week 8 Flashcards
what are the physiological adaptation of the newborn?
-Establishing and maintaining respirations
-Adjusting to circulatory changes
-Regulating temperature
in utero respirations
In utero the placenta acts as the organ of respiration for the fetus. Immediately after the birth baby has to immediately adapt to the extra uterine respiration.
Clamping the umbilical cord causes a rise in blood pressure (BP), which increases circulation and lung perfusion.
Establishing and maintaining respirations- chemical factors
-Activation of chemoreceptors in the carotid arteries and aorta due fetal hypoxia
-Contraction temporary decrease uterine blood flow and transplacental gas exchange-transient fetal hypoxia
-↓Po2 and ↑Pco2, ↓blood pH
-Stimulation of the respiratory centre
Establishing and maintaining respirations-thermal factors
-↓extrauterine environment
-stimulates receptors in the skin, resulting in stimulation of the respiratory centre in the medulla.
-Note: Cold stress may be important for initializing breathing, but prolonged exposure should be avoided
Establishing and maintaining respirations-Mechanical factors:
-Changes in intrathoracic pressure from compression of the chest during vaginal birth.
-Relieve of the pressure result in a negative intrathoracic pressure, which helps draw air into the lungs.
-Crying of baby
-increases the distribution of air in the lungs, promotes expansion of the alveoli.
-creates positive pressure which helps to keep the alveoli open.
Establishing and maintaining respirations-Sensory factors
-handling or drying the newborn, lights, sounds, and smells of the new environment can also be involved in stimulation of the respiratory centre.
-Pain associated with birth can also be a factor
Circulatory Adjustment - after birth
-Umbilical veintransport oxygenated
-Umbilical arteries transportdeoxygenated
-Ductus arteriosusis the connection between pulmonary artery and aorta-closes within 24-48 hours; permanent closure may take several weeks
-Foramen ovaleis a shunt between the right atrium and the left atrium
-Circulatory changes after birth
-Expansion of the lungs increases the baby’s blood pressure
-Resulting in a major decrease in the pulmonary pressures decreases the changes in pressure result in
-↓shunting of blood to the ductus arteriosus and closure of the ductus arteriosus
-↑ pressure in the left atrium of the heart and lower the pressure in the right atrium causing the foramen ovale to close.
-Failure may result in patent foramen ovale (hole in heart) and surgical repair is required
Thermoregulation
-Heat regulation is most critical to the newborn’s survival.
-Anatomical and physiological characteristics of newborns place them at risk for heat loss-hypothermia
-Larger body surface to body weight
-Less adipose tissue & fat in newborn
-Underdeveloped sweating and shivering mechanisms
-Blood vessels closer to skin surface – contribute to heat loss
-Environmental factors include the temperature and humidity of the air, flow and velocity of the air, and the temperature of surfaces in contact with and around the newborn.
-Goal of care is to maintain a neutral thermal environment in which heat balance is maintained.
-To allows the newborn to maintain a normal body temperature to minimize oxygen and glucose consumption.
-Axillary temp. – between 36.4 – 37.2°
Evaporation
-Loss of heat when water evaporates from the skin and respiratory tract
-heat loss is intensified by failing to completely dry after bathing
-Dry baby quickly and remove wet towels/blankets
Conduction
-Heat loss from the body surface to cooler surfaces in direct contact
-Prewarm incubator/radiant warmer to ensure warm mattress
-Cover x-ray plates and scales
-Prewarm hands, stethoscopes, blankets and other equipment
-weighing the newborn should have a protective cover to minimize conductive heat loss
-Skin to skin contact: Baby will gain heat if placed on warm surface
Skin-to-skin keep newborns warmer than swaddled
Radiation
-Heat lost to surrounding colder solid objects (not in direct contact) but in close proximity
-Keep incubator, warmer, examination table, crib cot away from outside walls and windows
-Dress baby
-Care providers need to avoid exposing the newborn to direct air drafts.
Convection
-Heat lost from the body surface to cooler ambient air
-Raise surrounding 22° and 26°C
-Cover baby’s head
-Wrap and dress baby
-Warm O2
cold stress on baby
Effects of cold stress. When a newborn is stressed by cold, oxygen consumption increases and pulmonary and peripheral vasoconstriction occur, thereby decreasing oxygen uptake by the lungs and oxygen to the tissues; anaerobic glycolysis increases; and there is a decrease in Po2and pH, leading to metabolic acidosis.
-oxygen consumption and energy are diverted from maintaining normal brain and cardiac function and growth to thermogenesis for survival
-decreased pulmonary perfusion and oxygen tension can maintain or reopen the right-to-left shunt across the ductus arteriosus.
-cold stress is protracted, anaerobic glycolysis occurs, resulting in increased production of acids.
