N106 Nursing Care of the Newborn - PowerPoint PPT Presentation

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N106 Nursing Care of the Newborn

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Title: Slide 1 Author: Mary Elllen Simmons Last modified by: msimmons Created Date: 3/23/2002 5:45:58 PM Document presentation format: On-screen Show – PowerPoint PPT presentation

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Title: N106 Nursing Care of the Newborn


1
N106Nursing Care of the Newborn
2
Immediate Baby Care
  • Airway - Clean mouth and nose
  • Thermoregulation - Warmth
  • APGAR
  • Gross assessment
  • Identification
  • Bonding safety against infection
  • Medications

3
Fetus to Newborn Respiratory Changes
  • Initiation of respirations
  • Chemicalsurfactant reduces surface tension
    34-36wksdecrease in oxygen concentration
  • Thermalsudden chilling of moist infant
  • Mechanicalcompression of fetal chest during
    delivery normal handling

4
Nursing Process for Respirations
  • Assess for respiratory distress
  • Plan Maintain patent airway
  • Interventions- Positioning infant head lower
  • - Suction secretions bulb, keep near head,
    mouth first, avoid trauma to membranes
  • Evaluation rate 30-60, no distress

5
Fetus to Newborn Neurological adaptation
Thermoregulation
  • Methods of heat loss
  • Evaporation wet surface exposed to air
  • Conduction direct contact with cool objects
  • Convection- surrounding cool air - drafts
  • Radiation transfer of heat to cooler objects
    not in direct contact with infant

6
Convection
Radiation
Evaporation
Conduction
7
Nonshivering thermogenesisThe distribution of
brown adipose tissue (brown fat)
8
Nursing Care Cold Stress
  • Preventing heat loss radiant warmer
  • Providing immediate care - dry quickly, cover
    head with cap, replace wet blankets
  • Providing on going prevention - safety
  • Restoring thermoregulation if becoming chilled
    - intervene

9
Effects of Cold Stress
  • Increased oxygen need
  • Decreased surfactant production
  • Respiratory distress
  • Hypoglycemia
  • Metabolic acidosis
  • Jaundice

10
APGAR
  • Heart rate above 100
  • Respiratory Effort spontaneous with cry
  • Muscle tone flexed with movement
  • Reflex response active, prompt cry
  • Color pink or acrocyanosis
  • 0-3 infant needs resuscitation
  • 4-7 Gentle stimulation Narcan
  • 8-10 no action needed

11
Early Assessments
  • Assess for anomalies
  • Head anterior fontanelle closes 12-18 mo
    posterior fontanelle closes 2-3 months
  • Neck and claviclesfracture of clavicle large
    infant, lump, tenderness, crepitus, decreased
    movement
  • Cord
  • Extremitiesflexed and resist extensionassess
    fractures, clubfeethipsvertebral column

12
Not crossing suture line
Cephalhematoma is a collection of blood between
the surface of a cranial bone and the periosteal
membrane.
13
Crossing suture line
Caput succedaneum is a collection of fluid
(serum) under the scalp.
14
A, Congenitally dislocated right hip
B, Barlows (dislocation)
maneuver. C, Ortolanis maneuver
15
Measurements
  • Weight loss of 10 normal
  • Length
  • Head and chest circumference
  • Normal VStemp 97.7-99.5F axillaryapical pulse
    120-160bpm respirations 30-60/min

16
head larger
A, Measuring the head circumference of the
newborn. B, Measuring the chest circumference
of the newborn.
17
Assessment of Cardio-respiratory Status
  • History
  • Airway
  • Assessrateq 30minX2hrssymmetrybreath sounds -
    moisture for 1-2 hrs

18
Assessment of Thermoregulation
  • Check soon after birth
  • Set warmer controls
  • Take temp q 30 min until stable
  • Rectal for first temp
  • Insert only 0.5 inch
  • Axillary route rest of time

