Newborn Care and Assessment Kim Martin RN, MSN Nursing Instructor HACC, Pennsylvania’s Community...

Newborn Care and Assessment

Kim Martin RN, MSN

Nursing Instructor

HACC, Pennsylvania’s Community College

Nursing 101; Summer 2012

Newborn Assessment• Begins immediately after birth • Continues throughout hospital stay• APGAR score at one minute and 5 minutes• Gestational age assessment within 2 hours • Complete assessment within 24 hours• Wear gloves until 1st bath

Newborn Assessment• Health History• Physical Assessment

– Hand washing and warm hands– Sleeping newborn

Temperature• Normal

– Axillary = 36.5 - 37.5° C (97.7 - 99.5° F)

– Rectal = 36.5 - 37.6° C (97.7 - 99.7° F)

– Axillary is preferred– Rectal done first in some

institutions

• Abnormal– Decreased – Elevated

Heart Rate and Pulses • Normal

– Heart rate = 120 - 160 BPM

– PMI 3rd - 4th intercostal space

– Brachial, femoral, and pedal pulses present and equal bilaterally

• Abnormal– Tachycardia – Bradycardia– PMI to right – Murmurs and

arrhythmias– Absent or unequal

pulses

Respirations• Normal

– Rate = 30 - 60 per minute

– Irregular, shallow, unlabored

– Chest movement symmetric

– Breath sounds present and clear in all lobes

• Abnormal– Tachypnea after 1st

hour– Slow respirations– Nasal flaring, grunting,

retractions– Apnea with color

changes– Asymmetric or

decreased chest expansion

– Abnormal lung sounds– Bowel sounds in chest

Weight• Normal

– 2,500 to 4,000 grams(5 lbs 8 oz to 8 lbs 130z)

– Weight loss < 10% in first 2 weeks

• Abnormal– LGA– SGA– LBW– VLBW– ELBW– Weight loss > 10%

Weighing

Length

• Normal– 45 - 55 cm– 17.75 - 21. 5 inches– Measure from crown

to heel

• Abnormal– Below normal– Above normal

Head Circumference

• Normal–31 to 33.8 cm–12.2 to 15 inches–Measured over

prominent part of occiput and just above eyebrows

• Abnormal–Small–Large

CHARACTERISTICS OF THE NEWBORN

Normal Skin Variations

AcrocyanosisLanugo

VernixVernix

Mottling

Harlequin Sign

ABNORMAL SKIN VARIATIONS

Excessive Vernix

Cyanosis

Jaundice

Forceps Marks

Petechiae

Nevus flammeus

Cafe’ au lait spots Nevus vascularis

HEAD AND FACE

Molding

Caput and Molding

Cephalhematoma

Ear Placement

Think “Ears and Kidneys”

Choanal Atresia

Mouth – Normal

Precocious teeth

Epstein’s pearls

Cleft Lip and Palate

CHEST AND ABDOMEN

Abnormal• Asymmetrical• Supernumerary nipples

Umbilical Hernia

Omphalocele

Gastroschisis

Bladder Exstrophy

Ambiguous Genitalia

EXTREMITIES

Polydactyly

Syndactyly

Brachial Plexus Injury

• Diminished movement of arm with extension and pronation of forearm – (Erb-Duchenne

paralysis)

Abnormal Lower Extremities• Ortolani and Barlow signs

positive• unequal leg length

• Malposition of feet = position in uterus, talipes equinovarus

NEWBORN REFLEXES

Moro/Startle Reflex

Grasp Reflex

Rooting ReflexSucking ReflexSwallowing Reflex

Tonic Neck/Fencing Reflex

Babinski Reflex

Stepping and Placing Reflex

ROUTINE PROCEDURES AND CARE

Thermoregulation

Prevention of Infection• Hand washing• Standard Precautions

– Gloves must be worn • Until first bath• Heel stick• Diaper changes• Breastmilk• Regurgitation• Suctioning

Infant ID

Prevent Hemorrhagic Disease

• AquaMephyton (Vit K) 1 mg IM in vastus lateralis

Eye Prophylaxis

Prevent Hepatitis B Infection

• HepB vaccine– O.5 ml IM Hepatitis B vaccine prior to hospital

discharge– Then at 1-2 months and 6 – 18 months of age– Moms with + HbsAG:

• baby also gets Hep B immune globulin (HBIG)

Newborn Hearing Screening

Lab Tests• Cord blood

– Blood type and Rh– Coombs’ prn

• State law mandates screening for inborn errors of metabolism– PKU– Hypothyroidism

• Some states include– Sickle cell, galactosemia, and MSUD

Labs continued…• Bilirubin (total and direct)• Microglucose, if at risk

– Perinatal stress– SGA– LGA– Maternal DM– Post term (> 41 wks.)– Pre term (< 37 wks.)– NORMAL = > 40 mg/dl

