Nursing of a family care-of-the-newborn.ppt

THE
1ST 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

IMMEDIATE
CARE OF THE
NEWBORN
• Airway
• Breathing
• Temperature

Airway & Breathing
• Suction gently & quickly using
bulb syringe or suction catheter
• Starts in the mouth then, the nose
to prevent aspiration
051104 Neonatal Care 4

Airway & Breathing
• Stimulate crying by rubbing
• Position properly- side lying / modified t-
berg
• Provide oxygen when necessary

Temperature
• Dry immediately
• Place in infant warmer or use droplight
• Wrap warmly

APGAR Scoring
• Standardized evaluation of the newborn
• Perform 1 minute and 5 minutes after birth
• Involves (5) indicators:
1. Activity
2. Pulse
3. Grimace
4. Appearance
5. Respirations

CARE OF THE NEWBORN
IN THE NURSERY

Components
• Anthropometric Measurements
• Bathing – Oil bath/ warm water bath
• Cord Care
• Dressing/ Wrapping - mummified
• Eye prophylaxis – Crede’s
• Foot printing / Identification
• Get APGAR score – 1 & 5 mins
• HR, RR, Temp, BP
• Injection of Vitamin K

Components
1. Proper identification –tag/bracelet
2. Oil bath/ Warm water bath
3. Cord Care/ Dressing
4. Measurements
1. Weight
2. Anthropometric measurements

6. Crede’s Prophylaxis
7. Vitamin K Administration
8. Foot printing/ marking
9. Vital signs
10. Dressing/ wrapping

Proper Identification
• After delivery, gender should be
determined
• Pertinent records should be
completed including the ID
bracelet
• Before transferring to nursery, ID
tag should be applied.

Bathing
• Oil bath or complete
warm water bath
• From cleanest to
dirties part
• DO NOT remove
vernix caseosa
vigorously

Cord Care

Weight/ Anthropometric Measurements

Crede’s Prophylaxis

Vitamin K Administration

Foot Printing

Vital Signs

Dressing/ Wrapping
• “Mummy”
• Wrap in warm blanket
• Cover head with
stockinette cap

Daily Care
1. Nutrition/ Feeding
2. Elimination
3. Weight
4. Bathing & Hygiene/ Grooming
5. Obtain vital signs
6. Rooming-in
7. Note for any abnormalities

NEWBORN
ASSESSMENT
Assessment of the newborn is essential to
ensure a successful transition

Major Time Frames
1. Immediately after birth
2. Within the 1st 4 hours after birth
3. Prior to discharge

APGAR Scoring System
A ctivity/ Muscle Tone
P ulse/ Heart Rate
G rimace/ Reflex Irritability/ Responsiveness
A ppearance/ Skin Color
R espiration/ Breathing
1 2 3 4 5

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

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% O2
CPR
Maintain body temperature
Parental support

General Guidelines
• Keep warm during examination
• From general to specific
• Least disturbing first
• Document ALL abnormal findings & provide nursing care

Posture
• Full term:
• Symmetric
• Face turned to side
• Flexed extremities
• Hands tightly fisted with thumb covered by the fingers

Special Concerns
• Asymmetric
• Fractured clavicle or humerus
• Nerve injuries (Erb-Duchenne’s Paralysis)
• Breech Presentation
• Knees and legs straightened or in FROG position

TEMPERATURE
• Site: Axillary NOT Rectal
• Duration: 3 mins
• Normal Range: 36.5 – 37.6 C
• Stabilizes within 8-12 hrs
• Monitor q 30 mins until stable for 2 hrs then q 8 hrs

Heat Loss Mechanisms
• Convection – the flow of
heat from the body
surface to cooler
surrounding air
• Eliminating drafts such as
windows or air con, reduces
convection
• Conduction – the transfer
of body heat to a cooler
solid object in contact
with the baby
• Covering surfaces with a
warmed blanket or towel
helps minimize conduction
heat loss

• Radiation – the transfer
of heat to a cooler object
not in contact with the
baby
• Cold window surface or air
con; moving as far from the
cold surface, reduces heat
loss
• Evaporation – loss of
heat through conversion
of a liquid to a vapor
• From amniotic fluid; NB
should be dried immediately

Nursing Considerations
• Keep dry and well-wrapped
• Keep away from cold objects or outside walls
• Perform procedures in warm, padded surface
• Keep room temperature warm

