Newborn Care Fundamental Flashcards
Sensory capabilities of newborns
- Fetuses have their own temperament
- Readiness for social interaction – with healthy, term newborns
- Newborns can see (blink reflex), can see the parents face further away at 6mths, black and white contrast to start, develop colour later
- Newborns are also drawn to round objects - built in survival feature to know where to go (the breast)
- Newborns can hear (same amniotic fluid left can cause muffled sound) – 1 in 3000 will have a hearing deficit upon newborn screening; can cause speech and learning deficits
- A lot is going on inside before they are able to vocalize it
- Babies can recognize and hear heart sounds, voice, smelling and voice of parent
- When born; place baby S2S with ammonitic fluid on parent to recognize smell
- Newborns can hold eye contact (not for as long as us); but have the ability to focus
Influencing factors of newborn behavioural adaptations
1) Gestational age – premature babies have a much lower threshold around stimulus, coping with stimulation, they becomes overwhelmed easier
2) Time – from birth, from last sleep, from last feed; newborns become more organized over time
3) Stimuli – loud noises, bight lights; can sense a nervous or tense parent who is holding them; smoothing effect of oxytocin helps
4) Medication – IM injection of different types of meds for labour goes directly into fetal bloodstream; can cause drowsiness; effect of epidurals and regional anesthesia still under research and inconclusive (need to account while assessing newborn)
Sleep-Wake States
Sleep states (2)
• Deep sleep
• Light sleep
Awake States (4)
• Drowsy
• Quiet alert – best state to interact with a newborn
• Alert
• Crying – can indicate their needs and wants; there are many different types of crying
Newborn Assessment Phases
1) Immediate (at birth)
2) Complete (head-to-toe)
3) Ongoing (until discharge home)
Purpose of the immediate newborn assessment
- Swift evaluation of adaptation to extrauterine life (including APGAR)*
- Airway maintenance
- Body temperature maintenance*
- Brief focused physical exam*
- Promote parent-newborn bonding*
- Universal medication administration*
- Overall are looking for: Gross abnormalities, congenital deformations, how they are adjusting to extrauterine life
- Done while skin-to-skin (S2S)
Nursing interventions during the immediate newborn assessment
- Assess HR, RR, Temp
- Measurements – head circumference (occipital to frontal), length, sometimes will do a chest circumference
- Weight – can compare before discharge
- ID bands – security; anti-infant abduction system
- Diaper, cap, safe swaddle
- Vitamin K and Erythromycin prophylaxis
*Requirements for S2S: there are not ABC issues, both the baby and the adult are healthy
APGAR Score Pneumonic
• 1 and 5mins after birth (baby nurse and/or peds)
• Then regulated intervals when sustained ressetation is required
A – appearance
P – pulse
G – grimace
A – activity
R – respirations
- Determines if interventions are requires immediately (ABCs)
- APGAR does not predict furutre neurological outcomes; only for in the moment
- Highest score is out of 10
- Usually lose 1 for acrocinaosis (purple/blueish hands and feet due to sluggish initial circulation, usually resilves a few hours ater birth)
- Usually done in our heads; start at 10 then subtract from there
- Assess HR at umbilical stump; can palpate until 5-10mins after birth (before it is clamped) for 6 seconds to assess quickly
- Score of 7-10 means baby is transitioning well and may need some intervention
- 4-6 means baby needs intervention
- 0-3 indicates severe distress
Newborn vital signs parameters
• Usually every 15min-every 30mins
P: 100-160 bmp – for one full minute
RR: 30-60 breaths/min – for one full minute
T: 36.5-37.5C (ax)
BP: 60/40 to 80/50 mmHg
Benefits of immediate S2S
Early S2S for clients and their healthy newborns is associated with:
• Enhanced breastfeeding success and duration
• Improved early maternal attachment behaviours
• No short- or long-term side effects (when done safely)
• *Don’t allow baby or adult fall asleep in this prone position – increase risk of SIDS
Associated newborn benefits: • Thermoregulation • Respiratory status • Oxygenation status • Higher blood glucose • Decreased crying
Benefits of immediate S2S post C/S
- Physiologic stability of birth parent and neonate – required to do it
- Emotional well-being of birth parent and neonate
- Potential reduction of pain for birth parent
