17

Click here to load reader

30105013 Newborn Assessment

Embed Size (px)

Citation preview

Page 1: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

MATERNAL and CHILD HEALTH NURSING

NEWBORN ASSESSMENT

Lecturer: Mark Fredderick R. Abejo RN, MAN

______________________________________________________________________

Newborn Assessment

Page 2: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

Newborn Assessment and Nursing Care

Temperature - range 36.5 to 37 axillary

Common variations

o Crying may elevate temperature

Stabilizes in 8 to 10 hours after

delivery

o Temperature is not reliable indicator

of infection

A temperature less than 36.5

Temp: rectal- newborn – to rule out imperforate

Anus

- take it once only, 1 inch insertion

Imperforate anus

1. atretic – no anal opening

2. agenetialism – no genital

3. stenos – has opening

4. membranous – has opening

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

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 – normal present. If absent COA

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

Seesaw respirations

Grunting

Nasal flaring

Retractions

Deep sighing

Tachypnea - respirations > 60

Persistent irregular breathing

Excessive mucus

Persistant fine crackles

Stridor

Breathing ( ventilating the lungs)

check for 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

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

Head should be 2 to 3 cms larger than the

chest

Abdominal circumference – 31-33 cm

Weight range - 2500 - 4000 gms (5 lbs. 8oz.

- 8 lbs. 13 oz.)

Length range - 46 to 54 cms (19 - 21 inches)

Normal length- 19.5 – 21 inch or 47.5 –

53.75cm, average 50 cm

Head circumference 33- 35 cm or 13 – 14 “

Hydrocephalus - >14”

Chest 31 – 33 cm or 12 – 13”

Abd 31 – 33 cm or 12 – 13”

Signs of increased ICP

1. abnormally large head

2. bulging and tense fontanel

3. increase BP and widening pulse pressure

4. Decreased RR, decreased PR

5. projective vomiting- sure sign of cerebral

irritation

6. high deviation – diplopia – sign of ICP older

child

a. 4-6 months- normal eye deviation

b. >6 months- lazy eyes

7. High pitch shrill cry-late sign of ICP

Page 3: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

Head to Toe Newborn Assessment

CIRCULATORY

STATUS

UMBILICAL VEIN and DUCTUS VENOSUS constrict after cord id clamped

DUCTUS ARTERIOSUS constrict with establishment of respiratory function

FORAMEN OVALE closes functionally as respirations established, but anatomic or

permanent closure may take several months

HEART RATE averages 140 b.p.m.

BP 73/55 mmHg

PERIPHERAL CIRCULATION acrocyanosis within 24 hours

RBC high immediately after birth; falls after 1st week

ABSENCE/ NORMAL FLORA INTESTINE Vitamin K

RESPIRATORY

STATUS

Adequate levels of surfactants (Lecithin and spingomyelin) ensure mature lung

function; prevent alveolar collapse and respiratory distress syndrome

RR = 30-80 breaths /minutes with short periods of apnea (< 15 seconds) = assess for

1 full minute change noted during sleep or activity

NOTE: Periodic apnea is common in preterm infants. Usually, gentle stimulation is

sufficient to get the infant to breathe

RENAL SYSTEM Urine present in the bladder at birth but NB may not void doe 1st 12-24 hours

Later pattern is 6-10 voidings/ day – indicative of sufficient fluid intake

Urine is pale and straw colored – initial voidings may leave brick-red spots on

diaper ( d/t passage of uric acid crystals in urine)

Infant unable to concentrate urine for the 1st 3 months

DIGESTIVE

SYSTEM

IMMATURE CARDIAC SPHINCTER – may allow reflux of food, burped,

REGURGITATE- placed NB right side after feeding

Newborn can’t move food from lips to pharynx. Insert nipple well to mouth

FEEDING PATTERS vary

- Newborns may nurse vigorously immediately afterbirth or may need as long as

several days to suck effectively

- Provide support and encouragement to new mothers during this time as infant

feeding is very emotional doe most mothers

NOTE: Distinguishing Neonatal Vomiting from Regurgitation

Vomiting is usually sour, looks like curdled milk due to HCL, with a sour odor, while

regurgitation has no sour odor or curdling of milk, or occurs during or immediately

after feeding.

