Care of the Newborn

Lecture Ten: Care of the Newborn
NURS 2208
T. Dennis RNC, MSN
Neonatal Transition

Respiratory Adaptations

• Fetal lung development
• Fetal breathing movements
• Initiation of breathing
• Mechanical events
• Chemical stimuli
• Thermal stimuli
• Sensory stimuli

Fetal Lung Development (681)

• Between 24-28 weeks Surfactant synthesis and storage begins to occur.
• Surfactant (composed of a group of surface active phospholipids, lecithin and sphingomyelin, which are critical for aveolar stability.
• The newborn born before the lecithin/sphingomyelin (L/S) ratio is 2:1 will have varying degrees of respiratory distress.
• May need synthetic surfactant if born with respiratory distress.

Breathing Movements (pg. 681-684)

• Breathing is a continuation of a process that began inutero.
• Lungs convert from fluid filled to gas filled organs.
• Pulmonary ventilation must be established through lung expansion following birth.
• A marked increase in pulmonary circulation must occur.
• Mechanical events, chemical stimuli, thermal stimuli, and sensory stimuli.
• Factors opposing the first breath: 1) aveolar surface tension, 2) viscosity of lung fluid within the respiratory tract and 3) degree of lung compliance.

Cardiopulmonary Physiology

• Cardio pulmonary adaptation
• Oxygen transport
• Maintaining respiratory function
• Characteristics of newborn respiration

Transitional Physiology (pg. 686-687)

• 1) Increased aortic pressure and decreased venous pressure:.
• 2) Increased systemic pressure and decreased pulmonary artery pressure.
• 3) Closure of the foramen ovale: venosus.
• occurs due to increased pressure in the left atrium.
• 4) Closure of the ductus arteriosus.
• 5) Closure of the ductus

Characteristics of Cardiac Function (pg. 687-689)

• Heart rate
• Blood pressure
• Heart murmurs
• Cardiac workload

Heart rate

• The average resting heart rate for full term newborns is 120 to 160 (when the newborn cries the heart rate may exceed 180).
• Apical pulses should be obtained by auscultation for a full minute, preferably while the newborn is asleep.
• The heart rate should be evaluated fore abnormal rhythms or beats.

Blood Pressure

• The newborn blood pressure tends to be higher immediately after birth.
• Blood pressure is sensitive to the changes in blood volume that occur in the transition to newborn circulation.
• Capillary refill should be less than 2 to 3 seconds when the skin is blanched.

Blood Pressure

• Crying may cause an elevation in blood pressure.
• Blood pressure should be taken while the newborn is in a quiet state.
• Measurement of blood pressure is best accomplished by using the Doppler technique or a 1 to 2 inch cuff and a stethoscope over the brachial artery.

Heart Murmurs

• Murmurs are usually produced by turbulent blood flow.
• 90% of all murmurs are transient and not associated with anomalies.
• Usually involve incomplete closure of the ductus arteriosis or foramen ovale.

Cardiac Workload

• Systemic blood volume and pulmonary blood volume are not equal in the neonate.
• The right ventricle does most of the work prior to birth.
• The left ventricle increases its workload after birth and gains in size and thickness.
• Right sided heart defects appear better tolerated than left sided defects.

Hematological Adaptations

• Physiologic anemia of infancy
• Delayed cord clamping and normal shift of plasma to extravascular spaces
• Gestational age
• Prenatal or perinatal hemorrhage
• The site of the blood sample

Temperature Regulation

• Thermal neutral zone (TNZ)
• Heat loss: Convection, Radiation, Evaporation and Conduction
• Heat production (Thermogenesis)
• Brown adipose tissue (BAT, brown fat)
• Response to heat

Hepatic Adaptations

Iron Storage and Red Blood Cell Production:

• 1) Iron is stored in the liver until needed for red blood cell (RBC) production.
• 2) Newborn iron stores are determined by total body hemoglobin content and length of gestation.
• 3) If the mother’s iron intake has been adequate, newborn iron stores will be stored to last until 5 month of age.
• 4) After about 6 months of age, foods containing iron or iron supplements may be given to prevent anemia.

