infants need to be breastfeed  Demonstrate technique for feeding to mother, note proper positioning of the infant, “latching on” technique, rate of delivery of feeding and frequency of burping  Provide a relaxed environment during feeding  Adjust frequency and amount of feeding according to infants response  Alternate feeding procedure (nipple and gavage feeding) according to infants ability.  Monitor mother’s effort, provide feedback and assistance as needed  Suggest mother to monitor infants weight periodicallyNewborn Assessment Abejo