IMPORTANT CONSIDERATIONS:

Breastfeeding can usually begin immediately after birth; bottle-fed newborns

may be offered few milliliters of sterile water or 5% dextrose 1 to 4 hours after

birth prior to a feeding with formula

An infant with gastrostomy tube should receive a pacifier during feeding

unless contraindicated to provide normal sucking activity and satisfy oral

needs.

At age4-6 months, an infant should begin to receive solid food foods one at a

time and 1 week apart.

FIRST STOOL is MECONIUM

- Black, tarry residue from lower intestine

- Usually passed within 12-24 hours after birth

If the amniotic fluid shows evidence of meconium staining, the physician most likely do

immediately after delivery is to suction the oropharynx immediately after the head is

delivered and before the chest is delivered.

TRANSITIONAL STOOLS thin, brownish green in color

After 3 days MILK STOOLS are usually passed

a. MILK STOOLS for BF infant – loose and golden yellow

b. MILK STOOLS for FORMULATED FED- formed and pale yellow

Page 4: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

HEPATIC Liver responsible for changing Hgb into conjugated bilirubin, which is further

changed into conjugated (water soluble) bilirubin that can be excreted

Excess unconjugated bilirubin can permeate the sclera and the skin, giving a jaundiced

or yellow appearance to these tissues

TEMPERATURE HEAT PRODUCTION in newborn accomplished by:

a. Metabolism of “ BROWN FAT”

- A special structure in NB is a source of heat

- Increased metabolic rate and activity

Axillary temperature: 96.8 to 99F

Newborn can’t shiver as an adult does to release heat

Newborns are unable to maintain a stable body temperature because they have an

immature vasomotor center, and unable to shiver to increase body heat.

NB’s body temperature drops quickly after birth – after stress occurs easily

Body stabilizes temperature in 8-10 hours if unstressed

Cold stress increases o2 consumption – may lead to metabolic acidosis and

respiratory distress

IMMUNOLOGIC NB develops own antibodies during 1st 3 months but at risk for infection during the

first 6 weeks

Ability to develop antibodies develops sequentially

Neonatal Physical Assessment

Birth weight=2500-400 grams (5 lbs. 8oz. – 8 lbs. 13 oz.)

Length= 45.7 – 55.9 cm. (18-22 inches)

HEAD Head circumference = 33-35 cm (2-3 cm. Greater than chest circumference)

Anterior fontanel (diamond shape) = closes 12-18 months

Posterior fontanel (triangle shape)= closes 2-3 months

NOTE: The posterior fontanel is located at the intersection of the sagittal and

lambdoid suture is the space between the pariental bones; the lambdoid suture

separates the two parietal bones and the occipital bone

Molding- asymmetry of head as a result of pressure in birth cana

Page 5: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

EYES Blue/ gray d/t scleral thinness; permanent color established w/in 3-12 mos.

Lacrimal glands immature at birth; tearless cry up to 2 months

Absence of tears is common because the neonate’s tear glands are not yet fully

developed

Transient strabismus

Doll’s eye reflex persist for about ten days

Red Reflex: A red circle on the pupils seen when an ophthalmoscope’s light is shining

onto the retina is a normal finding. This indicates that the light is shining onto the

retina.

CONVERGENT STRABISMUS (CROSS EYED)

It is common during infancy until age 6 months because of poor oculomotor

coordination

NOTE : Congenital Glaucoma

It is due to increased intraocular pressure caused by an abnormal outflow or

manufacturing of normal eye fluid.

Unequal size should be reported immediately.

