Module 5: Harley Flashcards
Normal findings head to toe assessment
- uncovering infant
- observe positioning
- looking at symmetry of movement
- skin for bruising, abrasion, rashes, birthmarks
- skin colour: pallor, cyanosis
- skin: clear? tissue turgor satisfactory?
- baby feel warm?
- stethoscope (warm it first): auscultate chest and abdomen –> for heart and bowel sounds
- while baby is calm & quiet: listen for respirations and quality of sounds on each side of chest (upper and lower lung field)
- RR: 30-60 breaths per minute
- Heart rate for full minute (100-160bpm) for any irregularities
- murmur may be normal
- bowel sounds in all 4 quadrants
- abdomen: soft? round?
HEAD - look at the side and size of head
- look for caput succedaneum (slight swelling on presenting part and cross suture line): pitting indentation (edema): resolve spontaneously 3-4days
- look for cephalohematoma: blood collected between skull bone and periosteum (swelling dont cross suture line): increases in the first 3-4days and resolve 2-3weeks
- assess anterior fontanelle and posterior fontanelle: feel for fullness or bulge
- fontanelle: soft? flat? sutures approximated?
- feel over suture bones (may still be overlapped)
- check ear for normal shape and position (any asymmetry?)
- check eyes (in align with pinna ears)
- note rotation of neck as you turn infants head
- neck: masses? crepitus?
FACE - look for symmetry of eyes, eyelid edema resolve 2-3days,
- assess lips, nail beds, earlobes for cyanosis
- observe nose for nasal flaring
- check palate and note the sucking reflex, can tongue extend itself beyond the lower lip or is there tongue tied?
- displaying rooting relfex: stroking baby cheek and to see if he turns in that same direction of the stroking
CHEST - note work of breathing,
- note retraction: subcostal, intercostal or substernal
- check to see if chest and abdomen are symmetrical
- check capillary refill by pressing on sternum and toes,
- look at umbilicus
- if cord clamp on: 3 vessel cord (2 arteries, 1 vein) –> keep this area clean and dry
Open diaper: - move down to check femoral pulses (in line with the nipples): hold your two fingers down in that area and feel for the pulses
- once you feel the femoral pulse, go feel for the brachial pulse: to assess if they are even
GENITAL and ANUS - stooling? voiding?
- may appear swollen (normal): resolve 2-3 days
- for female: inspect urethra, vagina, and anus: note patency of vaginal opening
- for male: note size and location of urethra: hypospadias (under side) or epispadius (on top of penis)
- DO NOT retract the foreskin
- palpate testes to make sure they have descended
- turn baby over to check anus patency
- may have mongolian spots (buttock or on back): benign + flat + congenital birth mark with wavy borders + irregular shape –> resolve by puberty
- while baby is prone check spine
SPINE - looking for curvature of spine and its intactness. look at the bottom of spine for sacral dimple
- return infant to its back
HANDS - how many fingers
- open each hand and look for palmar creases (2 creases on each hand)
LEG - are they equal in length
- rotate at the joints easily?
- observe foot position
- assess toes for colour and capillary refill
TEMP - check temperature auxillary 36.5-37.2: hold arm across chest with probe under armpit
WEIGHT - weight loss? gain?
DRESS the baby again - all infant are at risk for temperature instability
Whats included in the clinical decision-making process?
- knowing the self
- knowing the profession
- knowing the case
- knowing the person
- knowing the patient
- thinking
- cues, judgement, decision-making, and evaluation
What is the difference of basic assessment and in-depth assessment?
- Basic assessment is aimed at gathering basic data from all systems.
- In-depth assessment is aimed at gathering more than basic data
- Some infants will require only basic assessments. If they remain vulnerable, but do not become ill, they may never require more than a basic assessment.
- Infants who do become ill will likely require both a basic assessment and a more in-depth assessment.
What can be gathered from “hands off” assessment of infant?
- Tone and colour are readily apparent.
- Work of breathing, chest movement, and respiratory rate can be determined.
- Movements, position, sleep–wake state, and responsiveness can be observed.
- The abdomen may be visible, depending on the infant’s position.
- IV sites may also be visible.
- Monitors reveal HR, RR, and O2 saturation
When is hands on and hands off assessment done?
- Hands-off assessment is done continuously.
- Hands-on assessment is done routinely with handling and otherwise only when needed.