- Improved parent-neonate communication – cue reading, closeness
- Improved breastfeeding outcomes
Universal newborn medications
1) Eye Prophylaxis – Erythromycin Ointment
• Indication: prevention of ophthalmia neonatorum (can lead to blindness)
• Action: prevent infection
• Dose: 1-2cm ribbon of 0.5% ointment within 2 hours of birth
• Postpartum nurse – Adverse reactions: 24-48hr conjunctivitis; temporary blurring of vision
2) Vitamin K Prophylaxis IM Injection
• Indication: prevention/tx of hemorrhagic disease in the newborn
• Action: promotion hepatic formation of clotting factors
• Dose: 0.5-1mg IM within 2-6 hours of birth
• Postpartum reaction – Adverse reactions: edema, erythema, discomfort/pain at site
Key newborn respiratory adaptations
• Multiple factors trigger first breath
- Recoil of chest while clears the vaginal canal; noise, light, birth attending touching baby all help trigger breath
- Meconium aspiration can prevent baby from taking first few deep breaths to cry
• Establishment of respirations is most critical and immediate adjustment
- Makes shunts close
• Cutting of umbilical cord initiates rapid and complex physiologic changes
- Those respirations are key to starting the shifting. Process for everything else
• Initially respirations shallow and irregular, fine crackles may be heard
- Vaginal birth benefit from squeezing out and clearing some mucus/fluid from lungs but still some will be left
• Apnea lasting <20 secs WNL
- WNL is “within normal limits”
- Normal variations where they stop breathing
• Apnea lasting >20 secs concerning
- Can be due to condition, disease or pathological infection; needs to be assessed by physician
- Baby cannot be discharged if apnea is happening
Key newborn cardiovascular adaptations
• Fetal circulation turning into neonatal circulation
- In utero the placenta maintains the gas exchange and little blood is needed though the lungs
- Pressure of the air in the lungs causes the blood pressure in the body to change and blood flow occurs; pressure also closes shunt
- Closure of shunts
- Lung inflation/cutting of cord into pressure and resistance changes which allows pulmonary blood flow
- Ave HR 120-140 bpm (variations 90-180 bpm)
- Post term babies who are more mature and can have a lower resting HR
- There can also be pathological or abnormal reasons why (i.e. heart block)
- Above normal range: infection, dehydration, crying
The ‘Transition’ Period
Stages:
1) First period of reactivity
2) Period of decreased responsiveness
3) Second period of reactivity
First period of reactivity
- HR: increases to 160-180bmp and gradual decrease to baseline
- RR; irregular 60-80 breaths/min
- Activity; alert state, startles, crying
Period of decreased responsiveness
- Sleep period that can last 1-4 hrs (need to be woken to feed)
- HR; normal baseline
- RR; rapid, shallow, up to 60 breaths/min, transient
- Activity; sleep or marled decrease in motor activity
Second period of reactivity
- Can be 6-8hrs post birth
- HR; transient, brief tachycardia
- RR; transient, brief tachypnea
- Activity; increase in muscle tone, colour, mucus
- Mucus can last a few days
Thermogenic system: Cold stress
• Thermoregulation critical to survival
• The balance between heat loss and heat production in the body; the ideal is to have newborns in neutral environments
• Newborns are unable to regulate their body temperature
• Contributing factors
- Larger boy surface to body mass
- Higher metabolic rate with limited stores
- Poorly developed shivering response (they depend on non-shivering thermogenesis)
- Due to the presence of brown fat to be able to do this
- Heat loss though any of 4 modes
Brown fat sites
- If it needs to be activated for non-shivering thermogenesis it does a good job
- Richer blood and nerve supply than ordinary fat
- Can increase newborn heat production up to 100%
- Makes up about 5% of newborns total body fat
- Newborns should not have to use their brown fat reserves; but if cold they will start to use them up
Modes of heat loss
• Convention: flow of heat from the body surface to the cooler air in the room
- Why rooms warmer than the hallways, cannot open windows, keep them wrapped and a hat on their head
• Radiation: heat lost form the body to the cooler solid surfaces that are not in direct contact with the body but nearby
• Evaporation: vaporization of water to air
- Especially when baby has bath; ensure to dry them and not in contact with wet material
• Conduction: loss of body heat from the body surface to colder objects that are in direct contact with the body