Pulse
• Awake: 120 – 160 bpm—120 – 140 bpm
• Asleep: 90-110 bpm
• Crying: 180 bpm
• Rhythm: irregular, immaturity of cardiac regulatory
center in the medulla
• Duration: 1 full minute, not crying
• Site: Apical

• Keep warm
• Take HR for 1 full minute
• Listen for murmurs
• Palpate peripheral pulses
• Assess for cyanosis
• Observe for CP distress

Special Concerns
• (+) Prominent radial pulse = CHD
• (-) Femoral pulse = Coarctation of aorta

Respiration
• Characteristics:
Nasal breathers, gentle, quiet, rapid BUT shallow; may
have short periods of apnea (<15 secs) and irregular
without cyanosis—periodic respirations
• Rate: 30-60 cpm
• Duration: 1 full minute

• Position on side
• Suction PRN
• Observe for respiratory distress
• Administer oxygen via hood PRN and as prescribed

Blood Pressure
• NOT routinely measured UNLESS
in distress or CHD is suspected
• At birth: 80/46 mmHg*
• After birth: 65/41 mmHg*
• Using Doppler UTZ

Body Measurements
• Weight:
• 5.5 to 9.5 lbs (2500-4300 gms)
• Caucasian: 7 lbs
• Filipinos: 6.5 lbs
• 70-75% TBW is water
• LBW = below 2500 gms; regardless of AOG

• Length:
• 45 to 55 cm (18-22 inches)
• Average: 50 cm
• Techniques: using tape measure
• Supine with legs extended
• Crown to rump
• Head to heel

• Head Circumference (HC):
• 33 to 35.5 cm (13-14 inches)
• Technique: using tape measure
• From the most prominent part of the OCCIPUT to just above
the EYEBROWS

• 1/3 the size of an adult’s head
• Disproportionately LARGE for its body
• HC should be = or 2cm > CC

• Chest Circumference (CC):
• 30 to 33 cm (12-13 inches)
• Technique: using tape measure
• From the lower edge of the SCAPULAS to directly over the NIPPLE
LINE anteriorly
• CC should be = or < 2 cm than HC

•Under natural light
•Assess for:
•Color
•Hair distribution
•Turgor/ Texture
•Pigmentation/ Birthmarks
•Other skin marks

Skin Color
• Velvety smooth and puffy esp. at the legs, dorsal aspects
of hands & feet and in the scrotum or labia
• Pinkish red (light skinned) to pinkish brown to yellow (dark
skinned)
• “Ruddy” or reddish due to increased RBC concentration
and decreased subQ tissues

Skin Color
• Cyanosis/ Acrocyanosis
• Pallor
• Jaundice
• Meconium Staining

Acrocyanosis
• Bluish discoloration of palms of hands & soles of feet
• Due to immature peripheral circulation
• Exacerbated by cold temperatures
• Normal within 1st 24 hrs

Pallor/ Cyanosis
• May indicate hypothermia, infection, anemia,
hypoglycemia, cardiac, respiratory or neurological
problems

Jaundice
•Under natural light
•Blanch skin over the chest or tip of
the nose

• Physiologic
• FT: after the 1st 24 hrs (2-7 days)
• PT:after the 1st 48 hrs
• Peaks at 5-7 days & disappears by the 2nd week
• Due to immaturity of liver
• Usually found over the face, upper body and conjunctiva of
eyes

• Pathologic
• Within 1st 24 hrs
• May indicate early hemolysis of RBC or underlying disease
process
• Duration:
• FT: 1 wk
• PT: 2 wks

Management of Jaundice
• Monitoring serum bilirubin levels
• Physiologic: not more than 5 mg/dl per day
• Pathologic: more than 15-20 mg/dl (critical levels)
• Maintain hydration
• Place in bilirubin lights as needed
• Provide emotional support to parents

Phototherapy units

Nursing Responsibilities:
-cover eyes and sex organ

Meconium Staining
• Over the skin, fingernails & umbilical cord
• Due to passage of meconium in utero r/t fetal hypoxia

Lanugo
• Found after 20 weeks
of gestation on the
entire body except the
palms & soles
• Fine downy hair that
covers the shoulders,
back & upper arms

Nursing Considerations:
• More mature, less lanugo
• May disappear within 2 weeks
• Preterm: woolly patches of lanugo on skin and head
• Post term: parchment-like skin w/o lanugo

