Neonatal Assessment and Care (Part 1-3) PDF

BSN-3 Childbearing Family Nursing [SN3180] Neonatal Assessment and Care (Part 1-3) Dr. Shirley Lo School of Nursing The Hong Kong Polytechnic University 2024 Learning outcome: By the end of the lecture, students will be...

BSN-3 Childbearing Family Nursing [SN3180] Neonatal Assessment and Care (Part 1-3) Dr. Shirley Lo School of Nursing The Hong Kong Polytechnic University 2024 Learning outcome: By the end of the lecture, students will be able to: ▪ delineate the physiological & behavioural adaptations that the newborn make during the transition (from intrauterine to extrauterine) stage ▪ explain the mechanism of thermoregulation in the newborn and potential impacts of hypo- and hyperthermia ▪ understanding the process and rationale in assessing a neonate from “head to toes” ▪ recognise new-born infants’ reflexes (differential abnormal responses) ▪ describe nutritional needs of a neonate ▪ discuss immunization program & neonatal screening in HK ▪ identify cases and management of neonatal jaundice ▪ discuss care of neonates at health risk (e.g. infection) and relevant managements  Outline of the NN Lectures: 1 2 3 Neonatal needs: Major neonatal Nursing assessments nutrition, screening adaptations and care and others ▪ Physiological adaptations ▪ Immediately after ▪ Nutritional needs delivery (delivery ward) ▪ Neurological / ▪ Neonatal screening behavioural development ▪ Subsequent assessment ▪ Neonatal jaundice (postnatal ward) Newborn Adaptation to Extra-uterine Life Neonatal period – from birth through the 28th day of life Major adaptations during neonatal transition: the first 6-8 hours after birth Neonatal transition: A) Physiological adaptations: B) Behavioral development: 1. Establishing and maintaining respirations 1. Period of reactivity 2. Adjusting to circulatory changes 3. Regulating body temperature 2. State of organization 4. Endocrine adaptations 3. Sleep-wake pattern 5. Hepatic adaptations 6. Immunologic adaptation 7. Taking in, retaining and digesting nutrients 8. Eliminating waste 9. Regulating body weight 10. Sensory / neurological system The cone-shaped medulla oblongata is formed about 20 weeks of gestation Physiological adaptations: To survive the extra-uterine life, a neonate needs to breathe on its own First, initiating the first breath! https://www.youtube.com/watch?v=EpL3MJ5KHiQ 1 Respiratory Adaptation: Initiating the first breath… Chemical Factor Mechanical Factor Thermal Factor Sensory Factor Uterine contractions + Compression of the chest during vaginal Extra-uterine temp is birth forces ~1/3 of the fluid out of the significantly lower – Handlings with birth: umbilical cord clamping: suctioning, drying, decreased O2 & pH, fetal lungs. from 37oC to 21-23.9oC → sudden chilling of pain, lights, sounds, increased CO2, hence, As the chest is delivered, it recoils (re- the moist newborn smells, all involved in stimulate aortic and expands), generating a negative stimulates receptors in stimulating the carotid chemoreceptors, pressure → draw in air which further skin → stimulate respiratory centre to activating the respiratory replaces airway fluid. respiratory centre in the sustain respirations. centre in the medulla Crying increases the distribution of air oblongata to initiate medulla. in the lungs and promotes expansion of respiration by stimulating the alveoli. diaphragm to contract Crying (positive pressure) helps keep (draws in air). alveoli open. Internal External stimuli stimulus Lung functions must get to work right after birth, it depends on: 1. Surfactant production – a protein manufactured in type II lung cells; helps to decrease alveolar surface tension and hence the contracting force, and helps to prevent alveoli from complete collapsing with each expiration. Surfactant is decreased in infant born before 32 weeks 2. Lung compliance – the ease with which the lung is able to draw in air; surfactant promotes lung compliance 3. Airway resistance – resistive forces of fluid-filled lung necessitates ~30-40 cm H2O pressure to open the lung initially Successful sustaining of respiratory adaptations depends on: Reabsorption of lung fluid - at term, a newborn’s lungs hold ~20 ml of fluid per kg (London et al., 2020) with inspiration & expiration ▪ air distribute in alveoli at the end of expiration, establishing functional residual capacity (FRC) ▪ increase fluid flowing from alveoli across alveolar membranes into pulmonary interstitial tissue ▪ increase fluid absorption via capillary & lymphatic circulation suction (only when indicated) from newborn’s mouth, throat & nose complete absorption of lung fluid takes about 24 hrs Catecholamine – promote