Chapters 13 15 Nursing Assessment of Newborn in ... 13 15 Nursing Assessment of Newborn in Transition and the Normal Newborn Physiologic Adaptation • Antenatal – Completely

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Text of Chapters 13 15 Nursing Assessment of Newborn in ... 13 15 Nursing Assessment of Newborn in...

  • Chapters 13 & 15Nursing Assessment of Newborn

    in Transition and the Normal Newborn

  • Physiologic Adaptation

    Antenatal

    Completely dependant

    Lungs uninflated, fluid-filled

    Circulation by passes heart

    shunts

    Post natal

    Separate from maternal sources of oxygen, heat, nourishment

    Lungs air-filled

    Shunts close

  • Fetal vs neonatal circulation

  • Physiologic Changes in the Newborn

    Respiratory system

    Air-filled, low-pressure system encourages blood flow through the lungs for gas exchange

    Increased oxygen content of blood in the lungs contributes to the closing of the ductus arteriosus

    Lungs are site of gas exchange

    Circulation through the heart

    Pressures in the left atrium are greater than in the right, causing the foreman ovale to close

  • Physiologic Changes in the Newborn (cont.)

    Hepatic Portal Circulation

    Ductus venosus closes (becomes a ligament); hepatic portal circulation begins

    Thermoregulation

    Body temperature maintained through a flexed posture and brown fat

  • The Nurses Role in Caring for the Newborn

    Supporting the newborn as he or she adapts to life outside the womb

    Quickly recognizing the development of complications so that interventions can be initiated immediately

    Teaching the parents the skills needed to care for their newborn

  • Immediate Assessments of the Newborn

    Success of cardiopulmonary adaptation

    A vigorous or lusty cry

    Heart rate greater than 100 beats per minute (bpm)

    Pink color

    Apgar score

  • Five Parameters Assessed by the Apgar Score

    Heart rate

    Respiratory effort

    Muscle tone

    Reflex irritability

    Color

  • Apgar Scoring

    Heart rate: 2= HR> 100, 1= HR< 100, 0= no HR

    Respiratory effort: 2= strong, vigorous cry, 1= weak cry, slow or difficult respirations, 0= no respiratory effort

    Muscle tone: 2= maintains a position of flexion with brisk movements, 1= minimal flexion of extremities, 0= limp and flaccid

    Reflex irritability: 2= cries or sneezes when stimulated, 1=grimaces when stimulated, 0=no response

    Color: 2=Body and extremities pink, 1=body pink, extremities blue, 0= body and extremities blue or completely pale

  • Indications of Apgar Scores (cont.)

    Scores of 0 to 3

    Indicate severe difficulty in making the transition

    Infants require observation and care in a neonatal intensive care unit (NICU)

  • Indications of Apgar Scores

    Scores of 7 to 10

    Indicate a healthy baby adapting well

    Infant can be cared for in the regular newborn nursery or room-in with mother

    Scores between 4 and 6

    Indicate some difficulty in adjusting

    Infant is cared for in a special nursery with oxygen and monitoring devices

  • Assessments During the Transition Period

    Continue to observe newborn for signs of respiratory distress or cardiovascular compromise

    Observe the newborn closely for cold stress (body temperature of less than 97.6F [36.5C])

    Assess for hypoglycemia in the newborn

    Perform a full physical assessment, including gestational age assessment, within the first few hours of life

  • Adaptation and Change

    Hepatic:

    Liver is immature at birth

    Vitamin K needed to produce clotting factors

    Must process large number of surplus RBCs that die

    Biliruben released as cells die

    Liver conjugates bili making it water soluble for excretion in feces

    Overwhelmed liver cannot keep up

    Unconjugated biliruben builds up in bloodstream

  • Jaundice present when unconjugated biliruben levels> 4-6mg/dL

    Physiologic jaundice occurs in of all newborns

    Physiologic jaundice occurs after 24 hours (usually day 3-4), peaks between days 5-6.

    Pathologic jaundice occurs within first 24 hours

    Rising bilirubin levels place infants at risk for brain damage.

