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NEW BORN CARE Objectives
Describe the normal characteristics of a term newborn. Assess a newborn for normal growth and development. Formulate nursing diagnoses related to a newborn or the family of a newborn. Identify expected outcomes for a newborn and family during the first 4 weeks of life. li fe. Plan nursing care to augment normal development of a newborn, such as ways to aid parent-child bonding Implement nursing care of a normal newborn, such as administering a first bath or instructing parents on how to care for their newborn. Evaluate expected outcomes to determine effectiveness effectiveness of nursing care and outcomes achievement. Use critical thinking to analyze ways that the care of a term newborn can be more family centered. Integrate knowledge of newborn growth & development and immediate care needs with the nursing process to achieve quality maternal and child health nursing care.
The Neonate
From birth through the first 28 days of life Also called “the newborn period” 2/3 of all deaths that occur during the 1st year of life occur during this period; more than half occur in the 1st 24 hours after birth---an indication of how hazardous this time is for an infant How well a NB makes major adjustments depends on his or her: Genetic composition o The competency of the recent intrauterine environment o The care received during the neonatal period o
PRINCIPLES IN IMMEDIATE NEW BORN CARE 1st day of life 1. initiat initiation ion and and mainten maintenanc ancee of respira respiratio tionn (used bulb syringe initiate a/w)
2. 3. 4. 5. 6. 7. 8.
establishm establishment ent of extra uterine uterine circulatio circulationn cont contro roll of body body temp temp intake intake of of adequ adequate ate nouris nourishme hment nt establ establish ishmen mentt of waste waste elim elimina inatio tionn prev preven entio tionn of infe infect ctio ionn establishm establishment ent of of an infant infant parent parent relationsh relationship ip dev’t dev’t care that that balances balances rest rest and and stimulatio stimulationn or mental mental dev’t dev’t
Immediate care of the newborn. a/w, lung function begins after birth only) A-airway (most neonatal deaths with in 24 h caused by inability to initiate a/w, body temperature B- body check/asses the newborn C-check/asses D-determined identification I. Establish and Maintain a Patent Airway / Effective Respiration
Nursing Interventions: 1. Wipe Wipe the mouth mouth and and nose nose secretion secretionss after delive delivery ry of the the head 2. Suction Suction secretion secretionss from the the mouth mouth and nose nose prope properly rly.. Catheter Suctioning
1.) Place head to side to facilitate drainage 2.) Suction mouth 1st before nose -neonates are nasal breathers 3.) Period of time -5-10 sec suctioning, gentle and quick
2 Prolonged and deep suctioning can lead to hypoxia, laryngo spasm, brady cardia due to stimulation vagal nerve 4.) Evaluate for patency -cover nostril and baby struggles there’s a need for additional suctioning “If not effective, requires effective effective laryngoscopy to open a/w. After deep suctioning an endotracheal tube can be inserted and oxygen can be administered by an (+) pressure bag and mask with 100% oxygen at 40-60b/m.”
Nsg alert: No smoking Always humidify to prevent drying of mucosa Over dosage of oxygen can lead to scarring of retina leading to blindness ( retro lentalfibrolasia or retinopathy of prematurity) When mecomium stained (greenish) never administer oxygen with pressure ( O2 pressure will push mecomium inside)
3. Stimulate Stimulate the baby baby to cry if baby does does not cry spontan spontaneous eously ly or if baby’s baby’s cry is weak. “A crying infant is a breathing infant. Effective cry means effective breathing ”