fluid clearance from the lungs A fight-or-flight hormone Normal newborn respiration ▪ Appr. 30-60 bpm ▪ Initially shallow and irregular (count for 1 full minute) initially ▪ Diaphragmatic breathing, abdominal movement synchronous with chest movement ▪ Nose breather Abnormal newborn respiration ▪ At rest RR : < 30 or > 60 bpm ▪ Apnea (stop breathing) for >20 sec. (examine analgesic used during labour, e.g. Pethidine / Morphine) ▪ Tachypnea: inadequate clearance of lung fluid ▪ Retraction of ribs (inc. use of intercostal muscles) ▪ Cyanosis: blue skin or lips due to poor oxygenation and/or circulation ▪ Nasal flaring ▪ Expiratory grunting ▪ Stridor or gasping indicate airway obstruction ▪ Seek medical help if the above are noted 2 Fetal circulation: blood moves from R -> L side Bypassing the lungs https://www.youtube.com/watch?v=m3p5PsB6aZ4 copyright@Byte Size Med Fetal circulation: ▪ Umbilical vein – carries oxygenated blood to Ductus venosis to reach the heart sooner (bypassing the liver), via inferior vena cava ▪ Formen ovale – opening between the R. atrium and L. atrium, allows >50% of the blood entering the right atrium to cross immediately to the left atrium (bypassing the pulmonary circulation) ▪ Ductus arteriosus – connects pulmonary artery (from Rt. ventricle) with descending aorta (bypassing pulmonary circulation) ▪ Umbilical arteries (Hypogastric arteries) – 2 vessels from internal iliac arteries return deoxygenated blood to placenta Copyright @ Saunders  Cardiovascular Adaptations ▪ Placenta removed (↓ prostaglandins) & lungs start taking in air (↑ pO2 →) ___ in pulmonary P.; & ___ in systematic P. Umbilical vein: closed upon clamping of the umbilical cord, changed into a ligament. Closure of dutus venosus: becoming ligament Closure of dutus arteriosus: functionally closed almost immediately after birth; becoming ligaments in 1 to 3 months Closure of foramen ovale: functionally closed at birth; gradually fused and permanent closure within a few months or years in most people Closure of umbilical arteries: takes ~ 2-3 months fibrous proliferation; distal portion becoming lateral vesico-umbilical ligaments; proximal portions remaining open as superior vesicle arteries  Ductus arteriosus Ductus venosus Umbilical vein Umbilical arteries Foramen ovale Copy right @ Byte Size Med  [email protected]. Chakkarapani et al. (Nature), 2023 Features of transitional circulation. After cord clamping the systemic vascular resistance increases, lungs aerate and fetal shunts close functionally; the series of changes depicted in the figure allow transition from fetal to neonatal circulation.  Cardiovascular Adaptations Heart rate ▪ Initial heart rate ~110-180 bpm (may be irregular); then 100-160 bpm in the first week, may drop to ~80-100 bpm during deep sleep (Creehan, 2008), becoming more regular ▪ Heart murmur during neonatal period is common (due to incomplete closure of the ductus arteriosus or foramen ovale), may disappear by 6 months ▪ Heart murmur with clinical signs, e.g. poor feeding, apnoea, cyanosis or pallor should be investigated further Blood pressure (at term) ▪ at birth: 75-95/37-55 mmHg; ▪ 12 hrs: 50-70/25-45 mmHg; ▪ 96 hrs: 60-90/20-60 mmHg ▪ Average mean BP is 42-60 mmHg in a resting full-term newborn over 3kg * Not routinely checked unless a specific indication occurs ▪ If the SBP is more than 20 mmHg higher in upper extremities than in lower extremities, further testing may be needed to rule out vascular disease  Cardiovascular Adaptations Blood Volume at birth (term): ~ 80-100 ml/kg (Bagwell, 2007) (*delayed clamping may inc. blood volume (up to 100ml), inc. haematocrit & iron, leading to polycythaemia (NNJ), but usually not harmful) Haemogrobin: ~ 14-24 g/dL (dec. gradually to 12-20 g/dL in 2 weeks after birth) Hematocrit: ~ 43%-63 %; drc. to 39%-59% by week 8 RBC: 4.6-5.2 million/mm3 at birth (life span:80-100 days) WBC: high initially 9,000-30,000/mm3, then drops rapidly to 12,000/mm3 for neonatal period Platelets: 150,000-300,000/mm3 (constant in neonatal period); Vitamin K-dependent clotting factors (II, VII, IX & X) inc. slowly and reach adult levers by 6 months At birth, 70% fetal haemoglobin; by age 6-12 months: only trace of fetal haemoglobin remains (Christensen & Ohls, 2016) Cord management strategies A.A. Chakkarapani, et al., 2023 3 Thermal Regulation Normal axilla To : 36.4-37.2oC According to WHO (1997), neonatal hypothermia is axillary T0 90% of the blood volume transfer was achieved with the first few breaths in healthy term infants Decrease iron deficiency during infancy & childhood increase cognitive, motor and behavioral development Higher ferritin levels until 6 months, and fewer suffered