CARE OF THE NEONATE Flashcards
TRANSITION
- newborns undergo profound physiologic changes at the moment of birth
- within minutes after birth, a newborn has to initiate respirations and adapt a circulatory system to extrauterine oxygenation
- within 24 hrs, neurologic, renal, endocrine, and gastrointestinal functions must be operating completely for life to be sustained
- oxygen levels are lower in utero
INTRAUTERINE LIFE
- fetal breathing starts at 11 weeks, characterized by minimal circulation to the pulmonary bed. oxygenation occurs via the placenta. no gas exchange in fetal lungs
- fetal lungs are fluid filled. There is some reduction in this prior to birth. There is still 100ml remaining in the respiratory passages at delivery
INTRAUTERINE LIFE CONTINUED
surfactant promotes lung maturity by overcoming surface tension inside and outside the alveolar sacs in the fetus. surfactant peaks at 35 weeks and remains high. keeps sacs open .
- blood is shunted away from the pulmonary circulation to the systemic circulation via the formen ovale and ductus arteriosus
ADAPTATIONS TO EXTRAUTERINE LIFE
- extra uterine circulation begins with the first breath
- respiratory gas exchange in conjunction with marked circulatory changes must occur immediately for the baby to begin life as a separate being.
- 2 changes are needed to maintain life
1. lungs must expand to allow for pulmonary ventilation
2. marked increase in pulmonary circulation
INITIATION OF RESPIRATIONS
-happens within 1st min of life
PHYSICAL/ Mechanical Changes :
- thoracic sqeeze decreases fluid further. chest wall recoil - small amount of air in , more fluid out
Chemoreceptor response to :
-low PO2 and PH and high CO2 (normal in utero)
Temperature:
- cold air= increased respiratory effort
Sensory stimuli:
tactile, auditory and visual that stimulate respiratory effort
CARDIOVASCULAR SYSTEM
Three anatomic shunts normally close after delivery in response to pressure gradient shifts following the first few breaths
- foramen ovale
- ductus arteriosus
- ductus venosus
CARDIOVASCULAR SYSTEM ANATOMY
HEART RATE= 110-160
BLOOD PRESSURE= average is 50-55 mmHg ( 70/40)
SOUNDS=
- murmurs are frequently heard
- 90% are transient and not associated with CHD
- due to closing ductus arteriosus and / or foramen ovale
- cardiology work up needed if there are other symptoms of distress or murmur persists
3 CORD VESSEL
2 arteries, 1 vein - abnormal can be associated with other congenital defects
SIGNS OF DISTRESS
tachycardia, bradycardia, low BP, decreased perfusion CRT> 2-3 sec, low BP in LE
WHAT HAPPENS TO PULMONARY BLOD FLOW WITH FIRST FEW BREATHS ?
- lung fluid has been removed. pulmonary vascular resistance decreases and pulmonary blood flow increases
- sometimes this doesn’t happen right away and the baby developes transitory tachypnea of the newborn(TTN)
- treatment for TTN is support until the lungs clear: O2, hold PO feeds and IV fluids with expected recovery in 24- 72 hrs
RESPIRATORY SYSTEM
- initial respiratory are shallow, irregular in depth and rhythm
- respiratory rate usually 60-70 bpm
- breathing is abdominal( expected)
- breathing is periodic (expected)
- obligatory nose breathers
- acroncyanosis is normal for several hours. central cyanosis is abnormal after birth and resusucitaion
ABNORMAL RESPIRATORY FINDINGS
- abnormal findings include retractions, nasal flaring , cyanosis, expiratory grunting
TRANSITION PERIOD/IMMEDIATE CARE
- drying
- warming
- stimulation
- positioning ( head support)
- clear airway (suction )
NECESSARY FOR ALL NEWBORNS !
IMMEDIATELY AFTER DELIVERY
look at general appearance= color,and cry , ease of breathing
-first exam begins as nurse is drying stimulating and wrapping infant or when infant is placed on mother’s abdomen after being born. this is known as skin to skin and promotes bonding and breastfeeding
HEAT LOSS ( INCREASE BSA FACILITATES HEAT LOSS)
- Convection- losses from circulating air
- Radiation- body heat transferring to nearby objects
- Evaporation- heat loss when moisture on baby
- Conduction- body heat lost when baby in direct contact with cold object
IMMEDIATE CARE
- wear gloves
- maintain airway
- suction, O2 prn
- RR= 30-70’s
- APAGAR scoring - neutral thermal environment
- warmer, maintain temp of 36.5-37.2C , dry - Safety ID bands
THERMOREGULATION
- increase in muscular activity- shown by crying and restlessness= increased BMR= heat loss
- non-shivering thermogenesis- unique to newborns. uses the infants stores of brown fat.