Vernix Caseosa
• Protective cheesy-like, gray-white fatty
substance
• FT: skin folds under the arms and in the groin
under the scrotum or in the labia
• Nursing Considerations:
• Use baby oil
• DO NOT attempt to remove vigorously

Desquamation
• Dryness/ peeling of the skin
• Usually occurs after 24-36 hours
• Marked scaliness & desquamation = signs of postmaturity

Milia
• Multiple, yellow or pearly white
papules approx. 1 mm wide
• Due to enlarged or clogged
sebaceous gland
• Usually found on the nose, chin,
cheeks, eyebrows and forehead

Mongolian Spots
• Blue-green or gray
pigmentation
• Lower back, sacrum &
buttocks
• Disappears by 4 years
of age

Salmon Patches
• Seen commonly in NB
• More on Caucasian
• AKA: Naevus simplex,
"angel kisses" (when on
the forehead or eyelids),
and "stork bites" (over
the nape of the neck)
• midline malformations
consisting of ectatic
capillaries in the upper
dermis with normal
overlying skin.

Stork bites
• Telangiectatic Nevi
• Flat red or purple lesions
• Back of neck, lower occiput,
upper eyelid and bridge of
the nose
• After 2 years of age

Strawberry marks
• Nevus Vasculosus or Capillary
Hemangioma
• Dark red, raised lobulated tumor
• Head, neck trunk & extremities
• After 7 to 9 years of age

Large capillary hemangioma

Cavernous Hemangioma

Port-wine stain
• Nevus Flammeus or
Capillary Angioma
• capillary malformation
• Flat Red to purple, sharply
demarcated dense areas
beneath the capillaries
• Face
• Does not fade with time
• Associated with Sturge-
Weber syndrome

Sturge-Weber syndrome
• 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)

Mottling
• Cutis marmorata
• reticulated pattern of
constricted capillaries
and venules due to
vasomotor instability in
immature infants
• Bluish mottling or
marbling of skin in
response to chilling,
stress or overstimulation

Erythema toxicum
• Newborn rash
• Small, white, yellow, or
pink to red papular rash
• Trunk, face & extremities
• Within 48 hrs

Petechiae
• Pinpoint hemorrhages on skin
• Due to increased vascular
pressure, infection or
thrombocytopenia
• Within 48 hrs

Ecchymosis
• Bruises
• As a result of rupture of blood vessels
• May appear over the presenting part
as a result of trauma during delivery
• May also indicate infection or bleeding
problems

Harlequin Sign
• When on side, dependent
side turns red and upper
side/ half turns pale
• Due to gravity and
vasomotor instability or
immature circulation
• Skin resembles a CLOWN’S
SUIT

Café-au-lait spots
• Tan or light brown
macules or patches
• NO pathologic
significance, if <3cm in
length and <6 in
number
• If > 3 or 6 = Cutaneous
neurofibromatosis

Neurofibromato
sis

What to assess
•For symmetry, shape, swelling,
movement
•Soft, pliable, moves easily
•With some molding (if VSD); round
& well-shaped (if CS)
•Measure HC; HC = or > CC

•Fontanelles “soft spot”
•BAD (12-18 mos)
•LPT (2-3 mos or 8-12 wks)
•Bulging or sunken
•Sutures
•Overriding or separated

• Head lag
• Common when pulling newborn to a sitting position
• When prone, NB should be able to lift the head slightly and turn
head from side to side

Caput Succeedaneum
• Swelling of soft tissues of
the scalp
• Due to pressure
• Crosses the suture lines
• Presenting part
• 3 days after birth

Cephalhematoma
• Subperiosteal hemorrhage
with collection blood
• Due to rupture of capillaries
as a result of trauma
• Does not crossed suture lines
• Several weeks

Molding
• Overlapping of skull bones
• Due to compression during
labor and delivery
• Disappears in few days

Forcep Marks
• U –shaped bruising
usually on the cheeks
after forcep delivery

Craniotabes
• Localized softening of the cranial bones
• Can be indented by pressure of fingers
• MOST common among 1st born babies, pathological in
older child—metabolic disorder
• Caused by pressure of the fetal skull against the mother’s
pelvic bone in utero

Craniosynostosis
• Premature closure of the fontanelles

What to Assess
• Facial movement & symmetry
• Symmetry, size, shape and spacing of eyes, nose and
ears