NOSE Nose breathers for first few months of life

MOUTH Scant saliva with pink lips

Epstein’s Pearls - small shiny white specks on the neonate’s gums and hard palate

which are normal

EARS Incurving of pinna and cartilage deposition

NECK Short and weak with deep fold of skin

CHEST Characterized by cylindrical thorax and flexible ribs

NOTE:

appears circular since anteroposterior and lateral diameters are about equal

Respirations appear diaphragmatic

Nipples prominent and often edematous

Milky secretion (witch's milk) common ( effect of estrogen)

Page 6: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

ABDOMEN Cylindrical with some protrusion; scaphoid appearance indicates diaphragmatic hernia

Umbilical cord is white and gelatinous with two arteries and one vein and begins to dry

within 1-2 hours after delivery

NOTE: Umbilical cord

Three vessels, two arteries and one vein, in cord; if fewer than three vessels

are noted notify the physician

Small, thin cord may be associated with poor fetal growth

Assess for intact cord, and ensure that damp is cured

Cord should be clamped for at least the first 4 hours after birth; clamp can

be removed hen the cord is dried and occluded

Umbilical clamp can be removed after 24 hours

GENITALIA MALE: includes rugae on the scrotum and testes descended into the scrotum

Urinary meatus:

Hypospadias (ventral surface)

Epispadias (dorsal surface)

NOTE:

Meatus at tip of penis

Testes descended but may retract with cold

Assess for hernia or hydrocele

First voiding should occur within 24 hours

FEMALE: labia majora cover labia minora and clitoris

Pseudomenstruation possible (blood-tinged mucus) effect of estrogen

First voiding should occur within 24 hours

EXTREMITIES All neonates have bowlegged and flat feet

NOTE NORMAL FEATURES:

Major gluteal folds even Creases on soles of feet

Assess for fractures (especially clavicle) or dislocations (hip)

Assess for hip dysplasia; when thighs are rotated outward, no clicks should be

heard

Some neonates may have abnormal extremities:

Polydactyl (more than 5 digits on extremity)

Syndactyl (two or more digits fused together)

Page 7: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

Polydactyl Syndactyl

SPINE Should be straight and flat

Anus should be patent without any fissure

Dimpling at the base is associated with spina bifida

A degree of hypotonicity or hypertonicity is indicative of central nervous system (CNS

damage)

SKIN Assessment for Jaundice

The #1 technique is to blanch the skin over the bony prominence such as the

forehead, chest or tip of the nose.

NOTE: Jaundice starts at the head first, spreads to the chest, then the abdomen, then the

arms and legs, followed by the hands and feet, which are the last to be jaundiced.

Jaundice in the first 24 hours after the birth is a cause for concern that requires

further assessment. Possible causes of early jaundice are blood incompatibility,

oxytocin induction, and severe hemolytic process.

Mongolian Spots

Gary, blue or black marks that are frequently found on the sacral area, buttocks, arms

shoulders or other areas.

Harlequins Sign

Occurs on one side of the body turns deep red color. It occurs when blood vessels on

one side constrict, while those on the other side of the body dilate.

Page 8: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

Erythema toxicum Is an eruption of lesions in the area surrounding a hair follicle that are firm, vary

in size from 1-3 mm, and consist of a white or pale yellow papule or pustule w/ an

erythematous base.

It is often called “newborn rash” or “flea-bite” dermatitis

The rash may appear suddenly, usually over the trunk and diaper area and is

frequently widespread.

The lesions do not appear on the palms of the hands or soles of the feet.

The peak incidence is 24-48 hours of life.

Cause is unknown and no treatment necessary

Acrocyanosis versus Central Cyanosis

Acrocyanosis involves the extremities of the neonate, for example bluish hands

and feet due to neonates being cold or poor perfusion of the blood to the

periphery of the body.

Central cyanosis, which involves the lips, tongue and trunk indicating

HYPOXIA which needs further assessment by the nurse.

.

Milia are blocked sebaceous glands located on the chin and the nose of the infant.

VERNIX CASEOASA

Should not be removed by oil or hand lotion, because it is a protective layer of the

neonate after birth, and it disappears after birth. Never remove it with alcohol or

cotton balls, unless meconium skinned.

Page 9: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

BIRTH MARKS

Telangiectatic nevi (stork bites)

Appear as pale pink or red spots and are frequently found on the eyelids, nose,

lower occipital bone and nape of the neck

These lesions are common in NB w/ light complexions and are more noticeable

during periods of crying. These areas have no clinical significance and usually

fade by the 2nd birthday

Hemangioma is benign vascular tumor that may be present on the newborn

3 types Hemangiomas

1. Nevus Flammeus – port wine stain – macular purple or dark red lesions seen

on face or thigh. NEVER disappear. Can be removed surgically

2. Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the

entire dermal or subdermal area. Enlarges, disappears at 10 yo.