Do not slap the buttocks but rub the soles of the feet Do not stimulate the NB to cry unless the secretions have been suctioned to prevent aspiration lusty. Observe for the ff. abnormal cry: The normal infant cry is loud & lusty. High-pitched cry : hypoglycemia, increased ICP Weak cry: prematurity Hoarse cry: laryngeal stridor
4. Oral Oral mucus may may cause cause the NB to choke, choke, cough cough or gag during during the first first 12 to 18 hours hours of life. Place the neonate in a position that would promote drainage of secretions Trendelenburg (contraindicated to Increased ICP) Trendelenburg Side-Lying 5. Keep the nares nares patent. patent. Remove Remove mucus mucus and other particles particles w/c w/c can cause cause obstruction obstruction as newborn newbornss are “obligatory nasal breathers breathers” until they are about 2-3 weeks old. 6. Give Give O2 as need needed ed.. Oxyg Oxygen en shou should ld be give givenn for for 20-3 20-300 minu minute tess when when the the neon neonat atee rema remain inss cyanotic or tachycardic after initial suctioning and stimulation. * asphyxiation → hypoxia → hypercapnia(↑ CO2) → acidosis → coma → death •
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Obse Observ rvee prec precau auti tion on in givi giving ng oxy oxyge genn Do not give more than 40% O2 as this may lead to retrolental fibroplasia (blood vessels of the eyes become spastic leading to blindness) Use pulse oximeter and monitor O2 concentration every hour
• 7. If the heart heart rate falls falls below below 60 bpm, cardia cardiacc massage massage may need need to be carrie carriedd out. II. Maintain Appropriate Body Temperature Temp Regulation
goal in temp regulation is to maintain it not less than 97.7% F (36.5 C) maintenance of temp is crucial on preterm and SGA (small for gestational age) - babies prone to hypothermia or cold stress o Neonates have “physiologic resilience” wherein they tend to adopt or take temperature of their own environment. (poikilothermic) “cold stress (hypothermia) is more dangerous than hyperthermia” Effects of cold stress Cold stress metabolic acidosis CNS depression Coma Death Every NB is born slightly acidotic. Any new build-up of acid may lead to life-threatening o metabolic acidosis, which can be lethal even to normal newborn infants. The average NB temp.@ birth is around 37.2°C. o o NB lose heat easily because:
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They have immature temp.-regulating system Of very little amount of subcutaneous fat to provide heat They have a larger body surface area that results in more heat loss They have little ability to conserve heat by changing posture and no ability to adjust its own clothing
Methods of Heat Loss in Newborn • Convection – the flow of heat
from the NB’s body surface to cooler surrounding air; ex:
windows, air conditioners • Conduction- the transfer of a body heat to a cooler solid object in contact with a baby; ex: baby placed on a cold counter • Radiation – the transfer of body heat to a cooler solid obj. not in contact with a baby; ex: cold window or air con • Evaporation – loss of heat through conversion of a liquid to a vapor; ex: after delivery, newborns are wet, with amniotic fluid on their skin, tsb
Effects of Hypothermia ( Cold stress) 1.) Hypoglycemia- 45-55
mg/dl normal 50- borderline 2.) met acidosis-
catabolism of brown fats (best insulator of newborns body) will form ketones 3.) high risk for kernicterus- bilirubin in
brain leading to cerebral palsy 4.) additional fatigue to allergy stressful heart
To Prevent Hypothermia 1. Dry Dry and wrap wrap baby baby 2. Mechan Mechanica icall pres pressur suree – radian radiantt warm warmer er pre-heated first isolette (or square acrylic sided incubator) 3. Preven Preventt an necess necessary ary exposu exposure re – cover cover baby baby 4. Cove Coverr baby baby with with tin tin foi foill or pla plast stic ic 5. Embrace the baby- kangaroo care 6. Delay initial bath until temp. has stabilized for at least 2 hours. 7. Maintain ambient temp. of nursery at 24°C or 75°F. 75°F.