Hepatic Adaptations

Carbohydrate Metabolism:

• 1) Neonatal carbohydrate reserves are relatively low.
• 2) Energy crunch occurs at birth with the removal of maternal glucose supply and increased energy expenditure adjusting to extrauterine life.
• 3) Glucose is the main source of energy in the first 4 to 6 hours following birth.
• 4) Blood glucose level stabilizes at values of 50 to 60 mg/dL.
• 5) Glucose level is assessed by using a chemstrip method on admission to the nursery and at 4 hours of age.

Hepatic Adaptations

Conjugation of Bilirubin:

• 1) Conjugation of bilirubin is the conversion of yellow lipid soluble pigment into water soluble pigment.
• 2) Unconjugated (indirect) bilirubin is a breakdown product derived from hemoglobin that is released primarily from destroyed red blood cells.
• 3) Unconjugated bilirubin is not in an excretable form and is 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, then into the common duct and duodenum. The direct (conjugated) bilirubin then progresses down the intestines where bacteria transform it into urobilinogen. This product is not reabsorbed but is excreted as a yellow-brown pigment in the stools.

Hepatic Adaptations

Physiologic Jaundice:

• Physiologic jaundice is caused by accelerated destruction of fetal RBCs, 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 of bilirubin are delivered to the liver, 2) Defective uptake of bilirubin from the plasma, 3) Defective conjugation of the bilirubin, 4) Defect in 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 exhibit physiologic jaundice on the second or third postpartum day.
• There appears a characteristic yellow color that results from increased levels of unconjugated bilirubin and a temporary inability to eliminate bilirubin.
• The signs of physiologic jaundice occur after 24 hours after birth.
• Breast milk jaundice is controversial and difficult to distinguish from prolonged jaundice.

Hepatic Adaptations

Coagulation:

• Coagulation factors II, VII, IX, and X are activated under the influence of vitamin K and are considered vitamin K dependant.
• The absence of normal intestinal flora needed to synthesize vitamin K in the newborn gut results in low levels of vitamin K.
• Although newborn bleeding problems are rare, an injection of vitamin K (AquaMEPHYTON) is given prophylactically on admission to the nursery to combat potential clinical bleeding problems.

Gastrointestinal Adaptations (pg.697-698)

• By 36 to 38 weeks gestation, the gastrointestinal tract is adequately mature: 1) enzymatic activity present, 2) able to transport nutrients.
• Lactose is the primary carbohydrate in the breastfeeding newborn and is usually easily digested and well absorbed.
• By birth the newborn has experienced swallowing, gastric emptying, and intestinal propulsion.
• The newborn’s stomach has a capacity of 50 to 60 mls.
• The cardiac sphincter is immature, as is neural control of the stomach, so some regurgitation may be noted.
• Term newborns normally pass meconium (dark green to black) within 8 to 24 hours of life and almost always by 48 hrs.
• Transitional (thinner brown to green) stools are passed for the 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.

Urinary Adaptations (pg. 698-699)

• Full term newborns are less able than adults to concentrate urine (reabsorb water back into the blood) due to shorter and narrower tubules.
• Concentrating and dilutional limitations of renal function are important considerations in monitoring fluid therapy to avoid dehydration and overhydration.
• Many newborns void immediately after birth. A newborn who has not voided by 48 hours should be assessed for inadequate fluid intake, bladder distention, restlessness, and symptoms of pain.
• The first two days of birth the newborn voids two to six times 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 of maternal hormones) may be seen as blood on the newborn female’s diaper.

Immunologic Adaptations

• Limitations in the newborn’s inflammatory response results in failure to recognize, localize, and destroy invasive bacteria.
• The signs and symptoms of infection are often subtle and nonspecific 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 the newborn.
• Passive acquired immunity : transfer of antibodies (IgG) from the mother to the fetus in utero.
• Newborns have maternally induced immunity to tetanus, diphtheria, smallpox, measles, mumps, poliomyelitis, and a variety of other bacterial and viral disease.
• Immunity against common viral infections such as measles may last 4 to 8 months; whereas immunity to certain bacteria may disappear within 4 to 8 weeks.
• Colostrum, the forerunner of breast milk is very high in immunoglobulin IgA which may provide some passive immunity to the breastfeeding newborn.

