Normal newborn concept map PDF

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Terms: Neonate/Newb orn Term Infant Preterm Infant Early Term

Newborn period includes time from birth to day 28 of life p. 643 born between week 39 and the end of week 40 (40+6) Born before 37 weeks of gestation Between 37 weeks and the end of week 38 – associated with increased incidence of breastfeeding

Viability Post term Post-mature Infant

born after the completion of week 42 born after completion of week 42 and showing effects of placental insufficiency (pg. 690)

Transition period – in 2 phases (pg. 643-644) 1st phase – lasts up to 30 minutes after birth (First period of reactivity) : newborns heart rate initially increases to 160-180 bpm, but then will fall gradually. Resps may be irregular, rate 60-80 breaths/min. Fine crackles on auscultation may be present. Infant is alert. 2nd phase – from roughly 2 -8 hours after birth (second period of reactivity) and may last from 10 minutes to several hours. Could be brief tachycardia, tachypnea, increased muscle tone, and mucus production. Meconium commonly passed during this phase. The Newborn Initial Assessment & Care Need for Neonatal Resuscitation vs Routine care Apgar Scoring: 5 Signs Appearance, Pulse, Grimace, Activty, Respirations Neonatal Transition Period

All newborns require immediate assessment of their respirations – this is the primary goal of the nurse immediately after birth! If the infant is at term, is crying or breathing and has good muscle tone, routine care can begin (pg. 673) Routine Care – place infant on mother’s chest (skin to skin) and dry the infant by vigorously rubbing with towels. The drying has two purposes – to prevent heat loss from moisture and to stimulate the newborns breathing efforts. Assess the infant’s heart rate by palpating base of the cord or by auscultating, should be greater than 100 bpm An Apgar score – method of rapid assessment, based on 5 signs, should be evaluated at 1 minute and 5 minutes after birth, The score does not necessarily predict future outcomes but is useful to describe the newborn’s transition. Score of 0-3: Severe distress, 4-6: moderate difficulty, 7-10 minimal or no difficulty adjusting to extrauterine life (Pg. 673).

The Newborn Transition and Adaptation to Newborn Life Quick adaptation involves Respiration Circulation Temperature regulation Sources of nourishment Establishment of waste elimination No infections Establishment of parentinfant relationships

The first 24 hours of life are critical The baby has lots to accomplish in the first 24 hours! Learn how to breathe utilizing lungs and diaphragm, completely switch over the circulation from the umbilical cord to normal postbirth circulation, stabilize their body temperature, learn to how to eat and digest, begin voiding and stooling and bond with their caregivers! Often, they need to do this after a tiring and stressful labor experience, they may have bruising or other injuries. Also, if they are a preterm infant, these challenges are even greater. Focus of nursing care?

Hepatic System The newborn’s liver takes over for the placenta at birth The liver stores and releases iron as RBCs are destroyed / produced (iron supply depletes by 4-6 months old) The liver releases glucose from glycogen stores during the first 24 hours as feedings begin to establish The liver is responsible for conjugating bilirubin after birth Respiratory Gas exchange must now be taken over by the lungs The newborn is flooded with catecholamines (epinephrine) due to forces of labour and birth, and cold stress upon delivery – this increase promotes fluid clearance from the lungs After birth chest wall recoils, creates negative intrathoracic pressure; air is sucked back into lung fields, replacing fluid After first inspiration, newborn exhales, creating positive intrathoracic pressure Normal lung function is dependent on production of surfactant Initial transition into breathing is stimulated by hypercapnia, hypoxia, and acidosis due to labour After respirations are established, 30-60 is the range Periodic breathing is cessation of breathing for 5-15 seconds but no change in colour or HR Cardiovascular Changes Changes in circulation occur immediately after birth as the fetus separates from the placenta After the cord is clamped – chemoreceptors sense changes in arterial oxygenation –continued breathing Heart rate can range from 120-180 bpm during first few minutes of life, then ranges 110-160 bpm BP isn’t taken routinely on healthy newborns Blood volume varies in newborns – delayed cord clamping can improve CV adaptation Fetal RBCs are large but few in number, then gradually increase in number,

decrease in size The foramen ovale closes due to increased left atrial pressure with newborn’s first breath – separation between oxygenated and non-oxygenated blood The ductus arteriosus becomes functionally closed within hours of birth – gradually atrophies and forms a non-functional ligament The ductus venosus – connected umbilical vein to inferior vena cava, closes within a few days of birth Infant VS HR, RR, and T are the routine vital signs completed per unit protocol HR is done by taking apical pulse for a full minute (normal is 110-160) Respiratory rate can be taken with a stethoscope, listening to breaths for a minute (normal is 30-60) Temperature typically taken via axilla (normally 36.6-37.5)