4 8. Perform any extensive examination or procedure under radiant heat to prevent heat loss and expose only the part of the body to be examined. 9. Note the presence of any cyanosis: 2 types of cyanosis: a.) central cyanosis b.) peripheral cyanosis hands & feet are cyanotic, due to cold environment and poor circulation
Axillary temperature measurement. The thermometer should remain in place for 3 minutes. The nurse presses the newborn’s arm tightly but gently against the thermometer and the newborn’s side, as illustrated III. Perform Initial Assessment APGAR Scoring System
Developed by Dr. Virginia Apgar Apgar in 1958 It is a standardized method for evaluation of the newborn and serves as a baseline for future evaluations. o It is taken twice: initially @ 1 minute, and then @ 5 minutes after birth o Special Considerations: 1st 1 min – determine general condition of baby Next 5 min- determine baby’s capabilities to adjust extra uterinely Next 15 min – dependent on the 5 min o
0 A ppearance
APGAR Scoring System 1
Pale or blue all over absent No response
Body pink, extremities blue Below 100 grimace
A ctivity / Muscle
Limp, flaccid
Some flexion of the extremities
Tone R espiratory Effort
absent
Slow,irregular,weak cry
(Color) Pulse/♥ rate G rimace/Reflex Irritability
2 Pink all over Above 100 Sneezes,gags, coughs,vigorous cry and foot withdrawal Active motion/ well-flexed Good, strong,lusty cry
APGAR result
0 – 3 = severely depressed, need CPR, admission NICU 4 – 6 = moderately depressed, needs add’l suctioning & O2 7 - 10 =good/ healthy Silvermann & Anderson Scoring System o
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Devised Devised in 1956 and is a test used to evaluate or estimate the degrees of respiratory respiratory distress distress in newborns newborns or the respiratory status of premature infants. A NB is observed and then scored on each of five criteria ---0,1 or 2. The scores are then added. (the scores of this system are interpreted as opposite of the Apgar)
Chest Mo Movement
The Silverman & Anderson Scoring System 0 1 2 Synchronized respirations Lag on inspiration Seesaw respirations
5 Intercostal Retraction
none
Just visible
Marked
Xiphoid Retraction Nares Dilatation Expiratory Grunt
none none none
Just visible minimal Audible by stethoscope
Marked Marked Audible by unaided ear
Silvermann and Anderson Scoring Interpretation Int erpretation
0 : no respiratory distress 4-6 : moderate respiratory distress 7-10 : severe respiratory distress
IV. Proper Identification of the Newborn Proper Id is made in the delivery room before mother and baby are seperated. Identification Band o Footprints o Others – fingerprints, crib card, bead bracelet o Birth certificate A final identification check of the mother and infant must be performed before the infant can be allowed to leave the hospital upon discharge to ensure that the hospital is discharging the right infant. V. Preventing Infection Credes Prophylaxis – Dr. Crede
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-prevent opthalmia neonatorum or gonorrheal conjunctivitis how how tran transm smit itte tedd – mom mom wit withh gon gonor orrh rhea ea
drug: erythromycin ophthalmic ointment- inner to outer
*It is part of the routine care of the NB to give prophylactic eye treatment against gonorrheal conjunctivitis or ophthalmia neonatorum within the first hour after delivery. * Neisseria gonorrhea, the causative agent,maybe passed on to the fetus when infected vaginal and cervical secretions enter the eyes as the baby passes the vaginal canal during delivery. This practice was introduced by Crede, German gynecologist in 1884. Silver Nitrate, erythromycin and tetracycline ophthalmic ointments are the drugs used for this purpose. Ophthalmia neonatorum
Any conjunctivitis with discharge occuring during the first two weeks of life. It typically appears 2-5 days after birth, although it may appear as early as the first day or as late as the 13th.
silver nitrate (used before) – 2 drops lower conjunctiva (not used now) Administering Erythromycin or Tetracycline Tetracycline Ophthalmic Ointment
These ointments are the ones commonly used nowadays for eye prophylaxis because they do not cause eye irritation and are more effective against Chlamydial Chlam ydial conjunctivitis. Apply over lower lids of both eyes, then, manipulate eyelids to spread medication over the eyes. Wipe excess ointment after one minute Č sterile cotton ball moistened Č sterile water.
Principles of cleanliness at birth:
Clean hands Clean perineum Nothing unclean to be introduced into the vagina Clean delivery surface Cleanliness in cutting the umbilical cord Cleanliness for cord care of the newborn baby
Handwashing
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Before entering the nursery or caring for a baby In between newborn handling or after the care of each baby Before treating the cord After changing soiled diaper Before preparing milk formula.
VI. Preventing Hemorrhage NB’s As a preventive measure, 0.5 mg (preterm) to 1 mg (full term) Vit. K or Aquamephyton is injected IM in the NB’s vastus lateralis (lateral anterior thigh)muscle h ypoprothrombinemia Vit-K – to prevent hemorrhage R/T physiologic hypoprothrombinemia Aquamephyton, phytomenadione or konakion .1 ml term IM, vastus lateral or lateral ant thigh .05 ml preterm baby Vit K – synthesized by normal flora of intestine Vit K – meds is synthetic due intestine is sterile
Procedure for vitamin K injection. Cleanse area area thor thorou ough ghly ly with with alco alcoho holl swab swab and and allow skin to dry. Bunch the tissue of the upper outer thigh (vastus lateralis muscle) and quickl quicklyy insert insert a 25-gau 25-gauge ge 5/8-in 5/8-inch ch needle at a 90-degree angle to the thigh. Aspirate, then slowly inject the solution to dist distri ribu bute te the the me medi dica cati tion on even evenly ly and and minimize the baby’s discomfort. Remove the needle and gently massage the site with an alcohol swab.