Neurological and Sensory/Perceptual Functioning

• Intrauterine factors influencing newborn behavior: maternal nutrition and extrauterine environment (noise).
• Characteristics of newborn neurological function: partially flexed extremities, eye movements are observable, may fixate on faces, or geometric objects, cry is lusty and vigorous, knee jerk is brisk, plantar flexion is present.
• Periods of reactivity: First Period of reactivity, Period of Inactivity to sleep phase, Second period of reactivity.
• Behavioral states of the newborn: Sleep states and Alert states.
• Behavioral and sensory capacities of the newborn: Habituation, Orientation, Self-quieting ability, auditory capacity, olfactory capacity, taste and sucking, and tactile capacity.

Nursing Assessment of the Newborn

• Assessment of the newborn is a continuous process used to evaluate development and adjustments to extrauterine life.
• Assess immediately after birth: r/o resuscitation and allow bonding.
• Assessment within 1 to 4 hours after birth: progress of newborns adaptation, gestational age, ongoing assessment of high-risk problems.
• Assessment procedures in the first 24 hours or prior to discharge.

Nursing Assessment of the Newborn

 

Estimation of Gestational Age

• Must be established in the first four hours of birth.
• Ballard and Dubowitz.
• Include external physical characteristics and neurological or neuromuscular development evaluations.
• Some maternal conditions may affect certain gestational age assessment components. (PIH, Diabetes, analgesia).

Estimation of Gestational Age (pg 707- 714)

PHYSICAL CHARACTERISTICS:

• Resting posture: assessed undisturbed on a flat surface
• 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 gives shape. Pinna is firm at term.
• Male genitals: Size of scrotal sac, the presence of rugae, and descent of the testicles.
• Female genitals: size of labia majora and minora.
• Vernix: None in the post term infant. More seen with prematurity.
• Hair: Preterm patchy, term silky.
• Skull firmness: increases as the fetus matures.
• Nails: long may be a sign of postmaturity.

Estimation of Gestational Age (pg 707- 714)

NEUROMUSCULAR CHARACTERISTICS

• The square window sign: elicited by flexing the baby’s hand toward the ventral forearm until resistance is felt (the angle formed at the wrist is measured).
• Recoil: test of flexion development. Lower extremities are tested first.
• Popliteal angle: degree of knee flexion, angle is increased in the preterm infant.
• Scarf sign: elicited by placing the newborn in supine position and drawing an arm across the chest toward the newborn’s opposite shoulder. The location of the elbow is noted in relation to the midline of the chest.
• Heel to ear extension: with advancing age greater resistance 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 degree of flexion in the arms and legs are noted.
• Major reflexesevaluated.

Physical Assessment

• General appearance: Head larger than body
• Weight and measurements: average birth weight is 7lbs, 8oz, average length is 18 -22 inches.
• Temperature: assessed by axillary method after initial rectal temp. 97.7 to 98.6.
• Skin characteristics: (719)
• Head: 12.5 to 14.5 inches, approximately 2 cms larger than the chest circumference. Cephalohemotoma, caput succedenum
• Face: blue or dark. Chemical conjunctivits, subconjunctival hemorrhages. Epsteins pearls or thrush.
• Neck looks short, creased with skin folds. Fractured clavicle.
• Chest:engorged breasts
• Cry: strong and of medium pitch
• Respiration: 30 to 60 respiratory rate
• Heart: 120 -160 HR
• Abdomen: appears prominent
• Umbilical cord: white and gelatinous, bleeding is uncommon, umbilical cord hernia abnormal.
• Genitals: may have vaginal discharge in the first week of life (white, thick)
• Anus: check for imperforate anus or atresia (done visually)
• Extremities: check for abnormalities, polydactyly, Erb’s palsy.

