Nursing Care of The NewBorn Infant

Retnayu Pradanie01/04/09

IntroductionThe neonatal periode is the time frombirth through the twenty day of life.During this time the newborn mustaccomplish a number of physiologicand behavioral adjusments in order toestablish and maintain anextrauterine lifeTransition Period: Phases ofinstability during the first 6-8 hoursafter birth

Nurses play a vital role during thetransition periode

Help the newborn infant make a safetransition to extrauterine lifePerform the initial assessment of thenewborn infantProvide a physical environmentconducive to adaptationMonitor the newborn infant’s conditionduring the early adaptation phases

Immediate Care ofthe Newborn

Start by congratulating the mother onthe arrival of her new baby and ask ifshe has any concerns. The mother isusually the first person to notice anyproblems.Doing initial newborn assessment

Initial Newborn assessmentStimulate and dry infantAsses ABCsEncourage skin-to-skin contactAssign APGAR scoreGive eye prophylaxis & vit K• sterile ophthalmic ointment

containing 1% tetracycline or 0.5%erythromycin

•• 1 mg of 1 mg of VitVit K IM to prevent K IM to preventhemorhagichemorhagic

Initial assessment: Apgar ScoringThe most frequently used method toassess the newborn's immediateadjustment to extrauterine life.The score is based on observation of :

Heart rate.Respiratory effort.Muscle tone.Reflex irritability.Color.● Each item is given a score of 0, 1,or 2.

Apgar Scoring

Completelypink

Body pink,extremities

blueBlue, paleColor

CryGrimaceNo responseReflexirritability

Well flexedSome flexionof extremitiesFlaccideMuscle Tone

Good crySlow, weakcryAbsentRaespiratory

Rate

Over 100Slow (<100)AbsentHeart Rate

210

SCORESIGN

Initial assessment: Apgar Scoring

Evaluation of all five categories are madeat 1 and 5 minutes after birth and repeateduntil the infant's condition stabilized.Total scores of 0-3 represent severedistress.Scores of 4-6 signify moderate difficulty.Scores of 7-10 indicate absence of difficultyin adjusting to extrauterine life

Initial assessment: Apgar Scoring

The Apgar score is affected by thedegree of :- Physiologic immaturity.- Infection.- Congenital malformations.- Maternal sedation or analgesia.- Neuromuscular disorders.

Transitional assessmentPeriods for reactivity:First period of reactivity: For 6-8 hours afterbirth.

Initial stage of alertness and activity:- During the first 30 minutes.- The infant is very alert, cries vigorously,

very interest in the environment.- Neonate's eyes are usually open;- The newborn has a vigorous suck; this is

an opportune time to begin breast-feeding

Transitional assessment- physiologically, the resp rate is high as 80

breath/min, crackles may be heard, heart ratereach 180 beat/min, bowel sound are active ,mucus secretions are increased, and temp maydecrease.

2. Second stage:- Lasts to 2-4 hours,- Heart and resp rate decrease, temp continues to

fall, mucus production decreases ,and urine orstool is usually not passed.

- The infant is in state of sleep and relative calm.- Undressing or bathing is avoided during this time

Transitional assessmentThe second period of reactivity: beginswhen the infant awakes from this deepsleep.

- It lasts about 2-5 hours and- The infant is again alert and responsive,- Heart and resp rates increase.- The gag reflex is active gastric and

respiratory secretions are increased,- Passage of meconium frequently occurs.- This period is usually over when the

amount of respiratory mucus hasdecreased.

Clinical assessment of gestational age

A frequently used method ofdetermining gestational age is thesimplifies Assessment of GestationalAge by Ballard(1979):

- It assess six external physical and sixneuromuscular signs

- Each sign has a number score, andthe cumulative score correlate with amaturity rating of from 20 to 44 weeksof gestation.

Weight Related to Gestational Age:● Birth weight alone is a poor indicator of

gestational age and fetal maturity .● Maturity: functional capacity: the degree to

which the neonate's organ systems areable to adapt to the requirements ofextrauterine life

● Classification of infants at birth by bothbirthweight and gestational age providesamore satisfactory method for predictingmortality risks and providing guidelines formanagement of the neonate thanestimating gestational age or birth weightalone.

Clinical assessment of gestational age

● Appropriate for gestational age (AGA) :theinfant whose weight is between 10th and 90th

percentiles. Can be presumed to havegrown at a normal rate regardless of thetime of birth_ preterm, term, or post term.

● Large for gestational age (LGA): above90th percentile can be presumed to havegrown at an accelerated rate during fetal life

● Small-for-gestational-age (SGA) infantbelow 10th percentile can be assumed tohave intrauterine growth retardation ordelay.

Clinical assessment of the newborn(General Examination)

Examine skin for prematurity or dismaturity

Thin,transparent skin

in preterminfants

Wrinkled peeling skin ofdysmaturity in an IUGR infant

Pale pink skinof a term

infant (hairshaved to site

IV line)

Skin: some common normal findingsVernix caseosa: a cream/white cheesymaterial on the skin at birth which cleansoff easily with oil.Lanugo; fine downy hairs seen on the backand shoulders especially in preterm infants.Milia: pinpoint whitish papules on nose andcheeks due to blocked sebaceous glands.Mongolian blue spots: grey/bluish pigmentpatches seen in the lumbar area, buttocksand extremities in dark skinnedbabies.They usually disappear by one year.