from iron deficiency anaemia (Raju, 2013) Decrease infant needs for blood transfusion for anemia, lower risk of enterocolitis Slightly increase level of bilirubin and incidence of phototherapy, so need to monitor for neonatal jaundice But overall benefits > risks !! Immediate nursing care at birth … 2 ▪ Medications ▪ Vitamin K1 1mg IMI at: vastus lateralis ▪ to prevent vitamin K deficiency bleeding ▪ IMI: 0.5mg for ≤ 1.5kg infant; 1mg for >1.5kg infant, within the 1st hr of life ▪ Oral: vit K1 2mg P.O. (at first feed, 1st wk, 4th wk, 8th wk) – for those who cannot have IMI ▪ Hepatitis B immunoglobulin (HBIG) IMI within the first 12 hrs of life if mother is positive (or known) for Hep. B ▪ HBV 1st dose (0.5ml) IMI for every newborn ▪ Antibiotic eye ointment - prevent infectious neonatal conjunctivitis Copyright @ Pearson 2020 ▪ Identification of infant ▪ show the infant to the birthing mother, identification of gender ▪ Apply ID bracelet to the newborn’s left wrist and left foot ▪ Weighing the infant (~2.5-4kg) ▪ Put cloth / paper protective liner and adjust scale to “0” ▪ low birth weight (LBW) < 2.5kg; big baby (macrosomia) ≥4kg ▪ Possible risk factors: preterm, multiple pregnancy, maternal DM ▪ Maybe postpone after SSC Immediate nursing care at birth … 3 ▪ Promote bonding ▪ Skin-to-skin contact (SSC) ▪ Early skin-to-skin contact with mother can be done: ▪ While she is being attended to (with placenta delivery, suturing of the perineum) ▪ During transfer to postnatal ward or recovery room ▪ During assessments & initial interventions ▪ For the first hour after birth ▪ Start breastfeeding within the first hour after birth if not contraindicated ▪ If the infant is stable, should be placed with parents to initiate early attachment / bonding  Skin-to-skin contact: ▪ After birth, a baby is dried and put directly onto the mother’s bare chest, a warm blanket is used to cover both of them, until after the first feed ▪ SSC can be initiated in the operating theatre and recovery room if mothers who have had caesarean section under Epidural or regional anesthesia ▪ SSC should also be implemented when the mothers who become alert after caesarean section under general anesthesia Use of baby hat ▪ To keep warm ▪ Especially important in very preterm ( 180 bpm when crying ▪ Respiration (count for 1 full min) ▪ 30-60 / min ▪ Predominantly use diaphragm, should be synchronous with abdominal movements ▪ Signs of respiratory distress: tachypnea, nasal flaring, intercostal / subcostal retractions or grunting, suprasternal retractions with stridor / gasping, slow/depressed, apnoea, cyanosis ▪ Blood pressure (an appropriate sized cuff is essential for accuracy) ▪ Assessment of newborn BP is based on facility policy ▪ Varies with gestation and birth weight ▪ Temperature: ▪ Rectal: 37-38oC (only for the first time: to detect for imperforated anus) ▪ Axillary: 36.5-37.5oC Characteristics of a healthy newborn at birth RR – 30-60/min HR – over 100/min Color – pink (mostly) Cries and reacts to light and sounds Body To – 36.5o C – 37.5o C Moves both legs and arms equally Posture – arms and legs are flexed Is able to suck Passes urine within 24 hrs from Movements - active birth; then 6 or more times after 2nd day Has first stool (meconium) within 24 hrs from birth Head-to-toes assessments of the newborn: ▪ General appearance: ▪ Head – proportionally large for its body ▪ Neck – looks short (with chin rests on chest) ▪ Chest – round & with prominent abdomen ▪ Hips - narrow ▪ Muscles – flexed position with good muscle tone ▪ Extremities – looks short ▪ Hands – usually clenched tight  Newborn measurements: Weight: 2.5-4 kg (born between 37 & 41 weeks) Head circumference: 32-37 cm - Measure under the infant’s occiput, Body weight: wrap around the occiput, and measure o At birth, appr. 70-75% is water just above the eye - repeat measurement if molding exists o Physiological weight loss: 5-10% for term infant in the first 3-4 days; regains by D10-14 Chest circumference: 30-35 cm [appro. 2cm less than the HC] o After the 1st week and for the first 6 - Measured across the nipple line months, the newborn’s weight will increase about 7 oz weekly o Potential signs of distress & major Length: 46-56 cm abnormalities if birth weight 90th percentile rump to heel - will grow ~2.5cm/month for the first 6 months. Physical assessment of newborn: Areas assessed Normal findings Head o Symmetry, large (~ ¼ of body size); HC (occipital-frontal circumference): 32-37cm o May be asymmetry: molding (overriding of cranial bones during labor), caput succedaneum, cephalohematoma o 2 soft spots (fontanels), anterior fontanel (1-4cm in size) closes ~18 months, posterior fontanel (