Nursing Care of the Newborn - · PDF file• Gross assessment ... Nursing Process for...
Transcript of Nursing Care of the Newborn - · PDF file• Gross assessment ... Nursing Process for...
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Nursing Care of
the Newborn
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Immediate Baby Care
• Airway - Clean mouth and nose
• Thermoregulation - Warmth
• APGAR
• Gross assessment
• Identification
• Bonding – safety against infection
• Medications
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Fetus to Newborn:
Respiratory Changes
• Initiation of respirations
• Chemicalsurfactant reduces surface tension 34-36wksdecrease in oxygen concentration
• Thermalsudden chilling of moist infant
• Mechanicalcompression of fetal chest during delivery normal handling
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Nursing Process for Respirations
• Assess for respiratory distress
• Plan: Maintain patent airway
• Interventions- Positioning infant – head lower
- Suction secretions – bulb, keep near head, mouth first, avoid trauma to membranes
• Evaluation – rate 30-60, no distress
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Fetus to Newborn:
Neurological adaptation:
Thermoregulation
Methods of heat loss
Evaporation – wet surface exposed to air
Conduction – direct contact with cool objects
Convection- surrounding cool air - drafts
Radiation – transfer of heat to cooler objects
not in direct contact with infant
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Convection
Radiation
Evaporation
Conduction
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Nonshivering thermogenesis
The distribution of brown adipose tissue (brown fat)
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Nursing Care – Cold Stress
• Preventing heat loss – radiant warmer
• Providing immediate care - dry quickly,
cover head with cap, replace wet blankets
• Providing on going prevention - safety
• Restoring thermoregulation – if becoming
chilled - intervene
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Effects of Cold Stress
• Increased oxygen need
• Decreased surfactant production
• Respiratory distress
• Hypoglycemia
• Metabolic acidosis
• Jaundice
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APGAR
• Heart rate – above 100
• Respiratory Effort – spontaneous with cry
• Muscle tone – flexed with movement
• Reflex response – active, prompt cry
• Color – pink or acrocyanosis
• 0-3 infant needs resuscitation
• 4-7 Gentle stimulation – Narcan
• 8-10 – no action needed
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Early Assessments• Assess for anomalies
• Head – anterior fontanelle closes 12-18 mo
posterior fontanelle closes 2-3 months
• Neck and clavicles
fracture of clavicle – large infant, lump, tenderness,
crepitus, decreased movement
• Cord
• Extremities
flexed and resist extension
assess fractures, clubfeet
hips
vertebral column
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Cephalhematoma is a collection of blood between the
surface of a cranial bone and the periosteal membrane.
Not crossing
suture line
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Caput succedaneum is a collection of fluid (serum)
under the scalp.
Crossing
suture line
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A, Congenitally dislocated right hip
B, Barlow’s (dislocation) maneuver.
C, Ortolani’s maneuver
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Measurements
• Weight – loss of 10% normal
• Length
• Head and chest circumference
• Normal VS
temp 97.7-99.5F axillary
apical pulse 120-160bpm
respirations 30-60/min
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A, Measuring the head circumference of the newborn.
B, Measuring the chest circumference of the newborn.
head larger
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Assessment of Cardio-respiratory
Status
• History
• Airway
• Assessrateq 30minX2hrssymmetrybreath sounds - moisture for 1-2 hrs
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Assessment of Thermoregulation
• Check soon after birth
• Set warmer controls
• Take temp q 30 min until stable
• Rectal for first temp
• Insert only 0.5 inch
• Axillary route rest of time
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Axillary temperature measurement. The thermometer
should remain in place for 3 minutes.
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Assessment of Hepatic Function• Blood Glucose
Signs of hypoglycemia
jitteriness
respiratory difficulties
drop in temp
poor sucking
Tx- feed infant if glucose below 40-45 mg/dl
• Bilirubin
physiologic jaundice peaks 2-4 days of life
early onset may be pathologic
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Jaundice
• Hemolysis of excessive erythrocytes
• Short red blood cell life
• Liver immaturity
• Lack of intestinal flora
• Delayed feeding
• Trauma resulting in bruising or cephalhematoma
• Cold stress or asphyxia
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Potential sites for heel sticks. Avoid shaded areas to
prevent injury to arteries and nerves in the foot.
