New born - Normal newborn expectations (miller) PDF

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Neonatal AdaptationIntroduction — Newborn period – birth to 28 days — Neonate vs infant — Neonatal transition- critical period of rapid respiratory and circulatory adaptation from intrauterine to extrauterine life — Other systems adapt over longer time period — Nurse must recognize normal vs abnorma...

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Neonatal Adaptation Introduction  Newborn period – birth to 28 days  Neonate vs infant  Neonatal transition- critical period of rapid respiratory and circulatory adaptation from intrauterine to extrauterine life  Other systems adapt over longer time period  Nurse must recognize normal vs abnormal changes  Many teaching opportunities to facilitate family’s positive adjustment Cardiopulmonary Adaptation  Stimulated by the onset of respiration Ø Greater blood volume to the lungs contributes to conversion from fetal to newborn circulation Respiratory System-Critical Facts  Fetal breathing: 17-20 weeks and necessary for resp muscle development  Peak surfactant: 35 weeks to 40 weeks and necessary for alveolar stability  During labor, glucocorticoid and catecholamine surge  Promotes some fluid clearance from lungs  Still approximately 80-100 ml fluid in lungs at birth Mechanical Factors  Squeezing of thorax  ~ 1/3 lung fluid expelled  Chest recoil  negative pressure, 1stinspiration  Exhales & cries creating positive pressure  Distribution of air  Absorption of rest of fluid 12-24 hours after birth Chemical Stimuli  Brief asphyxia with cutting of cord  breathing   PCO2 pH O2  Stimulate aortic, carotid chemo receptors  Triggers respiratory center in medulla  breathing Thermal Stimuli   temperature  breathing  Stimulates nerve endings in skin  Triggers respiratory center in medulla  breathing Sensory Stimuli  Visual, Auditory, Tactile and All stimulate respiratory efforts

Initiation of Breathing

Cardiovascular Adaptations  Cutting cord leads to changes in pressures in cardiovascular system  Causes closure of  Foramen ovale  Ductus arteriosis  Ductus venosus  Heart murmurs may be heard; most benign Fetal to Neonatal Circulation https://www.youtube.com/watch?v=75fj1eoUZco

Transition to Neonatal Circulation

Risk Factors That Can Affect Neonatal Adaptation  Lack of prenatal care  Intrapartal factors  Birthweight/gestational age  Maternal medical conditions  Maternal substances abuse  Fetal anomalies Oxygen Transport  Neonate has high levels Hgb F  O2 binds more readily to RBCs  Higher levels of O2 saturation  Cyanosis often a late sign of hypoxia in the newborn!!! Hematopoietic System  Values influenced by timing of cord clamping  Physiologic anemia of infancy (usually benign)  Decline in Hgb over first 2-3 mos. of life  R/T decreased red cell mass  Shorter neonatal RBC life span (60-80 days)

Temperature Regulation  Body temperature related to metabolism and O2 consumption  Goal = “Neutral Thermal Environment” (an environment where newborn uses minimal energy to maintain core temperature)  All newborns at risk for hypothermia due to:  large body surface area compared to body mass  Small amt SQ insulating fat/ thin skin  Heat loss @ 4X adult rate  Hypothermia increases O2 use, metabolism potentially resulting in:  Hypoxia  Acidosis  Shock Heat Production (Thermogenesis)  Relies on nonshivering thermogenesis  Unique to newborn  Metabolizes stores of BAT (brown adipose tissue or “brown fat”)  Deposits appear in 3rd trimester and increase up to 5 wks after birth Heat Loss to Environment  4 major mechanisms  Essential to prevent heat loss

Implications for Care  Assessments under radiant warmer  Dry thoroughly  Skin to skin contact  Knit cap to head  Swaddle in blankets  Raise temp. birth room  Frequent temp checks  Delay bath Hepatic Adaptations  Healthy, term newborn has iron stored in liver to last until about 5-6 mos.  Stores CHO reserves in the form of liver glycogen though may be depleted rapidly  May be insufficient liver enzymes needed to convert bilirubin to excretable form –What is a possible result? Gastrointestinal Adaptations  By 36-38 wks relatively mature  Passes meconium by 24 hours  Has enzymes to digest lactose, proteins  Lacking enzymes to digest more complex CHO, fats so delay solids until ~6 mos.  Stomach capacity ~ 15-60 ml.  Cardiac sphincter immature so regurgitation common  Requires 120 cal/kg/day  Shift of fluids and insensible loss leads to weight loss of 5-10% of birth weight

