Neonatal Assessment and Care (Part 2) PDF

SN3180 – Childbearing Family Nursing Neonatal Assessment and Care (Part 2) Dr. Shirley Lo School of Nursing The Hong Kong Polytechnic University 2024  1 2 3 Ma...

SN3180 – Childbearing Family Nursing Neonatal Assessment and Care (Part 2) Dr. Shirley Lo School of Nursing The Hong Kong Polytechnic University 2024  1 2 3 Major neonatal Nursing care and Neonatal nutrition, adaptations assessments screening and others ▪ Physiological adaptations ▪ Immediately after ▪ Nutritional needs delivery (delivery ward) ▪ Neurological / ▪ Neonatal screening behavioural adaptions ▪ Subsequent assessment ▪ Neonatal jaundice (postnatal ward) 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  Timing and types of newborn assessments: Timing Types of assessments 71 95 Immediately after Need for resuscitation (e.g. using the Apgar Scoring assigned at 1 and 5 min birth of life) If stable → place with parents to initiate early attachment / bonding Within 1 to 4 hours Progress of newborn adaptations to extra-uterine life (read previous lecture) after birth Determination of gestational age Ongoing assessment for high-risk problems Within first 24 hours Complete all physical examination according to the protocol or before discharge Nutritional status and ability to feed (either breast / bottle / cup feeding) Behavioural state organization abilities Immediately physical assessment after birth Apgar Scoring System: (Dr. Virginia Apgar, 1952, 1958) ▪ a rapid standardized assessment to determine if the newborn is at risk / requires resuscitation ▪ are assigned at 1 minute and 5 minutes of life for all infants ▪ reflects the cardiorespiratory and neurological status at those time points ▪ scores between 0 & 2 in 5 different categories ▪ If score is 1 min after after birth birth or when cord pulsation has ceased World Health Organization, 2023 Delaying Cord Clamping (DCC) … Figure illustrating the mechanisms in placental transfusion through the umbilical vein. Source from Yau & Lind (1982) Placental transfusion: a clinical and physiological study. Neonatal outcomes of delayed cord clamping (ACOG, 2017) About 80-100 ml of blood transfuses from the placenta to the neonate in the first 3 mins after birth, this facilitates transfer of immunoglobulins and stem cells for tissue & organ repair >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 (