3. Cavernous hemangiomas – communication network of venules in SQ tissue

that never disappear with age.

Nevus Flammeus (port-wine stain) A capillary angioma directly below the epidermis, is a non-elevated, sharply

demarcated, red-to-purple area of dense capillaries.

Macular purple

The size & shape vary, but it commonly appears on the face. It does not grow in

size, does not fade in time and does not blanch. The birthmark maybe concealed by

using an opaque cosmetic cream.

If convulsions and other neurologic problem accompany the nevus flammeus,----

5th cranial nerve involvement.

Nevus vasculosus (strawberry mark) A capillary hemangioma, consists of newly formed and enlarged capillaries in the

dermal and subdermal layers.

It is a raised,clearly delineated, dark-red, rough-surfaced birthmark commonly

found in the head region.

Such marks usually grow starting the second or third week of life and may not

reach their fullest size for 1 to 3 months; disappears at the age of 1 yr. but as the

baby grows it enlarges.

Providing appropriate information about the cause and course of birthmarks often

relieves the fears and anxieties of the family. Note any bruises, abrasions,or

birthmarks seen on admission to the nursery.

Page 10: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

GESTATIONAL ASSESSMENT

PARAMETER NURSING

ACTION

‘TERM’ born between

37-42 weeks gestation

‘PRETERM’ born before 37 weeks

gestation

EAR Fold the pinna

(auricle) forward

Pinna recoils (springs

back)

Pinna opens slowly or stays folded

in very premature infants

BREAST TISSUE Measure it 3 mm Less than 3 mm

FEMALE GENITALIA Observe Labia majora cover

labia minora

Labia minora are more prominent;

vaginal opening can be seen

MALE GENITALIA Observe Scrotal sac very

wrinkled

Fewer shallow rugae on the scrotum

HEEL CREASES Observe Extend 2/3 of the way

from the toes to the heel

Soles are smoother, creases extend

less than 2/3 of the way from the

toes to the heel

NEWBORN REFLEXES

Immature central nervous system (CNS) of newborn is characterized by variety of reflexes

o Some reflexes are protective, some aid in feeding, others stimulate interaction

o Assess for CNS integration

Protective reflexes are blinking, yawning, coughing, sneezing, drawing back from pain

Rooting and sucking reflexes assist with feeding

“What reflexes should be present in a newborn? Reflexes are involuntary movements or actions. Some movements

are spontaneous, occurring as part of the baby's usual activity. Others are responses to certain actions. Reflexes

help identify normal brain and nerve activity. Some reflexes occur only in specific periods of development. The

following are some of the normal reflexes seen in newborn babies””

PALMAR GRASP

REFLEX

Newborn’s fingers curl around the examiner’s fingers and the newborn’s toes

curl downward.

The palmar grasp reflex is elicited by placing an object in the palm of a

neonate; the neonate's fingers close around it. This reflex disappears between

ages 6 and 9 months.

Palmar response lessens within 3-4 months

Palmar response lessens within 8 months

ROOTING

REFLEX

The rooting reflex is elicited by stroking the neonate's cheek or stroking near

the corner of the neonate's mouth.

The neonate turns the head in the direction of the stroking, looking for food.

This reflex disappears by 6 weeks.

SUCKING

REFLEX

The sucking reflex is seen when the neonate's lips are touched

Lasts for about 6 months

Page 11: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

MORO REFLEX Symmetric & bilateral abduction & extension of arms and hands

Thumb & forefinger form a C

“EMBRACE” reflex

Present at birth, complete response may occur up to 8 weeks

A persistent response lasting more than 6 months may indicate the occurrence

of brain damage during pregnancy

A normal reflex in a young infant caused by a sudden loud noise. It results in drawing

up the legs, an embracing position of the arms, and usually a short cry.

BABINSKI’ SIGN Beginning at the heel of the foot, gently stroke upward along the lateral aspect of

the sole; then the examiner moves the fingers along the ball of the foot

The newborn’s toes hyperextend while the big toe dorsiflexes

Absence of this reflex indicates the need for a neurological examination

The Babinski reflex is elicited by stroking the neonate's foot, on the side of the

sole, from the heel toward the toes.

