113 Unit 2 Study Guide PDF

113 Unit 2 Study Guide Handouts NTK: - **Congenital abnormalities handout** - **Module N handout** Module N: Newborn (Clinical Prep Lecture 10/22) - **Review handouts, newborn supplement packet**- testable! - CDC screening for congenital disorders - **Med prep sheet** for neonat...

113 Unit 2 Study Guide Handouts NTK: - **Congenital abnormalities handout** - **Module N handout** Module N: Newborn (Clinical Prep Lecture 10/22) - **Review handouts, newborn supplement packet**- testable! - CDC screening for congenital disorders - **Med prep sheet** for neonates after delivery - Know highlighted meds given to mom that can cause respiratory depression in neonates (in folder) - [Butorphanol ] - [Fentanyl ] - [Magnesium sulfate ] - **Ch. 23 p 536-579** for supplementing \- - - - - Module D: Oxygenation/Safe Sleep (Clinical Prep Lecture 10/22) - **Class handout** - Guide to **safe sleep link** in folder on BB - **SIDS and SUIDs** terms link in folder in BB Module A: **Adaptation** - Transition from intrauterine life to extrauterine life - Major adaptation occurs 6-8 hours after birth [Respiratory system ] - Establishment of respiratory function **begins with cutting of umbilical chord** - **Most critical adjustment** as air inflates lungs with first breath Factors that initiate respiratory changes - **Surfactant Synthesis** - Alveolar ducts store and synthesize in 24-38 weeks gestation - [Without surfactant, alveoli cannot open and can cause resp distress ] - Amount increases through gestation - Surfactant can support breathing around 35 weeks - Lecithin sphingomyelin ration **(L-S Ration): 2:1** - **Chemical changes** - Transitory asphyxia during L&D (contractions constricts UC vessels) - Oxygen decreases, CO2 increases, pH drops and becomes acidic - **These changes stimulate chemoreceptors in respiratory center in medulla to initiate breathing** - When cord is clamped, brief period of asphyxia which causes gasp - Prolonged asphyxia can cause respiratory and CNS depression - **Thermal changes** - Baby's temp drops from warm body to environmental temp - **Nerve endings stimulated to initiate breathing** - **Sensory/physical stimuli** - Drying with towel, stimulating foot - **Mechanical stimuli (**compression of lungs through birth canal) - 1/3 of fluid is squeezed out during 2^nd^ stage of labor - [Compression leads to recoil as air is pushed in as they exit canal] - Fluid flows from alveoli across membrane and is reabsorbed - C-section babies are at higher risk for respiratory difficulties due to this - Lungs may sound moist for first 24 hrs Establishment of Respirations depends on: - **Amount of fluid squeezed out during birth** - Too much fluid can increase respiratory effort - **Adequate pulmonary blood flow** - Should be 100% by 24 hrs of life - Establishment of circ function aids in respiration and lung effors - **Capacity for surfactant production** - Premature have less surfactant Respiratory system characteristics - Airway is narrow, tongue is large - Obligate nose breathers - Decreased \# of functioning alveoli in preterms - Bony rib cage not as developed - Capillary network in lungs not fully developed - Mucus membranes delicate - **Normal pattern: Shallow & Irregular** - **Breathes should be unlabored;** symmetric rise and fall - Rate: 30-60 minute - Bradypnea \60 (normal for first few hours) - Short periods of apnea is normal - Apnea \>20 seconds must be evaluated (usually bradycardia and desaturation follows) Signs of respiratory distress - **Tachypnea**- 1^st^ sign! - Nasal flaring - Expiratory grunt - Intercostal retractions - Central cyanosis [Fetal circulation] - Umbilical cord has one vein, two arteries and flow of blood is opposite - **When cord is clamped, switches to normal adult circulation** Basic changes: - **Cord is clamped and causes vessels to constrict** - **Aortic pressure increases**, and venous pressure decreases - **1^st^ breath increases blood flow to heart** - **Systemic BP increases** and pulmonary artery resistance decreases - **All 3 openings in heart close** - Foramen ovale closes (within 1-2 hours) - Ductus arteriosus closes (within 24-72 hours) - Ductus venosus closes (right away) - Murmurs common in first few hours due to shunts being open - **After 24 hours, murmur should disappear**; if not will need ECHO to evaluate - Infants with complications like asphyxia, prematurity, cold, or infection at greater risk of shunts not closing or reopening Circulatory Normal Vitals - **HR 110-160** - **BP 60-80 Systolic/ 40-50 Diastolic (80/50- 60/40)** - **SPO2 \>95%;** if less needs evaluation and should be less than 3% difference in R hand and foot - **RR 30-60** - **Temp 36.5-37.4 (97.8-99.4)** Hematopoietic changes - Total blood volume= 85 mL/kg - Delayed cord clamping increase blood volume, but increases risk for polycythemia - WBC: 9k-30k; will drop to normal values after few