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Assessment of Neuro System
• Reflexes
• Babinski
Grasp
Moro
Rooting
Stepping
Sucking
Tonic neck reflex “fencing”
• Cry
• Infant response to soothing
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Assessment of Gastrointestinal
System
• Mouth
• Suck
• Abdomen
• Initial feeding
• Stoolsmeconium – within 12-48 hours of birth
dark greenish blackbreastfed – soft, seedy, mustard yellowformula-fed – solid, pale yellow
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Assessment of Genitourinary
System
• Umbilical cord vessels
• Urine – within 24 hours of birth
• Voiding – 6 to 10 times a day after 2 days
• Genitalia
female – edema normal, majora covers
minora, pseudomenstruation
male – pendulous scrotum, descended
testes by 36 wks gest., placement of meatus
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Assessment of Integumentary System• Vernix – white covering
• Lanugo – fine hair
• Milia
• Erythema toxicum – red blotchy with white
• Birthmarks
Mongolian spots – sacral area
Telangiectatic nevus “stork Bite” - blanches
Nevus flammeus “port wine stain”
- no blanching
Nevus vasculosus “strawberry hemangioma”
usually on head, disappears by school age
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Erythema toxicum
Port Wine Stain
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Fetus to Newborn:
Psychosocial adaptation• Periods of Reactivity
active – 30-60 min
sleep – 2-4 hours
alert – 4-6 hours
• Behavioral States
quiet sleep
active sleep
drowsy state
quiet alert – best for bonding
active alert
crying state
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Gestational Age Assessment
• Assessment tool – Dubowitz, Ballard
• Weeks from conception to birth
• Used to identify high risk infants
• Neuromuscular characteristicsPosture – more flexionSquare window – more pliableArm recoil - activePopliteal angle - lessScarf Sign – less crossing Heel to ear – most resistance
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Newborn maturity rating and classification
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Gestational Age Assessment
• Physical characteristics
Skin- deep cracking, no vessels seen, post-leathery
Lanugo – less as age
Plantar creases – more with age
Breasts – larger areola
Eyes and Ears – stiff with instant recoil
Genitals – deep rugae, pendulous, covers minora
• Gestational Age & Size – may not correspond
small SGA <10% for weight
large LGA >90% for weight
appropriate AGA between 10-90%
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Classification of newborns based on maturity and
intrauterine growth.
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Classification of newborns by birth weight and
gestational age.
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Ongoing Assessment and Care
• Bathing
• Cord care
• Cleansing diaper area
• Assisting with feedings
• Protecting infant
identifying infant
preventing infant abduction – alert to unusual
preventing infection
• Review beige cue cards in center of book for teach
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One method of swaddling a baby.
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Common Breastfeeding Positions
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Infant in good breastfeeding position : tummy-to-tummy,
with ear, shoulder, and hip aligned.
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LATCH was created to provide a systematic method for
breastfeeding assessment and charting.
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Infant teaching checklist is completed by the time of
discharge.
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Circumcision
• Most common neonatal surgical procedure
• Reasons for choosing
• Reasons for rejecting – hypospadias,
epispadias
• Pain relief
• Methods
• Nursing care
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Circumcision using a circumcision clamp.
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Circumcision using the Plastibell.
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Other Concerns
• Immunizations
Hepatitis B – begin vaccine at birth
• Screening tests
Hearing
Phenylketonuria – by law
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Further Assessments
• Complications r/t poorly functioning placenta
hypoglycemia
hypothermia
respiratory problems
• Complications r/t LGA infant
hypoglycemia
birth injury due to size
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Shoulder Dystocia
• Risk factors
diabetes; macrosomic infant
obesity
prolonged second stage
previous shoulder dystocia
• Morbidity- fracture of clavicle or humerus,
brachial plexus injury
• Management – generous episiotomy
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Neonatal morbidity by birth weight and gestational age.
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High Risk Infants
• Preterm – before 38 weeks gestation
• IUGR – full term but failed to grow normally
• SGA -
• LGA
• Infants of Diabetic mothers
• Post mature babies
• Drug exposed
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Preterm infants
• Survive - Weight 1250 g -1500 g – 85-90%
500-600g at birth 20% survive
• Ethical questions
• Characteristics – frail, weak, limp, skin
translucent, abundant vernix & lanugo
• Behavior – easily exhausted, from noise
and routine activities, feeble cry
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Nursing Care of Preterm Infants• Inadequate respirations
• Inadequate thermoregulation
• Fluid and electrolyte imbalance – dehydration sunken fontanels <1ml/kg/hr or over hydration bulging, edema and urine output >3ml/kg/hr
• Signs of pain – high-pitched cry, >VS
• Signs of over stimulation - >P, >RR, stiff extended extremities, turning face away
• Nutrition – signs of readiness to nippleresp <60/m, rooting, sucking, gag reflex
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Measuring gavage tube length.
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Auscultation for placement of gavage tube.
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Complications of Preterm Infants
• Respiratory Distress Syndrome -RDS
• Bronchopulmonary dysplasia – chronic lung disease
• Periventricular-Intraventricular Hemorrhage30% infants <32 wk gest or <1500 g
• Retrolenthal fibroplasia – visual impairment or blindness from O2 & ventilator
• Necrotizing Enterocolitis (NEC) – distention, increased residual, Tx - rest bowel
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Respiratory Distress Syndrome
• RDS also know as “hyaline membrane disease”
• Cause – besides preemie, C/S, diabetic mothers, birth asphyxia – interfere with surfactant
• S & S tachypnea - over 60/min retractions- sternal or intercostal
nasal flaring cyanosis- centralgrunting- expiratoryseesaw respirationsasymmetry
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Evaluation of respiratory status using the
Silverman-Andersen index.