Transition to Extra Uterine Life- 1st period of reactivity
-Lasts up to 30 minutes after birth
-Newborn’s heart rate increases to 160 to 180 beats/min
-Respirations irregular: 60 to 80 breaths/min
-Decrease in motor activity after first period
-Period of decreased responsiveness
-Lasts 60 to 100 minutes
Transition to Extra Uterine Life- second period of reactivity
-Occurs 2 to 8 hours after birth
-Lasts 10 minutes to several hours
-Tachycardia, tachypnea occur
-Meconium commonly passed
-Increased muscle tone, changes in skin colour, and mucus production
Immediate Newborn Assessment-Apgar Scoring
-Immediate assessment of the newborn done at 1 and 5 minutes after birth
-Scores of 0 to 3-indicate severe distress,
-Scores of 4 to 6 indicate moderate difficulty
-Scores of 7 to 10 indicate that the newborn is having minimal or no difficulty adjusting to extrauterine life
-Reassessment is at 10 and 20 minutes if the score is less than 7 at 5 minutes
-Resuscitation may occur at any point when the newborn is compromised and should not wait until the initial 1-minute Apgar score
what does APGAR scoring stand for?
a-appearance
p-pulse
g-grimace
a-activity
r-respiration
Respiratory System -assessment
-Respirations
-Observe rise/fall of chest for 1 full minute
-Auscultate lung sounds
-Normal – 30-60 bpm,
-shallow & irregular;
-apneic periods of 5-10 seconds as fluid is being –absorbed/expelled
-Possible crackles - 1st hr. after birth
-Acrocyanosis – normal finding during transition
-Look for signs of respiratory distress
-Chest retractions
-Grunting with expirations
-Increase use of the intercostals muscles
-Nasal flaring
-Respiratory rate < 30 or > 60 breaths/min should be reported
Cardiovascular system-assessment
-heart rate between 110 and 160 beats/min
-Heart rate <110 or >160 re-evaluate after 30 t0 1 hour
-Heart murmurs heard during the first few weeks have -no pathologic significance
-murmurs disappear by 6 months
-Average systolic BP is 60 to 80mm Hg, and average diastolic BP is 40 to 50mm Hg
-Fetal Hb – high affinity for oxygen to promote oxygenation while infant begins producing own Hb postnatally
-Hb level 14-24 g/dl
-Blood volume 300mls
-Time taken to clamp cord
Sign of Cardiovascular concern
-Persistent tachycardia (more than 160 bpm)
-anemia, hypovolemia, hyperthermia, or sepsis.
-Persistent bradycardia (less than 100 bpm) congenital heart block, hypoxemia, normal sinus bradycardia, or hypothermia.
-Unequal or absent pulses, bounding pulses, and decreased or elevated blood pressure can indicate cardiovascular concerns
body measurement -weight
-Female: 3 400g
-Male: 3 500g
-Acceptable weight loss: 10% or less in first 3–5 days
-Regaining of birth weight within first 2weeks
-Weight ≤2 500g (preterm, small for gestational age, rubella syndrome)
-Weight ≥4 000g (large for gestational age, maternal diabetes, heredity—normal for these parents)
-Weight loss 10–15% (growth failure, dehydration); assess breastfeeding
Body Measurement-length
-45–55cm
<45cm or >55cm may be due to chromosomal abnormality or heredity—normal for these parents
Head circumference
– distance around head –
-33–35cm
-Circumference of head and chest approximately the same for first 1 or 2 days after birth
< 32 –microcepahly
-Microcephaly: head ≤32cm (maternal rubella, toxoplasmosis, cytomegalovirus, Zika virus, fused cranial sutures
[craniosynostosis])
-Hydrocephaly: sutures widely separated, circumference ≥4cm more than chest circumference
-infection
-Increased intracranial pressure (hemorrhage, space-occupying lesion) due
to extra fluid or extra tissue (tumour etc.)
Fontanelles
-Anterior fontanel 5-cm diamond, increasing as moulding resolves
-Closes within 12-18 months
-Posterior fontanel triangle 0.5x1 cm, smaller
than anterior
-Closes within 8-12 weeks after birth
Sutures (Allow for brain growth)
-Should be palpable and separated suture, possible overlap of sutures with moulding
-Widely spaced (hydrocephaly)
-Premature closure (fused) (craniosynostosis)
Sign Fontanels concerns:
Full, bulging (tumour, hemorrhage, infection)- due to increased pressure, hemorrhage, a
lot of fluid
* Large, flat, soft (malnutrition, hydrocephaly, delayed bone age, hypothyroidism)
* Depressed (dehydration
Cephalohematoma
-Collection of blood between a skull bone and its periosteum. caused by external
-Pressure during L & D
- Forceps delivery
▪ Largest on the second or third day,
▪ Feels boggy, edemtous to touch
▪ Does not cross suture lines
▪ Resolves in 3 to 6 weeks
▪ Not aspirated due to risk of infection
Caput Succedaneum
▪ During vacuum assisted delivery
▪ Not as bulging as the hematoma one, usually to do with the suture and increased fluid
▪ Localized edematous area the soft tissues of scalp.
-Presenting part causes compression of local vessels slowing venous return
-in increase in tissue fluids within the skin of the scalp
-edematous swelling develops.
▪ Extends across the suture lines of the skull* major difference then the hematoma one
▪ Disappears spontaneously within 3 to 4 days.
-due to increase fluid
eyes
Size & shape should be symmetric
- Eyes close together can be linked to down syndrome
◼ Space between eyes is one-third the distance from outer (left) to outer (right) canthus
◼ Iris is usually blue or gray for light skinned; brown for darker skinned newborns.