weeks - RBC: 4.8-7.1 million - HGB: 14-24; \< 14 anemia - HCT: 44-64%; \>65% polycythemia (delayed cord clamping increases risk) - Platelets: 150,000-300,000 (same as adults) - Cord blood sample may be used to identify baby's blood group and Rh type - Decrease in RBC, H&H in 2-5 weeks due to short life-span of fetal RBC; temporary anemia - Temporary anemia around 2-3 months old [Module C: Newborn Thermoregulation ] - Provide neutral, thermal environment - Goal: **maintain normal core temp and minimal oxygen consumption and calorie expenditure; DRY QUICKLY** and keep baby warm - Newborns have large surface to weight ratio, and blood vessels close to the surface and low insulation putting them at greater risk for issues Baby's production of heat - **Brown fat**: broken down to produce heat - *Pre-term and SGA babies have less,* higher risk for thermos issues - Heat produced by increased metabolic activity - Use O2 and calories to break down brown fat to produce heat - Becoming chilled increases O2 demands and uses up brown fat reserves How does a baby lose heat - **Conduction**: baby [directly contacts cold objects] - Prevent: warm room bed, cover scale, change wet diapers and linens) - **Convection**: [cold air around] baby - Prevent: Keep room warm, put hat on baby, away from drafts/AC, warm O2 if needed - **Evaporation**: when liquid evaporates from baby's warm surface (baby's skin) - Prevent: Dry baby quickly and delay bathing if not stable - **Radiation**: baby is near a cold object and baby's heat is radiated to nearest solid object) - Keep nursery warm, keep baby away from cold windows or walls p6.gif (19684 bytes) Consequences of Hypothermia - Metabolic rate increases when hypothermic causing: - **Hypoglycemia, acidosis, and hypoxia** - **Hypothermic= axillary temp below 36.5 or 97.8** - **Manifestations of cold stress:** pallor, cool to touch, mottling, cyanotic trunk, tachypneic, apnea, bradycardic - Hypothermia can cause a healthy baby to become ill & sick quickly - Newborn should be warmed slowly over 2-4 hour depending on severity - Correct hypoxia, acidosis, and hypoglycemia - **Babies in sepsis often display signs of hypothermia** Consequences of Hyperthermia - **Causes:** maternal fever before birth, direct overheating, overheating environment, sepsis - Neonates have reduced ability to sweat so may appear normal - Overheating causes **increased metabolic rate, increased HR and RR, and be irritable, lethargic, poor feeding** - Can be **[hypotensive and dehydrated]** from water loss - Both Hypo/Hyperthermia can put babies at severe risks Special considerations - Babies at greater risk for [hypothermia:] - **Pre-term** - **SGA** - **Sick -- low temp indicates something is wrong** - **Resuscitation at birth** - **Newborns in respiratory distress** - Babies at greater risk for [hyperthermia:] - **Phototherapy** - **Radiant warmer/incubator** Caring Interventions For Thermoregulation - Early skin-skin contact - Bathing: quick warm and stable - Proper swaddling with skull cap - Change when wet - Room temp: 70-75 - Decreased exposure time during assessments - Educate on parents on skin-skin, room temp, proper dressing, and bathing safety [Hepatic Adaptation] - Enough iron should be in neonates for 4-6 months of life stored in liver to sustain RBC production - IF mom had enough iron intake! - Temporary anemia normal 2-3 months during RBC transition (fetal RBC transitioning) - Iron stores depleted sooner in preterm and SGA babies - **Formula fed should be fed iron-fortified formulas** - Breastfed should be ok until 4 months, then start supps - Iron rich foods or supplement recommended until 6 months of age Liver & CHO metabolism - Initial decrease in serum glucose after birth - **Glucose levels: \> 45 after birth; Greater than 60 by 3^rd^ day of life** - Glycogen stored in liver - Glucose depletion within 24 hrs - Glucose is further depleted by cold, stress, hypoxia, prolonged resuscitation, or lack of nutrition - Anything that requires neonate to work harder to maintain body function - **Increased occurrence of hypoglycemia in**: - Stressed in utero - Preterm - Meconium stained - LGA & SGA - Infant of diabetic mothers - Asphyxiated - Cold stressed - Infected - IUGR - **S/S of hypoglycemia:** - Tremors/jittery - Poor feeding - Hypothermia - Diaphoresis - Weak, high pitch cry - Convulsions - Coma - Usually orders standing to check sugar if showing s/s - Tx of hypoglycemia: - Feed early and frequently - Breastfed, formula, or both - Glucose gel in cheek - Very low or pattern of low= IV D10W [Jaundice] Liver pathophysiology & formation of bilirubin \*do not need to memorize, just understand) - RBC become hemoglobin - Hemoglobin becomes heme & globin - Heme breaks to iron & unconjugated bilirubin - Unconjugated bilirubin carried to liver by albumin - Unconjugated bilirubin becomes conjugated bilirubin - Conjugated bilirubin excreted