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The Normal Newborn:Assessment, Care, Feeding
Presented by,
Joy Haskin, RN, MS
Joke for the day….
Should children witness childbirth?
TERMS:
Neonatal Period:Birth --> 28 days of life
Term Infant:38 - 42 weeks of gestation
Transition Period: Phases of instability during the first 6-8 hours after birth
Viability
Capacity to live outside of the uterus - about 22 to 24 weeks since the last menstrual period, or fetal weight greater than 500 g.
In the past was 28 weeks - with technology and advancements this is becoming shorter and shorter…...
Physiologic Changes of the NB to adjust to extrauterine life:
What happens during birth to the neonate?
Circulatory:
Transitional Circulation = acrocyanosisPeripheral circulation = sluggishHigh: RBC 4.8-7.1; Hgb 14-24; Hct 44-64WBC 18,000 @ birth; 23-24,000 @ 1 day Coagulation: Vit K dependent clotting
factors are decreased.Platelet counts ok (150,000-350,000)
Respiratory
Before birth O2 needs met by placentaL/S ratio should be > 2:1After delivery need mature lungs that
are vascularized, have surfactant and sacules - usually adequate by 32-35 weeks-
at term the lungs hold approx. 20 ml of fluid/kg
What initiates respiration?
Periodic Breathing -vs- Apnea
Apnea: no breathing for periods of greater than 15 seconds should be evaluated.
Periodic Breathing:
Notify MD if resp < 30 or > 60
Gastrointestinal System
Immature at birth, reaches maturity at 2-3 years of age
place food at back of tonguesucking becomes coordinated @32
wkslittle saliva until 3 months of agebowel sounds after 1 hour of birth
Gastrointestinal (continued)
NB have difficulty digesting complex starches and fat
Abdomen becomes easily distended after eating
Initial fecal material = meconiumNo normal flora at birth in GI system
to synthesize Vit. K
Immune System
Limited specific and Non-specific immunity at birth
passive immunity(from mom- IgG) for the first 3 months of life ~ this will be reduced if baby is born premature
breastfeeding = ^ passive immunity (IgA)
Temperature Regulation
Non-Shivering thermogenesis:brown fat is the primary source of heat
production. Brown fat is broken down into glycerol & fatty acids producing heat.
Brown fat is found @ the nape of the neck, axillae, around the kidneys and in the mediastinum.
Slightly warmer to touch than nml skin.
Cold Stress
An increase in the metabolic rate associated with non-shivering thermogenesis --> increased O2 demands and caloric consumption
It’s important to provide a neutral thermal environment to prevent metabolic acidosis and prevent depleted brown fat.
Kidneys and Urination
92% of all healthy infants void in the first 24 hrs of birth
initial urine:cloudy, scant amounts, uric acid crystals-> reddish stain on diaper
Kidneys not fully functional until child is 2 years of age.
Hepatic Function
Liver produces substances essential for clotting of blood.
Stores needed iron for the first few months. Preterm & small infants have lower iron stores than full term and heavier infants. (full term infants stores last 4-6 mo)
NB at risk for Physiologic Jaundice after 24 hours of age, d/t increased breakdown of RBC’s and immature liver functioning.
Increased Bilirubin Levels
Jaundice in the 1st day is NOT normalBilirubin level greater than 12 at any
time needs further attentionMaternal causes of increased bilirubin
levels in the NB: epidural use, oxytocin induced labor, infection, hepatitis
Ethnic Influences: Asian infants levels may be double other ethnic groups.
Kernicterus
Complication of neonatal hyperbilirubinemia --> encephalopathy
basal ganglia and other areas of the brain and spinal card are infiltrated w/ bilirubin (produced by the breakdown of hemoglobin -> levels of 20 - 25 or more).
Poor prognosis if untreated.