Respiratory Distress

Measurements Average weight of a healthy newborn ranges from 2500-4000 grams 4000 grams in term infant is LGA (Large for gestational age) Common for 5-10% weight loss from birthweight before the baby begins to gain weight from feedings. *Important teaching point! Normal newborn length ranges from 45-55cm Weight is measured at birth and once per day until discharge Length is measured at birth only Head circumference – 33-35 cm is normal Head Circumference is measured routinely once prior to discharge, but may be measured more frequently if baby was born via forceps or vacuum to monitor for subgaleal hemorrhage Thermoregulation; Keep Baby Warm How do newborns lose heat? Thermoregulation; maintaining newborn body temperature. So important to help Conduction – transfer of heat from newborn to another object or maintain an “optimal thermal environment” for the newborn. Cold stress increases the person by direct contact need for oxygen and can deplete glucose stores = hypoglycemia. Also increases Convection – transfer of heat from newborn’s body surface, to re can become cyanotic. surrounding cooler air / circulating air S partner when possible. Keep head well Evaporation – Loss of heat from newborn due to fluid evaporation c s separated from mother, should be Radiation – loss of heat from newborn to colder object by indirect th During all procedures heat loss should contact – i.e. newborn placed near window b efits – temperature stabilization, re and duration and facilitates infantc Why do newborns lose heat? C Signs/Symptoms of Cold Thin skin with vessels close to surface, lack of shivering ability, lack of Stress (Hypothermia) Acrocyanosis and cool, voluntary muscle movement mottled, or pale skin Limited stores of glucose, glycogen, and fat – lack of subcutaneous fat Hypoglycemia Large body surface area / weight – vasoconstriction to prevent heat loss Transient hyperglycemia can make skin feel cold, and acrocyanosis to be present. Infants will stay in Bradycardia flexion to try and minimize body surface area exposed to cold. (p. 650).

Tachypnea, restlessness, shallow and irregular respirations Respiratory distress, apnea, hypoxemia, metabolic acidosis Decreased activity, lethargy, hypotonia Feeble cry, poor feeding Decreased weight gain

Inability to communicate feeling cold / hot, inability to adjust clothing / blankets / position Brown fat – present in higher amounts in full-term infants – why preterm infants are more prone to cold stress. Unique to newborns. Metabolism increases heat production in newborn. Can Newborns Overheat? Newborns are prone to overheating due to limited sweating ability and limited insulation The newborns immature CNS (hypothalamus) makes it difficult to balance heat production and heat loss / gain Overheating increase fluid loss, respiratory rate, and metabolic rate considerably The Newborn Head to Toe Assessment Start at the Head Skin Assess for shape and size, symmetry, roundness Colour and Texture Palpate for both fontanels (anterior and posterior) Pink or red or tan in the first few days after birth Anterior fontanel diamond shaped, on top of head Acrocyanosis is common in the first 24 hours of life Posterior fontanel is triangle shaped, back of head, much smaller than Not normal – generalized cyanosis or pallor; jaundice anterior – roughly fingertip sized Dry and peeling skin Anterior fontanel (4-6 cm), posterior (1-2 cm) Bumps, rashes, & other common marks Palpate the skull for any irregularities, should be smooth Stork bite Assess for molding, Caput succedaneum, Cephalohematoma Milia These variations normally disappear within days to weeks after birth – no Mongolian spots intervention normally needed Erythema toxicum (newborn rash) May find some over-riding of sutures which will resolve on its own Nevi flammeus (port wine stain) A. Caput - generalized edema to scalp – due to the sustained pressure of the head on the cervix during labor. It extends across suture lines. B. Cephalohematoma - collection of blood between skull bone and the periosteum, does not cross suture lines. Often occurs simultaneously with caput. Forceps extraction can also cause.

Subgaleal Hemorrhage ABNORMAL bleeding in the subgaleal compartment commonly associated with difficult vaginal birth involving vacuum extraction. With the vacuum the scalp is pulled away from the bony part and vessels can be torn resulting in blood collecting in that space. Early detection is important – and is done by repeating head circumference measurements and observing for increasing edema in all infants born with vacuum. Molding Face