Eyes
• Color:
• white sclera
• Slate gray, brown or dark blue
• Final eye color: after 6-12 months
• Symmetrical
• Pupils equal, round, reactive to light
• (+) Blink reflex

• (+) transient strabismus due to weak EOM
• Able to move and fixate momentarily
• (+) Red reflex – if (-), cataract
• (+) Edema on eyelids r/t pressure during delivery or
effects of medication
• (-) Tear formation (begins @ 2-3 mos)

• Administer eye medication within 1 hr after birth to
prevent Ophthalmia neonatorum
• DOC: Erythromycin 0.5%
Tetracycline 1%
Silver Nitrate 1%
• From inner to outer canthus of the eye (conjunctival sac)

Nose
• Small & narrow
• Flattened, midline
• Nasal breathers
• (+) Periodic sneezing
• Reactive to strong odors
• (+) Flaring = respiratory distress
• (+) Low nasal bridge = Down’s syndrome

Ears
• Soft and pliable; with firm cartilage Pinna should be at the
level of outer canthus of the eye
• (+) Low set ears = renal or chromosomal abnormalities
• May be congested and hear well after few days

Low set ears

Accessory tragus:
remnant of 1st branchial
arch
Congenital preauricular sinus:
ends blindly
risk for infection

Mouth
• Pink, moist gums
• Intact soft & hard palates
• (+) Epstein’s pearls
• Uvula midline
• Tongue moves freely, symmetrical with short frenulum
• (+) Extrusion & Gag reflexes

• Small mouth or large tongue = chromosomal problems
• (+) white patches on tongue or side of the cheek = Oral
thrush

Neck
• Short, thick, in midline
• Able to flex and extend but cannot support the full weight
of head
• Creased with skin folds
• Trachea midline
• Thyroid gland not palpable
• Intact clavicle

Chest
• CC = or < 2cm than HC
• Cylindrical; equal AP:T diameters
• Symmetrical
• Abdominal breathers

•(+) Bronchial sounds
•(+) Breast engorgement ;
subsides after 2 wks
•(+)Prominent/ edematous nipple
•(+) Accessory nipples
•(+) “Witch Milk”

Abdomen
• Umbilical Cord
• 2 arteries; 1 vein
• White & gelatinous immediately after birth
• Begins to DRY between 1-2 hrs following birth
• Blackened or shriveled between 2-3 days
• Dried & gradually falls off by 7 days

Daily Cord Care
• Keep cord dry and clean & clamp secured
• Apply 70% isopropyl alcohol to the cord with each diaper
change and at least 2-3x a day.
• DO NOT cover with diaper
• Note for any signs of bleeding or drainage from the cord
and other abnormalities
• Sponge bath until cord falls off.

• GIT:
• Capacity: 90 ml, with rapid intestinal peristalsis ( 2 ½ to 3 hrs)
• Bowels sounds; (+) within 1-2 hrs after birth
• Presence of mass, distention depression or protrusion
• (+) Scaphoid = diaphragmatic hernia
• (+) Distended = LGIT obstruction/ mass

• Anus
• Check patency
• First stool (Meconium) – within 1st 24 hrs
• Sticky, tarlike, blackish-green, odorless material

Transitional Stool
• Within 2- 10 days after birth
• Breastfed:
• golden yellow, mushy, more frequent 3-4x and sweet smelling
• Bottlefed:
• Pale yello, firm, less frequent 2-3x, with more noticeable odor

• Breastfeeding can usually begin immediately after birth
• Bottlefeeding may be started with sterile water to 4 hrs
after birth prior to formula feeding
• Burp during and after feeding
• Position properly during and after feeding

Genitals
• Female:
• Labia: edematous
• Clitoris: enlarged
• (+) Smegma
• Pseudomenstruation possible
• Visible “hymen tag”
• First voiding within 24 hrs

• Male:
• Prepuce covers glans penis
• (+) adherent foreskin = Phimosis
• Scrotum: edematous
• (+) enlarged = Hernia
• Meatus: central
• (+) ventral/ dorsal = Hypo/epispadias
• Testes: descended
• (+) undescended = Cryptorchidism

Back
• Spine
• Straight, posture flexed
• Supports head momentarily
• Arms & legs flexed
• Chin flexed on upper chest
• Check for protrusion, excessive or poor muscle contractions =
CNS damage