A neonate will fan his toes, producing a positive Babinski sign, until about age 3

months

STEPPING OR

WALKING

REFLEX

The newborn simulates walking, alternately flexing and extending the feet

The reflex is usually present 3-4 months

TONIC NECK

REFLEX

While the newborn is falling asleep or sleeping, gently and quickly turn the head

to one side

As the newborn faces the left side, the left arm & leg extend outward while the

right arm & leg flex

When the head is turned to the right side, the right arm & leg extend outward while

the left arm & leg flex

Usually disappears within 3-4 months

Page 12: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

CRAWLING Place the newborn on the abdomen

The newborn begins making crawling movements with the arms and legs

The reflex usually disappears after about 6 weeks

BASIC TEACHING NEEDS OF NEW PARENTS

CORD CARE Cleanse the cord with alcohol and sometimes triple dye once a day

Keep the area clean and dry

Keep the newborn’s diaper below the cord to prevent irritation

Signs of infection: redness, drainage, swelling, odor

Notify physician for signs of infection

NOTE:

Note any bleeding or drainage from the cord

Triple dye may be applied for initial cord care because it minimizes

microorganisms and promotes drying; use a cotton-tipped applicator to paint

the dye, one time, on the cord on 1 inch of surrounding skin

Application of 70% isopropyl alcohol to the cord with each diaper change and

at least two r three times a day to minimize microorganisms and promote

drying.

NOTE: The skin is surrounded with alcohol which promotes drying and cleans the area.

The umbilical cord dries and falls off about 14 days. Peroxide and lanolin promote

moisture, which can inhibit drying and allow growth of bacteria. Water doesn’t

promote drying.

It is best to care for the neonate’s umbilical cord area by cleaning it with cotton

pledgets moistened with alcohol. The alcohol promotes drying and helps decrease the

risk of infection. An antibiotic ointment maybe used instead of alcohol, because there

are a lot of bacteria which is resistant against some bacteria. Other agents such as

wipes, sterile water and soap & water are not as effective as alcohol.

CIRCUMCISION

CARE Observe for bleeding, first urination

Apply diaper loosely to prevent irritation

Notify physician for signs of infection

BONDING Encourage parent to talk to, hold, and sing to infant

Promotes skin-to-skin contact between parent and infant

Feedings are opportunities for parent-infant bonding

Notify physician for signs of infection

NOTE: Sense of Touch

The most highly developed sense at birth that is why, neonates responds well to

touch.

Page 13: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

PRE TERM INFANT ( PREMATURE INFANT)

Definition PRE TERM INFANT

A neonate born before 38 weeks age of gestation

Synonym Low birth weight

Contributing factors

Low socioeconomic level

Poor nutritional status

Lack of pre natal care

Multiple pregnancy

Prior previous early birth

Race (non whites have a higher incidence of prematurity than

whites)

Cigarette smoking

The age of the mother ( the highest incidence is in mother’s

younger than age 20.)

Order of birth ( early termination is highest in first pregnancies

and in those beyond the forth )

Closely spaced pregnancies

Abnormalities of the reproductive system such as intrauterine

septum

Infections ( specially urinary tract infections)

Obstetric complications such as premature rupture of membranes

or premature separation of the placenta

Early induction of labor

Elective cesarian birth

Cardinal signs

Appears small and underdeveloped

The head is disproportionately large ( 3 cm or more greater than

chest size)

Skin is thin with visible blood vessel and minimal subcutaneous

fat pads

Vernix caseosa is absent

Both anterior and posterior fontanelles are small

Abnormal laboratory values Decreased RBC’s

Decreased serum glucose

Increased concentration of indirect bilirubin

Decreased serum albumin

NOTE: The normal range of urine output for a preterm

baby is 1 to 2ml/kg/day. The normal specific gravity for a

preterm baby is 1.020. The normal range for blood glucose

level in a preterm baby is 40 to 60 mg/dl.

Best procedure Resuscitation

NOTE: resuscitation becomes important for infant who fails to

take first breath or difficulty maintaining adequate

respiratory movements on his own.