- Why skin to skin is so important, table is warmed up before birth
Effects of cold stress on newborn
- Increase O2 consumption
- Increases resp rate
- Causes pulmonary vasoconstriction
- Decreases O2 uptake by lungs and decreases O2 to tissues
- Increases anaerobic glycolysis
- Decreases in PO2 and pH
- Causes metabolic acidosis
- Also causes acrocynaosis, centro-cynaosis
Complete physical assessment (head-to-toe)
• Done within first 24 hours of life once neonate has stabilized
- Usually when the order that the baby can be discharged has occurred at 24hr
- Needs to be follow up for another assessment within the week with the family health provider
• Nursing assessment: Vital signs, general appearance, skin, growth parameters, HEENM, chest, abdomen, genitalia, extremities, back, anus, reflexes/neuro, ins & outs
- Head, Eyes, Ears, Nose, Mouth (HEENM)
- MD/Midwife/NP assessment: all of the above + pulses, hips, red reflex, pupillary light reflex
- Post discharge follow up assessment typically within 1st week
On-going assessment
• A constant, on-going, essential component of newborn nursing care
- One a shift, once every 8hr (at minimum); if there is more need it becomes more frequent
• May be a formalized process but also conducted throughout all care giving activities
• Critical in identifying subtle changes in the newborn
• Promoting parent support, education, reassurance, boning with newborn
Nursing assessment of newborn cardiopulmonary system
Respiratory Assessment • Colour – pink • Observe respiratory rate (abdominal breathers) • Auscultate breath sounds • One full minute
Cardiovascular Assessment • Colour • Auscultate apical pulse (PMI) - 3-4th intercostal space mid-clavicular line • One full minute • Pulses
Repeat abnormal findings
Nursing assessment of Ins and Outs
Renal • Urine colour – pale and straw coloured • Urine output: 1 void in first 24hrs • Increases by number of days e.g. day 2 = 2 voids • Up to 1 week old = 6-8 voids daily
Gastrointestinal
• Stool transitions
• Meconium
• 1 stool within 24hrs
Newborn respiratory assessment red flags
• Tachypnea (>60) – that is persistent (when baby is not crying)
- Septic, cold stress, respiratory distress, etc.
• Bradypnea (<30)
- Narcotic analgesia from labour or illicit drugs, etc.
• Retractions/indrawing/grunting
- Grunting: sounds newborns makes upon expiration
• Unequal breath sounds
- Embolism, lung infection, congenital malformation of the lungs, etc.
• Poor colour
• Apnea
- Can be common in newborn, <20secs os bad
Newborn cardiovascular assessment red flags
• Tachycardia (>180) - Dehydration, infection, pneumonia, respiratory distress • Bradycardia (<80) • Abnormal heart sounds - Extra sounds, murmurs • Abnormal location of heart sounds - Enlarged heat, displaced heart, heart is on right side of the body instead of left • Weak, absent or unequal pulses
Newborn CNS assessment red flags
• Jitteriness/tremors - And/or seizure activity • Lethargy - Lasts, persists no matter what you do • Irritability • Bulging fontanelles - Can indicate pressure in the brain, increased ICP, can see and palpate • Hyper or hypotonic - Muscle tone; too tight vs flaccid, number of conditions contribute • Seizure activity
Sudden Infant Death Syndrome (SIDS)
- Definition: the sudden death of an infant less than one year of age, which remains unexplained after a thorough case investigation, including the performance of a complete autopsy, an examination of the death scene, and a review of the clinical history
- Cause: unknown
- Incidence: anytime during 1st year, peaks at 2-4 months
- High risk: male babies, premature babies, and babies of indigenous community
Modifiable risk factors for SIDS (50% decline)
- “Back to sleep” – reducing the risk of SIDS since the 90s (public health initiative), has reduced the incidence of SIDS by 50% or more
- Smoking in pregnancy
- Sleep environment
- SIDS increased 12-fold when baby sleeps prone
- RNAO: no pillows, no toys, no bumper pads, light jumper or sleep sac, spine position, firm CSA mattress, distance between bars meets CSA guidelines
- Baby not share sleep surface with anyone else to reduce risk of SIDS
- Room sharing is good for first 6mths; but not sharing the sleep surface
Pros of swaddling
- Effective age-old practice
- Soothes, calms fussy young babies
- Promotes womb-like environment
- Improved sleep
- Risk of SIDS equivocal
- No evidence that safe swaddling is harmful
- Can provide relief for painful procedures
- Cost effective(?)