Urinary Adaptations  Most void within 24 hours  First 2 days only 2-6 times/day  Then 5-25 times/day  May see rust/pink stains or small blood stains in diaper  Uric acid (“brick dust spots”)  Pseudomenstruation  Kidneys less able to concentrate or dilute urine  Adequate hydration depends on regular feedings Immunologic Adaptations  Immune system immature at birth  Difficulty recognizing, localizing and destroying antigens  S&S of infection often subtle, non-specific  Fever unreliable indicator; may see hypothermia  Maternal IgG antibodies transferred during 3rd trimester giving newborn passive acquired immunity  Maternal IgA antibodies in breastmilk  Responds to vaccines by producing active acquired immunity Neurologic Adaptations  Minimally influenced by birth process  Significant cephalo-caudal development  Should observe  Symmetrical motor activity  Eye movements  Lusty cry  Hypertonic muscle tone  Newborn reflexes  Complex behaviors (i.e., hand to mouth, remove cloth over face) Neurologic Adaptations – Periods of Reactivity  First period of reactivity  Birth to approx 30 minutes  Newborn awake, alert  Strong sucking reflex  Ideal to initiate bonding/ breastfeeding  Sleep phase:  Begins at approx 3o min/ lasts 2-4 hrs  Deep sleep  Second period of reactivity:  Awake and alert  Lasts about 4-6 hours  May have some additional mucus, VS instability  Another feeding or feeding initiated if not in first period

Behavioral States  Sleep States:  Deep or quiet sleep// Active REM sleep  Alert States  Drowsy, Quiet alert (wide awake), Active alert (active awake), Crying Behavioral/Sensory Capacities  Self-soothing ability  Habituation – can block out repetitious disturbing stimuli  Orientation – can follow and fixate on attractive visual stimuli  Prefers human face  Bright shiny objects  Black & white, primary colors  Responds to auditory stimuli  AAP recommends hearing screening before D/C  Can select their mother by smell  Responds to varying tastes; seems to prefer sweet  Strong sucking reflex  Responsive to cuddling, being held, touched Timing of Newborn Assessments  Immediately after birth/ 1-2 hours after birth/ Prior to discharge Apgar Score https://www.youtube.com/watch?v=XFjNyx8jGnI

Newborn care in Birthing Room  Dry/tactile stimulation, Clear airway, Apgar  Maintain temperature  VS at 30 min after birth  Weights and measures  Identify  Promote bonding  Vitamin K- (AquaMephyton)  Erythromycin  Ongoing assessment Weight  3400 g (7 lb, 5 oz)  2500-4000 g (5 lb, 8 oz -8 lb, 13 oz) range  Varies by ethnicity  May lose 5-10% first 3-4 days  Gains ~ 7 oz/wk first 6 mos. Length  50 cm (20 inches) ave  44-56 cm ( 17-22 inches) range  Grows ~ 1 inch/month first 6 mos. Head Circumference  32-38 cm (13-15 in.) ave.  Range: 32-38 cm  Head ~ 2cm > chest circumference  Shape of the head may already be altered from vaginal birth. Its okay to reassess this later. (molding or caput succedaneum) Chest Circumference  32 cm (12.5 inches) ave.  30-36 cm (12-14 in.) range  Abdominal girth may also be measured Newborn Assessment Components  Perfusion  Oxygenation  Nutrition  Elimination  Metabolism  Infection control  Neural regulation  Comfort mobility behavior  Table 18.3 page 622

Newborn Heart Rate/BP  Resting apical pulse:110-160 bpm count for 1 full minute  Check for presence of peripheral pulses  BP systolic mean: 42-60 mm Hg (not routinely measured in healthy, term newborns)  Which babies may be at risk for ineffective cardiac transition?

