Newborn Assessment Flashcards
Physiological changes of a newborn
Pulmonary gas exchange
A neonatal cardiovascular pattern
A stable serum glucose level
Thermoregulation
We want to assess and monitor neonatal adaptations in order to detect complications such as …
Hypoxia Cold stress Hypoglycemia Infection Polycythemia Hyperbilirubinemia
What assessments do we complete on a newborn?
Vital signs, especially temperature (BPs are rarely done) BPs only done when were suspicious of cardiovascular anomalies Nutrition Elimination Transition to extrauterine life Activity state Umbilical cord If indicated: Glucose monitoring Bilirubin Circumcision assessment
APGAR SCORING purpose
Indicative of the need for resuscitation, not the degree of asphyxia
Infants are scored at one and five minutes and if needed at ten minutes
what are we looking at when doing APGAR scoring?
heart rate respirations muscle tone reflex irritability color
heart rate (apgar)
0 = absent 1 = < 100 2 = > 100
respirations (apgar)
0 = absent 1 = weak cry hypoventilation 2 = good, strong cry
muscle tone (apgar)
0 = limp 1 = some flexion 2 = active motion
reflex irritability (apgar)
0 = no response 1 = grimace 2 = cry, withdrawal
color (apgar)
0 = blue or pale
1 = body pink, extremities blue
2 = completely pink
** acrocyanosis is normal in the newborn for the first few days **
pulmonary adaptation
The fetal lungs secrete lung fluid throughout pregnancy
Production of lung fluid diminishes 2 to 4 days before the onset of spontaneously occurring labor
Induced labor → infant may not have diminished lung fluid
80 to 100 mL remain in the passageway of a full-term newborn
During labor and birth, fetal chest is compressed and this squeezes part of the fluid out “vaginal squeeze”
This fluid must be expelled or absorbed after delivery
This fluid can often be heard in the lungs at delivery as fine crackles
Infants who have difficulty clearing the fluid are at risk to develop a respiratory complication called transient tachypnea of the newborn (TTN)
Retained fluid in the alveoli of the lungs
C-section: at greater risk for TTN b/c there is no vaginal squeeze
Compression of chest → recoil chest → mechanically triggers respiration
Increase in alveolar PO2 opens alveolar blood vessels → increases vascular flow
Initiation of respirations
** explain image **
What is the normal O2 sat for a newborn in the first minute of life?
65%
Goes up 5% every minute for the first 5 minutes
goes up 90-95% at 10 minutes
Does vaginal or c-section birth have the greatest risk for TTN (TRANSIENT TACHYPNEA OF THE NEW BORN)
c-section because there is no vaginal squeeze
What is the first breath
inspiratory gap!
triggered by increased PCO2 and decrease in pH and PO2 receptors
What triggers the brain’s respiratory center?
changes trigger aortic and carotid chemoreceptors
what types of hormonal stimuli occur?
prostaglandins are released by the placenta throughout pregnancy and suppress respiration
with the clamping of the cord prostaglandin levels drop and there is an increase in respiratory drive
Mechanical stimuli
Natural result of a normal vaginal birth is the “vaginal or thoracic squeeze” released at the delivery of the chest allowing for lung expansion
What can happen when there is a significant decrease in environmental temp after birth
Stimulates skin nerve endings
Newborn responds with rhythmic respiration
Why do we avoid excessive cooling of the infant?
excessive cooling of the infant may lead to profound depression of respiration as the result of “cold stress”
sensory stimuli during intrauterine life
Dark
Sound dampened
Fluid-filled environment
Weightless
sensory stimuli newborn experiences at delivery
Light
Sounds
Effects of gravity
Abundance of tactile, auditory, and visual stimuli of birth
respirations
Normal newborn respiratory rate: 30 to 60 breaths per minute
Initial respirations may be mainly diaphragmatic shallow and irregular depth and rhythm
Respiratory rate may increase with crying
It is important to count respirations with a stethoscope in the newborn for a full minute
Periodic breathing is common especially in the first few hours of life. It consists of pauses lasting from 5-15 seconds
Pauses of longer than 20 seconds are apnea- always need additional assessment
signs of respiratory distress (7 signs)
increased/decreases respiratory rate <30->60 seconds
Flaring of nares
Expiratory grunting
Primary respiratory issue for newborns is potential for alveoli to collapse
Try to keep alveoli inflated → close off epiglottis as it exhales to maintain surface tension in the lung
Retractions
Use accessory muscles to assist in respiration
Color changes
Circumoral cyanosis- general cyanosis
Circumoral cyanosis- cyanosis around the mouth- normal bc tissue is so thin and vascular
General cyanosis (in the trunk) is not normal
See-saw breathing
Alternating effort between abdomen and chest
additional problems/signs of respiratory distress
Decreased muscle tone More relaxed, less flexed Problems with temperature regulation Baby is breathing out warm, moist hair Takes in cool air and lowers temperature Increased SA of baby for cooling → drops temperature Increased water loss
CV adaptation
Requires the transition from fetal to neonatal circulation with the change from placental to pulmonary gas exchange
Fetal circulation differs from neonatal circulation
The fetal lungs are essentially nonfunctional. Most blood bypasses the lungs and is shunted to other parts of the body
What vein does the oxygenated blood return to the fetus from the placenta
placental vein
how does the blood travel
Oxygenated blood returns to the fetus from the placenta through the placental vein. Much of the blood (40-60%) bypasses the liver via the ductus venosus and enters the inferior vena cava
As it enters the right atrium, 50-60% is shunted across the atrium through the foramen ovale to the left atrium
Fetal circulation
There is low systemic resistance and high pulmonary resistance. 60% of the blood from the right ventricle is shunted through the ductus arteriosus to the umbilical arteries and toward the placenta
There are openings & shunts in the fetus that begin to close off as the baby is delivered and starts its neonatal circulatory pattern
Difference between fetal circulation and neonate circulation
fetal = low systemic resistance and high pulmonary resistance neonate = low pulmonary resistance and higher systemic resistance
what causes neonate circulation to be low pulmonary resistance and higher systemic resistance?