19
Axillary temperature measurement. The thermometer
should remain in place for 3 minutes.
20
Assessment of Hepatic Function
  • Blood GlucoseSigns of hypoglycemia
    jitteriness respiratory difficulties drop in
    temp poor suckingTx- feed infant if glucose
    below 40-45 mg/dl
  • Bilirubinphysiologic jaundice peaks 2-4 days of
    lifeearly onset may be pathologic

21
Jaundice
  • Hemolysis of excessive erythrocytes
  • Short red blood cell life
  • Liver immaturity
  • Lack of intestinal flora
  • Delayed feeding
  • Trauma resulting in bruising or cephalhematoma
  • Cold stress or asphyxia

22
Potential sites for heel sticks. Avoid shaded
areas to prevent injury to arteries and nerves in
the foot.
23
Assessment of Neuro System
  • Reflexes
  • BabinskiGraspMoroRootingSteppingSuckingTonic
    neck reflex fencing
  • Cry
  • Infant response to soothing

24
Assessment of Gastrointestinal System
  • Mouth
  • Suck
  • Abdomen
  • Initial feeding
  • Stoolsmeconium within 12-48 hours of birth
    dark greenish blackbreastfed soft, seedy,
    mustard yellowformula-fed solid, pale yellow

25
Assessment of Genitourinary System
  • Umbilical cord vessels
  • Urine within 24 hours of birth
  • Voiding 6 to 10 times a day after 2 days
  • Genitaliafemale edema normal, majora covers
    minora, pseudomenstruationmale pendulous
    scrotum, descended testes by 36 wks gest.,
    placement of meatus

26
Assessment of Integumentary System
  • Vernix white covering
  • Lanugo fine hair
  • Milia
  • Erythema toxicum red blotchy with white
  • BirthmarksMongolian spots sacral
    areaTelangiectatic nevus stork Bite - blanches
  • Nevus flammeus port wine stain - no
    blanchingNevus vasculosus strawberry
    hemangioma usually on head, disappears by
    school age

27
Port Wine Stain
Erythema toxicum
28
Fetus to Newborn Psychosocial adaptation
  • Periods of Reactivityactive 30-60 minsleep
    2-4 hoursalert 4-6 hours
  • Behavioral Statesquiet sleepactive sleepdrowsy
    statequiet alert best for bondingactive
    alertcrying state

29
Gestational Age Assessment
  • Assessment tool Dubowitz, Ballard
  • Weeks from conception to birth
  • Used to identify high risk infants
  • Neuromuscular characteristicsPosture more
    flexionSquare window more pliableArm recoil -
    activePopliteal angle - lessScarf Sign less
    crossing Heel to ear most resistance

30
Newborn maturity rating and classification
31
Gestational Age Assessment
  • Physical characteristicsSkin- deep cracking, no
    vessels seen, post-leatheryLanugo less as
    agePlantar creases more with ageBreasts
    larger areola Eyes and Ears stiff with instant
    recoilGenitals deep rugae, pendulous, covers
    minora
  • Gestational Age Size may not correspondsmall
    SGA lt10 for weight large LGA gt90 for
    weightappropriate AGA between 10-90

32
Classification of newborns based on maturity and
intrauterine growth.
33
Classification of newborns by birth weight and
gestational age.
34
Ongoing Assessment and Care
  • Bathing
  • Cord care
  • Cleansing diaper area
  • Assisting with feedings
  • Protecting infantidentifying infantpreventing
    infant abduction alert to unusualpreventing
    infection
  • Review beige cue cards in center of book for teach

35
One method of swaddling a baby.
36
Common Breastfeeding Positions
37
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38
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39
Infant in good breastfeeding position
tummy-to-tummy, with ear, shoulder, and hip
aligned.
40
LATCH was created to provide a systematic method
for breastfeeding assessment and charting.
41
Infant teaching checklist is completed by the
time of discharge.
42
Circumcision
  • Most common neonatal surgical procedure
  • Reasons for choosing
  • Reasons for rejecting hypospadias, epispadias
  • Pain relief
  • Methods
  • Nursing care