- Unless an infant must be disturbed for another reason, they should be assessed in a hands-off manner: colour, sleep/wake state, RR, work of breathing, tone
- Hands-on assessment should be done with other handling unless there are abnormal findings in the hands-off assessment that warrant handling: head to toe assessment
What is systematic inquiry?
- correct diagnosis requires systemic inquiry aimed at compiling a complete picture of sources of vulnerability, risk factors, and clusters of signs.
- This enables you to create a list of more likely problems and eliminate less likely diagnoses.
- from a list of more likely problems, you can continue to systematically inquire, look for pieces of information that were previously missing, ask specific questions, and hone in until you have identified one or two most likely explanations for an infant’s illness.
What is an important factor to consider when determining infants vulnerability?
- their gestational age
- premature infant: particularly vulnerable because their organ systems are not only immature, but so much so that extrauterine life poses a severe threat to the functioning of those systems
- late premature infant: are challenging to care for because we aren’t always sure about the likelihood that a particular problem will occur.
What can be used to determine gestational age (3)?
- date of the mother’s last menstrual period,
- ultrasound measurements, and
- fundal height
What is vernix? lanugo?
Vernix caseosa:
- is a white, creamy, naturally occurring biofilm covering the skin of the fetus during the last trimester of pregnancy.
- Vernix coating on the neonatal skin protects the newborn skin
Lanugo:
- Lanugo is fine, soft, unpigmented hair that is often present in fetuses, newborns,
Does the uncertainty about how a late-preterm infant can be expected to do increase the infant’s vulnerability?
- particularly when an infant’s actual gestational age is not accurately estimated and the infant is younger than the staff think he or she is.
- These kinds of inaccuracies can prevent borderline premature infants from receiving the monitoring and care appropriate for their degree of vulnerability
What are 3 signs of infant developing respiratory distress?
- tachypnea (ex. RR 68)
- hypothermia (ex. 36.2)
- feeding difficulties
What are some problems late pre term infants at risk for in every system (1)?
- respiratory: RDS, transient tachypnea of the newborn (TTN)
- cardiovascular: patent ductus arteriosus (PDA)
- neurological: intraventricular hemorrhage (IVH)
- gastrointestinal: NEC, feeding difficulties
- genitourinary: fluid and electrolyte imblanace
- metabolic: hypothermia, hyperbilirubinemia
- immune: sepsis
What is P from PWSOAC framework?
Pink: Establish and maintain respirations
- initial breaths are swallow and irregular
- normal RR is 30-60
- infant are nasal breathers
- RR and WOB should be monitored
- skin to skin contact be maintained
What is W in PWOSAC framework?
Warm: regulate temperature
- Thermoregulation: the balance between heat loss and heat production
- Thermogenesis: primarily from brown fat
- Newborns have a large surface area -to-body weight ratio.
- Changes in environmental temperature will affect the infant.
- Temperature needs to be monitored.
- Skin-to-skin contact should be maintained.
What are the 4 ways heat loss happens in infants? What are the preventions for each one?
Evaporation:
- Loss of heat through conversion of a liquid to a vapour as water evaporates from the infant’s body—about 20%:
- Dry the NB immediately after birth to prevent heat loss (32 weeks and under—do not dry, immediately place in a polyethylene plastic bag).
Conduction:
- Transfer of body heat to a cooler solid object in contact with the body —about 5%
- Do not place NB on cold surfaces such as the weighing scale.
Convection:
- Flow of heat from body surface to cooler surroundings—about 40%
- Wrap the NB immediately with a blanket and promote flexion to minimize body surface exposed to cool air.
Radiation:
- Transfer of body heat to a cooler solid object not in contact with the body—about 40%
- Wrap the NB immediately with a blanket and promote flexion.
What is S in PWSOAC framework?
Sweet: Maintain blood sugar
-Provide early access to breast, bottle, NG/OG feeds, or intravenous therapy for nutrition.
- Monitor blood sugar levels.
- Monitor intake.
- Maintain skin-to-skin contact.
What is O in PWSOAC framework (3)?
Organized: Maintain an optimum state
- An organized infant is one that is free of stress; this allows for optimal growth as stress increases calorie consumption.
- Pace handling of the infant.
- Limit invasive procedures if possible; if not, provide supportive care.
- Bundle care to allow for long periods of uninterrupted sleep.
- Limit noise to protect sleep.
- Provide non-pharmacologic and pharmacologic pain management as appropriate.
- Maintain skin-to-skin contact.
What is A in PWSOAC framework?
