Newborn Focused Care: Respiratory & Circulatory

• Focused Care elements include maintaining respiratory and cardiac function, decreasing the risk of infection, assessing for signs of complications, and assisting parents in providing appropriate nutrition and education.

Respiratory System

• Breathing is essential for the transition to neonatal circulatory patterns.
• Respiratory issues can arise from conditions in the lungs or prematurity.
• Decreased surfactant levels in immature lungs can lead to hypoxemia/acidosis and increased pulmonary vascular resistance (PVR).
• Approximately 10% of newborns need respiratory assistance, while 1% require extensive resuscitation.

Circulatory System

• The newborn circulatory system contains three major shunts: ductus venosus, foramen ovale, and ductus arteriosus.
• The ductus venosus connects the umbilical vein to the inferior vena cava and closes after birth.
• The foramen ovale is an opening between the right and left atria that closes within 24-48 hours post birth; can reopen if significant neonatal hypoxia occurs.
• The ductus arteriosus connects the pulmonary artery with the aorta,closing within 15 hours after birth; hypoxia or increased PVR can cause it to remain open or reopen.

Thermoregulation

• A neutral thermal environment helps maintain body temperature while minimizing oxygen consumption and metabolic rate.
• Newborns lose heat through evaporation, conduction, convection, and radiation.
• Exposure to cold causes newborns to increase their metabolic rate, consume more oxygen, increase muscle activity, constrict peripheral vessels, and metabolize brown fat.
• Amniotic fluid helps newborns maintain a constant temperature in utero.
• Newborns are at higher risk of cold stress due to their body surface area to mass ratio, limited fat, high metabolic rate, and inability to shiver.

Cold Stress

• Excessive heat loss causes compensatory mechanisms to maintain body temperature.
• Consequences of cold stress include hypoglycemia, hypoxia, metabolic acidosis, decreased surfactant production, respiratory distress, increased bilirubin and jaundice, poor feeding, weight loss, apnea, and death.
• Risk factors for cold stress include prematurity, SGA, hypoglycemia, prolonged resuscitation efforts, and sepsis.
• Signs and symptoms: a temperature less than 36.5°C, cool skin, restlessness or crying, acrocyanosis, tachypnea/grunting, hypoglycemia, hypotonia/lethargy, jitteriness, and a weak suck.
• Interventions: dry the newborn immediately after birth, remove wet blankets, apply a hat, initiate skin-to-skin contact with warm blankets, pre-warm surfaces, delay the bath, swaddle, monitor temperature, and raise the room temperature.

Metabolic Hypoglycemia

• Hypoglycemia is defined as a blood glucose level below 40-45 mg/dL on the first day of life, which requires a glucose check.
• Risks of developing hypoglycemia include macrosomia (4,700 g), SGA (1,500 g), GDM, and being born to mothers with diabetes, LGA/SGA, post term/preterm, hypothermia, infection, respiratory distress, neonatal resuscitation, or birth trauma.
• Signs and symptoms: including jitteriness, tremors, irritability, tachypnea/grunting, seizures, apnea, hypotonia, lethargy, hypothermia, cyanosis, and poor feeding.
• Interventions include monitoring blood sugar, feeding, IV infusion, and maintaining temperature.

Uncontrolled Diabetes Mellitus

• Possible complications for newborns are low blood sugar, respiratory distress syndrome (RDS), hyperbilirubinemia (jaundice), congenital anomalies, and seizures
• Infants born to mothers with uncontrolled diabetes often exhibit extra weight/fat and underdeveloped lungs, often needing supplemental oxygen.

Neonatal Assessment

• Neonatal assessment includes an Apgar score, vital signs, and general survey immediately after birth.
• A head-to-toe assessment should be completed within the first two hours.
• Review prenatal and birth records for risk factors, such as late or limited prenatal care, maternal drug/alcohol use, maternal age younger than 16 or older than 35, chronic maternal illness, hypertensive disorders, preterm birth, medications used in labor, and prolonged rupture of membranes (mec stained fluid).