- brown fat is found in the midscapular area, around the neck, in the axillas, and around the trachea, kidneys, and adrenal glands (premies don’t have this)
COLD STRESS HYPOTHERMIA
increase O2 consumption (to keep warm ) =increased RR = pulmonary vasoconstriction and peripheral vasoconstriction= decreased O2 to tissues causes
- anaerobic glycolysis
- decreased O2, increased CO2= low PH = metabolic acidosis
CORD CLAMPING
- keep at level of uterus
- 45 second delay in clamping has benefits
- place clamp 1 inch from abdomen
- assess for 2 arteries/ 1 vein
- remove plastic clamp in about 24hrs and offer save it for patients
APGAR SCORING SYTEM
7-10 good condition
4-6 moderately depressed
0-3 severely depressed
5 things assessed
HR,RR, muscle tone, reflex irritability, color
taken at 1 and 5 minutes
NORMAL RANGES FOR VITAL SIGNS
axillary temp- 36.5-37.2 respirations - 30-60 apical pulse- 120-160 BP(not generally done )- 80-60/45-40 weight - 2500-4000 grams length - 46-56cm head circ. - 32-37 cm
IMMEDIATE CARE FOR BABY
- Vitamin K injection
- check cord clamp
- footprints and ID bands
- Security tag
VIATMIN K INJECTION
- muscular injection in thigh
- preventing ophthalmic neonatorum
- erythromycin ointment both eyes
PROTECTION FROM HYPOGLYCEMIA
- closely monitor
- SGA,LGA,IUGR
- stressed infants
- infants of diabetics
- cold stress
- symptomatic can over lap can look like sepsis
- feed as soon as possible
HYPOGLYCEMIA HEEL STICK PROCEDURE
-BLOOD SUGAR 45-60(NORMAL)
-BLOOD SUGAR <45(REQUIRES FEEDING )
- BLOOD SUGAR <20-25 (REQUIRES PARENTERAL GLUCOSE)
-
-warm heal, select correct lancet size and correct heel location
GENAERAL APPEARANCE
- head disproportionately large for body
- neck appear short
- prominent abdomen
- sloping shoulders
- rounded chest, narrow hips
- body appears long, extremities short
- extremeties flexed
- hands tightly clenched
HEAD
- fontanels , anterior and posterior
- symmetry of face
- ears recoil and placement (low set= genetic problem_
- eyes
- nose= obligatory nose breathers
- scalp swelling
- mouth= palate, tongue or teeth
- neck mobility and webbing
CHEST
- barrel shape
- breath sounds -grunting, retracting, flaring
- periodic breathing vs apnea
- clavicles
- nipples- discharge can be normal
-auscultate hear for rate, rhythm and murmur. check cap refill and pulses
GESTATIONAL AGE (ga) ASSESSMENT
SGA- small =less than or equal to 2500g
AGA - average= 2500-4000g
LGA- large = >4000g
IUGR- intrauterine growth restriction
VERNIX CASEOSA
white cottage cheese, a greasy deposit covering the skin of a baby at birth
LANUGO
fine, soft hair, especially that which covers the body and limbs of a human fetus or newborn
ACROCYNOSIS
bluish or purple coloring of the hands and feet caused by slow circulation this is normal
ERYTHEMA TOXICUM
-white pustule in middle of red patch
is a common rash in neonates.
- It appears in up to -half of newborns carried to term, usually between day 2–5 after birth; it does not occur outside the neonatal period.
MILIA
Tiny white bumps that commonly appear on a baby’s face
-often found in clusters
FONTENELS
a space between the bones of the skull in an infant or fetus, where ossification is not complete and the sutures not fully formed. The main one is between the frontal and parietal bones.
Anterior: stays open
Posterior: can close at birth or a few months after
CAPUT SUCCEDANEUM
refers to the swelling, or edema, of a newborn’s scalp soon after delivery. It appears as a lump or a bump on their head. This condition is caused by prolonged pressure from the dilated cervix or vaginal walls during delivery. Caput succedaneum usually goes away on its own within a few days.