Attached: Promote attachment with family
- Facilitate care by parents.
- Provide family-centred care.
- Encourage and support breastfeeding.
- Maintain skin-to-skin contact.
What is C in PWSOAC framework?
Clean: Protect from infection
-Ensure hand-washing.
- Follow aseptic procedures.
- Ensure aseptic IV and central line insertion and management.
- Bathe as per hospital protocol.
- Change IV solutions/tubing as per hospital protocol.
- Provide mouth care/OIT with breast milk/colostrum.
- Feed with mother’s own/donor breast milk.
- Monitor for signs and symptoms of infection (temperature, CBC, CRP, blood culture, LP, IV site monitoring, perfusion, colour, VS, WOB).
- Clean and change isolette/cot as per hospital protocol.
- Change linen as per hospital protocol.
- Maintain skin-to-skin contact.
What makes late pre-term infants experience mild degree RDS?
directly related to their prematurity:
- lower levels of surfactant,
- fewer alveoli,
- fewer capillaries,
- weak respiratory muscles, and a
- compliant rib cage.
What is transient tachypnea of the newborn (TTN) or wet lung?
- respiratory disorder (temporary difficulty with breathing)
- caused by a delay in the clearing of fluid from the lungs after birth
What is the difference between RDS and TTN?
RDS is a problem of immature lungs:
- few alveoli,
- few capillaries,
- soft rib cage,
- weak muscles,
- lack of surfactant
RDS typically affects preterm infants, and the lower the gestational age, the more likely RDS is to develop.
TTN is a problem of inadequate clearage of lung fluid immediately after birth.
- TTN typically affects infants born by C-section
- those born without labour.
**RDS is restrictive, TTN is obstructive.
Which infant are most at risk for pneumonia? why?
Preterm infants are most at risk because:
- their immune systems are immature.
- have less IgG (passed transplacentally in the last trimester),
- likely to be intubated and experience other invasive procedures.
Other infants at risk are those born to mothers who:
- are Group B streptococcus positive,
- have a UTI,
- have fever, or
- have prolonged rupture of membranes.
Any infant who is ill and/or is in the NICU is at increased risk.
- Handling by multiple caregivers and invasive procedures threaten to introduce microorganisms.
- Colonization can quickly become infection and, just as quickly, sepsis.
- Term newborns are less at risk as their immune systems are somewhat more developed, but are still immature.
**Until age 3, children’s immune systems are growing and developing.
What can be done to keep infant pink (3)?
- monitor with pulse oximetry
- keep oxygen saturations 90% or greater
- position prone with head of bed slightly elevated (only when monitored)
- maintain temperature
- minimize handling
- prevent pneumonia with clean and aseptic techniques
- provide comfort and other developmentally supportive measures
- facilitate skin-to-skin care with parents
What are some reasons as to why oxygenation could be supported by positioning infant prone with head of his bed slightly elevated (2)?
- the infants feel safe, contained, and comfortable (leading to better sleep and decreased oxygen consumption),
- the position allows for increased perfusion to the dorsal lung fields,
- decreasing ventilation/perfusion mismatching,
- improved lung expansion
What are the benefits of good positioning for infant (3)?
- promotes improved rest
- supports optimal growth
- helps normalize neurobehavioural organization
- increase sense of security and support through containment
- decrease stress
- makes infant calmer
- helps gain weight
- support self-regulation behaviours
What are the Phillips positioning tool include (6)?
- Snuggle up: help provide proper positioning and physiological stability
- bendy bumper: promote containment and flexion, provide a reflex stimulus
- Frederick t frog: mimics comforting hands to support around head and neck. weighted support
- Prone plus: provides ventral support, help support NB to facilitate natural rounding of the shoulders, hand to mouth coordination
- Gel-E donuts: assist in alleviating pressure (head molding)
- Squishon 2 & 3: support NB head and body, help relieve pressure caused by prolonged immobility
What sleeping positions can Philips positioning tool for infants?
- supine
- side lying
- prone
What is the infant normal temperature? hypothermia?
- normal: 36.5- 37.5
- cold stress or mild hypothermia: 36.0 - 36.4
- moderate hypothermia: 32.0 - 35.9
- severe hypothermia: <32.0
What is non-shivering thermogenesis?
- the main mechanism of heat production in neonates (use of brown fat)
- process in which newborns produce heat by increasing their metabolic rate.
- This type of heat production has a large caloric demand
What are 2 consequences of cold stress?
