Physiologic & Behavioral Transition to Extrauterine LifeThe Normal Newborn

Assessments @ 1 min. and 5 min.A = appearanceP = pulseG = grimaceA = activityR = respirationsAPGAR Scores

Physiologic Transitions of Major Systems Pulmonary system transitionCardiac system transitionThermoregulationMetabolic transitionGastrointestinal system transition

Assessing for Congenital Anomalies:Observe general appearance.Gross external anomalies.Observe breathing pattern & auscultate chest.Cardiorespiratory problems, diaphragmatic hernia.Observe breathing with infants mouth closed.Choanal atresia.

Congenital Anomalies (cont.)Pass gastric tube or aspirate stomach contents.Esophageal atresia.Observe appearance of abdomen.Intestinal atresia (distended), diaphragmatic hernia (scaphoid), omphalocele, gastroschisis.Confirm passage of meconium & observe appearance of anus including wink reflex; perform rectal temperature.Imperforate anus.

Count umbilical vessels.

IMPORTANT NORMAL VALUES:Axillary temp: 97.1-97.8 F (36-36.5 C).Heart rate: 120-160 bpm apical (assess for 1 full minute).Respirations: 30-60 per min. not crying (assess for 1 full minute). Infants are considered AGA if weight, length, & head circumference are btw.10th & 90th percentiles, on standardized growth chart.

Average weight: 7.5 lbs. (3.5 kg).Average length: 20 in. (51 cm).Head circumference: 13-14 in. (33-35.5 cm).Chest circumference: 12-13 in. (30.5-33 cm).Head circumference: 0.8 in. larger than chest circumference (2 cm).

Assessment of the Normal Newborn

NEONATAL PHYSICAL ASSESSMENT:GENERAL APPEARANCE:Color.Observe general tone, activity, & posture (initially & throughout exam).Observe & palpate skin.Measure & record weight & length, and plot on growth curve.Measure & record temperature.

Head, Face and Neck:Measure & record head circumference, & plot on growth curve.Inspect & palpate head.Palpate sutures.Palpate & measure fontanelles.Observe face, nose, & lips.Observe eyes & measure position.

Observe and palpate ears, measure position.Inspect & palpate mouth.Inspect & palpate neck, clavicle, & shoulders; assess mobility.

Chest, Abdomen, and Back:Observe thorax.Measure chest circumference at nipple line.Observe breathing movements.Count respiratory rate.Auscultate lungs.Auscultate heart sounds.Count heart rate.Auscultate bowel sounds (all 4 quadrants, before palpation).

Observe & palpate abdomen.Inspect umbilical cord & umbilicus.Palpate femoral lymph nodes & pulses.Record passage & character of stools.Determine patency of anus (rectal temperature).Palpate & inspect spinal column.Observe back & buttocks.

Genitals & Urinary System:Confirm urination; observe stream of urine in male infant.Note appearance of external genitalia.Observe genitalia & palpate testes of male infant.Observe genitalia of female infant.

Extremities:

Observe arms & legs for symmetric appearance, size, length, & movement.Observe hands & feet.Evaluate rotation of hips: Ortolani & Barlow maneuvers.Palpate peripheral pulses.

Reflexes:Rooting (assess bilaterally).Swallow.Sucking.Moro (startle reflex).Palmar and planter grasp (assess bilaterally).Tonic neck reflex or fencing (assess bilaterally).

Stepping or walking.Pull to sit (traction).Blink (glabellar).