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Therapeutic Management of RDS
• Surfactant replacement therapy
• Installed into the infant’s trachea
• Improvement in breathing occurs in minutes
• Doses repeated prn
• Other treatment
mechanical ventilation
correction of acidosis
IV fluids
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Post Term Infants
• Born after 42 weeks
• Increase risk of meconium aspiration
• Hypoglycemia
• Loss of subcutaneous fat
• Skin –peeling, vernix sparse, lanugo absent, fingernails long
• Focus on prevention – “due date”
• Attention to thermoregulation & feeding
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Meconium Aspiration Syndrome
• Occurs most often post term infants,
decreased amniotic fluid /cord compression
• Meconium enters lung – obstruction
• S & S vary from mild to severe respiratory
distress: tachypnea, cyanosis, retractions,
nasal flaring, grunting
• Tx – suction at birth, may need warmed,
humidified oxygen, or ventilators
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Hyperbilirubinemia
• Pathologic jaundice – occurs within first 24 hours
• Bilirubin levels >12 in term or 10-14 preterm
• May lead to kernicterus – brain damage
• Most common cause – blood incompatibility of mother and fetus, Rh or ABO – only occurs with mother negative Rh or O blood
• Treatment focus on prevention, assess coombs, monitor bilirubin levels, most common treatment is phototherapy, blood transfusions
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Conjugation of bilirubin in the newborn.
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Phototherapy for Hyperbilirubinemia
• Phototherapy – bilirubin on skin changes into water-soluble excreted in bile & urine
• “Bili” lights placed inside warmer, need patches over eyes, infant wearing only diaper or fiberoptic phototherapy blanket against skin
• Side effects of phototherapy: freq, loose, green stools, skin changes
• Can use at home
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Other interventions for
hyperbilirubinemia
• Exchange transfusions – if lights not working
• Maintain neutral thermal environment – not
too hot or too cold
• Provide optimal nutrition – hydrate
• Protecting the eyes from retinal damage
• Enhance therapy by expose as much skin
as possible to light, remove all clothing
except diaper, turn frequently
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Infant of a Diabetic Mother
• Macrosomia – face round, red, body obese, poor muscle tone, irritable, tremors
• High risk for – trauma during birth, congenital anomalies, RDS, hypocalcemia
• Hypoglycemia occurs 15-50% of time<40-45 mg/dl, test right after birth, q 2hX4,then q 4 hrX6 until stable
• Most frequent symptom: jitteriness or tremors
• Tx – fed, gavage or IV if needed
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Hypoglycemia
• Serum glucose is below 40 mg/dL
• Tx: feed infant formula or breast milk and
retest until glucose stable
• S & S: jitteriness, lethargy, poor feeding,
high-pitched cry, irregular respirations,
cyanosis, seizures
• Risk factors: DM, PIH, preterm, post term,
LGA, cold stress, maternal intake of ritodrine
or terbutaline
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Large for Gestational Age
• Infants weight is in the 90th % for neonates
same gestational age, may be pre, post, or
full term infants
• LGA does not mean post term
• Most common cause – maternal diabetes
• Infant at risk: birth injuries, hypoglycemia,
and polycythemia - macrosomia
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Small for Gestational Age
• Infant whose wt is at or below the 10th %
• Results from failure to thrive
• Is a high risk condition
• SGA does not mean “premature.”
• Causes: anything restricting uteroplacental
blood flow, smoking, DM, PIH, infections
• Complications: hypoglycemia, meconium
aspiration, hypothermia, polycythemia
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Mother with Substance Abuse
• Use of alcohol or illicit drugs
• Tobacco and alcohol are most frequent
• Prenatal alcohol exposure is the most
commons preventable cause of mental
retardation
• Signs of maternal addition: wt loss, mood
swings, constricted pupils, poor hygiene,
anorexia, no prenatal care
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Drug Withdrawal in Infants
• Signs of drug exposure
opiates – 48-72 hours
cocaine – 2-3 days
alcohol – within 3-12 hours
• Symptoms: irritable, hyperactive muscle
tone, high-pitched cry
• High risk for SGA, preterm, RDS, jaundice
• Obtain infant mec and urine sample for test
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Nursing Care of Drug-Exposed Infant
• Feeding – more difficult may need to
gavage
• Rest – keep stimulation to minimum,
reduce noise and lights, calm, slow
approach
• Promote bonding
• Teach measures for frantic crying: rock,
coo, dark room, avoid stimulation
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Phenylketonuria - PKU• Genetic disorder causes CNS damage from toxic levels of amino acid phenylalanine
• caused by deficiency of the enzyme phenylalanine hydroxylase
• Signs- digestive problems, vomiting, seizures, musty odor to urine, mental retardation
• Tx – low phenylalanine diet – start within 2 months
• Screening before 24-48 hours needs to be repeated for accuracy
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Signs Bonding Delayed
• Using negative terms describing infant
• Discussing infant in impersonal terms
• Failing to give name – check culture
• Visiting or calling infrequently
• Decreasing length of visit
• Refusing to hold infant
• Lack of eye contact with infant