Page 14: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

Suctioning

NOTE: allows removing mucus and prevents aspiration of any

mucus and amniotic fluid present in the mouth and

nose of the newborn to establish clear airway.

Intubations

NOTE: head of the infant in neutral position with towel under

shoulder.

Best position

Positioning the infant on the back with the head of the mattress

elevated approximately 15 degrees to allow abdominal contents to

fall away from the diaphragm affording optimal breathing space.

Best position for suctioning:

Infant on the back and slide a folded towel or pad under shoulders

to rise, head is in neutral position.

Complications

Anemia of prematurity

Hyperbilirubinemia/ kernicterus

Persistent patent ductus arteriosus

Periventricular / intraventricular hemorrhage

Respiratory distress syndrome

Retinopathy of prematurity

Retrolental fibroplasias are a complication that occurs if the

infant is overexposed to high oxygen levels.

Necrotizing enterocolitis

Bedside equipment

Preterm size laryngoscope

ET tube

Suction catheter with synthetic surfactant

Isolettes (incubator)

Drug study

1. Naloxone (Narcan)

Nature of the drug:

Narcotic antagonist

Side effects:

Hypertension, irritability, tachycardia

2. Surfactan ( Survanta)

Nature of the drug:

Lung surfactant to improve lung compliance

Side effect:

Transient bradycardia, rales

3. Vitamin K (Aquamephyton)

Use for prophylaxis to treat hemorrhagic disease of the

newborn.

Side effects:

Hyperbilirubinuria

4. Eye prophylaxis

(Erythromycin 0.5% Ilotycin, Tetracycline 1%

Silver Nitrate 1% ( not already used – causes chemical

conjunctivitis)

Prophylactic measure to protect against Neisseria

gonorrhoeae and Chlamydia trachomatis

Side effects:

Silver nitrate can cause chemical conjuctivitis

Nursing diagnosis 1. Impaired gas exchange related to immature pulmonary

functioning

2. Risk for fluid volume deficit related to insensible water loss at

birth and small stomach capacity

Page 15: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

3. Risk for aspiration related to weak or absent gag reflex a nd/or

administration of tube feedings

4. Hypothermia related to lack of subcutaneous and brown fat

deposits, inadequate shiver response, immature

thermoregulation center, large body surface area in relation to

body weight, and/or lack of flexion of extremities toward the

body.

5. Risk for infection related to immature immune response, stasis of

respiratory secretions, and/ or aspiration

6. Imbalanced nutrition: less than body requirements related to

lack of energy to suck and/or weak or absent sucking reflex

Nursing intervention The nurse’s first priority in preparing a safe environment for a

preterm newborn with low Apgar scores is to prepare

respiratory resuscitation equipment. Airway maintenance is the

first priority.

Give the mother oxygen by mask during the birth to provide the

preterm infant with optimal oxygen saturation at birth ( 85-90%).

Keeping maternal analgesia and anesthesia to a minimum also

offers the infant the best chance of initiating effective respiration.

Bedside larngyoscope, endotracheal tube, suction catethers and

synthetic surfactant to be administered by the endotracheal tube.

Infant must be kept warm during resuscitation procedures so he

or she is not expending extra energy to increase the metabolic

rate to maintain body temperature.

Observe for changes in respirations, color and vital signs

Check efficacy of Isolette: maintain heat, humidity and oxygen

concentration, administer oxygen only if necessary

Maintain aseptic technique to prevent infection

Adhere to the techniques of gavage feeding for safety of infant

Observe weight-gain patterns

Determine blood gases frequently to prevent acidosis. Institute

phototherapy when hyperbilirubinemia occurs

Support parents by letting them verbalize and ask questions to

relieve anxiety.

Provide liberal visiting hours for parents, allow them to

participate in care.

Arrange follow-up before and after discharge by a visiting nurse.

Page 16: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

POST TERM INFANT

Definition

POST TERM INFANT

A neonate born after 42 weeks age of gestation

Contributing factors

Low socioeconomic level

Poor nutritional status

Lack of pre natal care

Multiparous mother’s

Cigarette smoking

The age of the mother (the highest incidence is in mother’s younger

than age 20.)

Mother’s with diabetes mellitus

Congenital abnormalities such as omphalocele.