through feces & urine - Fetal blood cells broken down quicker, so liver can get overwhelmed quickly - At birth newborns liver is slightly immature so cannot process as quick as needed How to check bilirubin levels: - **Transcutaneous bili meter**: measures direct (unconjugated) bili thru skin - Shows up on forehead, spreads down, then clears up in forehead last - [Forehead] gives highest amount of unconjugated - **Total bilirubin**: blood draw measuring total bilirubin (often done if transcutaneous is high) - **Total= indirect + direct** - Indirect: unconjugated - Direct: conjugated Bilirubin levels - Jaundice visible to eyes @ indirect bili of 5-7 - Values to know and report: - **12 hour: less than 6** - **24 hour: less than 8** - **Peak for total bili by 3 days, 12 (term) and \>\_15 (preterm/bf)** - **Bili** **\> 25 can cause encephalopathy & Kernicterus** (irreversible delayed effects on brain caused by bili moving from blood to brain) - Increased levels of unconjugated bili are neurotoxic Types of Jaundice - **Physiologic Jaundice**: caused by increased bili production from short RBC lifespan, liver immaturity, and reabsorption in sm intestine - Occurs in 60% of newborns - Appears at 2^nd^ or 3^rd^ day of life - Yellow tinting - Cephocaudal progression/regression - Lasts less than a week - **Pathologic Jaundice**: caused by blood group incompatibility & hemolytic reaction, or infection/blood disorders - Appears before 24 hours - **Indirect bili increasing by 0.5 or more per hour, or peaks at \> 13 in full term** - May last \> 14 days - Requires immediate attention and interventions - Put on phototherapy sooner - If baby is **[Coombs/DAT+]** bili level is monitored closely b/c at risk of this! - **Breastfeeding Jaundice**: caused by decreased liver clearance of bili due to decreased volume leading to decreased stooling b/c of milk not coming in yet - Babies exclusively bf have delayed liver clearance of bili - Due to delay in milk coming in - 5-10 days of age (delayed onset) Treatment of Hyperbilirubinemia - **Promote feeding to promote stooling** (baby might be too tired) - **Provide hydration** (if too lethargic may need IV to maintain blood sugar) - **Phototherapy** if level high enough - Eye protection - Monitor and read light power - Source of heat so monitor temp - **Exchange transfusion** used as last resort in extreme cases where above interventions do not work (slowly exchanging babies blood) Liver - Coagulation - Coagulation factors activated by vitamin K - Since bowel sterile @ birth, deficiency 2-5 days of life - **Administer vitamin K injection at birth for prophylaxis** [Gastrointestinal System] Concerns at birth: - Sucking & rooting reflexes - Position of nipple in mouth - Bacteria introduced with air and feeding - Bowel sounds heard within 2 hrs after birth - Control of stomach immature - Small stomach volume (15 mL at birth) - Spitting is common - Patent anus observed upon meconium Metabolism - **Decreased ability to absorb carbs and fats until 6 months** - **NO cows milk until 1 year of life** Carbohydrates - Decreased amylase in pancreas Fats - Low amounts of lipase in pancreas Protein - Able to digest well (unless preterm) - **Easily digestible proteins found in breast milk** Initiation of Feedings - **Breastfeeding initiated in 1^st^ 30 minutes** (first period of reactivity) - **Bottle-feeding initiated in 4-6 hours** (when stabilized) - Feeding behaviors observed, recognize feeding cues - If baby sleepy and its been 3-4 hours, wake baby up and assist in feeding - Preterm: NG/OG feedings until gestational age 32-35 weeks - AAP guide for 1^st^ 3 months: 100-120 cal/kg/day - Exclusive BF for 6 months - No solids until after 6 months Stooling - **Meconium**: 1^st^ stool, lasts around 1-3 days - [Made of cells and amniotic fluid] - Sticky & thick - **Transitional**: as intake increases stool changes, mix of meconium and yellow - **Breastfed**: day 5 yellow and seedy/curdy - **Formula**: day 5 yellow and green, peanut butter - First stool should occur within 24 hrs, 3-4 stools per day for first month depending on feeding style Signs of Dehydration - Low wet diapers - Low stools - Sunken fontanels - Sunken, hollow eyes - Dry membranes - Inactive infant - Weight loss (\>7% needs evaluation) - Some weight loss after birth normal, but should be back to birth weight around 7-10 days [Renal System] - 34-36 weeks gestation renal organs functioning - [As blood flow increases, renal perfusion improves] after birth - **GFR low**; newborns unable to dispose of water and solutes rapidly - Overhydration is easy and big concern - GFR rapidly improves - **Limitation of tubular reabsorption**; can lead to inappropriate loss of substance - Initial bladder volume 6-44 mL Renal Characteristics - Voids once in 24 hours, 2x in 2^nd^ day, 3x in 3^rd^ day - 6-8x day after 4^th^ day - Urine is straw color and odorless - Low specific gravity (\