Health Promotion of the Newborn and Family Flashcards
Maturation of systems
Respiratory and cardiovascular systems change immediately at birth while other organ systems evolve over time
Respiration
-Most critical and immediate physiologic change
-Fetal lung fluid removal: compression of chest w/ passage thru birth canal, lymphatic vessels and pulmonary capillaries
-Expansion of alveoli: occurs w/ initiation of breathing, role of surfactant in keeping alveoli expanded
Circulation
-Foramen ovale circulatory changes allow blood to flow thru lungs
-Pressure changes in heart, lungs, vessels
-Functional closure of fetal shunts d/t increased oxygenation of blood: ductus arteriosus and venosus
Sequential circulatory changes
-Inspired O2 dilates pulmonary vessels
-Pulmonary vascular resistance decreases and pulmonary blood flow increases
-Pressure in RA, RV, pulmonary arteries decreases
-Gradual increase in systemic vascular resistance after campling of cord
Further circulatory changes
-LA pressure greater than RA pressure leads to closure of foramen ovale
-Increase of pulmonary blood flow and dramatic reduction of pulmonary vascular resistance begins to close the ductus arteriosus
Typical times for circulatory chnages
-Foramen ovale: close soon after birth
-Ductus arteriosus: closure in about 4 days after birth
-Failed closure of shunts takes blood away from pulmonary circulation
Thermoregulation
-Critical to survival
-Principal thermogenic sources: heart, liver, brain, brown adipose tissues (BATs)
-Babies born w/ lots of brown fat behind shoulder blades, newborns can’t shiver so brown fat acts as built-in heater
Factor predisposing newborn to excessive heat loss
-Large surface area results in heat loss
-Thin layer of adipose is poor insulator
-Can’t shiver –> produces heat thru nonshivering thermogenesis (NST)
Fluid and electrolytes
-BW is 73% fluid (adult is 58%)
-2x higher rate of metabolism than adult
-Immature kidneys produce more acid and inability to concentrate –> prone to dehydration, acidosis, overhydration
GI system
-Ability to digest, absorb, metabolize food is adequate: certain enzymes are limited
-Mucosa: barrier to foreign antigens
-Salivary gland fxn decreased
-Small stomach capacity
-Intestine longer than adult: increased absorption
Stool patterns
-Meconium: occurs 24-48 hrs after birth
-Transitional stools: appears by 3rd DOL
-Milk stools: usually appears by 4rth DOL, differences in breastmilk and formula stools
Renal system
-Fxnal deficiency in kidney’s ability to concentrate urine
-Total volume of urinary output per 24 hrs is 200-300 mL by end of 1st week
-Bladder capacity approximately 15 mL
-1st void occurs within 24 hrs after birth
-Newborn may void as many as 20x/day
-Urine is colorless, odorless, and specific gravity of 1.020
Skin
-Immature integumentary fxn
-Active sebaceous glands
-Eccrine (sweat) glands
-Apocrine glands small and nonfxnal
-Hair follicles
-Melanin low at birth: lighter skin than in later life, UV susceptibility
Musculoskeletal
-Large amt of cartilage than ossified bone
-Rapid ossification in 1st year of life
-Almost completely formed at birth
-Muscular growth by hypertrophy rather than hyperplasia
Immune
-Skin and mucous membranes 1st line of defence
-2nd line of defense is cells: neutrophils, eosinophils, lymphocytes
-3rd line of defense is antibody formation: breastmilk provides passive immunity (IgG)
Endocrine
-Developed but fxn is immature
-ADH and vasopressin production is limited: risk of dehydration
-Effects of maternal sex hormones in newborn
Neurologic
-At birth, nervous system is incompletely integrated
-Primitive reflexes
-ANS crucial
-Myelination of nerves follows cephalocaudal-proximodistal progression
Sensory fxns
-Vision: pupils react to light, blink and corneal reflexes; tear glands have minimal fxn until 2-4 weeks
-Hearing
-Smell
-Taste
-Touch
Physical assessment phases
-Initial: APGAR
-Transitional: during periods of reactivity
-Gestational age
-Comprehensive, systemic
APGAR assessment
-Score of 1-10, score of 7-9 is normal
-Appearance, Pulse, Grimace, Activity, Respiration
-Score at ages 1 min and 5 min
-Reflects condition of infant
-Not used to determine need for resuscitation at birth
Factors affecting APGAR score
-Low tone
-Reduced reflex irritability
-Infection
-Congenital anomalies
-Maternal sedation or analgesia
-Hypovolemia
-Neuromuscular disorders
Transitional assessment
-Periods of reactivity
-1st reactivity pd: 30-60 min after delivery (alert, interested in environment), 2-4 hr after delivery (sleepy and calm)
-2nd reactivity pd: lasts 2-5 hr (alert and responsive)
Behavioral assessment
-Sleep: 6 states
-Brazelton neonatal behavioral assessment scale (BNBAS): 28 items organized in clusters
-Newborn behavioral observations (NBO) system: 18 observations
Cry assessment
-Strong, lusty cry at birth
-5 min - 2 hr or more per day
-Weak groaning cry or grunting during expiration indicates respiratory disturbance
-Absent, weak, or constant crying may suggest pathology
-High-pitched, shrill cry indicates increased ICP