Infant Heel Stick

Umbilical Cord

Circumcision

• Surgical removal of foreskin of penis– Controversial– Nursing Care

• Assess for bleeding• Assess for signs of infection• Voiding

Gomco

Plastibell

Health Promotion and Safety• General Hygiene

– Complete bath 2 – 3 times/week– Mild soap and water; no powder– Wash hair with bath, brush while washing to

prevent cradle cap (seborrheic dermatitis)– Cut nails straight across while infant is asleep– Diapering and diaper rash– Suctioning prn

Diaper Rash

Health Promotion and Safety• Never leave infant alone• Hold during feedings• Prevent heat loss• Support head at all times• Always use seatbelt in carriers, swings,

strollers, etc.• DO NOT leave alone with young siblings• Clothing

BACK TO SLEEP

Car Seats

Car Seat necessary for all infantsFederally approvedMust have seat to leave hospitalLaw in all 50 statesRear-facing until one year AND 20 lbs.

Health Promotion and Safety• Increased frustration• Smoking• Domestic Violence• Sexual Abuse• CPR

Shaken Baby Syndrome

Health Promotion and Safety• Signs of Illness

– Change in skin color– Difficulty breathing or absence of breathing– Axillary temp. > 37.8° C (100° F)– Projectile vomiting– Refuses 2 consecutive feedings– Excessive crying, fussiness, lethargy, or difficulty

waking infant– Stool or urine changes– S&S of infection from cord or circ site– Appears or act ill

NEWBORN NUTRITION

Maternal Choice

• Many factors influence mother’s preference to breast or bottle feed

• Breastfeeding is almost ALWAYS BEST for infant, but may not be best choice for mother

Breastfeeding • Assess latch• Listen for

suck/swallow• Observe infant and

mother for comfort level

• Count wet and soiled diapers

Breastfeeding• Supplements maybe recommended for

breastfed infants– Vitamin D– Vitamin K– Iron– Fluoride

• Mother should continue prenatal vitamins• Mother needs proper diet

Formula• Closely resembles human breastmilk• Provides essential vitamins• Should be Iron enriched • WIC (Women, Infant,

Children) = state/federal

supplemental food

program

Formula• Types:– Cow milk based– Soy based– Predigested

• Forms:– Ready to feed– Liquid concentrate– Powdered

• Teach parents importance of following directions

Bottle Feeding• Positioning

– Held in semi-upright position– Lying down predisposes to:

• Middle ear infections• Aspiration

– Nipple filled with formula

to avoid air– Burp every ½ oz.

Bottle Feeding

• After feedings, position on back• Give feedings at room temperature• Warm cold formula or breastmilk in pan of warm

water• DO NOT MICROMAVE formula or breastmilk• Clean bottles with soap/water or dishwasher• If well water, boil water 5 – 10 minutes

HIGH-RISK NEWBORN

The Preterm Infant

Click icon to add picture

Appearance of Preterm Infant• “Winkled old man”

– Lacks subcutaneous fat– Skin delicate, thin, transparent

• Covered with lanugo• Prominent fontanels/suture lines• Weak cry• Abundant vernix• Few creases on soles of feet

Appearance of Preterm Infant• Abdomen protrudes• Short nails• Genitals small

– Testicles high in scrotum– No rugae until after 36 weeks– Clitoris exposed– Labia majora opened– Ears lack shape/cartilage

Thermoregulation for Preterm Infant• Problems

– Decreased brown and subcutaneous fat– Large body surface area in relation to weight– Poor muscle tone– Thin skin– Blood vessels close to surface

• Warmer or isolete – Monitor skin temperature with sensor

COMPLICATIONS OF PREMATURITY

Respiratory System• Functionally and structurally immature

– Insufficient surfactant– Chest muscles not fully developed– Abdomen distended = pressure on diaphragm– Respiratory centers in brain immature

• Irregular pattern; apnea• Predisposed to respiratory distress and infection

RESPIRATORY COMPLICATIONS

RDS (Respiratory Distress Syndrome)

• Hyaline Membrane Disease–Membrane forms around alveoli and prevents

exchange of O2 and CO2–Lack of surfactant–Synthetic or natural surfactant introduced

into neonate’s endotracheal tube

RDS Chest X-Ray

Bronchopulmonary Dysplasia(BPD)

• Supplemental O2 for extended period of time causes:– Thickening of alveolar sacs– Atelectasis and scaring

• Results in long term dependence on oxygen• Prevention

– Monitor O2 concentrations closely– Maintain lower O2 saturations

BPD Chest X-Ray

Retinopathy of Prematurity (ROP)