CEPHALOHEMATOMA
traumatic subperiosteal haematoma that occurs underneath the skin, in the periosteum of the infant’s skull bone
- one area of the head
DIGITS/ POLYDACTYLY
extra digit
PALM CREASE- SIMIAN CREASE
palm crease all the way across hand , related to down syndrome
GENITALIA MALE
- determine meatus location: hypospadias, epispadias
- warm hand before inspection of scrotum
- palpate testes separately (two)
- assess for hydrocele: fluid swelling of scrotum
GENITALIA FEMALE
-examine:
labia majora
labia minora
clitoris
- observe for pseudo-menstruation : discharge in diaper
NEUROMUSCULAR SYSTEM
REFLEXES:
- root,suck,swallow
- grasp(palmar and plantar)
- moro (startle reflex)
- Babinski(a reflex action in which the big toe remains extended or extends itself when the sole of the foot is stimulated, abnormal except in young infants.)
SENSES:
- vision
- hearing
- touch
GESTATIONAL AGE ASSESSMENT
TWO PARTS
- external physical characteristics
- neurological characteristics
- maternal conditions may impact certain components of gestational assessment
- observable characteristics should be evaluated while not disturbing baby
- prioritize needs based on:
SGA,AGA,LGA
EARLY ASSESSMENT OF NEONATAL DISTRESS
-parental teaching
- observe for:
changes in color or activity
grunting or sighing sounds
rapid breathing
chest retractions
facial grimacing
NEWBORN GROWTH CHART
- head circumference
- weight
- height
PHYSICAL MATURITY CHARACTERISTICS-BALLARD SCALE
- resting posture (flaccid =preemie, flexed=normal)
- skin
- lanugo
- plantar creases
- breast tissue
- ear formation and cartilage development
- evaluation of genitals
NON- BREAST FEEDING GUIDELINES
- 1st feeding by 5 hrs of age, 2nd period of reactivity
- Enfamil, similac,good start (20kcal/oz)
- various bottles and nipples available NUK nipple vs standard and high flow vs normal. Dr. Brown bottles may help with reduction in gas
- no honey on pacifier -risk for botulism
GENERAL FEEDING GUIDELINES
- establish a feeding routine after the first week or so. incorporate baby’s cues into feeding routine, initially feed Q 3-4hrs
- identify signs of intolerance including reflux,diahrea, frequent emesis
- burping every 1-2 ounces initially
- refrigerate mixed formula
- use warm warmed formula within an hour
- dilute correctly when using concentrate or powders
ASSESSMENT OF THE FAMILY
- psychological
- sociocultural
- developmental
- spiritual
- social services consult may be needed to identify community resources that foster optimum development
ONGOING CARE OF THE NEWBORN
- cardiopulmonary- vitals, resp, and CV
- neutral thermal environment -monitor temp, cap,swaddle, warmer as needed
- hydration/nutrition- feeding, voiding and stooling
- skin integrity - bathing ,umbilical cord care
- promotion of safety- verify identity , ongoing
- monitor for complications- sepsis,TTN,Jaundice
DISCHARGE TEACHING
GENERAL CARE
- when to call pediatrician
- how to take temp and use bulb syringe
- number of wet/soild diapers as normal comforting and positioning baby
- cord care, circumcision
FEEDING SAFETY
- car seat
- sleeping position
- preventing shaken baby syndrome
BREAKDOWN OF FETAL HEMOGLOBIN
bilirubin is a bile pigment secreated by the liver, can be toxic if elevated
TWO TYPES
- water insoluble -unconjugad (indirect)
- water soluble- conjugated(direct)
- total bilirubin measures both conjugated and unconjugated types
PHYSIOLOGICAL JAUNDICE
criteria observed at least 24hrs after birth
- total serum bilirubin levels of 5mg/dl seen prior to jaundice. factors like rate of increase considered prior to planning treatment
- serum and bili- meter levels generally peak by 3-7 days
- up to 66% of term or 80% of preterm develop jaundice
TREATING PHYSIOLOGICAL JAUNDICE
- hydration and monitoring stool output
- phototherapy may or may not be needed
- when needed can use overhead lights or a bili- blanket with proper protection
- monitor temp
- sensory stimulation (take eye covering off)