Skin: some common normal findings

Capillary heamangiomas (“stork bite”naevi): red flat patches which blanchwith gentle pressure. Commonlyoccur on upper eyelids, forehead andnape of the neck.Erythema toxicum: small white/yellowpapules or pustules on a red baseseen on face, trunk and limbs.Develop 1 – 3 days after birth andusually disappear by one week.

Colour

Note palor or plethora

Cyanosis: the baby should be uniformlypink

Blueness of the hands and feet (peripheralcyanosis) may be due to cold extremeties.

Blueness of the mucous membranes andtongue is central cyanosis and is usually dueto lung or heart problems

Bruising (ecchymosis) is common afterbirth trauma. Unlike cyanosis, bruisingdoes not blanch on gentle pressure.

JaundiceJaundice is common in the firstweek of life and may be missedin dark skinned babies

Blanch the tip of the nose or holdbaby up and gently tip forwardand backward to get the eyes toopen.

Teach mother to do the same athome in the first week and reportto hospital if significant jaundiceis observed.

After general examinationAfter these general observations,examine the infant starting with thehead and moving down the body(Head to toe examination)Count the respiratory rate

normal 30 – 40 breaths/min in terminfantsfaster in preterms.> 60 / minute abnormal

After general examination…

Measure:

Weightnormal 2.5 – 3.99 kg

Lengthnormal 48 – 52 cm

Occipitofrontal circumference (OFC)normal 33 – 37 cm

Infants at Riskgagging --> turning blue (esp. afterfeeding)generalized cyanosisweak crygrunting or respiratory distressdecreased or absent movementsexcessive twitching or trembling

Nursing Diagnosis:

Ineffective Airway Clearance R/T excessiveoropharyngeal mucusIneffective Thermoregulation R/T newborntransition to extrauterine lifeHigh Risk for infection R/T maturationalfactors, immature immune systemPC: Hypoxemia PC: Hyperbilirubinemia(W) Beginning Integration of NB into FamilyUnit

Nursing care of the newborn

The major elements of routine care:

Cord care

Thermal control

24 hour rooming in

Feeding

Immunization

Maternal education on hygiene

Cord CareThe umbilical stump needs particularattention as there are risks of bleeding andinfection.

Good cord care includes:Cutting cord with sterile equipment or a newrazor blade depending on the settingLigation with a sterile plastic clamp or cleanthreadKeeping cord stump exposed, clean (with 70%alcohol, 4% chlorhexidine or simple soap andwater) and dry

Cord Care and Research

1,811 NB’s- 2 groups - onereceiving cord care withalcohol and one group not:equal # infections in infantswho received and did notreceive cord carecord separation ~ alcoholuse: 9.8 days and noalcohol use: 8.16 days

Thermal ControlThe causes of heat loss at birth:Evaporation: the lost of heat through

moisture (a major cause).Radiation: the lost of heat to cooler solid

objects in the environment that are not indirect contact with the infant.

Conduction: loss of heat from the bodybecause of direct contact of skin with acooler solid object

Convection is similar to conduction,except that heat loss is aided bysurrounding air currents; as direct flow ofair from air conditioner vent.

Measures to prevent hypothermiainclude:

Delivery in a warm environmentImmediate drying of the infant tominimize heat loss by evaporationBath after temperature is stableKeep out of draftsSkin to skin contact with motherProper clothing and wrapping upwith linen including use of bootiesand bonnetsRegular feeds

A well dressed baby

Rooming Inrefers to the practice of nursing babies withtheir mothers rather than keeping them in aseparate nursery

Advantages:

Promotes bonding

Makes exclusive breastfeeding easy

Mother is able to keep a close watch on her infant.She should be encouraged to report any concernsthat she has to the health care staff.

FeedingBreast feeding remains the bestmethod of feeding the newborn and hasthe following advantages:

Breastmilk is nutritionally balancedIt reduces the risk of infection especiallyin unhygienic situationsProtects against diarrhoea and otherinfections in infancyPromotes mother-child bondingIt is readily availableIt helps in child spacing

ImmunizationExample of an immunisationschedule

At birth BCG, Oral polio & HBV16 weeks DPT1, Oral polio & HBV210 weeks DPT2, Oral polio14 weeks DPT3, Oral polio & HBV39 months Measles, yellow fever

Hygiene and prevent infectionHand washing.A common practice in many newborn nurseries isthe use of cover gowns to prevent infection.Eye care, umbilical care, bathing, care of thecircumcision.Vitamin K is administered to protect againsthemorrhage.Proper identification.No tub baths until cord off and healedclean around organs of elimination and mouthafter soiling to prevent skin break downfold diapers away from umbilicus

Questions andDiscussions

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