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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