Skin Characteristics (pg 719)

• 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)

Assessment of Neurological Status (pg. 732)

• Tonic neck reflex
• Grasping reflex
• Moro reflex
• Rooting reflex
• Sucking reflex
• Babinski reflex
• Trunk incurvation (Galant reflex)

Newborn Behavioral Assessment

• Habituation
• Orientation to inanimate and animate visual and auditory assessment stimuli.
• Motor activity
• Variations in quiet alert states, state changes and color changes.
• Self quieting activity assessment on how often and how quickly newborns quiet themselves.
• Cuddliness or social behaviors.

Nursing Care Management of the Newborn During Stay in the Birthing Unit (pg.762-776)

Nursing Diagnosis

• Risk for ineffective breathing pattern
• Altered nutrition: less than body requirements
• Altered urinary elimination
• Risk for infection
• Knowledge deficit
• Altered family processes

Nursing Plan and Implementation (pg. 762-772)

• Maintenance of cardiopulmonary function
• Maintenance of a neutral thermal environment
• Promotion of adequate hydration and nutrition
• Promotion of skin integrity
• Prevention of complications and preventing safety
• Enhancing parent-newborn attachment

Maintenance of Cardiopulmonary Function

• Assess vital signs every 6 to 8 hrs or more depending on the newborn’s status.
• “Back to Sleep” , side lying to prevent aspiration and facilitate drainage of mucus.
• Keep bulb syringe readily available.
• Vigorous fingertip stroking of the spine frequently stimulates respiratory activity.
• Cardiac/respiratory monitor may be required.
• At-risk indicators: pallor, cyanosis, ruddy color, and apnea.

Maintenance of a Neutral Thermal Environment

(pg. 763-764)

• Maintain the newborn’s temperature within the normal range.
• Make certain the infant is dressed and bundled appropriately. Small caps may be used for the LBW or premature infant.
• Newborns use calories for warmth rather than growth.
• Chilling increases the affinity of serum albumin for bilirubin.
• Chilling increases oxygen use and may cause respiratory distress.
• Overheating will increase respiratory rate and activity in an attempt to cool the body, also increasing insensible fluid loss.

Promotion of Adequate Hydration and Nutrition (pg 764)

• Weigh at the same time each day.
• Weight loss of up to 10% is considered normal during the first week of life.
• Birth weight should be regained by the 2 nd week of life.
• The nurse records voiding and stooling patterns.
• The first void should occur within the first 24 hours and passage of stool in the first 48 hours.
• Assess for abdominal distention, bowel sounds, hydration, fluid intake, voiding pattern, and temperature stability.
• Excessive handling may cause an increase in the newborn’s metabolic rate, calorie use and fatigue.

Promotion of Skin Integrity (pg 764-765)

• Bathing is important for health, appearance, and infect5ion control in the nursery.
• Ongoing skin care includes cleansing of the buttocks and perineal area with water and a mild soap with diaper changes.
• Assess the umbilical cord for signs of bleeding or infection: 1) apply triple dye on admission to nursery and 2) alcohol after each diaper change.
• Cord care with each diaper change.
• Eye and skin care related to phototherapy.
• Skin care following circumcision.

Prevention of Complications and Promoting Safety (pg 765-767)

• Pallor may be an early sign of hemorrhage.
• Circumcision is assessed for signs of hemorrhage and infection.
• Initial scrub for 2-3 minutes when direct contact with the newborn is anticipated.
• Handwashing between each client contact and contact with floor, face, or any soiled surface.
• Encourage parents to wash hands prior to holding the infant and wear a gown over street clothes.
• Teach parents to limit visitors who may have a communicable disease.
• Check namebands with each encounter with the parents.
• Instruct clients in security measures in place to prevent infant abduction.

Enhancing Parent-Newborn Attachment

(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 the infant

 

Discharge Planning and Preparation (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 immunization Program

Community-Based Nursing Care for the Newborn (pg. 773-776)

• The family should have access to the birthing unit and physician phone numbers.
• The client should be made aware of follow-up programs such as PRS, early intervention and high-risk referral.
• Referral to the public health department.
• Hospital phone follow-up.

Questions?

DOWNLOAD PPT NOTES : Lecture 10