Care of the Cord
The cord is clamped and cut approx. within 30 sec after birth. In the DR, the cord is clamped twice about 8 inches from the abdomen and cut in between. When the NB, is brought to the nursery, nursery, another clamp is applied ½ to 1 in from the abdomen and the cord is cut a second time. The cord and the area around it are cleansed w/ antiseptic solution. The manner of cord care depends on hospital protocol or the discretion of the birth attendant in home delivery, delivery, what is impt. Is that principles are followed. Cord clamp is removed after 48 hours when the cord has dried. The cord stump usually dries and falls off within 7-10 days leaving a granulating area that heals on the next 7-10 days. Leave cord exposed to air. Do not apply dressing or abdominal binder over it. The cord dries and seperates more rapidly if it is exposed to air. air. Report any unusual signs & symptoms s ymptoms that indicate infection: Foul odor in the cord o Presence of discharge o Redness around the cord o The cord remains wet and does not fall off within 7-10 days o o Newborn fever
7 “Tetanus microorganism thrives in anaerobic environment so you actually prevent infection if cord is exposed to air”.
Full bath – safely given when cord fall 3 cleans in community
clean hand clean cord o clean surface o betadine or povidone iodine – to clean cord check AVA, then draw 3 vessel cord o
If 2 vessel cord- suspect kidney malformation
- leave about 1” of cord - if BT or IV infusion – leave 8” of cord best access - no nerve - check cord cord every 15 min min for 1st 6 hrs – bleeding .> 30 cc of blood bleeding of cord – Omphalagia – suspect hemophilia Cord turns black on 3rd day & fall 7 – 10 days
Faiture to fall after 2 weeks- Umbilical granulation
Dressing the Umbilical Cord – strict asepsis to prevent tetanus Bathing
- oil bath – initial - to cleanse baby & spread vernix caseosa Fx of vernix caseosa 1. insulator 2. bac bacteri terioo- stati taticc Babies of HIV + mom – immediately give full bath to lessen transmission of HIV - 13 – 39% 39% pos possi sibl blyy of tran transm smis issi sion on of HIV
Mgt: silver nitrate or catheterization
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clea cleann with with nor norma mall sali saline ne sol solut utio ionn not not alco alcoho holl don’t use bigkis – air persistent moisture-urine, suspect patent uracus – fistula bet bladder and normal umbilicus
dx: nitrazine paper test – yellow – urine mgt: surgery Immediate Care of the Newborn
A irway B ody temperature C heck/ assess the newborn D etermine identification
Stimulate & dry infant Assess ABCs Encourage skin-to-skin contact Assign APGAR scores Give eye prophylaxis & Vit. K Keep newborn, mother, & partner together whenever
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Newborn Assessment and Nursing Care Physical Assessment
Temperature - range 36.5 to 37 axillary Common variations Crying may elevate temperature o Stabilizes in 8 to 10 hours after delivery Temperature is not reliable indicator i ndicator of infection o A temperature less than 36.5 Temp: rectal- newborn – to rule out imperforate anus - take it once only, 1 inch insertion Imperforate anus 1. atre atretic tic – no no anal anal ope openi ning ng 2. agen agenet etia iali lism sm – no no geni genita tall 3. sten stenos os – has has open openin ingg 4. me memb mbra rano nous us – has has ope openi ning ng Earliest sign: 1. no mecomium 2. abd destention 3. foul odor breath 4. vomitous of fecal matter 5. can aspirate – resp problem Mgt: Surgery with temporary colostomy
Heart Rate
range 120 to 160 beats per minute Common variations
Heart rate range to 100 when sleeping to 180 when crying Color pink with acrocyanosis cr ying Heart rate may be irregular with crying Although murmurs may be due to transitional circulation-all murmurs should be followed-up and referred for medical evaluation Deviation from range Faint sound Cardiac rate: 120 – 160 bpm newborn Apical pulse – left lower nipple Radial pulse – normally absent. If present PDA Femoral pulse pulse – normal present. present. If absent- COA - coartation of aorta
Respiration
