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Lecture 12
Adequate breathing pattern established Mouth suctioned 1st Nurse wraps infant in warm blanket & places under radiant warmer Drying motion usually stimulates 1st cry. Drying helps prevent heat loss Note time of 1st cry & success at breathing attempts. May need resuscitative attempts. infant kept unwrapped on clean/dry radiant warmer to promote thermoregulation
Apgar Score
Apgar score - assessment scale since 1958 to assess newborn well-being at 1 & 5 min. Newborn observed & rated on 5 components . Heart rate Respiratory effort Muscle tone Reflex irritability Color
Apgar score
Score of 0, 1, or 2 - each component Five scores added & final number @ 1 & 5 min 9/9 common - 2 on HR, Resp, reflexes, muscle tone & 1 on color d/t acrocyanosis. Heavy sedation of mother may lower respiratory effort or reflex irritability score. Score of 4 or less indication that infant most likely needs resuscitative efforts Score of 4-6 may indicate suctioning and oxygen therapy.
Umbilical Cord
Umbilical Cord: After delivery, 2 clamps placed Cord clamped again 1- 2 inches from umbilicus Vessels counted [2 arteries; 1 vein - AVA]. Bleeding may occur if clamp not tight umbilical stump; falls off by 7th - 10th day Teach: do not bathe infant until site completely healed Sponge bath
Identification of Newborn
Done immediately > delivery by same nurse assisting mother Prevent giving wrong infant to wrong mom. Identification is 1 band on mom, one on significant other & 2 on baby. Footprints of infant & mothers thumb print on footprint sheet.
In DR, infant given to mom to begin bonding process & breast feeding started.
Admission to Nursery Infant transferred to Newborn Nursery. Report given by L&D nurse to NBN nurse. Routine newborn care. Infant under radiant warmer, VS, measurements, head to toe assessment, bath [98.0 R]. To mom in 4 hrs. if WNL. [98.0] Universal security system on maternity units ensure safety of all newborns on unit. Alarm placed on infant ankle or umbilical cord stump. All doors in unit are alarmed & locked.
Newborn Adaptation
Newborns ability to adapt successfully depends upon conditions in utero, care it receives during intrapartum period, & newborn period aka neonatal period = 1st 28 days of life. 2/3rds of all deaths that occur in 1st year of life occur during neonatal period [1st 28 days of life].
Anterior fontanel diamond shaped, measures 2-3 cm. wide & 34 cm. long. Closes @ 12-18 months. @ juncture of frontal & parietal bones. Overriding sutures w. NSVD. Level C/S Posterior fontanel - triangular shaped; small [~0.5 cm.] hard to feel; juncture of occipital & parietal bones. Closes 2 mos. *Depression indicates dehydration *Bulging > hydrocephalus Hair gestational marker; preterm sparse
Eyes
Eyes: usually blue or gray Permanent color develops 3 - 12 mos of age. Iris does not develop color til 3-6 mos. Lacrimal [tear] glands- not fully mature Subconjunctival hemorrhage: from stress of vaginal delivery First 6 wks; transient strabismus; not able to focus. Constant strabismus < 6 weeks, further assessment needed. Strabismus > 6 weeks, referral needed. Scant purulent discharge > erythromycin ointment Pupils round & equal; should constrict - normal response to light PERL =pupils equal & reactive to light
Nose
Nose: Infants obligatory nose breathers. Note size & shape, & presence of nasal discharge or stuffiness. Clean nose with bulb syringe; saline drops. Observe for nasal flaring
Mouth
Mouth: Examine palate with index finger Cleft lip and/or cleft palate Epsteins pearls [small, round, white cysts] Note size & shape of tongue and length of frenulum membrane
Ears/Neck
Pinna should be fully formed and firm. Term infant: pinna recoils easily Preterm infant, < 36 wks - relatively shapeless and flat; little cartilage. Slow recoil. Skin tag harmless; may be associated w. kidney disease. Hearing test done before newborn D/C home; If fails 2nd time, hearing eval.done as outpt. Neck: Normal newborn neck short, chubby w.creased skin folds. Head support necessary. Inspect masses, limitation of movement & webbing. Clavicles: straight, palpate each clavicle for intactness; crepitus Common in larger infants delivered vaginally
Chest
Chest: Inspect shape, symmetry, position, development of nipples; breast tissue. Chest 12-13 in. [30 33 cm.]. Breast engorgement maternal hormones. Normal respirations 40 60 breaths/minute. Retractions abnormal; indicates respiratory distress. RR can be in 30s [sleep]. After 4 hr. transition period, RR 40s. Grunting [hoarse sound - expiration] transient d/t mucous in lungs. Suction. If retractions/grunting not clear by 4-6 hrs, may indicate respiratory distress TTN; transient tachypnea of NB. RR = 70-80s for several hrs. [transition period] if more > 4 hrs., NICU.