◼ Immature lacrimal ducts – tears only produced at around 2 months
◼ Blink reflex -elicited by bright lights, lightly touching eyelid
◼ Pupils equal, reactive to light
◼ Eyelids may be edematous for the first few days
◼ Colour vision after 1 st three months
◼ Epicanthal folds when present with other signs (chromosomal disorders such as Down,
cri-du-chat syndromes)
◼ Discharge: purulent (infection)
◼ Permanent colour occurs later
◼ Lacrimal ducts can become clogged – respond to manual pressure on nasal bridge
◼ Eyelids edematous from pressure of face through vaginal canal during birth
◼ Acuity - distance from infant at breast to mother’s face
◼ Colour vision after three months – explains why infants are attracted to dark & light
contrasts vs. brightly coloured objects
ears
-Firm, well formed cartilage of pinna in term infant
-Well-formed, firm cartilage
-Small, large, floppy, soft and pliable
-Correct placement: line drawn through inner and outer canthi of eyes reaching to top notch
of ears (at junction with scalp)
-Hearing assessed by responsiveness to loud noise without vibration
ear anomalies
-Agenesis
-Lack of cartilage (preterm)
-Low placement (chromosomal disorder, cognitive impairment, kidney disorder)
-Preauricular tag or sinus
-May indicate renal disorders
nose
Midline
◼ Slight deformity (flat or deviated to one side) from passage through birth cana
◼ Newborns – nose breathers in first few months
◼ Narrow passageways, easily obstructed with mucous & amniotic fluid
◼ Some mucus but no drainage
◼ Sneezing as reflex to clear passageways.
◼ response to overstimulation of autonomous nervous system
◼ Smell is present in newborns.
◼ Allows newborns to turn to milk
◼ Infants prefer mother’s milk to other mothers’ milk
◼ Infants react to noxious smells shortly after birth
mouth
-Lips should be symetrical
-Pink, moist lips and mucosa
-Sucking blisters - from breastfeeding latch
-Saliva not excessive
-Intact hard and soft palate; freely moving tongue
-Tongue not protruding; freely movable; symmetrical in shape, movement
-Sucking pads inside cheeks
-Soft and hard palates intact
-Uvula in midline
-Anatomical groove in palate to accommodate nipple, disappearance by 3–4yr of age
Epstein’s pearls:
small, firm white cysts on gums. Resolve on own during first weeks
common mouth conditions
-Thrush: White plaque – similar to milk curds, does not easily scrape off
-Precocious tooth: premature eruption of a tooth, often around lower incisors.
-Cleft lip/palate Cyanosis, circumoral pallor (respiratory distress, hypothermia)
-Asymmetry in movement of lips (seventh cranial nerve paralysis)
-Teeth: predeciduous or deciduous (hereditary)
Short lingual frenulum (ankyloglossia- tongue-tie
neck
-Short with skin folds
– Neck muscles not fully developed to handle the baby head, that is why, when
we hold the baby, making sure to support the neck
- Putting baby on belly so the baby moves their head up and down for
development
-Freely mobile range of motion
-Head lag is associated with prematurity
Genito-urinary System- Urinary system
◼ 40 mls may present in the bladder at birth
◼ Void within 24 hours, may void during delivery
◼ At 1 day of age, a minimum of one void
◼ At 1 week six to eight voidings per day.
◼ First and seconds day -2-5 times, afterwards 2-8 times per day
◼ Amount per void 15 to 60 mL/kg/day
◼ pale straw-coloured urine are indicative of adequate fluid intake
Daily fluid requirement for newborns weighing more than 1 500 g:
-60 to 80 mL/kg/day during the first 2 days of life
-100 to 150 mL/kg/day from 3 to 7 days
-120 mL/kg/day to 180 mL/kg/day from 8 to 30 days
Female genitialia
-Labia – examined for size. Labia majora develops close to term
-Assess to ensure that labia not fused
-Assess ambiguous genitalia
-Milky vaginal discharge- due to circulating maternal hormones (normal after delivery)
-Pseudomenses: blood tinged mucous – due to hormones of pregnancy
-Vaginal tag: (hymenal tag) usually disappears in first few weeks after birth
- Swelling of the breast tissue in term newborns of both sexes-due to hyperestrogenism in
utero
o few newborns a thin discharge can be seen.
-Ambiguous geneialia – when clitoris excessively prominent; vaginal opening not clearly patent
Male genitalia
-Hypospadias: Urinary meatus on ventral surface of penis (underside).
-Circumcision is contraindicated in the presence of hypospadias or epispadias
since the foreskin is used in repair of these anomalies
- Epispadias: Meatus on the dorsal surface
- Phimosis: Foreskin cannot be fully retracted A tightprepuce(foreskin) is common in
newborns and completely covers the glans
- Hydrocele: Collection of fluid around testes
- Discoloration of testes – assess for testicular torsion
- Crepitus in groin or scrotal sac indicates hernia
- Undescended testes; (cryptorchidism)
- Failure of testes to descend into scrotal sac in term infant
Abdominal
-Rounded, prominent, and domed shaped
-Bowel sounds within 2 hrs. post birth
-Patent anus
-Meconium passed within first 24 hrs.