- range 30 to 60 breaths per minute Common variations
Bilateral bronchial breath sounds Moist breath sounds may be present shortly after birth
Signs of potential distress or deviations from expected findings
Asymmetrical chest movements Apnea >15 seconds Diminished breath sounds
9 Seesaw respirations Grunting Nasal flaring Retractions Deep sighing Tachypnea - respirations > 60 Persistent irregular breathing Excessive mucus Persistant fine crackles Stridor
Breathing Breathing ( ventilating the lungs)
check for breathlessness breathlessness if breathless, give 2 breaths- ambu bag 1 yr old- mouth to mouth, pinch nose < 1 yr – mouth to nose force – different between baby & child infant – puff
Circulation
Check for pulslessness :carotid- adult ♦ Brachial – infants breathless/pulseless CPR – breathless/pulseless Compression – inf – 1 finger breath below nipple line or 2 finger breaths or thumb CPR inf 1:5 Adults 2:30 Blood Pressure
-not done routinely Factors to consider •
Varies with change in activity level Appropriate cuff size important for accurate reading 65/41 mmHg
General Measurements
Head circumference - 33 to 35 cm Expected findings o Head should be 2 to 3 cms larger than the chest o Abdominal circumference – 31-33 cm o Weight range - 2500 - 4000 gms (5 lbs. 8oz. - 8 lbs. 13 oz.) o Length range - 46 to 54 cms (19 ( 19 - 21 inches) o Anthropometic measurement normal length- 19.5 – 21 inch or 47.5 – 53.75cm, average 50 cm head circumference 33- 35 cm or 13 – 14 “ o
Hydrocephalus - >14”
Chest 31 – 33 cm or 12 – 13” Abd 31 – 33 cm or 12 – 13” 13” Signs of increased ICP
1.) abnormally abnormally large large head 2.) bulging bulging and and tense tense fonta fontanel nel
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increase BP and widening pulse pressure #3 & #4 are Cushings triad of Decreased Decreased RR, decre decreased ased PR ICP projective projective vomiting vomiting-- sure sign of cerebral cerebral irritation irritation high deviation deviation – diplopia diplopia – sign sign of ICP older older child 4-6 months- normal eye deviation >6 months- lazy eyes 7.) High pitch shrill cry-late sign of ICP
Skin o o o o
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Skin reddish in color, smooth and puffy at birth At 24 - 36 hours of age, skin flaky, flaky, dry and pink in color Edema around eyes, feet, and genitals Venix Caseosa -whitish, cheese-like substance, covers the fetus while in utero and lubricates the skin of the NB. The skin of the term t erm or postterm nb has less vernix and is frequently dry; peeling is common, esp. on the hands & feet i n preterm; absent in postterm; shed after 2 weeks Lanugo -moderate in full term; more in in time of desquammation Skin color Turgor Turgor good with quick recoil blue – cyanosis or hypoxia Hair silky and soft with individual strands White – edema Grey – inf Nipples present and in expected locations Yellow – jaundice , carotene Cord with one vein and two arteries Cord clamp tight and cord drying Nails to end of fingers and often extend slightly beyond
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Acrocyanosis Bluish discoloration of the hands and feet maybe present in the first 2 to 6 hours after birth This condition is caused by poor peripheral circulation , w/c results in vasomotor instability &
capillary stasis, esp. when the baby is exposed to cold. If the central circulation is adequate, the blood supply should return quickly when the skin is blanched with a finger. Blue hand handss and and nails nails are are poor poor indi indica cato torr of oxyge oxy genat nation ion in NB. NB. The nurse nurse should should assess the face & mucus membranes for pinkness reflecting adequate oxygenation
Mongolian Spots
Patch of purple-black or blue-black color distributed over coccygeal and sacral regions of infants of AfricanAmer Am eric ican an or Asia Asiann desc descen ent. t. Not Not malign malignant ant.. Resolv Resolves es in time. time. They They grad gradua ually lly fade fade durin duringg the the firs firstt or seco second nd year ear of life life.. They They ma mayybe mistaken for bruises and should be documented in the NB’s NB’s chart.