The initiation of respirations by the infant and the clamping of the cord at birth shifts the resistance in the circulation
What causes pressure closure change of the foramen ovale in the heart
change in neonate circulation resistance
Foremen ovale
opening between the atrium
what constricts in neonate circulation?
the ductus arteriosus
CV assessment
start with general color assessment
acrocyanosis
occurs in the first 7-10 days, not unusual for the hands and feet to remain blue
circumoral cyanosis
blue tint to the skin surrounding the lips, but not on the lips. This is normal and simply the blue color of the veins just below the skin in this area. You may notice this blue tint most of the time. When the arterial blood in this area diminishes for various reasons, you will see the blue tint
Noticeable after feedings
when is circumoral cyanosis noticeable
after feedings
general cyanosis
blue tint to the skin that covers the face, trunk, and extremities. It is associated with poor oxygenation of the tissues and is an ominous sign. Can be respiratory or cardiac in origin
Heart rate (General information)
taken apically at the 4th intercostal space, left
Assessed for a full minute
Normal: 110-160 at rest
May drop to 100 when asleep
May accelerate up to 180 when stressed
Crying may increase rate
Consistently high >180 or low <100 warrants further investigation
What should you do if you hear a heart murmur?
this is not uncommon, most are nonpathological and disappear by 6 months
HOWEVER all murmurs warrant further investigation and assessment
hearing a murmur is the most common means of recognizing cardiac disease
what are abnormal findings accompanied by a heart murmur
poor feeding, cyanosis, pallor or apnea
Total blood volume
varies with amount of placental transfusion received by the newborn during expulsion of placenta
82.3 ml/kg of body weight at 3 days life with early cord clamping (before 30 sec of life)
92.6 ml/kg at three days with early cord clamping (after 30 seconds of life)
In the normal size infant this would be about 1 to 1 ½ cup of blood total
What increases blood volume (loss?)
delayed cord clamping
what forces blood from the baby back to the placenta
vaginal squeeze
what happens when you clamp the cord immediately
not enough time for blood flow to come back to the baby and restabilize blood volume
how long do you wait before clamping?
30 seconds
Newborn lab values
Hemoglobin- 14-20 g/dL (↑)
Need to capture as much O2 as possible
Hematocrit- 43-64%
WBCs- 10,000-30,000 (↑)
blood sample sites
Peripheral blood flow can be sluggish and create RBC stasis
Hgb and Hct levels are higher in capillary blood than in venous blood
Blood vessels taken from venous samples are more accurate than capillary samples
Break down RBCs because of oxygen rich environment → excrete bilirubin
Bilirubin needs to be protein-bound to be excreted from the body
normal glucose levels in newborn
40-80 mg/dL in the first 6 hours of life
45-90 mg/dL after that
what happens if glucose levels are below 40 to 45
treated with either glucose gel, a feeding or 10% dextrose in sterile water
hypoglycemia in newborns
Persistent hypoglycemia can result in neurological damage in the newborn
Hypoglycemia results from inadequate availability of glucose (poor feeding), abnormal endocrine regulation (infants of diabetic mothers) or increased utilization of glucose (cold stress, infection)
Hypoglycemia can be life threatening and can result in seizures and learning disabilities
Hyperglycemia is more common in premature and small for gestational age infants
S/S of hypoglycemia
S/S are frequently absent despite extremely low blood glucose levels:
Jitteriness (most common)
Also seen with withdrawals
Hypothermia
Diaphoresis (especially face and forehead)
Hypotonia
Irritability, tremors, muscle twitching, seizures
Abnormal cry
Poor feeding
Lethargy
Respiratory distress, tachypnea, apnea
Cyanosis, tachycardia, cardiac failure, cardiac arrest
normal temp
97.6
rarely elevated
abnormal temp
below 97.6
can lead to significant distress from cold stress
temp assessment
Can be assessed by axillary skin method, continuous skin probe, rectal route
Axillary is preferred method
Research indicates tympanic and digital axillary methods are accurate indicators of body temperature
inappropriate thermoregulation
Inappropriate management of heat stress and cold stress in neonates is associated with metabolic complications such as hypoglycemia, increased O2 consumption, increased lactic acid production, increased metabolic acidosis and death
heat loss in newborns can occur through
conduction, convection, radiation and evaporation