-Umbilical cord-whitish grey – 2 arteries & 1 vein
-Definite demarcation between cord and skin; no intestinal structures within cord
-Bowel sounds present within minutes after birth in healthy term newborn
-Meconium stool passing within 24–48hour after birth
- This is to check for if bowel sounds are working
- Roll the baby to check if the anus is normal or perforated
- Cord status
abdominal anomalies
- One artery (renal anomaly)
- Meconium stained (intrauterine distress)
- Bleeding or oozing around cord (hemorrhagic disease)
- Redness or drainage around cord (infection, possible persistence of urachus)
- Hernia: herniation of abdominal contents through cord opening (e.g., omphalocele);
o defect covered with thin, friable membrane, possibly extensive - Scaphoid, with bowel sounds in chest and severe respiratory distress (congenital
diaphragmatic hernia) - Gastroschisis: herniation of abdominal contents to the side or above the cord
Meconium
- Meconium is the newborn’s first stool, composed of amniotic fluid and its constituents,
intestinal secretions, shed mucosal cells - Meconium is greenish black and viscous and contains occult blood.
- Pass meconium within 12 to 24 hours of life, and almost all do so by 48 hours.
- Failure to pass meconbowel obstruction
- small or large bowel atresia,
- an inborn error of metabolism (e.g., cystic fibrosis),
- congenital disorder (e.g., Hirschsprung disease or an imperforate anus).
Transitional Stools
- usually appear by the third day after initiation of feeding
- greenish brown to yellowish brown and less sticky than meconium and may contain some
milk curds
Milk stools
-usually by 4 th day
- breastfed newborns: stools are yellow to golden, pasty in consistency- resemble a mixture
of mustard and cottage cheese- odour similar to sour milk
- formula fed: pale yellow to light brown, firmer consistency- odour similar to adult stool
Skin
Normal infant –
- Pink varying with ethnic group, well perfused
- Perfusion assessed by capillary refill of 2 seconds or less
- Skin should spring back when pinched
- Skin is soft, dry texture.
- Acrocyanosis: Bluish discoloration of hands and feet 1 st 6 -8 hr. post birth (due to
cardiovascular immaturity) - Only on extremities
- After pinch is released, skin returns to original state immediately
- dehydration fold of skin persisting after release of pinch)
- Post-mature infants may have dry skin, cracking on feet and hands
- Loose, wrinkled skin (prematurity, postmaturity
- Mottling: due to temperature instability; overstimulation of autonomous nervous system
(due to poor perfusion) - in a nursing home, if there is an elderly and they start to mottle in the feet, it is
a sign that they may be passing away, body is starting to shut down - in babies, not normal as per say but you need to start looking out for
cardiovascular complications ASK!! IS THIS NORMAL IN
NEWBORNS?? - Tense, tight, shiny skin (edema, extreme cold, shock, infection)
Vernix caseosa:
-Waxy, cheesy substance.
- Protects skin from astringent effect of amniotic fluid and disappear closer to term
- Absent (postmature)
- Absent or minimal (post-term)
- Abundant (preterm)
- Green colour (intrauterine release of meconium or presence of bilirubin)
- Odour (possible intrauterine infection)
Lanugo:
-fine downy hair on neonate’s body
- Most abundant – 28-32 weeks
- Decreases with fetal maturity.
- Disappears from face 1 st day, then extremities
- Abundant (preterm, especially if lanugo abundant, long, and thick over back)
Telangiectatic nevus; nevus simplex)
- Pale pink or reddish discolouration at nape of neck or lower occipital bone,
eyelids, and above nasal bridge - More prominent in fair skinned, light haired infants
- More noticeable with crying
- Generally, fades by second birthday
- Is resolved after 2 years
Birth Injuries to Skin
-Marked bruising on the entire face of a newborn born vaginally after face presentation.
-Less severe ecchymoses were present on the extremities. -Phototherapy was required for
treatment of jaundice resulting from breakdown of accumulated blood.
- Swelling of genitalia and bruising of the buttocks after a breech birth
Extremities
-Full range of motion of arms & shoulders
- Assess leg length – equal, with symmetrical gluteal creases
-Assess for club foot (talipes equinovarus)
-Back should be straight, flexible
-Pilonidal dimple - cleft at base of sacrum, generally benign
-Digits
-Extra digits: polydactyly
-Webbing: Syndactyly
Newborn Reflexes-Sucking:
When anything is placed in mouth or touches lips
Newborn Reflexes-Rooting:
infant turns head when side of mouth/ cheek/stimulated. Present for 3-4 months.
- Aids in latching
Newborn Reflexes-Moro:
Startling infant, - response by symmetrically extending arms outward while knees
flex. Can last up to 6 months
- Most sensitive assessment for infant’s neurological system
Newborn Reflexes-Babinkski
(plantar reflex). Hyperextension of toes when the sole stroked from heel up to
ball of foot. Disappear by age 1 year.
- I this continues after 1 year, there is some issue in motor development
Newborn Reflexes-Galant/Trunk:
Incurvation of trunk with stroking or tapping spine in prone position.