-Crying status alone is not a dx tool
Attachment assessment
-Parent-infant bonding
-Requires more skills in terms of observation and interviewing
-Key elements in assessing attachment behavior requires additional training
GA assessment
-New ballard scale (NBS)
-Appropriate for 20-44 weeks gestation
-Perform in immediate post-delivery period for highest accuracy
-Assesses 6 external physical and 6 neuromuscular signs
Weight r/t GA
-BW is poor indicator of maturity
-Gestational age reflects fetal
-AGA: growth between 10th and 19th percentile
-SGA: < 10th percentile
-LGA: > 19th percentile
Newborn maturity and general measurements
-Term: 36-42 completed weeks of gestation
-Preterm: < 36 weeks completed weeks of gestation
-Postterm: > 42 weeks of gestation
-General measurements: head circumference, chest circumference, abdominal circumference, length, BW
Physical exam
-Normothermic and nonstimulating area
-Proceed quickly
-Undress only 1 area at a time to prevent heat loss
-Proceed head to toe: ascultatation first, reflexes last, compatible measurements
-Comfort infant during exam: involve parent
General measurements
-Head-to-heel length: extend legs fully, 19-21 in
-Abdominal circumference if distention is suspected
-BW: lose up to 10% in 1st few days and return to BW by day 10-14
-6-9 lb is average
Vital signs
-Temperature: axillary (benefit vs risk), tympanic (concerns in use), temporal artery (concerns in use), rectal (benefit vs risk)
-Count for full 60 sec: apical HR (120-140 BPM), RR (30-60 BPM)
-BP: baseline eval of CV status
-Routine pulse ox screening for congenital heart disease for all newborns
General appearance
-Posture: flexion
-Behavior: easily awakened by loud noise, easily comforted, level of responsiveness to noxious status, transition of sleep states evident
Skin assessment
-Texture: smooth, puffy areas
-Color: central vs peripheral cyanosis (peripheral is benign)
Head assessment
-Contour of head
-Fontanels: anterior and posterior
-Degree of head control of head lag
-Result of birth trauma: caput succedaneum, cephalhematoma, physiologic craniotabes
Eye asessment
-Edema for 1st DOLs
-Drainage
-Sclera
-Corneal reflex
-Nystagmus
-Strabismus
-Red reflex
Ear assessment
-Pinna
-Canals
-Tympanic membrane
-Auditory ability (ABR testing)
-Startle reflex
Nose assessment
-Patency of nasal canals
-Structure
-Appearance
-Obligatory nose breathers
Mouth and throat assessment
-Palate
-Epstein pearls
-Frenulum and lingual frenulum
-Sucking and rooting
-Uvula
-Teeth
Neck and chest assessment
-Short neck w/ folds of tissue
-Observe for abnormal appearance
-Chest anteroposterior and lateral diameters are equal
-Ribs flexible: observe for retractions
-Breast: supernumerary nipples or 3rd nipple
Lungs assessment
-Periodic breathing
-RR is 30-60 BPM
-Pause in breathing < 20 sec WNL, > 20 sec is apnea
-Auscultate when infant is quiet (clear, equal, bilateral0
-s/s of respiratory distress (tachy, grunting, nasal flaring, intercostal retractions, stridor, abnormal breath sounds, cyanosis and pallor
Heart assessment
-HR 120-140 BPM
-Dextrocardia (heart pointed toward R side of chest)
-Auscultation may be difficult: murmurs, S1 and S2 clear
-Point of maximum intensity (PMI): 4th or 5th intercostal space, L of midclavicular line
Abdominal assessment
-Contour
-Umbilical cord
-Liver
-Spleen
-Kidneys
-During exam of lower abdomen: femoral pulses
Genitalia assessment
-Labia majora and minora, hymenal tag
-Vaginal discharge
-Pseudomenstruation
-Penis
-Foreskin/smegma
-Scrotum and testes: hydrocele, hernias
Back and rectum assessment
-Spine: sacral dimple, sacral tuft, pilonidal sinus/cyst, spina bifida (occulta)
-Anus: imperforate anu
Extremities assessment
-Symmetry, ROM, reflexes
-Digits: polydactyly (more than 5 digits), syndactyly (conjoined digits)
-Muscle tone, nail beds, babinski reflex
Neurological assessment
-Reflexes
-Posture, tone, head control, body movement
-Behavioral response to care: consolability, cry frequency and pitch
Maintain patent airway
-Supine neutral position critical to achieving a patent airway
-American Academy of pediatrics: supine position during sleep for all infants
-Bulb syringe
-Mechanical suction
-Avoid aspiration of amniotic fluid or mucus: clear pharynx before nasal passages
Maintain stable body temp
-Heat loss thru evaporation: dry skin
-Heat loss thru radiation: maintain ambient temp
-Heat loss thru conduction: skin to skin/padded surface
-Heat loss thru convection: transport in solid side crib
Protection from injury and infection
-Hand hygiene
-Eye care
-Umbilical cord care
-Bathing
-Circumcision
-Vitamin K (at birth in nursery)
ID
-Verify ID thru banding
-Proactive emergency plan in hospital to prevent infant abduction
-Discuss safety measures w/ parents
Nutrition
-Human milk
-No cow’s milk before 1 y
-Cultural considerations
Breastfeeding
-Preferred
-WHO promotion
-Consider economics and availability
-Breast cancer significantly lower in women who have breastfed
-Protects child from obesity, allergy, DM, atherosclerosis
