week 10: nursing care of the newborn Flashcards
define the newborn period + physiological adaptation
- birth to day 28 of life
physiological adaptation:
- establishing and maintaining respirations
- adjusting to circulating changes
- regulating temperature
- nutritional intake and digestion
- regulating wt
describe APGAR scoring
- rapid assessment of newborn’s transition to extrauterine at 1 and 5 min of life; repeat at 10 and 20 mins if less than 7 at 5 min
HR
0 - absent
1 - less than 100 bpm
2 - greater than 100 bpm
RR
0 - absent
1 - slow, weak cry
2 - good, crying
Muscle Tone
0 - flaccid
1 - grimacing
2 - cry or active withdrawal
reflex irritability
0 - no response
1 - grimacing
2 - cry or active withdrawal
colour
0 - blue, pale
1 - body pink, extremities blue
2 - completely pink
what is the APGAR mnemonic
A = appearance (skin colour)
P = pulse
G = grimace (reflex irritability)
A = activity
R = respiratory
skin to skin benefits of birthing parent
- breastfeeding (increased rates of exclusive breastfeeding and longer duration)
- less anxiety 3 days after birth
- less chest engorgement/pain at 3 days after birth
- higher satisfaction
benefits of skin to skin for infant
- newborn physiological stabilization (HR, RR, O2 stable)
- improved blood glucose
- thermoreg
- more effective sucking during initial breastfeeding
- comfort (less crying)
sudden unexpected postnatal collapse (SUPC)
- sudden collapse within the first week of life
- 1/3 cases -> infant becomes rapidly unstable within the first 2 hours after birth
- appears initially healthy but often internal health problem
- studies have found that 74% of cases occurred while the baby was lying face down during skin-to-skin contact with their birthing parent
- 77% of cases, the birthing parent or both parents were alone w the newborn at the time of the episode
strategies to prevent SUPC
- increase direct time and observation during first 2 hrs of birth
- educate parents
- elevate head btwn 35-80 degrees so newborn is not flat
- alignment of newborn’s neck and ensure that nose and mouth are not blocked
norm newborn vital signs
HR: 110-160
RR: 30-60
Ax Temp: 36.5-37.5 (WHO, AAP) or 36.3-37.2 (ACoRN)
BP:
@ birth systolic 60-80/40-50
at 10 days systolic 95-100/40-50
describe first period of reactivity
up to 30 min
- alert, startles, cries, movement of head
- HR increases rapidly to 160-180
- HR then falls to baseline 100-160
- RR may be irregular w increase to 60-80
- fine crackles, audible grunting, nasal flaring, retractions but should resolve within first hr after life
- BS audible and meconium may be passed
describe period of decreased responsiveness
(60-100 mins)
- sleeps or marked decrease motor activity
- skin colour pink
- resp may be rapid and shallow (up to 60 bpm) but not laboured
describe second period of reactivity
(btwn 2-10 hrs after birth and lasts 10 min to several hrs)
- brief periods of tachycardia and tachypnea
- increased muscle tone
- skin colour changes
- mucous production
- meconium commonly passed
very preterm infants do not experience this transition due to physiological immaturity
4 ways respiration is induced
- shift from intrauterine oxygenation via transplacental gas exchange to extrauterine oxygenation via lungs
- clamping the cord -> rise in blood pressure -> increase circulation and lung perfusion
- chemical
- mechanical
- thermal
- sensory
describe chemical respiration
During contractions blood flow decreases, leading to decreased oxygenation of baby and respiratory acidosis which send a signal to the infant brain to initiation respirations after birth
describe mechanical respiration
While the baby goes through the birth canal lungs are compressed, and then will recoil when they come out. This change in pressure helps bring air into the lungs and fluid fluid out.
describe thermal respirations
Change in temp from amniotic fluid to the air creates a thermal response sending signals to the brain to start breathing.
describe sensory respirations
Stimulating the baby helps in initiating breathing.
normal resp findings
Preference nose breathers with abdominal breathing and acrocyanosis
Shallow and irregular; may have periods of apnea less than 20 seconds
30-60 RR
On auscultation should hear loud, clear breath sounds equal bilaterally
how should transient tachypnea appear in a newborn
*Transient tachypnea of the newborn should resolve within 1-2 hrs after birth, more serious tend to last longer than 2 hrs after birth.
signs of respiratory distress
Nasal flaring, intercostal or subcostal retractions
Abnormal breath sounds like crackles, wheezing, grunting, stridor or grasping
Diminished or absent air movement
Seasaw or paradoxical respiration
Central cyanosis
RR <30 or >60 and SPO2 <95%
3 categories of the neborn CVS sys
- Expansion of collapsed fetal lungs with air lowers pulmonary vascular resistance, and pressure in right atrium, ventricles and artery decreases
- Loss of placenta blood flow causes high systemic vascular resistance, pressure in the left atrium, ventricle and aorta increase
- Drop in prostaglandins after delivery of the placenta triggers closure of the ductus arteriosus and ligament.