Pelvis turns to stimulated side – to 6 months
Newborn Reflexes-Plantar grasp:
Toes curl downward when a finger is placed at the base. Disappear 3-4
months
Newborn Reflexes-Palmar grasp:
when object placed in infant’s palm. Grasp tightens with attempts to
remove object.
Disappear by 8 months
Newborn Reflexes-Crawling:
Newborn makes crawling movements with arms and legs when place
newborn on abdomen and place pressure on the foot
Newborn Reflexes-Stepping:
Stimulate walking when held upright with his or her feet touching a solid
surface. This reflex lasts about 2 months
Newborn Reflexes-Tonic Neck:
When the newborn head is turned to one side, the arm on that side stretches
out and the opposite arm bends up at the elbow. Disappear by about 5 to 7 months.
- Any persistent reflexes that do not disappear when required is an issue for motor
development
Prophylactic & Screening Measures
- 0.5% Erythromycin eye ointment within 1 hr. of birth vs. maternal gonococcal
transmission - Why? Because, if the mom had group B strep is a measure to prevent this
- Vitamin K injection within 1 hr. birth vs. hemorrhage
- Hep. B vaccine at birth (against all known Hep B subtypes), HBIG 12 hrs after birth
If maternal hep. B surface antigen is positive or unknown - Blood glucose monitoring – baseline at 2 hr. post-birth if gestational diabetes, LGA,
or SGA; ½-1 hr. post birth if symptoms of hypoglycemia occur earlier - Because the baby has a lot of sugar due to GDM, there pancreas islet will
make a lot of insulin, higher risk of hypoglycemia and hypoglycemia is
very critical - Heel prick for bilirubin levels, phenylketonuria (PKU) & hypothyroidism (mental
retardation if untreated), sickle cell, - Screening for congenital heart disease: pre-ductal (right hand) and post-ductal (any
foot) oxygen saturation obtained. Repeat screen if >3% difference between 2 readings
or if O2 sat is less than 94% on either extremity.
-Hearing to assess for hearing loss
-Heel used because of rich capillary bed
-PKU (Phenylketonuria )treated with diet (Defect in gene that helps create the enzyme that lets body
break down phenylalanine) - Hypothyroidism treated with hormone
vitamin k
helps in the synthesis o the protein required for blood clotting Newborns
don’t produce enough vitamin K this is because the body produces vat K through the
foods we eat and the healthy bacteria in our intestines. Until they begin s to eat solid
food at about 6 months of age, babies don't have enough naturally produced vitamin
KNewborn do not have enough vitamin Vitamin K is not transmitted in utero. Needed
for clotting
Circumcision
-Cultural factors in circumcision decisions
Parental choice
-Some health benefits e.g. easier hygiene, decreased risk UTI, STI, penile cancer and some penile problems
-Routine circumcision is not recommended in developed countries
-Contraindicatory in premature, known bleeding problem, or has a genitourinary defect such as hypospadias or epispadias as foreskin may be needed for repair
-Risks: hemorrhage, difficulty urinating, infection, discomfort, separation of circumcision edges.
-If baby requires hypospadias or epispadias, they would not recommend the circumcision
Circumcision- patient teaching
-Check circumcision for bleeding
-Observe for Urination
-Check wet diaper after circumcision
-Provide Comfort
-Check for infection (redness, swelling, or discharge-white exudate is normal within the first 3 days
-Keep area clean
-Change the diaper and inspect every 4 hours.
-Wash the penis gently with warm water to remove urine and feces.
-Do not use newborn wipes because they can contain alcohol.
-Do not wash the penis with soap until the circumcision is healed (5 to 6 days).
-Apply the diaper loosely over the penis to prevent pressure
pain in the newborn
-Newborn responses to pain
-Assessment of pain in the newborn
-Goal of newborn pain management
minimize the intensity, duration, and physiological cost of the pain
maximize the newborn’s ability to cope with and recover from the pain.
-Nonpharmacological management
-Pharmacological management
pain in the newborn vital signs
-increase HR, increase BP, rapid and shallow respirations,
-increase O2, decrease arterial oxygen saturation
-pallor or flushing, diaphoresis, palmar sweating
-crying, whispering, groaning
-grimaces, brow furrowed, chin quivering, eyes tightly closed, mouth open and squarish
-limb w/drawl, thrashing, rigidity, flaccidity, fist clenching
-changes in sleep -wake cycles, feeding behaviour, activity level, fussiness, irritability, listlessness
Management of Pain in the Newborn (Nonpharmacological)
-Non-nutritive sucking on a pacifier promote comfort
-Oral sucrose in small amounts given with a syringe with or without a pacifier for sucking
reduces pain during single events
- Skin-to-skin contact (kangaroo) care help reduce pain during a painful procedure
- Breastfeeding or breast milk helps reduce pain during heel lancing and blood collection
-Swaddling or snugly wrapping the newborn with a blanket aids in self-regulation, and
reduces physiological and behavioural stress resulting from acute pain
- Safe swaddling is important
- Touch, massage, rocking, holding, and environmental modification (e.g., low noise and
lighting).