Newborn Respirations  Normal (at rest)  30-60 resp/min.  Irregular, shallow  Periodic breathers (not apnea!)  Nose breathers  Abdominal breathers  Chest and abdomen work synchronously  Know signs respiratory distress!  Apnea = > 20 secs, may see color, HR changes  Nursing intervention? Signs of Respiratory Distress

Newborn Temperature  Temp: 36.5-37.5C 97.7-99.4F  Axillary or skin temperature probes preferred for safety reasons Assessment of Gestational Age: New Ballard Score  Establishes gestational maturity (see pg 603-605)  Helps plan care for needs of preterm or postterm newborn  Six physical characteristics  Skin, lanugo, sole creases, breast tissue, ear cartilage, genitals  Six neuromuscular characteristics  Posture, square window wrist, arm recoil, popliteal angle, scarf sign, heel to ear  Points are given for each assessment parameter, with a low score of –1 point or –2 points for extreme immaturity to 4 or 5 points for post maturity. The scores from each section are added to correspond to a specific gestational age in weeks.

Skin Lanugo Sole Creases Breast Tissue Ear Cartilage Genitals Head to Toe Physical Assessment  Review Assessment Guide: Newborn Physical Assessment on pp. 622. General Newborn Appearance  Head large for body, neck short  Prominent abdomen, rounded chest  Body long, extremities short  Flexed position  Ruddy color with acrocyanosis Skin - Acrocyanosis  Bluish discoloration of hands and feet  Normal for first days  Caused by immature peripheral circulation Skin - Mottling  Lacy pattern of dilated blood vessels seen beneath pale skin  May come and go in early newborn period  May be sign of chilling  Persistent mottling may be sign of illness Skin - Harlequin sign  “Clown’s suit”  Half body deep red, other half pale  Due to dilation/ constriction of vessels  Document if seen, usually benign Skin - Jaundice  Yellow coloration first appears on face, sclera and mucus membranes  Develops in head to toe fashion  Related to bilirubin levels in bloodstream  May be:  physiologic (appears > 24 hrs) or pathologic (appears < 24 hrs) Skin - Erythema Toxicum  Raised white or yellow papule with reddened base  “newborn rash”  Appears suddenly often at 24-28 hours, spreads rapidly; often trunk, diaper area  Self-limiting; wash with mild soap and H2O

Skin - Milia  Raised white spots across face  Exposed sebaceous glands  Benign; wash with warm water Skin - Vernix Caseosa  Whitish substance covers fetal skin in utero; protects/lubricates skin  Preterm newborn has abundance; less with increased maturity  Postterm newborn often has dry, peeling skin Skin – Forceps Marks  Reddened areas over face  Generally disappear in day or two  Transient facial paralysis rarely occurs Birthmarks - Mongolian Spots  Bluish-black or gray-blue discolorations over lower back/buttocks  More common in dark skinned infants  Most fade by 2nd birthday  May be mistakenly identified as bruising Birth Marks - Telangiectatic Nevi  “Stork bites” common in light skinned newborns  Pale pink to red non-raised spots found over bridge of nose, eyelids, nape of neck  Caused by dilated capillaries  Most fade by 2nd birthday Birth Marks - Nevus Flammeus  “Port wine stain” Deep red/purplish non-elevated discoloration; common on face  Dense capillaries just below epidermis  Does not fade Birth Marks - Nevus Vasculosus  “Strawberry mark” or capillary hemangioma; rough, raised red mark  Enlarged capillaries in dermal and subdermal layers  Grows in size during infancy  Shrinks and often resolves spontaneously by school age Newborn’s Head  Vaginal birth  Molding common, Overlapping cranial bones. Resolves in a few days  Look for  Microcephaly (small head)  Hydrocephalus (large head due to fluid in brain)  Craniosynostosis (early closure of cranial sutures)