  • Behavioral and Social Adaptation

    Each infant is unique

    Communicate through behavior and controlling responses to the environment

    Recognize mothers voice at an early age

  • Phases of Brazeltons Neonatal Behavioral Assessment Scale

    Deep sleep

    Light sleep

    Drowsy

    Quiet alert

    Active alert

    Crying

  • Patient Goals for the Newborn

    Experience adequate cardiovascular, respiratory, thermoregulatory, and metabolic transitions to extrauterine life

    Remain free from signs and symptoms of infection

    Maintain hemostasis

    Be adequately identified before separation from the parents

  • Nursing Interventions for the Newborn

    Supporting cardiovascular and respiratory transition

    Maintaining thermoregulation

    Preventing injury from hypoglycemia

    Preventing infection

    Preventing imbalanced fluid volume

    Preventing misidentification of a newborn

  • Maintaining Thermoregulation

    Kangaroo

    Swaddling

    Avoid drafts

    Caps

  • The higher ratio of body surface (proportional to heat loss) to body volume (proportional to heat production)

    The higher proportional surface area of the head

    The low amount of musculature and the inability or reluctance to shiver.

    A lack of thermal insulation, e.g. subcutaneous fat and fine body hair (especially in prematurely born children)

    The inability to move away from cold areas, air currents or heat-draining materials

    The inability to use additional ways of keeping warm (e.g. turning up a heater, drying their skin, changing clothes or performing physical exercise)

    The nervous system is not fully developed and does not respond quickly and/or properly to cold (e.g. by contracting blood vessels in the skin)

  • Brown Fatheat producing tissue found only in fetuses and newborns. Located at nape of the neck, in the armpits, between the shoulder blades, along the abdominal aorta, and around kidneys and sternum.

    Not renewable

    Lower amount in premature infants

  • Risk Factors for Hypoglycemia Gestational HTN

    Maternal diabetes

    Prolonged labor

    Fetal distress during labor

    Titodrine or terbutaline administered to mother

    IUGR

    LGA

    SGA

    Prematurity

    Postmaturity

    Macrosomia

    Respiratory or cardiovascular depression

  • Normal Blood glucose during 1st 24 hours: 40-60 mg/dL

    Use heel stick to obtain specimen

    Asymptomatic newborns at risk tested 2,4,6,12,24,&48 hours after delivery

  • Signs of Hypoglycemia in the Newborn

    Jitteriness or tremors

    Exaggerated Moro reflex

    Irritability

    Lethargy

    Poor feeding

    Listlessness

    Apnea or respiratory distress

    High-pitched cry

  • Expected Vital Signs of the Term Newborn

    Heart rate

    110160 beats per minute

    Respiratory rate

    3060 breaths per minute

    Axillary temperature

    97.798.6F (36.537C)

    Blood pressure

    6080/4045

  • Average Physical Measurement Ranges of the Term Newborn

    Weight

    25004000 grams

    Length (head-to-heel)

    4853 cm

    Head circumference

    3335.5 centimeters

    Chest circumference

    30.533 centimeters

  • Physical Characteristics of the Normal Newborn

    Skin

    Should be supple with good turgor and a pink color

    Head and face

    Molding may be present

    The hard and soft palates should be intact

    Neck and chest

    The neck is short and thick

    Webbing should not be present

    Periodic breathing episodes are normal

  • Characteristics of Newborn Skin

    Vernix caseosa

    A white cheese-like substance covering the body of the fetus during the second trimester to protect against skin dryness

    Lanugo

    A fine downy hair present in abundance on the preterm infant but found in thinning patches on the shoulders, arms, and back of the term newborn

  • Common Skin Manifestations of the Normal Newborn

    Harlequin sign

    Dark red on one side of the body, pale on the other caused by dilation and constriction of blood vessels

    Mottling

    red and white lacy pattern on the skin of fair skinned infants

    Acrocyanosis

    A bluish color to the hands and feet of the newborn; normal in the first 6 to 12 hours after birth

  • Erythema toxicumNewborn rash commonly appears on the chest, abdomen, back, and buttocks of the newborn

    Milia Small white spots on the newborns face, nose, and chin that resemble pimples

  • Nevus flammeus or port-wine stain

    Dark reddish-purple birthmark that most commonly appears on the face. Caused by a group of dilated vessels. Does not blanch with pressure or disappear over time

  • Mongolian spotBluish-black areas of discoloration on the back and buttocks or extremities of dark-skinned newborns. Not to be confused with signs of abuse. Fade by about 2 years of age.

  • Telangiectatic nevi

    Pale pink or red marks found on the nape of the neck, eyelids, or nose of fair-skinned newborns. Blanch when pressed and fade by about 1 year of age.

  • Physical Characteristics of the Normal Newborn (cont.)

    Abdomen

    The abdomen is protuberant

    The cord should be clamped and drying at the base

    Genitourinary

    The newborn should void within the first 24 hours

    Genitalia of both sexes may be swollen

    B