APGAR Scoring System

• The Apgar score is performed at 1 and 5 minutes of life, assessing activity, pulse, grimace, appearance, and respiration.
• A score of 0-3 indicates severe distress requiring interventions.
• A score of 4-6 indicates moderate difficulty, also requiring interventions.
• A score of 7-10 indicates minimal or no difficulty with adjusting to life.

Vital Signs and Measurements

• Temperature: axillary, normal range 36.5°C to 37.2°C; low temperature interventions include skin-to-skin contact, blankets, and adjusting room temperature.
• Pulse: normal range is 110-160 bpm (90 bpm during sleep, 180 bpm while crying).
• Respirations: normal range is 30-60 breaths per minute (pauses less than 15 seconds are acceptable).
• Pulse Oximetry: > 95%.
• Blood Pressure: Normal range 50-75/30–45 mmHg.
• SpO2 Targets After Birth (pulse oximetry should be measured on the right hand): 1 minute (60-65%), 2 minutes (65-70%), 3 minutes (70-75%), 4 minutes (75-80%), 5 minutes (80-85%), and 10 minutes (85-95%); avoid over-oxygenating.
• Length: 46-52 cm.
• Weight: 2500 - 4100 g; newborns should return to their birth weight by 2 weeks old.
• Head Circumference: 32–36 cm (measured above the ears and eyebrows).
• Chest Circumference: 30.5–33 cm (typically 2-3 cm less than the head circumference).

Assessment Findings

• Posture: normal findings include extremities flexed, symmetrical movements, and clenched hands. Abnormal findings include limp/floppy limbs and asymmetrical movements.
• Respirations: normal findings include unlabored, diaphragmatic breathing without use of accessory muscles, and with possible crackles. Abnormal findings include apnea and tachypnea/bradypnea.
• Pulse: normal heart sounds, murmurs are common in the 1st 24 hours; abnormal findings include tachycardia and bradycardia.

Integumentary System

• Normal findings include pink, warm skin, acrocyanosis (for up to 24 hours), milia, lanugo, peeling, cracking, hemangiomas, stork bites, and a newborn rash. Abnormal findings include central cyanosis (after 10 minutes of life), jaundice before 24 hours, pallor, petechiae, and a pilonidal dimple.

Head

• Normal findings include molding, fontanels that are soft and intact, and overriding sutures. Abnormal findings that may indicate increased intracranial pressure (ICP) include firm, bulging fontanels, depressed fontanels, bruising or lacerations, caput and cephalohematoma.

Neck

• Normal findings include short neck with skin folds and a positive tonic neck reflex. Abnormal findings include webbing, large thick skin folds, and an absent tonic neck reflex.

Eyes

• Normal findings include equal and symmetrical eyes, absence of edema, white sclera, subconjunctival hemorrhage, and pupils that react to light. Abnormal findings include unequal pupil reactions.

Ears

• Normal findings include the top of the ears aligned with the eyes and well-formed pinna. Abnormal findings include low-set ears, absent startle reflex, and skin tags, which may indicate Down syndrome.

Nose

• Normal findings include a flattened, bruised nose, patent nares, and small amounts of mucus. Abnormal findings include a large amount of mucus, a flat nasal bridge, and nasal flaring, which may indicate Down syndrome.

Mouth

• Normal findings include a pink and moist mouth, intact mucous membranes, a positive suck and gag reflex, and Epstein pearls. Abnormal findings include cyanosis, dry mucous membranes, natal teeth, or cleft lip/palate.

Chest/Lungs

• Normal findings are barrel-shaped and lungs sound clear; crackles in the first few hours after birth may be present. Abnormal findings include retractions, persistent crackles, grunting, or prolonged periods of apnea and decreased breath sounds.

Cardiac

• Normal findings are S1 and S2 sounds and present and equal pulses. Abnormal findings include dextrocardia and persistent murmur.

Abdomen

• Normal findings include a soft and round abdomen and passage of meconium 24 hours. Abnormal findings include asymmetrical or failure to pass mec.

Rectum

• Normal findings include a patent anus and passage of stool. Abnormal findings include imperforated anus, fissure, or fistula.

Female Genitalia

• Normal findings include labia, labia minora, clitoris, edema, pseudomenstration, brick dust, and a midline urinary meatus. Abnormal findings include ambiguous genitalia.