- safe swaddling involves wrapping the baby snugly in a lightweight blanket with the arms
extended, legs flexed, and hips in neutral position without rotation
Immunizations
-DTap: Diphtheria, tetanus and acellular pertussis vaccine
-HB: Hepatitis B vaccine
-Hib:Haemophilus influenzae type b conjugate vaccine
-HPV:Human papillomavirus vaccin
-Inf: Influenza vaccine
-IPV: Inactivated poliomyelitis vaccine
-Men-C: Meningococcal conjugate C vaccine
-Men-C-A,C,Y,W-135: Meningococcal conjugate -ACYW-135 vaccine
-MMR: Measles, mumps and rubella vaccine
-MMR-Var: Measles, mumps, rubella and varicella vaccine
-Pneu-C-13: Pneumococcal conjugate 13 valent vaccine
-Rot: Rotavirus vaccine
-Tdap: Tetanus, diphtheria and acellular pertussis vaccine
-Var: Varicella (chickenpox) vaccine
Vaccine hesitancy
What factors contribute to vaccine hesitancy?
-Gender, media, education, social impact (anti vaccine) etc.
-Women are more hesitant than man because they think about future consequences related
to fertility and menses
- Affect of media
- Type of vaccine itself (ex. Pfizer vs Moderna)
Discharge Planning and Teaching
-Community follow-up
- Temperature
- Respirations
- Feeding patterns
- Elimination
- Prevention of sudden infant death syndrome (SIDS)
- Rashes
- Diaper rash
- Other rashes
- Clothing
- Car seat safety
- Non-nutritive sucking
- Bathing
- Umbilical cord care
- Newborn follow-up care
- Cardiopulmonary resuscitation
- Practical suggestions for the first weeks at home
- Interpretation of crying
- Period of PURPLE Crying ®
- Recognizing signs of illness
purple stands for
-peak of crying (baby may cry more each week the most in month 2, then less months 3-5
-unexpected (crying can come and go and you don’t know why
resists soothing (your baby may not stop crying no matter what you try)
pain-like face (a crying baby may look like they are in pain, even when their not)
long lasting- (crying can last as much as 5 hours a day or more)
evening -(your baby may cry more in the late afternoon and evening )
the word period means that the crying has a beginning and an end
Car seat legislation
◼ Children must ride in a rear facing car seat until they are a minimum of 20 pounds (9 kg).
◼ Children between 20 pounds (9 kg) and 40 pounds (18 kg) must ride in an appropriate car
seat.
◼ Children must ride in a booster seat until they are a minimum of 4 feet, 9 inches (145 cm)
tall, or a minimum of 80 pounds
◼ Important to remind parents about checking for safety recalls and unsafe products
Holding Baby
Holding newborn securely with support for the head.
A, holding infant while moving infant from
scale to bassinet.
B, Holding baby upright in “burping”
position.
C, “Football” (under the arm) hold. D, Cradling hold
Caring High Risk Newborn
- Infants who are born considerably before term and survive are particularly susceptible to
development of sequelae related to preterm birth. - High-risk infants are most often classified according to:
- birth weight
- gestational age
- common pathophysiological problems
- Jaundice
- Preterm
- post-Late preterm, term, and term newborns
- Diabetes
- Meconium aspiration in newborn
Jaundice
- Hyperbilirubinemia
- bilirubin greater than 340 mcmol/L in the first 28 days
- Causes
- Cephalohematoma can cause jaundice too
- Increase bilirubin level due break down in Rbc
- Short lifespan of leads to RBC mass breakdown
- Immature liver to cannot break down bilirubin for excretion
- Hepatic obstruction
- Unconjugated bilirubin is highly toxic to neurons- leading to neurological damage
- Intervention for this condition:
- Put the baby in front of the sun or under light
- Phototherapy
risk factors for jaundice
- Maternal fetal Rh or ABO incompatibility
- Sepsis
- Polycythemia
- Biliary atresia
- Liver impairment
- Hypoglycemia
- Pre-term birth
- Polycythemia
- Delayed passage of meconium
- Large cephalohematoma at birth
- Hypoxia
- Hypothermia
Types of Newborn Jaundice
Physiological jaundice:
▪ 60% of newborns born at term and 80% of preterm infants.
▪ Appears after 24 hours of age and usually resolves without treatment.