- increased metabolic rate: decreased surfactant production + hypoxemia, increase consumption of glucose, failure to gain weight
- metabolism of brown fat: metabolic acidosis
What happens when the metabolic rate increased due to cold stress (3)?
(1) Decreased surfactant production and hypoxemia leading to respiratory distress:
- When the metabolic rate of a neonate is increased, the need for oxygen also increases.
- As cold stress progresses, surfactant production also diminishes, thereby impeding lung expansion.
- As a result, hypoxemia will be noted and mild respiratory distress can become severe hypoxia if oxygen must be used for heat production
(2) Increased consumption of glucose, resulting in hypoglycemia:
- When the metabolic rate rises for the body to produce heat, the glucose requirement also increases.
- As the demand of glucose surges, the body compensates for this need by converting glycogen stores to glucose.
- When glycogen stores are converted to glucose, they may be quickly used up, resulting in hypoglycemia.
(3) Failure to gain weight:
- Infants who must use glucose for temperature regulation and maintenance have a smaller available supply for growth and development.
What happens when brown fat is metabolized in presence of low O2 supply due to cold stress?
- When brown fats are metabolized in the presence of insufficient oxygen supply, increased acid production will result.
- Rising amount of acids causes metabolic acidosis, which can be a life-threatening condition.
- Aside from that, elevated fatty acids in the blood can interfere with the transport of bilirubin to the liver for conjugation, thus increasing the risk of jaundice in a newborn.
What are some factors contributing to a preterm infant temperature being below normal (3)?
- small size,
- decreased fat stores/brown fat,
- large body-surface-to-weight ratio,
- poor feeding/lack of intake resulting in decreased ability to generate heat
- immature CNS response,
- lack of ability to regulate temperature
- radiant and convective heat loss due to cool ambient temperature
- evaporative heat loss from respiratory distress/dry environment/uncovered while feeding/visiting
How often would nurse check infants temperature if its below normal? for how long?
- Q1H until stable and normal,
- then Q3–4H with handling
What are some ways to increase infants temperature (3)?
- such as skin-to-skin cuddling,
- incubator,
- radiant overhead warmer, and
- use of a blanket and hat,
- plastic bag/wrap,
- skin protectors,
- humidity, and
- warming pads
Why is humidity important factor in thermoregulation?
- Very preterm infants require the addition of humidity to their isolette in order to prevent heat loss and reduced trans-epidermal water loss.
- more premature the infant is, the higher percentage of humidity they require. For example, an infant less that 28 weeks will require 85% humidity initially,
- while an infant born greater than 32 weeks will not require any additional humidity at all
**Infants are generally slowly weaned off humidity to support the maturation of the epidermis and stratum corneum (the outermost layer of the skin).
What are some nursing care aimed at minimizing hypothermia (3)?
- monitoring temperature Q1H until stable, then Q3–4H with handling
- maintaining neutral thermal temperature
- preventing heat loss by evaporation, radiation, convection, and conduction
- using skin-to-skin contact to provide thermoregulation
- using isolette to provide heat
- weaning to a cot with clothes, blankets, and a hat when stable
What are some feeding difficulty a late preterm infant have (3)?
- be sleepy and require waking for feeding
- need assistance to latch effectively and stimulation throughout the feed in order to take in sufficient calories for growth
- tire easily
- have immature suck/swallow reflexes; this results in an inability to feed without assistance and gavage feeds may be necessary
- have increased risk for jaundice and may therefore be drowsy
What should be closely monitored to ensure infant getting required amount of nutrition to promote growth and development (3)?
- feeding patterns
- time
- weight
What is premature infant at risk for due to decreased glycogen stores?
- hypoglycemia
A mother mentions about bottle feeding while breastfeeding, how would a nurse counsel the family about breastfeeding?
- clarify any misconceptions
- we have a lot of strategies to deal with breastfeeding problems;
- that low milk supply is usually easily remedied with attention to simple measures such as position and latch
- discuss supply and demand principle of breastfeeding and how bottles can interfere with this
- ensure family are well informed regarding benefits of breastfeeding
- ensure that mom is well informed regarding potential hazards of introducing bottles before breastfeeding is well established and
- that bottling once per day may decrease duration of breastfeeding and milk supply
- teach and support pumping to establish milk supply
- discuss the role that fathers can play in care other than feeding: diapering, bathing, settling babe to sleep, playing, quiet time
** support their choice once you know they have made a well-informed choice and clarify any concern parents may have