43
Circumcision using a circumcision clamp.
44
Circumcision using the Plastibell.
45
Other Concerns
  • ImmunizationsHepatitis B begin vaccine at
    birth
  • Screening testsHearingPhenylketonuria by law

46
Further Assessments
  • Complications r/t poorly functioning
    placentahypoglycemiahypothermiarespiratory
    problems
  • Complications r/t LGA infanthypoglycemiabirth
    injury due to size

47
Shoulder Dystocia
  • Risk factorsdiabetes macrosomic
    infantobesityprolonged second stageprevious
    shoulder dystocia
  • Morbidity- fracture of clavicle or
    humerus,brachial plexus injury
  • Management generous episiotomy

48
Neonatal morbidity by birth weight and
gestational age.
49
High Risk Infants
  • Preterm before 38 weeks gestation
  • IUGR full term but failed to grow normally
  • SGA -
  • LGA
  • Infants of Diabetic mothers
  • Post mature babies
  • Drug exposed

50
Preterm infants
  • Survive - Weight 1250 g -1500 g 85-90500-600g
    at birth 20 survive
  • Ethical questions
  • Characteristics frail, weak, limp, skin
    translucent, abundant vernix lanugo
  • Behavior easily exhausted, from noise and
    routine activities, feeble cry

51
Nursing Care of Preterm Infants
  • Inadequate respirations
  • Inadequate thermoregulation
  • Fluid and electrolyte imbalance dehydration
    sunken fontanels lt1ml/kg/hr or over hydration
    bulging, edema and urine output gt3ml/kg/hr
  • Signs of pain high-pitched cry, gtVS
  • Signs of over stimulation - gtP, gtRR, stiff
    extended extremities, turning face away
  • Nutrition signs of readiness to nippleresp
    lt60/m, rooting, sucking, gag reflex

52
Measuring gavage tube length.
53
Auscultation for placement of gavage tube.
54
Complications of Preterm Infants
  • Respiratory Distress Syndrome -RDS
  • Bronchopulmonary dysplasia chronic lung disease
  • Periventricular-Intraventricular Hemorrhage30
    infants lt32 wk gest or lt1500 g
  • Retrolenthal fibroplasia visual impairment or
    blindness from O2 ventilator
  • Necrotizing Enterocolitis (NEC) distention,
    increased residual, Tx - rest bowel

55
Respiratory Distress Syndrome
  • RDS also know as hyaline membrane disease
  • Cause besides preemie, C/S, diabetic mothers,
    birth asphyxia interfere with surfactant
  • S S tachypnea - over 60/min retractions-
    sternal or intercostal
  • nasal flaring cyanosis- centralgrunting-
    expiratoryseesaw respirationsasymmetry

56
Evaluation of respiratory status using the
Silverman-Andersen index.
57
Therapeutic Management of RDS
  • Surfactant replacement therapy
  • Installed into the infants trachea
  • Improvement in breathing occurs in minutes
  • Doses repeated prn
  • Other treatmentmechanical ventilationcorrection
    of acidosisIV fluids

58
Post Term Infants
  • Born after 42 weeks
  • Increase risk of meconium aspiration
  • Hypoglycemia
  • Loss of subcutaneous fat
  • Skin peeling, vernix sparse, lanugo absent,
    fingernails long
  • Focus on prevention due date
  • Attention to thermoregulation feeding

59
Meconium Aspiration Syndrome
  • Occurs most often post term infants, decreased
    amniotic fluid /cord compression
  • Meconium enters lung obstruction
  • S S vary from mild to severe respiratory
    distress tachypnea, cyanosis, retractions, nasal
    flaring, grunting
  • Tx suction at birth, may need warmed,
    humidified oxygen, or ventilators

60
Hyperbilirubinemia
  • Pathologic jaundice occurs within first 24
    hours
  • Bilirubin levels gt12 in term or 10-14 preterm
  • May lead to kernicterus brain damage
  • Most common cause blood incompatibility of
    mother and fetus, Rh or ABO only occurs with
    mother negative Rh or O blood
  • Treatment focus on prevention, assess coombs,
    monitor bilirubin levels, most common treatment
    is phototherapy, blood transfusions