Fontanelles  Two fontanelles  Anterior – diamond shaped; closes by 18 mos.  Posterior – triangular shaped; closes by 2-3 mos.  Look for:  Sunken fontanelle – dehydration  Bulging fontanelle – increased intracranial pressure Cephalhematoma  Injury to blood vessels during birth  Collection of blood between cranial bone and periosteal membrane  Remains localized over one cranial bone; does not cross suture lines  May increase risk for jaundice  May take weeks to resolve Caput Succedaneum  Edematous swelling over head due to pressure during delivery  Does cross suture lines  Common with vacuum extraction  Resolves in a few days Facial Features  Eye placement/shape  Blue/gray or dark color  3-12 mos. for true color  Strabismus common  Lacks tears  Can see objects 8-10 inches  Ear placement/shape  Low set ears – chromosomal/ renal disorders  Pinna springs back in place  Can hear/respond to sounds  Nose symmetry/patency  Nose breathers  Mouth/oral cavity  Clefts of lips/palate  Strong suck  Precocious teeth  Epstein’s pearls – white cysts on gums  Thrush (Candida albicans)-white patches on mucus membranes Ears / Hearing

Neck – Chest - Abdomen  Neck  Short/skin folds  Weak muscle tone  Check clavicle region/ elicit Moro reflex  Chest  Cylindrical shape  Nipples symmetrical, may see engorgement/ milk secretion  No retractions  Abdomen  Cylindrical shape/ no distention  Bowels sounds present by 1 hr  Three vessel cord  l  Patent anus  Document meconium  Imperforated anus Patent urethra  Document voiding  Males  Check for hypospadius/epispadius  Testes descended  Scrotum full/deeply colored with rugae Genital Area  Female  Labia majora cover minora and clitoris  Some edema present  Thick white mucus  Blood tinged discharge common - pseudomenstruation Extremities  Assess for symmetry of length, shape, movement, flexion  Check for brachial palsy  Check for hip dislocation  Check for club foot  Check for syndactyly, polydactyly Assessing Digits  Polydactyly = more than 5 fingers  Syndactyly = more than 5 toes. Club Foot Congenital Hip Dislocation  Sign = uneven buttcheeks Shoulder Dystocia Brachial Palsy

Back - Buttocks  Spine straight/flat  No evidence of dimpling excessive hair which could be associated with spina bifida Reflexes of the Newborn  Moro  Moro Reflex persists until about 6 mos. Hands form a C  Palmar Grasp  Grasp when palm is touch (birth – (4-6mon)   Rooting  Cheek is stroked. Infant turns to the side (birth – 3 mon)  Sucking  Sucks when something placed in mouth (birth- (2-5 mon)  Blinking  Pupillary  Tonic Neck  (“Fencing”) Reflex disappears by 3rd month  When lying supine, extremities are externed to which side the head is facing, and opposite side is flexed.  Abdominal  Withdrawal  Walking  Babinski  Toes move lateral when feet touched (birth -12mon)  Plantar grasp  Grasp when bottom of food is touched (birth – 9mon)  Crying  Stepping Reflex (disappears by 4-8 weeks)  Table 25.1 page 926

Newborn Crying  Newborn’s means of communication  Parents will learn to read different cries  Crying vs. colic  Teach coping mechanisms to avoid abuse/shaken baby syndrome Risk Factors affecting Neonatal Adapation  Maternal pregnancy/prenatal care history, Socioeconomic status, Maternal medical conditions, Labor and birth progress, Delivery method, Meconium staining, Gestational age, Birth weight, Infections, Substance abuse and Prescription drug use Lifespan Considerations for Neonatal Adaptation  Preterm (born < 37 weeks)  Immaturity of all body systems  Term (born >37 < 42 weeks)  Lowest risk for complications  Postterm (born > 42 weeks)  Concern regarding placental calcification decreased perfusion Culture Influences Many Beliefs about Newborn Care  Feeding, Sleeping location, Cord care, Circumcision, Parent – infant contact, Primary caretaker, Involvement of father/extended family, Health and illness Common Labs/Diagnostic Tests  Cord blood collected at birth  ABO blood type, Rh status, Direct Coombs and CBC  Heelstick capillary blood  Glucose, Bilirubin and Genetic /Inborn errors of metabolism screening (i.e., PKU)  Hearing screening Parent Learning Needs  Immediate safety measures  Bulb syringe  Sleep position  Feeding techniques  Voiding/stooling patterns  Bathing/skin care/cord care  Dressing  Circumcision/ uncircumcised care  Techniques for waking/soothing  Newborn behaviors  Newborn screenings  Signs of illness/thermometer use/ when to call pediatrician  Car seat safety  Well baby care/immunizations