describe HR and sounds
Apical pulse is at the 4th intercostal space
HR should be 110-160 bpm with S1 and S2 sounds, may be variations during sleep and wake periods (reassess within 30 mins)
Most heart murmurs during infancy have no pathological significance and disappear by 6 months
Open ductus arteriosus can be detected as a heart murmur
Concerns with heart murmur include apnea, cynanosis, pallor or poor feeding.
heat loss w newborns
- Aim to maintain a neutral thermal environment to minimize oxygen and glucose use. When baby is cold will use up more oxygen and glucose putting them at risk for hypoxia and hypoglycemia
- Babies are more susceptible to temperature loss as they are smaller and have less brown fat/subQ tissue, greater water content and no ability to shiver
what are the 4 sources of heat loss
- Convection:
Flow of heat from the body to cooler air - Radiation:
Loss of heat from the body to a cooler surface not in direct contact but relative proximity - Evaporation:
Loss of heat when liquid is converted to a vapour - Conduction:
Loss of heat from body surface to cooler surfaces
describe temperature in newborns
- Normal range 36.5-37.5 and auxiliary is preferred route for measuring
- Subnormal may be seen in preterms, infection, dehydration or the environment
- Increase may be seen with infection, dehydration, chemical dependence, environmental
*delay newborn bath as heat loss can occur
thermogenesis
increased muscle activity (crying, restlessness) to generate heat in response to a cooler environment.
nonshivering thermogenesis
metabolism of brown fat and increased metabolic activity of the brain, heart and liver. Causes decreased glucose stores leading to hypoglycemia, and increase use of oxygen which may cause hypoxia
describe newborn physical examination for vital signs
Pain assessment: newborns feel pain and may have different responses such as crying, resistance, grimace, clenched hands, increased BP & HR. Use tools such as premature infant pain profile (PIPP) and neonatal infant pain scale (NIPS). Need to provide comfort measures for painful procedures.
- Skin to skin
- Breastfeeding
- Sucrose
- Swaddled
- Pharmacological pain control
newborn physical exam measurements
Average BW: 2500g-4000g, acceptable for term infants to lose up to 10% (dont want it to be >7%) of their BW and regain it in the first two weeks
Head circumference: 32-36.8 cm (average 34)
Length: 45-55cm
growth and development newborn physical examination
General appearance: There will be size differences in newborns due to diabetic mothers, IUGR, etc.
Newborn rash/erythema toxicum
blotchy red rash with small bumps filled with fluid that can appear on skin after birth, common & harmless usually clearing in 2 weeks.
White papule milla
hard white balls smaller than 2mm in size commonly found on the face but can be anywhere on the body, harmless and often go away on their own.
Congenital dermal melanocytosis
flat blue or gray birthmarks commonly found on the lower back or buttocks, are harmless and fade away on their own.
Languo hair
may cover the entire body and look like a layer of delicate fur, its essential and typically falls off before birth but may still be present at birth.
Normal peeling
Newborns shed their top layer of skin in the first couple weeks before birth, so this can be noticeable in post-date babies. Does not require treatment but can use interventions to help prevent dryness.
Facial bruising
can be related to facial trauma during birth, on the body it is a concern regarding internal bleeding.
Petechiae
spots 1-2 mm that are non-blanching caused by trauma or may indicate more serious conditions (sepsis, internal bleeding).
Stork bite/nevus simplex/salmon patch
common type of birthmark in newborns that appears as a flat pink, red or salmon coloured patch on neck, eyelid, upper lip or forehead, and usually fade within 18 months of birth.
Vernix caseosa
cheese-like whitish substance that fuses with the epidermis and serves as a protecting coating for the fetus.
Jaundice
visible yellowish colour of the skin and sclera due to elevated unconjugated (indirect) bilirubin. The liver is responsible for conjugating bilirubin. Heme from breakdown of RBCs is converted to bilirubin, indirect bilirubin is insoluble and is bound to albumin. Unbound bilirubin permeates skin, sclera and oral membranes.
Capput succedaneum
swelling/edema due to pressure on the newborn’s head while moving through the birth canal during prolonged/difficult delivery.
Moulding
head is temporarily reshaped due to pressure from the birth canal as the boney plates of the newborn’s skull shift and overlap. Usually goes away within a few days after birth.