Nutritional Needs of the NewbornTHE NORMAL NEWBORN

NUTRITIONAL ALLOWANCES FOR THE NEWBORN

CaloriesGrowth in the neonatal periodNeeds of the newborn and infants up to 2 months and after 2 monthsActual caloric requirement...depends on the infant activity level and growth rate

ProteinNecessary for the formation of the new cellsThe newborn and infant need amino acidsUnaltered cows milk not recommendedCasein Vs. Lactalbumin

FatLinoleic acid......Necessary for growth and skin integrity in infants

CarbohydrateLactose found in human milk and commercial formulas........Improves calcium absorption and assist in nitrogen retention.........Allows protein to be used for building new cells rather than calories........Decrease the possibility of gastrointestinal illness

CalciumAid in bone growth Decrease level lead to tetany

IronTerm infant will not need iron supplement for the first 3 monthsUntil they begin to produce adult hemoglobin

FluorideAid in building teeth and preventing tooth decay Given to child at 6 months of age ......If the child not receiving adequate amount from breast feeding

Fluid Fluid requirements for a newborn is 150-200 ml/kg (2.5-3.0 oz) over 24 hrsFruit juice is not recommended.

Physical examination of the newbornVital signsGrowth measurementsSkinHead and neckRespiratory SystemCardiovascular systemAbdomenGenitaliaMusculoskeletal systemCentral nervous system

Positions for Breastfeeding

Advantages of BreastfeedingFor Mother:Helps the uterus to shrink back to pre-pregnancy size more quicklyServes as a protective function in preventing breast cancerConvenience breast milk is always ready to use, clean & is always at the right temperature for the baby and can be refrigerated for later useStrengthens mother-baby bondingCost

Advantages of BreastfeedingFor Baby:Breast milk is individualized for the babyBetter digestionLessens susceptibility to allergiesBetter mouth developmentA DISADVANTAGE of breastfeeding is that the breast milk may carry microorganisms (i.e.: Hep B, Cytomegalovirus, HIV)

BurpingBurping is important during and after feedings to bring up any excess air that was taken in during feedingBaby should be burped every couple of ounces or between breast change Three common ways of burping baby: 1. Over the shoulder 2. Face baby down on your lap while sitting 3. Sitting Up

Myths about BreastfeedingMyth: You cant breast feed if you have small breasts. Reality: Breasts of all shapes and sizes can satisfy the hungry baby. Myth: Breast feeding is a lot of trouble. Reality: Breasts, as opposed to bottles, are ready when the baby is ready. Myth: Breast feeding ties you down. Reality: Breast milk can be stored if mother decides she wants to go out. When the mother goes out she always has the food supply for the baby no matter how long she plans to stay out. Myth: Breast feeding ruins your breasts. Reality: Breast-feeding does not change the shape or size of the breasts. There are other factors (i.e. age, not wearing a bra, or excess weight) that can change the shape & size of breasts. Myth: The father is excluded during breast feeding. Reality: An involved father will take advantage of opportunity such as bathing, diapering, holding, & playing with the baby.

Nursing Outcomes Mom is able to demonstrate following:Comfortable position to breastfeedDetermines whether or not the breast is full prior to feedingNo nipple tendernessRecognizes hunger signs Is satisfied with breastfeeding

Teaching

Milk ProductionFirst stage of milkColostrummilk ejection or let down reflexMilk production can be influenced byEmotional stressAmbivalence to breastfeedingPhysical well being of infant and mother

Nutritionextra calories (250 - 500)6-8 glasses of water or liquidSelection from each of the four main food groupMaternal use of iron or iron supplementsAdvance of alcohol, tobacco and drugs

Nutritional Management at homeNurse baby every 1-3 hoursboth breast at each feedingexpect 6-8 wet diapers every 24 hours (after first weekbowel movement (consistency + appearance) most babies have periods of irritable cryinggrowth spurtscommunity resources - LaLeche League, WIC, community Lactation Consultants, hospital programs + support groups

Common Problems Encountered in Breast Feeding

Cracked or Sore Nipplescheck for correct latchfrequent feedingsrotation during breastfeedingair dryingwarm soaks

Flat or Retracted Nipplesuse of milk cupselectric pumpsice wrapped

Infants PositionEncourage rooting reflexareola into mouthavoid having infant press noseremoval of infant from the breastlast first, first lastburp

Care of the Breast and Nipplesair drypadssupport bracramp

Advantages of Bottle FeedingBaby is satisfied longerMonitoring intakeMore freedom for mother (i.e.: if she wishes to go out for the evening)Father is able to participate in feeding the babyIncreased opportunity for sibling as to participate in feedingBirth control methods are less restrictiveLess stress for feeding the baby in public