Male Genitalia

• Normal findings include a urinary tip at the tip of the penis, large pendulous edematous scrotum, Testes descend, void 24. Abnormal findings include hypospadias, epispadias, ascended testes, hydrocele, inguinal hernia

Musculoskeletal

• Normal findings include symmetrical number of fingers and toes. Abnormal findings include polydactyly, syndactyly, simian creases, short fingers, wide space toes

Neuro

• Normal findings include Flexed, positive reflexed, sleepy. Abnormal findings include hypotonia, hypertonia, paralysis

Reflexes

• Key newborn reflexes include Moro, tonic neck, rooting, sucking, palmar grasp, plantar grasp, Babinski, and stepping/dancing.

Gestational Age Assessment:

• Ballard score determines the weeks of gestation based on external characteristics
• Used for: No prenatal care, premature, postdates, weight < 2500g or > 4000g, diabetic mothers, NICU admission

Pain Assessment

• Includes; swaddling, non-nutritive sucking, massage, skin to skin, breastfeeding, sensory stimulation, heel warmers, Tylenol and oral sucrose

Medications

• Phytonadione (Vitamin K) (IM) Prevents bleeding

Erythromycin Ophthalmic Ointment

• Erythromycin Ophthalmic Ointment Treats Gonorrhea and Chlamydia

Screening Test

• A genetic disease screen/metabolic screen should be done between 24-48 hours. This test screens for infections, genetic diseases, and metabolic disorders.
• An oxygenation test is done via pulse ox to screen for congenital heart defects

Car Seat Challenge Test

• Performed on premature babies to see if they will experience oxygenation drops
• Check pulse and oxygenation

Circumcision

• Benefits-reduced risk of STI/HIV/UTI/ penile cancer
• Contraindications-preterm, GU defects, bleeding problems

GOMCO / MOGEN

• Removes the foreskin; Vaseline and gauze helps prevent infection
• D/C teaching-Decreases infection risk with Vaseline for 7-10 days

Plastibell

• Skin slowly falls off due to device, without vaseline

Bath

• Support head/neck, clean - dirty, use gloves, educate and swaddle; do it warm room with submersion or sponge bath in warm room between 5-10 min
• DO NOT use baby powder, Q-tips or soap on face

Parent Education

• Bulb syringe
• SIDS
• crying
• safety
• car seat
• cord care
• swaddling between 3-4 hours

Newborn Nutrition and Breastfeeding

• Infant benefits - decrease risk of infections/SIDS
• Mom benefits -Decreased blood loss, decreased infection, increased weight loss and decreased risk of DM/osteoporosis and cancers
• Containdications- passes through breast milk

Formula

• Directions on can
• Do NOT support bottle
• Hold head up

Normal Output

• Formula is DARK and thick with less frequent bowls movements
• Breastmilk is Yellow/Runny with one every feeding

Preterm Infant (< 37 Weeks)

• RDS
• hypothermia,
• hypoglycemia
• Infection
• jaundice
• Breakdown

Newborn Scoring

• Premature prolonged, prolomg infection, small

• Causes bracycardia and blood in storl (apnea)

• Retinopathy: Eye idsease that effects babies/low birth

• Meconium - obstructs airway and causes RDS is common

Persistent Pulmonary Hypertension of Newborn (PPHTN)

• Causes blood failure
• Use suction
• Medications to correct the blood

Hyperbilirubinemia (Jaundice)

• Causes brain damage from high bilirubin

Tests

• Blood/serum
• TCB
• Coomb's

Pharm

• Phototherapy
• Jaundice treatment
• Converts bilirubin to water

S/S of Neonatal Infection

• Increased or decreased temprature
• skin rash
• Diarrhea
• Tremors/seizures

Neonatal Abstinence Syndrome (NAS) can take weeks - months

• The newborn is going through drug exposure.
• Report scores to doctors: do NOT breastfeed.
• Use Small, frequent/skin to skin
• Give Gentle, soothing environment and educate parents

Down Syndrome

-Low-set ears, flat nasal bridge, , Muscular hypotonicity, simian palmer crease

Heel Stick:

• Preformed on the edges of the heels
• do NOT heel stick if jittery, not eating and lethargic