Cons of swaddling
- Can reduce S2S time (reduced touch, communication between baby and parent, impact on breastfeeding)
- Greater risk of SIDS with prone position
- Increased risk for hip dysplasia
- Increased risk for respiratory illnesses
- Increased risk of overheating, asphyxia, strangulation
- Limited use (until baby can roll)
- Cost prohibited?
Safe swaddling
• Swaddling not a pre-requisite for sleep: informed decision to swaddle
• Thin lightweight breathable blanket/wrap to prevent overheating
• Snug enough but not too loose: ensure enough room for chest expansion and for legs and hips to move freely
• “Back to sleep” and safe sleep environment
• Stop swaddling when baby can roll (2months of age)
• Always be combined with ABCs of sleep
- Alone (without people, blankets or objects)
- Back to sleep
- Crib (or other approved sleep surface)
Sucking and rooting reflex
- Touch infant’s lip, cheek, or corner of mouth with nipple or finger
- Infant turns head toward stimulus and opens mouth
- Difficult to elicit after baby has been fed
- Response disappears after 3-4 months but may persist up to 1yr
Swallowing reflex
- Feed infant; swallowing usually follows sucking and obtaining fluids
- Swallowing is usually coordinated with sucking and breathing and usually occurs without gagging, coughing, apnea or vomiting
Palmas reflex
- Place finger in palm of hand
- Infant’s fingers curl around examiner’s fingers
- Response lessens 3-4 months
Plantar reflex
- Place finger at base of foot
- Toes curl downwards
- Response lessens by 8 months
Tonic neck or “fencing” reflex
- With infant in a supine neutral position, turn head quickly to one side
- With infant facing left side, arm and leg on that side extend; the opposite arm and leg flex
- Turn head right and extremities assume opposite postures
- Complete response disappears 3-4 months
Moro or “startle” reflex
- Hold infant in semi-sitting position, allowing head and trunk to fall backwards (with support)
- or place infant on flat surface; make a loud, abrupt noise
- Symmetrical abduction and extension of arms are seen; fingers fan out and form a C with thumb and forefinger
- Legs may follow similar pattern
- Complete response seen until 8 weeks
Stepping or “walking” reflex
- Hold infant vertically under arms or on trunk, allowing one foot to touch table surface
- Infant will simulate walking, alternating flexion and extension of feet
- Present for 3-4 weeks
Crawling refelx
- Place newborn on abdomen
- Newborn makes crawling movements with arms and legs
- Presents until 6weeks
Deep tendon reflex
- Use finger to elicit patellar (kne jerk) reflex
- Newborn must be relaxed
Babinski (plantar) reflex
- On sole of foot, beginning at heel, stoke upward along lateral aspect of sole, the move finger across ball of foot
- All toes hyperextend, with dorsiflexion of big toe
Newborn physiological responses to pain
Vital signs
- Increased HR
- Increased BP
- Rapid, shallow respirations
Oxygenation
- Decreased tanscutaneous oxygen saturations
- Decreased arterial oxygen saturation
Skin - observe colour and character
- Pallor or flushing
- Diaphoresis
- Palmar sweating
Lab evidence of metabolic or endocrine changes
- Hyperglycemia
- Lowered pH
- Elevated corticosteriods
Other observations
- Increased muscle tone
- Dilated pupils
- Decreased vagal nerve tone
- Increased intracranial pressure
Newborn behaviour responses to pain
Vocalizations - Observe quality, timing and duration
- Crying
- Whimpering
- Groaning
Facial expressions - Observe characteristics, timing, orientation of eyes and mouth
- Grimaces
- Brow furrowed
- Chin quivering
- Eyes tightly closed
- Mouth open and squarish
Body movements and posture - Observe type, quality, and amount of movement
- Limb withdrawal
- Trashing
- Rigidity
- Flaccidity
- Fist clenching
Changes in state - Observe sleep, appetite, activity level
- Changes in sleep-wake cycles
- Changes in feeding behaviour
- Changes in activity level
- Fussiness, irritability
- Listlessness
Newborn Normal Vitals
T: 36.5-37.5 C
R: 30-60 breaths/min
HR: 110-160bmp
BP: 60-80/40-50 mmHg