Neurologic
All neurons are present, but many are immature:
uncoordinated movementspoor muscle control
startle easilytremors in extremities
Weight Loss
It is normal for the newborn infant to loose 5-10% of weight in the first 4 to 5 days of life.
Infants at Risk
“RED FLAGS” after birth include:gagging --> turning blue (esp. after fdg)
generalized cyanosis weak cry
grunting or respiratory distress decreased or absent movements excessive twitching or trembling
OTHERS>>>>>
Nursing Diagnosis:
Ineffective Airway Clearance R/T excessive oropharyngeal mucus
Ineffective Thermoregulation R/T newborn transition to extrauterine life
High Risk for infection R/T maturational factors, immature immune system
PC: Hypoxemia PC: Hyperbilirubinemia(W) Beginning Integration of NB into Family
Unit
Nursing Care to Meet NB Needs
Prevent infection:handwashing, stay away from large
groups or ill individuals, prophlactic agents (EES, cord care, bathing)
VernixBreastfeeding
Warmth
Bath after temperature is stablewarmer/isolette/bundlehatkeep out of draftsskin to skin
Position of sleep/prevent SIDS
Back to sleepfeet to foot of bedno stuffed animals or excessive
blankets in beddon’t cover head in strollerdon’t keep house too warmNo smoking around infant
Cleanliness
No tub baths until cord off and healedclean around organs of elimination and
mouth after soiling to prevent skin break down
daily head to toe bath not necessaryOK to clean and touch the “soft spot”fold diapers away from umbilicusNEVER leave child alone in tub!!
Research and Cord Care
1,811 NB’s- 2 groups - one receiving cord care with alcohol and one group not:
* equal # infections in infants who received and did not receive cord care
*cord separation ~ alcohol use: 9.8 days
–no alcohol used: 8.16 days
Carseats
“AS a condition for licensure, public and private hospitals, birth centers, and clinics must have a written policy on the dissemination of child passenger restraint system information to parents or the person to whom the child is released” (SB503 REQ)
Genital Care
Male Infant: if penis is uncircumcised DO NOT RETRACT THE FORESKIN--- “leave it alone”
Female Infant: wipe front to back. If “smegma” has accumulated in the labial folds it can be carefully removed
Infant Feeding
Why may a mother decide to Breast Feed?
Discussion
Formula feeding
Why may a mother decide to formula feed her infant?
Discussion
Frequency of Feedings
Breastfeeding: successful latch-on and feeding should occur every 1.5 to 3 hours daily.
Formula Feeding: 3-4 oz every 3-4 hours for full-term babies.
Baby should have 6-10 wet diapers/daycalculate amnt of formula mult. baby’s wt
in lbs by 2 then 3, this is oz per day. (EX: 8lb. Baby~ 8 X2 = 16; 8 x3 = 24 therefore 16-24oz of formula
per day is needed for adequate nutrition)
Nursing Diagnosis
Effective BreastfeedingRisk for Altered Nutrition (more or
less than body requirements) R/T (insufficient caloric intake or excessive caloric intake)
Circumcision
Elective ProcedureNot pd for by medi-calDecision made based on tradition,
religion, culture, or personal factorsVALUE
OPPOSITION
Procedure
Usually delayed 12 to 24 hours until NB is stabilized
Do not feed 1 hr prior to procedureConsent required from one parentMethods: Gomco or PlastibellRestraint requiredAnesthetic is physician dependent
After Care
Comfort measureskeep wound clean and dry (warm
water)ck urination w/in 12 hrs after
proceduremonitor for bleedings/s of infection will not occur
immediately after procedure
Periods of Reactivity
REVIEW1st period of reactivity:after birth of baby,
bursts of rapid movements. Quiet times during this period are ideal for breastfdg & interacting
Deep Sleep - lasts 60-100 minutes2nd period of reactivity: occurs 4-8 hrs after
birth lasts 10 min to several hours. Periods of tachycardia & tachypnea. Increased muscle tone, skin color, mucus production, pass meconium
The end….