Observe for fullness and symmetry - If forceps were used marks may be apparent – reassure parents this resolves without treatment Nose: midline, patent nares, sneezing is normal Mouth: symmetric, palate intact, assess for tongue tie Ears: level with eyes, patent auditory canals Eyes: symmetrical, blinking, transient strabismus Torso and Extremities Neck – holds head midline, clavicles intact / straight Chest – size, shape, symmetry, breast buds normal. Auscultate lungs and heart, chest should be barrel shaped Back – palpate spinous processes, spine should be straight (observe for dimple at coccyx) Extremities – limbs symmetric, spontaneous movements, 5 digits – no fusing, palmar creases Abdomen Auscultate BS in all four quadrants, inspect for size and shape Palpate gently for any abnormalities (hernia, masses) Inspect umbilical cord, note if 3 vessels are apparent (1 larger vein, 2 smaller arteries), observe for hernia or infection Umbilical Cord Cochrane review of 21 studies: no difference in dry cord compared with those treated with antiseptics Current recommendations to clean the area with water using a Q-tip around the base of the cord and dry well, twice a day. The stump usually is dry within 24-36 hours The cord will fall off on its own within 7-10 days. The clamp is usually not removed unless it is irritating the newborn Genitalia Males: inspect penis and scrotum (check position of urinary meatus, should be midline at tip of glans); palpate scrotum to ensure both testes are descended, note presence of any edema Females: inspect the external genitalia, urethral meatus / vagina should be midline, labia may be edematous, vaginal discharge & some blood may be present due to maternal hormones Inspect for patent anus in both males and females Elimination Meconium Formed in utero Passes within 48 hours Black, sticky, tarry, will slowly transition to yellow, ”seedy” in breastfed infant Voiding 93% void by 24 hours May be infrequent until feeding well established. Brick Staining (rust color) is normal variation Should have about 6 wet diapers day after day 6 -

Newborn stomach can hold 30-90mL – empties q2-4h Kidneys are immature at first, cannot concentrate urine until about 3 months old, not fully mature until 2 years Brick Staining – When baby is not producing very much urine, the

Left to right top to bottom: stork bite, milia, Mongolian spot, erythema toxicum, lanugo, vernix

Neurological Status Assess for alertness, posture and muscle tone, and reflexes Hold the newborn prone with one hand under the chest – observe for ability to hold head up briefly Assess for newborn reflexes (blinking, sucking, rooting, moro, grasp, babinski, stepping, fencing) Newborn Reflexes

(A) Rooting reflex. (B) Palmar grasp reflex. (C) Moro’s reflex (startle reflex). (D) Tonic neck reflex. (E) Babinskis reflex. (F) Stepping reflex.

Newborn Senses Vision At birth, can fixate on object and track movement Can see objects up to 5 cm away Prefer highly contrasted and contoured objects 20-30cm away Hearing Prefer high intonation and rhythmic sounds Will turn head in response to mother’s voice Smell

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uric acid crystals may be visible in the very concentrated urine in the diaper. It is not a cause for concern if baby is feeding well. Abnormal if infant does not void in first 24 hours. Important to document any wet/ soiled diapers.

Touch -

Breastfed infants can identify their mother’s milk scent Fetus responds to touch as early as 2 months Well developed at birth

Normal Newborn Behaviour Divided into 3 periods: 1. First period of reactivity birth-30 minutes, prime time to initiate BF, baby is alert and quiet, moves extremities in uncoordinated way, startles easily, sucking motions 2. Period of decreased responsiveness (Sleep phase 2-4 hours) 30-120 minutes of age, baby enters sleep phase, muscles relax, responsiveness to external stimuli decreases 3. Second period of reactivity baby awakens and shows interest in environment, lasts 4-6 hours, peristalsis increases, may pass first meconium Newborn Behavior How a newborn interacts with their world is called neurobehavioural response Orientation: the response of baby to stimuli, they become more alert when presented with a new stimulus, stare intently at new objects and faces, build familiarity Habituation: ability of baby to process and respond to visual and auditory stimuli, and block out external stimuli as they become accustomed to it Motor Maturity: depends on gestational age – evaluation of posture, tone, coordination, and movements – as baby adapts, smoother movements Self-quieting Ability: baby’s ability to quiet and comfort themselves, varies between babies – “consolability” is change from crying to non-crying state, some babies may require parental help with this Social Behaviours: cuddling and snuggling with parent, most newborns enjoy being cuddled or held Common Laboratory and Diagnostic Tests Parental Attachment Routine testing Promote early and extended contact and Blood glucose; If symptomatic or at risk for hypoglycemia promote confidence Bilirubin levels Complete assessments while infant is skin-too monitoring of bilirubin levels in healthy newborns at 35 weeks gestation or older, before skin if possible discharge from hospital (usually done at 24 hours of age) and then using a nomogram Encourage breast feeding within the first ½ hour that lists hour-specific serum bilirubin levels to determine the infant’s risk for developing hyperbilirubinemia that will require treatment or more screening. Crying – is how infants communicate, responsiveness to an infant’s cries forms Newborn screening tests attachment (infant develops trust) o P ecessive trait), it’s a deficiency or a ino acid Phenylalanine, a build up in th early diagnosis and treatment is im irth. o H ngenital disorders o B ique Gestational Age Assessment with Ballard Ballard Score Score Physical assessment includes: Skin texture Lanugo Plantar creases Breast tissue Eyes and ears Male genitals Female genitals Neuromuscular assessment includes: Posture Square window Arm recoil

Popliteal angle Scarf sign Heel to ear Hypoglycemia...