Extremities
• Flexed, full ROM, symmetrical
• Clenched fists; flat soles
• With 10 fingers and toes in each hand
• Legs bowed
• Even gluteal folds

• (+) Creases on soles of feet
• (-) Creases = prematurity
• Check for hip fractures or dysplasia
• (+) Ortolani’s click & uneven gluteal folds = Hip dysplasia

• (+) inward turning of the foot = club foot or talipes
equinovarus

• (+) extra digits = Polydactyly
• (+) web fingers = Syndactyly

Sucking/ Rooting
• Touch the lip, cheek or corner of the mouth
• Turns head toward the nipple, opens mouth, takes hold of
the nipple and sucks
• Disappears after 3-4 mos up to 1 year

Extrusion
• Anything place on the anterior portion of the tongue will
be “spit out’
• To prevent swallowing of inedible substances
• Disappears after 4 months
• Disappearance indicates readiness for semi-solid to solid
foods

Swallowing
• Occurs spontaneously after sucking and obtaining fluids
• NEVER disappear
• Newborn swallows in coordination with sucking without
gagging, coughing or vomiting

Tonic Neck/ Fencing
• While the baby is falling asleep or sleeping, gently and
quickly turn the head to one side
• As the baby faces the left side, the left arm and leg extend
outward while the right arm or leg flex and vice-versa
• Disappears within 3-4 mos

Palmar(Grasping)/ Plantar
• Place a finger in the palm of the baby’s hand, then place a
finger at the base of the toes
• Fingers will curl or grasp the examiner’s finger and the
toes will curl downward
• Palmar: fades within 3-4 mos
• Plantar: fades within 8 mos

Moro
• Hold baby in a semi sitting position then allow the
head and trunk to fall backward to at least a 30-degree
angle
• 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

• Present at birth; complete response at 8 weeks
• MOST significant singular reflex indicative of CNS
problem (>6 mos)
• Disappears after 4-5 mos.

Startle
• Best elicited if baby is 24 hrs old
• Make a loud noise or claps hands
• Baby ‘s arms adduct while elbows flex with fists clenched
• Disappears within 4 mos

Babinski
• Gently stroke upward along the lateral aspect of the sole,
starting at the heel of the foot to the ball of the foot
• Dorsiflexion of big toe and fanning of little toes
• Disappears starts a 3 mos to 1 year
• Disappearance indicates maturity of CNS

Stepping/ Walking/ Dancing
• Hold baby in a standing position allowing one foot to
touch a surface
• Simulates walking by alternately flexing and extending
feet
• Disappears after 3-4 mos

Assessment of Gestational Age
• Dubowitz Maturity Scale
• Gestational rating scale
• NB are observed and tested according to the criteria
• Help determine whether the NB needs immediate high-risk
nursery intervention

Usher’s Criteria
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

Ballard’s Scoring
• Completed in 3-4 min
• 2 portions: physical maturity and neuromuscular maturity

Physical maturity

Neuromuscular Maturity

Scoring

Physical maturity
19

Neuromuscular Maturity
17

Scoring
19+17=36
36 39

Other Nursing Responsibilities
• Identification band
• Birth Registration
• Birth record and
documentation

Newborn Screening
• 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
• Performed after 24 hours of life up to 3 days
except for patient in intensive care, must be
tested by 7 days

• Congenital Hypothyroidism (CH)
• Congenital Adrenal Hyperplasia (CAH)
• Galactosemia (GAL)
• Phenylketonuria (PKU)
• Glucose-6-Phosphate-Dehydrogenase Deficiency
(G6PD Def)

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

Infant Care Skills
• Holding the baby
• Football Hold
• Cradle Hold
• Shoulder Hold

Football Hold
Purpose: to carry on one hand free
A holding technique in bathing a baby
Use for small babies
Procedure:
1. slide forearm under his back
2. support neck and head with your hand
3. press his arm firmly against your side
4. his head faces you
5. infant’s feet tucked under your elbow

Cradle Hold
Purpose: use for feeding and cuddling a baby
Procedure:
• support head in the crook of your arm
• encircle the body with your arm
• press baby firmly against your side
• use other hand to support bottom and thigh

Shoulder Hold
Purpose: use for burping
Procedure:
• draw baby towards your chest with one forearm
• bracing his back and your hand cradling his head
• support your baby’s bottom and thighs with your other arm
• gently press his head against shoulder

THE END

Nursing of a family care-of-the-newborn.ppt

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