Abdomen/Kidneys
Abdomen: palpate for masses/organs Umbilical Cord: Inspect 3 vessels (AVA); falls off in 7 10 days. Let dry. If only 2 vessels present, artery and vein, observe infant closely d/t association with heart or kidney anomalies. Kidneys may be felt on right & left side of abdomen by deep palpation. S/S infection
Genitalia - Male
Genitalia: Male: Assess for gestational maturity & sexual ambiguity. Scrotum in full term infant swollen; + rugae; both R & L testes descended into scrotal sac. Testes may be in process of descending. If one or both testes are undescended = cryptorchidism, Agenesis [no testes] or closed scrotal sac Normal length of newborns penis = ~ 2cm long. Assess for urethral opening aka urinary meatus Abnormal placement on dorsal surface *epispadias*; ventral surface *hypospadias
Genitalia - Female
Female: Vulva typically swollen. Labia minora & clitoris large with labia majora covering both Female infants have pseudomenstruation Hymenal tag or small piece of pink tissue protrudes between labia
Extremities
Extremities: Assess for muscle tone Note length of arms/legs; should be symmetrical Limp arm may have nerve damage [birth injury] aka brachial plexus palsy. Observe palm: simean crease [single Assess: syndactyly: webbing of fingers/toes & polydactyly: > than 10 fingers or toes. Assess sole creases; mature infant: 2/3rds or full sole w.creases
Skin
Reddish in color; smooth and puffy At 24 - 36 hours of age, skin flaky, dry and pink in color. Edema around eyes, feet, genitals. Acrocyanosis: Bluish discoloration of hands and feet. Lasts for 24-48 hrs. Mucous obstruction may cause central cyanosis Milia: Pinpoint white papules; Disappear 2-4 wks Neck: Normal newborn neck short, chubby w. creased skin folds. Support is necessary. Inspect for masses, limitation of movement & webbing
Clavicles: straight, palpate for intactness; feel for crepitus Commonly found in larger infants delivered vaginally.
Skin
Lanugo: fine hair covering newborns upper arms, shoulders, & back that decreases as gestational age increases Vernix caseosa: white, cream cheese like substance; skin lubricant. Erythema neonatorum [toxicum]: NB rash; red rash with fleabiten appearance. Stork Bites - a.k.a. telangiectasia - pink spots found on nape of neck, nose, upper eyelids, upper lip. Disappear in 1-2 yrs. Mottling: Generalized red and white discoloration of skin of exposed infants with fair complexion. Mongolian Spots: Collections of pigment cells [melanocytes] that appear as patches across infants sacral area and buttocks. Tend to occur in newborns of Asian, African, or Southern European descent
Skin
Capillary Hemangiomas: 3 types, all are vascular Nevus flammeus: macular (flat), purple or dark red lesions, present @ birth. Aka port wine stain
Strawberry hemangiomas: raised areas formed by immature capillaries & endothelial cells. Occurs typically in term infant.
Cavernous hemangiomas: Raised; resembles strawberry hemangioma Can be surgically removed
Back/Anus/Rectum
Spine: Assess for intact spine without masses or openings. Small indentation @ base of spine may suggest pilonidal dimple. May be pilonidal sinus [opening]; represents possible spina bifida occulta. Tuft of hair present @ base of spine = Nevus pilosus. Anus & Rectum: Assess rectal patency [NBN] with 1st temp; lubricated thermometer. If rectum not patent, called imperforate anus
Tactile Olfactory
REFLEXES
Sucking place finger in mouth; infant sucks right away. Moro [startle reflex] elicit by loud noise; infant extends arms & legs suddenly. Rooting touch cheek; turns head in direction of touch. Babinski stroke sole of foot from top to bottom; toes fan out. Grasping place finger in newborns hand; grabs & hold. Stepping hold infant upright w. feet on surface; stepping movements
Behaviors Sleep/Awake
Predictable Behaviors: 1st 4 hours > delivery:
1st period of reactivity: alert, active state; awake, crying, sucking. Then Sleep phase 4-6 hrs. 2nd period of reactivity 2-3 hrs. Sleep/awake during day. Sleep States 1. Deep Sleep 2. Light Sleep Awake States Drowsy; Quiet Alert best time for breast feeding/bonding Active Alert; Crying
Behaviors
Brazelton Neonatal Behavioral Assessment Scale: Scale developed in 1970s to evaluate newborns behavior to stimuli Assesses motor maturity & social behavior. Takes ~ 30 min to do
Ballard Assessment scale: developed 1970s to assess gestational maturity; takes 2-3 minutes to do. Assesses physical & neuromuscular maturity. Useful in differentiating between SGA infant & miscalculated due date SGA infant is mature gestationally. Full term infant gets score of ~ 3.3 in each category. Compare infants in NICU to those in NBN.