Body is covered with lanugo

Old man facies

Classic signs Intrauterine weight loss, dehydrations and chronic hypoxia “old

man faces’

Long & thin with cracked skin which is loose, wrinkled and

strained greenish yellow, with no vernix nor lanugo

Long nails with firm skull

Wide eyed alertness of one month old baby

Abnormal laboratory

values

Increased total no. of RBC’s

Increased hematocrit level

Decreased serum glucose

Screening test

Sonogram

Best procedure

Resuscitation

NOTE: resuscitation becomes important for infant who fails to take

first breath or difficulty maintaining adequate respiratory

movements on his own.

Suctioning

NOTE: allows removing mucus and prevents aspiration of any

mucus and amniotic fluid present in the mouth and nose of the

newborn.

To establish clear airway.

Intubations

NOTE: head of the infant in neutral position with towel under

shoulder.

Best position

Positioning the infant on the back with the head of the mattress

elevated approximately 15 degrees to allow abdominal contents

Complications

Meconium aspiration syndrome

Respiratory distress syndrome

NOTE: Post mature neonates have difficulty maintaining glucose

reserves. Other common problems include Meconium aspiration

syndrome, polycythemia, congenital anomalies, seizure activity and cold

stress.

NOTE: The infant who are exposed to high blood-glucose levels in

utero may experience rapid and profound hypoglycemia after birth

because of the cessation of a high in-utero glucose load. The small-for-

gestational-age infant has use up glycogen stores as a result of

intrauterine malnutrition and has blunted hepatic enzymatic response

with which to carry out gluconeogenesis.

Page 17: 30105013 Newborn Assessment

Maternal and Child Health Nursing

Newborn Assessment

Newborn Assessment Abejo

NOTE: The patient with post-term pregnancy is at high risk for

decreased placental functioning, therefore increasing the risk of

inadequate oxygen circulation to the fetus

Bedside equipment

ET tube

Suction catheter

Drug study

1. Vitamin K (Aquamephyton)

Use for prophylaxis to treat hemorrhagic disease of the newborn

Side effects:

Hyperbilirubinuria

2. Eye prophylaxis

(Erythromycin 0.5% Ilotycin, Tetracycline 1% Silver Nitrate 1%

Prophylactic measure to protect against Neisseria gonorrhoeae and

Chlamydia trachomatis

Side effects:

Silver nitrate can cause chemical conjuctivitis

Nursing diagnoses 1. Ineffective airway breathing

2. Risk for fluid volume deficit related to insensible water loss at birth

3. Ineffective infant feeding pattern

Nursing interventions Assess newborn’s respiratory rate, depth and rhythm. Auscultate

lung sound.

Note: Meconium stained syndrome of POST MATURE neonates

Aspiration of meconium is best prevented by suctioning the neonate’s

nasopharynx immediatelt after the head is delivered and before the

shoulders and chest are delivered. As long as the chest is

compressed in the vagina, the infant will not inhale and aspirate

meconium in the upper respiratory tract. Meconium aspiration

blocks the air flow to the alveoli, leading to potentially life

threatening respiratory complications.

Suction every 2 hours or more often as necessary

Position newborn on side or back with the neck slightly extended

Administer O2, anticipate the need for CPAP or PEEP

Continue to assess the newborn’s respiratory status closely.

Encourage as much parental participation in the newborn’s care as

condition allows

Administer IV fluids after birth to provide Glucose to prevent

hypoglycemia, monitor closely the infusion rate.

Kept the infant under a radiant heat warmer to preserve energy

Monitor baby’s weight, serum electrolytes and ensure adequate

fluid intake

Measure urine output by weighing diapers

Check for blood stools to evaluate for possible bleeding from

intestinal tract.

Keep a restful environment.

Anticipate the infants need to be breastfeed

Demonstrate technique for feeding to mother, note proper

positioning of the infant, “latching on” technique, rate of delivery

of feeding and frequency of burping

Provide a relaxed environment during feeding

Adjust frequency and amount of feeding according to infants

response

Alternate feeding procedure (nipple and gavage feeding) according

to infants ability.

Monitor mother’s effort, provide feedback and assistance as needed

Suggest mother to monitor infants weight periodically