61
Conjugation of bilirubin in the newborn.
62
Phototherapy for Hyperbilirubinemia
  • Phototherapy bilirubin on skin changes into
    water-soluble excreted in bile urine
  • Bili lights placed inside warmer, need patches
    over eyes, infant wearing only diaper or
    fiberoptic phototherapy blanket against skin
  • Side effects of phototherapy freq, loose, green
    stools, skin changes
  • Can use at home

63
Other interventions for hyperbilirubinemia
  • Exchange transfusions if lights not working
  • Maintain neutral thermal environment not too
    hot or too cold
  • Provide optimal nutrition hydrate
  • Protecting the eyes from retinal damage
  • Enhance therapy by expose as much skin as
    possible to light, remove all clothing except
    diaper, turn frequently

64
Infant of a Diabetic Mother
  • Macrosomia face round, red, body obese, poor
    muscle tone, irritable, tremors
  • High risk for trauma during birth, congenital
    anomalies, RDS, hypocalcemia
  • Hypoglycemia occurs 15-50 of timelt40-45 mg/dl,
    test right after birth, q 2hX4,then q 4 hrX6
    until stable
  • Most frequent symptom jitteriness or tremors
  • Tx fed, gavage or IV if needed

65
Hypoglycemia
  • Serum glucose is below 40 mg/dL
  • Tx feed infant formula or breast milk and retest
    until glucose stable
  • S S jitteriness, lethargy, poor feeding,
    high-pitched cry, irregular respirations,
    cyanosis, seizures
  • Risk factors DM, PIH, preterm, post term, LGA,
    cold stress, maternal intake of ritodrine or
    terbutaline

66
Large for Gestational Age
  • Infants weight is in the 90th for neonates same
    gestational age, may be pre, post, or full term
    infants
  • LGA does not mean post term
  • Most common cause maternal diabetes
  • Infant at risk birth injuries, hypoglycemia, and
    polycythemia - macrosomia

67
Small for Gestational Age
  • Infant whose wt is at or below the 10th
  • Results from failure to thrive
  • Is a high risk condition
  • SGA does not mean premature.
  • Causes anything restricting uteroplacental blood
    flow, smoking, DM, PIH, infections
  • Complications hypoglycemia, meconium aspiration,
    hypothermia, polycythemia

68
Mother with Substance Abuse
  • Use of alcohol or illicit drugs
  • Tobacco and alcohol are most frequent
  • Prenatal alcohol exposure is the most commons
    preventable cause of mental retardation
  • Signs of maternal addition wt loss, mood swings,
    constricted pupils, poor hygiene, anorexia, no
    prenatal care

69
Drug Withdrawal in Infants
  • Signs of drug exposureopiates 48-72
    hourscocaine 2-3 daysalcohol within 3-12
    hours
  • Symptoms irritable, hyperactive muscle tone,
    high-pitched cry
  • High risk for SGA, preterm, RDS, jaundice
  • Obtain infant mec and urine sample for test

70
Nursing Care of Drug-Exposed Infant
  • Feeding more difficult may need to gavage
  • Rest keep stimulation to minimum, reduce noise
    and lights, calm, slow approach
  • Promote bonding
  • Teach measures for frantic crying rock, coo,
    dark room, avoid stimulation

71
Phenylketonuria - PKU
  • Genetic disorder causes CNS damage from toxic
    levels of amino acid phenylalanine
  • caused by deficiency of the enzyme phenylalanine
    hydroxylase
  • Signs- digestive problems, vomiting, seizures,
    musty odor to urine, mental retardation
  • Tx low phenylalanine diet start within 2
    months
  • Screening before 24-48 hours needs to be repeated
    for accuracy

72
Signs Bonding Delayed
  • Using negative terms describing infant
  • Discussing infant in impersonal terms
  • Failing to give name check culture
  • Visiting or calling infrequently
  • Decreasing length of visit
  • Refusing to hold infant
  • Lack of eye contact with infant
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