• Also Called Retrolental Fibroplasia – Prolonged high concentrations of O2 cause

proliferation and rupture of retinal blood vessels

– Blindness • Prevention

– Monitor O2 carefully– Decrease lighting in NICU– Reduce stress to infant

CIRCULATORY SYSTEM

PDA (Patent Ductus Arteriosus) • S&S = systolic murmur, active precordium,

bounding peripheral pulses• Medical Management

– indomethacin (Indocin) inhibits prostaglandin synthesis – diuretics – surgical ligation

• Nursing Care – Accurate I&O, – O2 sats, – ABG’s

Nervous System• Immature• Suck, gag, and swallow reflexes

uncoordinated or absent before 34 to 35 weeks gestation

• Intraventricular Hemorrhage

GI System• Weak sucking and swallowing• Delayed stomach emptying• Reduced intestinal motility• Small capacity• Poor fat absorption• Stomach sphincter immature – vomiting• Tire easily – feeding uses a lot of energy• Usually tube fed or IV nutrition only

Necrotizing Enterocolitis(NEC)

• Ischemia of bowel• Cells stop secreting protective mucus• Intestinal cell damage and death• Intestinal wall becomes invaded by

bacteria• Untreated, it can be fatal

Necrotizing EnterocolitisTREATMENT: NG with suction to decompress bowel

IV antibiotics

Parenteral nutrition = TPN to rest gut

Urinary System• Kidneys are immature• At risk for fluid retention and/or over

hydration

Immune System• Preterm at high risk for infection

– Invasive procedures– Fragile skin– Decreased immunity acquired from mom

• Meticulous hand washing and good aseptic technique

Endocrine System• Hypoglycemia due to inadequate brown

fat and glycogen stores• Increased glucose needs for growth and

needs of heart and brain• Microglucose done

Caregiver Role Strain• Family may need to grieve loss of

“perfect” baby• May initially be afraid to become

attached • Encourage visits and involvement in

care ASAP• Allow verbalization

Cuddling TwinsEat better

Sleep better

THIVE

Post-term Infant• Born after 42 weeks gestation• Placenta does not function well after 40 weeks

– Decreased O2• In labor, O2 reserve is limited • Higher risk of fetal distress and meconium aspiration

– Decreased nutrients• Increased risk of hypoglycemia• Look thin with loose skin

– Decreased vernix • Skin dry and cracked

NEONATAL COMPLICATIONS

Hypoglycemia

• Plasma glucose levels < 40 mg/dL–At risk

• Preterm• LGA• Infants born to mothers with DM

Hypoglycemia• Common signs

• Lethargy Poor feeding• Hypotonia Tachypnea• Jitteriness Apnea• Sweating Shrill cry• Low temperature Seizures

–Treat immediately

Neonatal Sepsis• Generalized bacterial infection in blood stream• Caused by

– Staph aureus– Staph epidermidis– E-coli– Haemophilus influenzea– Group B strep

Neonatal Sepsis• Signs of sepsis

• Lethargy• Hypothermia• Respiratory distress • Cyanosis, pallor• Jaundice• Poor sucking and

feeding• Vomiting• Diarrhea

• Treatment• Prevention • Antibiotic therapy• O2 therapy• Careful regulation of

fluids and electrolytes

Hyperbilirubinemia• Excessive level of bilirubin in blood• Characterized by jaundice• Common in newborn• Destroyed or dead RBC’s release bilirubin as

they breakdown

Hyperbilirubinemia• Physiological Jaundice

– Common – Self-limiting– Peaks 3 – 4th day of life– Screening tool: Cutaneous

bilimeter– Blood test: Direct Bili

Hyperbilirubinemia• Pathologic Jaundice

– Occurs within 24 hours of birth– Total serum Bili 12 mg/dl or > in term infant

• Formula fed < 12 mg/dl• Breast fed < 14 mg/dl

– Total serum Bili of 16 mg/dl or > in preterm infant– Primary cause is Rh and ABO incompatibilities

Rh and ABO Incompatibility

Next Pregnancy

First Pregnancy

Rhogam = Prevention

Hyperbilirubinemia• Bilirubin encephalopathy

– CNS damage from deposits of unconjugated bilirubin – High levels of bilirubin may cause

• Decreased activity• Poor feeding• Lethargy

Long-term effects• Mental retardation• Behavior disorders• Motor dysfunction

HyperbilirubinemiaDiagnostic Tests

• Total serum bili: – Measures conjugated (direct)

and unconjugated (indirect) bili• Direct Coombs:

– Measures antibody coated Rh + RBC’s in infant’s blood

– Performed to ID hemolysis• Indirect Coombs:

– Measures Rh + antibodies in mother’s blood

PhototherapyProtect eyes and skin; maintain temp and fluid balance