Nutrition in Newborn
Bonding process reinforced during feeding w. breast & bottle. Approx. 64% of women breast feed in early post partum period 29 % still nursing @ 6 months; 16% still nursing @ 1 year. Growth & caloric requirements during neonatal period & early infancy are faster than any other period of life. Newborns can lose up to 5-10% of birth weight while waiting for breast milk to come in. Colostrum rich in antibodies but has less calories than breast milk. Breast milk has no allergies.
Education
Teach mom: ^ calories by 500/day ^ fluids by 8 glasses/day Well balanced diet; omit caffeine/alcohol. Breast feed q2-3 hrs./day; Bottle feed q 3-4 hrs./day Avoid fish containing mercury. Teach positions for breast feeding; football hold for C/S. Any position OK as long as baby has nipple & areola; infant can breathe. Find comfortable position; Use pillows - free up hands.
Nutrition in Newborn
Daily Requirements: Calories: body maintenance & growth. Birth to 2 months of age: require 110-120 calories/kg/24 hrs. Up to 6 months, require 108 cal/kg/24 hrs. 6 mos. to 1 yr. require 98 cal//kg/24 hrs. Protein: needed to form new cells; important for rapid growth. Up to 2 months, 2.2 g/kg/24hrs required. 6mos.-1yr. 1.6g/kg req. Fluid: 150-200 mL/kg/24 hrs 75% of NB body composed of water Fluids: Need 65 ml/kg [30 ml/lb] daily 1st 2 days of life then 100150 ml/kg [45-68 ml/lb/day] afterwards. Voids: 1st few days 2-6 voids/day; > 2-3 days: 6 or more voids.
Nutrition in Newborn
Fat: [Linoleic acid] found in both breast milk & formulas Carbohydrates: Lactose most easily digested of carbohydrate group. Helps to reduce GI illness in newborns by producing stool with gram + bacteria instead of gram negative bacteria. Rare to have infant with lactose intolerance
Helps with uterine involution. May help prevent breast cancer. Empowering effect on mother; self esteem. Provides more frequent close contact Inexpensive. Complete nutrition for baby. Provides extension of immunity for up to 6 mos. Colostrum IgA [immunoglobulin] which binds to bacteria & viruses; proteins/enzymes destroy bacteria. Macrophages produce interferon - interfere with virus growth. Father feels left out. Sore nipples. Painful engorgement. More frequent feeding required so less time with other children. Embarrassment R/T feeding in public. Mastitis. Infections: Hepatitis B & HIV can pass thru milk.
finding. Gastrointestinal: GI tract sterile @ birth; bacteria enters GI tract thru mouth within 24 hrs.of life. Bacteria needed for prod. Vit.K
Infant: limited ability to digest fats & starches Meconium passed 1st 24-48 hrs. of life By 2nd - 3rd day, transitional stool passed
Thermogenesis
Brown fat : helps conserve body heat; produces heat. Found in upper chest, back of neck, around abdomen. Is deposited in 2nd trimester; Helps regulate body temp>delivery. Radiant warmer - helps regulates body temp. by conserving heat. Newborns can produce sufficient heat in optimal thermal Environment if warm enough. Rapid heat loss occurs in suboptimal environment [cooler]. Infants do not shiver; can go into cold stress quickly. Uses up extra glucose & oxygen to thermoregulate. Leads to: metabolic acidosis; respiratory distress Hypoglycemia; Jaundice; decreased surfactant production
Thermogenesis
Infants Lose heat in 4 ways: Convection Evaporation Conduction Radiation IMMUNOLOGIC: Newborn still prone to infection, handwashing important! IgG: Infant born with passive immunity from mom. Fetus makes own starting @ 20 wks IgM too large to cross; makes own after delivery. IgA do not cross placenta. Produced by infant > birth @ 6-12 wks. Found in breast milk.
Labs
Hemoglobin: 15-20 g/dl.; Hct: 43-61% Blood volume: 80-110 ml/kg. or 300 ml. WBC: 10-30,000 mm Glucose 45-60 mg/dl - heel stick < 45 & feed with oz formula. Repeat within hour. Send serum blood glucose as per protocol. JAUNDICE: Breast Fed Jaundice: 1 out of 3 breast feeding infants. Most common cause: insufficient intake - 1st week of life. Bili can reach 12mg/dl. Theory: Enzymes in breast milk thought to interfere with conjugation process. Feed @ least 8-10 feedings in 24 hrs. Teach moms: ^^ their own po fluids Kernicterus rare with breast fed jaundice