Infant FormulaWhat is formula? All formula is designed to similate nutritional content of breast milkWhat does formula contain? Protein,fat,iron,carbs &vit A,D,E,K linoleic acidCaloric: 20 cal. per oz.AllergiesSoy for sensitivity to milk protein,lactose free for possible lactose , and alimentum for severe for severe food allergies/colic r/t protein sensitivity

Types Of FormulaPowdered, Prepared,ConcentrateCost $$$- Which is best?Preparation-boil H2O approx 1 min.

Feeding

Initial feedings are only -1 oz.Most newborns approx. 2-3 oz per feeding q 2-3 hrs. Add 2 or 3 to infants age. Ex. A 3 month old would require 5-6 oz.Ample feedings will produce 6-8 wet diapers per dayDiscard unused bottle formula after, discard formula after baby is done, bacteria from babys mouth has passed into milk. Bacteria.Can be stored in fridge up to 24 h

Nursing Process

AssessmentNutritional status prior to and during mothers pregnancyAssess the newborn for adequate nutritionIdentify mothers skills and knowledge about breastfeeding vs. formula usage.Mothers ability to recognize signs of hunger in a newborn (e.g., restlessness, tense body posture, smacking lips, or tongue thrusting) Check moms knowledge whether newborn is receiving enough feeding by voiding, growing, and alert

Nursing Dx:Imbalanced nutrition, less than body requirements r/t poor newborn sucking response.Health seeking behavior r/t lack of knowledge about lactation and breast feeding techniqueEffective breast feeding r/t well prepared mother and healthy newbornIneffective breast feeding r/t anxiety and inexperiencePain r/t breast engorgement or sore nipplesDeficit knowledge r/t potential harm to baby of drugs taken by breast feeding motherHealth seeking behaviors r/t techniques of bottle feeding

Planning/Interventions

Begins while the newborn is pregnantFocus on providing information on breast feeding or bottle feedingProvide information to woman who expects to formula feed to purchase supplies in advanceAdvise client to drink at least 4 to 6 8oz. Glasses of fluid per dayGive information on how / where to allocate community resources base on financial needs

Outcomes For BreastfeedingThe client will be able to verbalize knowledge in the following:Hunger signs of the baby & signs of proper nourishmentProper positioning & techniques of breastfeeding

The client will be able to verbalize knowledge in the following:Latch on properly, proper sucking & tongue placementSwallowing should be audible at a minimum of 5-10 minutes per breast at 8 feedings per day2 or more loose, yellow, seedy stools per day (at least 6 voidings per day)

Nursing Outcomes Mom is able to demonstrate following:Comfortable position to breastfeedDetermines whether or not the breast is full prior to feedingNo nipple tendernessRecognizes hunger signs Is satisfied with breastfeeding

**APPEARANCE:0 = blue or pale1 = body pink; extremities blue2 = pinkPULSE:0 = absent1 = below 1002 = above 100GRIMACE: Reflex irritability (response to stimulation on sole of foot)0 = no response1 = grimace2 = cryACTIVITY: Muscle tone0 = limp1 = some flexion of extremities2 = active motion; extremities well flexedRESPIRATIONS: Respiratory effort0 = absent1 = minimal; weak cry2 = good; strong cry*****Infants are periodic breathers , with periods of respiration intermixed with brief periods (approx.5-10 seconds) without breathing.

*********ORTOLANIS MANEUVER:Flex knees & hops, placing fingers bilaterally on trochanters with thumbs greipping medial aspect of femurs. Adduct and abduct hips. Jerking motion as femur passes over acetabulum requires further evaluation for congenital hip dysplasia.

BARLOW TEST:Flex hip & knee 90 degrees. Pull the femoral head out of the acetabulum by lateral pressure of the thumb and by rocking the knee medially with the knuckle of the index finger. Palpable or audible hip click requires further evaluation.**********************************************