Cephalohematoma
collection of blood between the scalp and skull, may be due to prolonged pushing. Appears within the first few hours, largest around day 2-3 and then resolves. Increases risk of jaundice.
Bruising of the vertex
bruising on the head of newborns that may be large, and various shapes of red and blue. Common finding and may be due to sample blood gases during labour or fetal scalp clip.
Edema to eyelids
common especially after a newborn receives erythromycin, make sure the newborn can open their eyes.
Eye symmetry
look for symmetry in the alignment of the eyes
Low set ears
top of ear lower than corner of eye, may indicate congenital abnormality.
Ear skin tag
common finding that may be benign but important to check if underlying issues with the kidneys as they develop at the same time at the ears.
Tongue tie/ankyloglossia
common condition where the lingual frenulum is abnormally short, thick or tight. Affects babies ability to breastfeed and may have speech and oral hygiene issues later in life. Can be surgically fixed.
Epstein pearl
small white or yellow benign cysts that are made of extra keratin on the gums or roof of the mouth. Harmless and resolve on their own.
Thrush
white odd shaped patches in the mouth that do not come off easily, type of yeast infection caused by Candida albicans.
Umbilical cord
check that there are two arteries and one vein, may have black stripes throughout due to coagulated blood. Look if meconium is stained. Will dry and fall off between 1-2 weeks through a natural progression. Watch for infection making sure the area is clean and dry
Umbilical hernia
bulge near the umbicilar cord due to weakening in the abdominal wall. Common in newborns and usually close on their own within 5 yrs of age. Seek care if it is stuck out, gets bigger, red, etc.
genitalia Edema
newborns may have edema to their geneitals due to maternal hormone exposure
Pseudomenstruation
false menses, normal vaginal discharge in female newborns due to sudden drop in maternal estrogen levels after birth
Urine
Should void once in 1st 24 hours. Day 1 min 1 void, Day 2 min 2 voids, Day 3 min 3 voids, Day 4 min 4 voids, Day 5 onwards 5-6 wet diapers/day.
Uric acid (urate crystals)
Peach coloured crystals in urine, normal finding.
Patency
check patency of anus.
Stool
should stool once in the 1st 48 hours, if not investigate reasons why as may be a concern.
Meconium
first stool composed of amniotic fluid, intestinal secretions, shed mucosal cells and possibly ingested maternal blood. Delayed passage in VLBW infants.
Transitional stool
usually appears by the 3rd day after initiation of feeding, greenish brown to yellowish brown, thinner and less sticky compared to meconium.
Milk stool
usually appears by 4th day and is a pasty mustard/yellow/golden colour with an odour similar to sour milk
Formula stool
usually appears by the 4th day is pale yellow to light brown or green with a firmer consistency and an odour like normal stool.
Hip dysplasia
expert examiners should perform the barlow test and ortolani manoeuvre to assess for hip dysplasia. If the newborn leg creases dont line up this is also a sign of hip dysplasia
Breech position in utero
if baby was breech may find abnormal leg extension upwards.
Facial nerve palsy
facial nerve paralysis, may or may not resolve depending on where damage is, due to forceps assisted birth.
Sacral dimple
investigate risks to neural tube defects, how large the area is and if there are any patches of tuff hair. More concerns if there are multiple dimples or if it is a higher up dimple.
Rooting reflex
infant turns head towards stimulus and opens mouth
sucking reflex
infant opens mouth and begins to suck
moro (startle) reflex
symmetrical abduction and extension of arms followed by return to relaxed flexion
grasp reflex
Infants finger curl around examiner’s fingers (palmar), toes curl downwards (plantar)
tonic neck
Infant facing left side, arm and leg on that side extended, opposite arm and leg flex.
babinski
Stroke sole of foot upwards and all toes hyperextend with dorsiflexion of the big toe.
Vitamin K prophylaxis
Prevent hemorhagic disease of the newborn (HDN) as vitamin K synthesized by the GI flora is not present at birth
Provide a single Im injection within 6 hours, must aspirate before injecting to ensure the medication is not going into a blood vessel.
vit k dosing
Dosing:
1mg for BW equal or greater than 1500g
0.5 mg for BW less than 1500g
IM injection newborn
Im injection newborns
25 gauge, ⅝ to ⅞ in length.
Preferred injection site is in the vastus lateralis
Maximum volume is 0.5 ml per injection
90-degree angle
Pain management strategies (skin to skin, sucrose, breastfeeding, etc)
initial newborn baths
Delay the first bath until the baby is stable and has completed their transition period. Should be delayed until 24 hours after birth, if this is not possible bathing should be delayed for at least 6 hours.
Immersion baths are preferable to sponge baths as there is less of a chance for heat loss.