▪ unless bilirubin levels rise higher or faster than normal
Types of Newborn Jaundice
Pathological Jaundice
▪ Appears within 24 hours of birth
▪ Total unconjugated bilirubin levels >100 mcmcol/L in 24 hours
▪ level exceeds >256 mcmol/L at any time
▪ Untreated ↑ unconjugated bilirubin is neuro toxic to brain
▪ Acute bilirubin encephalopathy (lethargy, hypotonia, poor sucking irritability, seizures,
coma, and death
▪ Kernicterus: irreversible long-term consequences of bilirubin toxicity, (hypotonia,
delayed motor skills, hearing loss, cerebral palsy, and gaze abnormalities)- due to
unmanaged unconjugated bilirubin
▪ Kernicterus
irreversible long-term consequences of bilirubin toxicity, (hypotonia,
delayed motor skills, hearing loss, cerebral palsy, and gaze abnormalities)- due to
unmanaged unconjugated bilirubin
Phototherapy (treatment for pathological jaundice)
- Use to reduce the level of circulating unconjugated bilirubin or to keep it from increasing
- bilirubin level begin to decrease within 4 to 6 hours after within 24 hours decrease by 30
to 40% - to discontinue therapy is based on a definite downward trend in bilirubin value
- The time of onset of jaundice is a key factor in evaluating its cause and determining if
treatment is needed
phototherapy - precautions
- Newborn’s eyes must be protected by to prevent retinal damage (cover baby’s eyes)
- Temperature should be closely monitored at least every 2 hours
- Possibility of heat loss and dehydration
- (feeding is critical)
- No ointments- heath absorption and cause burns
- Loose stool due to bilirubin breakdown-buttocks must be cleaned after each stool to
maintain skin integrity
Preterm
- Preterm-born before completion of 37 weeks of gestation regardless of the weight of the
infant - Organ systems are immature
-Lack adequate physiological reserves to function in the extrauterine environment. - Is the leading cause of newborn deaths globally
- accounting for almost 40% in Canada
- Low birth weight (LBW)-newborns weighing 2 500 g or less Increase risk for health
issues, - Extremely low birth weight (ELBW)-birth weight of less than 1000 g (2 lb, 3 oz)
- Practical and ethical dimensions of resuscitation of extremely low-birth-weight infants
(ELBW) - Injecting what injection helps enhance lung maturity and for proper respiratory
function-dexamethasone
Causes of preterm birth multifactorial
-poverty (which can contribute to suboptimal health care and prenatal nutrition)
-maternal infections
-previous preterm birth
-multiple pregnancies
- pregnancy-induced hypertension, placental conditions that interrupt the normal course
of gestation
- Smoking
- Advanced maternal age
- Fetal disorders
- intrauterine growth restriction (IUGR) - (Associated with LBW)
Preterm Risk
- advanced age, adolescents who are pregnant
- low SES
- Substance abuse
- Placenta previa/abruption
-Respiratory distress - Thermal instability
- Hypoglycemia
- Jaundice’
- Feeding difficulties
- Neurodevelopmental issues (speech, behavioural, and cognitive)
- Infection
- Sepsis
preterm complications
-Respiratory distress syndrome (RDS)
- Patent ductus arteriosus
-Periventricular-intraventricular hemorrhage
- Necrotizing enterocolitis
- Risk for hypoglycemia
- Jaundice
- Risk for difficulty feeding
- Delays in cognition, social development or behaviour (speech, walking etc)
Nursing Care
Respiratory support
- Oxygen therapy
- Nasal cannula
- Continuous distending pressure
- Mechanical ventilation
- Weaning from ventilatory support
Nursing Care
Cardiovascular support
-Assess
- heart rate and rhythm, skin colour, blood pressure, perfusion, peripheral pulses,
oxygen saturation
- congenital anomalies
Nursing Care
Neurological
- Monitor for seizure activity, hyperirritability, CNS depression, elevated
intracranial pressure, and abnormal movements.
Nursing Care
Nutrition and Hydration
- Breastfeed if sucking and swallowing reflexes are adequate and no other
contraindications. - Gavage feeding (nasogastric or orogastric tube)
- Gastrostomy feeding (surgical placement of a tube through abdomen into the stomach.
- Supplemental parenteral fluids to supply additional calories, electrolytes, or water.
Nursing Care
Renal support
- Assess acid–base and electrolyte balance
- serum levels of medication for adequate therapeutic range for treatment and to
prevent toxicity - Hematological support
- Signs of bleeding, anemia
Nurturing environment
- Avoid slamming doors (including isolette portholes), listening to radios, talking loudly,
and handling equipment (e.g., trash containers), jarring chairs - Monitoring sound levels in the nursery
- Shielding newborns’ eyes from bright lights
- Clustering of care and assessments to enable undisturbed sleep periods
Skin care
- Care must be taken to avoid damage to the delicate structure.
- Use skin products (e.g., alcohol, chlorhexidine, povidone-iodine) with caution
- Rinsed with water afterward to prevent severe irritation and chemical burns in
VLBW and ELBW infants. - Minimal use of adhesive tape, backing the tape with cotton, and delay removal
adhesive until adherence is reduced
Protection from infection
Strict hand hygiene is the single most important measure to prevent infections
Developmental Care
Developmental care is a comprehensive strategies and interventions designed to reduce
the effects of negative stress in newborn and optimize neurobehavioural development
- NICU produces multiple exposures to noxious stimuli that affects the preterm
infant’s brain
Components Developmental care (IMPORTANT)
Recommended for preterm babies
- Protected sleep
- Nesting
- Kangaroo mother care
- Cluster care- all ADLs should be done in a one time frame to
minimize the disturbing
- Activities of daily leaving
- Massaging
- Feeding
- Skincare and diaper changing
- Healing environment
- Dim lights during the day
- Lifting of chair/do not drag
- Facilitate smooth transition
- Management of pain
- Non nutritive sucking
- Swaddling
- Containment during procedures
- Family centered care
-Involvement of families in caregiving activities - Educating and empowering
- Emotional support during critical time
Developmental care is tailored to each newborn on based on comprehensive assessment
- Skin-to-skin contact
Family support and involvement
- Psychological tasks of parents of a high-risk infant
-Facilitating parent–infant relationships
-Anticipatory grief
-Parent education-Sudden infant death syndrome (SIDS)
- Cardiopulmonary resuscitation (CPR)
The Post-term Infant
Post-term infant
- Gestation beyond 42 weeks, regardless of birth weight
- associated with placental insufficiency,
post-term infant characteristics
- thin, emaciated appearance at birth due to loss of subcutaneous fat and muscle mass
- dry, loose, peeling skin;
- meconium staining of the fingernails;
- hair and nails may be long
- vernix may be absent..