Nursing Interventions  Apgar score  Newborn stabilization/airway clearance  Use of bulb syringe  Watch for respiratory distress  VS/temperature  Prevent hypothermia  Protect from infection  Ongoing nursing assessments for signs of newborn distress Nursing Interventions -Newborn Identification  In DR  Bracelets – baby, mother, significant other  Footprint baby, fingerprint mother  Security device  Staff must wear picture ID Nursing Interventions – Eye Prophylaxis  Legal requirement  Protects against opthalmia neonatorum  Caused by gonorrhea or chlamydia  Erythromycin opthalmic ointment : apply moving from inner to outer eye.  May be delayed up to 1hr Nursing Interventions - Cord Care  Cord blood samples, Cord blood banking & Inspect cord vessels  Clean & dry (Avoid tub baths and Expose to air)  Evidence-based practice and alcohol  Report signs infection  Falls off 1-3 weeks Nursing Interventions - Vitamin K Injection  Prevention of hemorrhage (cord site)  Absence of gut bacteria influences production of vitamin K  0.5 to 1mg Vitamin K1 Phytonadione (AquaMEPHYTON)  IM in vastus lateralis  Administer within 1-2 hours after birth Nursing Interventions –Initiate feedings  Breastfeeding immediately after birth  Fed q 2-4 hours on demand  Important to prevent newborn hypoglycemia (< 40-45 mg/dL)  Secondary benefits:  Promotes bonding  Promotes uterine contraction

Nursing Interventions -Bathing  Once temperature is stable (36.5 C / 97.7 F)  First bath under radiant warmer/wear gloves  Sponge baths with mild soap only  Progress using principle- from clean to dirty  Work quickly; dry and dress to prevent heat loss Nursing Interventions associated with Circumcision  Performed by OB doc  3 possible procedures  Gomco clamp  Mogen clamp  Plastibell (rarely used)  MD preference Current Recommendations AAP  Health benefits outweigh risks of procedure (decreased UTIs, HIV, STDs, transmission to partners)  Parental choice based on cultural, social, family tradition  Recommend local anesthesia, pacifier with sucrose H2O  Avoid if preterm, bleeding problems, hypospadias/ epispadias, other complications  ~ 30% of males circumcised worldwide; ~ 50% in US Circumcision - Pre-procedure  Physician explains procedure, Ask if further questions, Verify permit is signed, Gather equipment and Restrain on circ board Circumcision  During Procedure  Assist MD  Assess newborn response  Comfort measures  Post Procedure  Hold and comfort  Assess for signs hemorrhage q 30min X 2hr  Document 1st voiding, voiding patterns  Petroleum gauze  Yellowish granulation tissue is normal  Teach parents circ care  May give mild analgesics if ordered Care of Uncircumcised Infant  Foreskin does not retract until school age  No special newborn care necessary other than good routine hygiene  Begin teaching school aged child to retract and clean

Nursing Interventions –Newborn Immunizations  Hepatitis B vaccine (10 mcg IM)  Dose 1 @ birth  Dose 2 @1-2 months  Dose 3 @ 6 -18 months  HBsAg-positive mothers  Vaccine @ birth, 1 month, 6 months  Hepatitis B immunoglobulin (HBIG) given concurrently Nursing Interventions- Family Education  Teach while performing all nursing care  Encourage family involvement  Provide discharge instructions  Include warning signs to report to pediatrician Warning Signs in the Newborn   or temperature  Vomiting  Refusing feeds  Lethargy  Cyanosis  Apnea > 20 secs  Inconsolable cry  High pitched cry  Bleeding  Infection  Green watery stools  No wet diapers  Eye drainage  “Just doesn’t seem right” EBP Examples r/t Neonatal Adaptation  Delayed cord clamping offers protection from anemia  Skin to skin contact after birth reduces heat loss  Non-nutritive sucking as pain management technique  Supine sleep position reduces SIDS risk  Early initiation of breastfeeding R/T 22% reduction in infant mortality in developing countries http://www.breastcrawl.org/ C...