Meconium aspiration syndrome (MAS) - meconium in the amniotic fluid necessitates careful supervision of labour and close
monitoring of fetal well-being. - Infant showing breathing problems may require neonatal resuscitation
Large for gestational age LGA
Large for gestational age LGA:
Newborn birth weight is above the ninetieth percentile on growth
charts
- Higher incidence of birth injuries
- Asphyxia
- Congenital anomalies such as heart defects.
Causes of LGA
- Maternal diabetes in the mother (most common cause)
- Maternalobesity
- Having had previous LGA babies
- Genetic abnormalities or syndromes
- Excessive weight gain during pregnancy
Infants of Diabetic Mothers
-Higher Risk of Hypoglycemia
- High maternal blood glucose levels during fetal life stimulate the fetal islet cells to
produce insulin
-Leads to hypertrophy and hyperplasia of the pancreatic islet cells-transient state of
hyperinsulinism
- Sudden removal of newborn’s glucose supply after birth + continued production of
insulin - depletes the blood of circulating glucose
- creating a state of hyperinsulinism and hypoglycemia within 0.5 to 4 hours
- Quick drops in blood glucose levels leads to neurological damage or death
Clinical Manifestations of diabetic mothers
-Macrosomia or Large for gestational age
- Very plump and full faced
- Abundant vernix caseosa
- Plethora (ruddy complexion)
- Listless and lethargic
- Possibly meconium stained at birth
- Hypotonia
complications of diabetic mothers
-Hypoglycemia, hypocalcemia, –hypomagnesemia, polycythemia, hyperbilirubinemia,
cardiomyopathy,
- Respiratory Distress Syndrome
- CNS anomalies-anencephaly, spina bifida, and holoprosencephaly
- Cardiac anomalies- ventricular septal defects and coarctation of the aorta
- Sacral agenesis and caudal regression
- Increased risk for birth injuries
management of nursing care -diabetic mothers
- Feedings with breast milk or formula initiated within the first hour after birth if
cardiorespiratory status stable - If enteral supplementation failed or infant unable to feed
- continuous IV infusion of 10% dextrose at 4 to 6 mg/min/kg
- If blood blood glucose is below 1.8mmol/L, a one-time bolus infusion of 10%
dextrose (200 mg/kg) should be given over 2 to 4 minutes, - followed by a continuous IV infusion of 10% dextrose
- Evaluation of serum glucose 30 minutes
- pharmacological agents (glucagon and diazoxide) may be required
- Monitoring for symptoms of hypoglycemia in an IDM include
- jitteriness or tremors,
- cyanotic episodes,
- seizures,
- intermittent apneic episodes
- difficulties feeding
- Assess for congenital anomalies, signs of possible respiratory or cardiac issues
- Maintenance of adequate thermoregulation
- Introduction of carbohydrate feedings as appropriate
- Monitoring of serum blood glucose levels.
- Monitored closely for hyperbilirubinemia.
Small For Gestational Age Infants (SGA)
Infant weight <the 10th percentile for gestational age
Small For Gestational Age Infants (SGA)
Risk Factors
- Intrauterine exposure to maternal substances
- Maternal diabetes
- Maternal pre-eclampsia
- Maternal chronic systems failure (renal, cardiac, etc.)
- Maternal anemia, thrombocytopenia
- Uteroplacental insufficiency
- Intrauterine viral infection
- Fetal chromosomal abnormalities
- Cord prolapses, cord thrombosis causing insufficient intrauterine growth
Other Risk factors for SGA
-Geography – poor neighborhood; rural area with limited access to prenatal and L&D
care.
- Multiple gestations (twins, triplets)
- Maternal age (teen or 35+)
- Parity (number of pregnancies)
- Previous preterm birth
- Maternal hypertension
- Substance abuse (smoking, drugs, alcohol
Clinical manifestations include: SGA
-Jittery, hypoglycemic
- Polycythemia (elevated Hct., ruddy colour)
- Temperature instability
- Meconium staining
- Perinatal asphyxia, hypoxia
Discharge Planning High Risk
- Parents should be given the opportunity to room-in and spend a night or two
providing care - Rooming in
- Tell them to change the diapers etc.
- Home care needs of infant's parents are assessed.
- Referrals for appropriate resources
- Assistance with medical supplies
- Prent teaching include bathing and skin care, infection prevention
- Nutritional requirements for meeting nutritional needs
- Parent education and opportunity for return demonstrations care skills
- Age-appropriate car seat
- Health care provider contact
- Appropriate immunizations, metabolic screening, hematology assessment, and
evaluation of hearing and for retinopathy of prematurity (ROP) before discharge - Transport to a regional centre
-Kangaroo Care: to enhance temperature regulation
