Newborn Chapter 9 PDF

Newborn Chapter 9 s Copyright © 2021 by Elsevier, Inc. All rights reserved. Standards of Care  Newborn (Neonatal) period: first 28 days of extrauterine life  Healthy People 2020 objectives  Major focus of many public health effo...

Newborn Chapter 9 s Copyright © 2021 by Elsevier, Inc. All rights reserved. Standards of Care  Newborn (Neonatal) period: first 28 days of extrauterine life  Healthy People 2020 objectives  Major focus of many public health efforts:  increasing breastfeeding rates to provide optimal nutrition  obtaining recommended universal screening panel (RUSP) for state-mandated diseases  reducing the proportion of children with a metabolic disorder who require special education services  increasing the percentage of healthy full-term newborns who are placed to sleep on their backs to prevent infant mortality. Copyright © 2021 by Elsevier, Inc. All rights reserved. 2 Standards of Care  Guide to Clinical Preventive Services and Advisory Committee on Heritable Disorders in Newborns and Children recommend:  Prenatal screening  Promoting breastfeeding  Screening neonates for sickle hemoglobinopathies  Screening for congenital hypothyroidism  Screening for phenylketonuria (PKU) for all newborns before discharge from the nursery  Topical ocular prophylaxis of all newborns  Screening for developmental hip dysplasia  Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents and the American Academy of Pediatrics (AAP) Committee on Practice and Ambulatory Medicine Copyright © 2021 by Elsevier, Inc. All rights reserved. 3  Anatomy and Physiology  Intra-to-extrauterine transition  placenta (responsible for metabolic functions, blood supply to baby)  Umbilical vessels- clamped and severed and newborn begins to breathe  Foramen ovale closes 6 mo-1 yr after birth/ductus arteriosus- within a few days after birth  Pulmonary vascular pressure- drops, allowing blood to flow to lungs for oxygenation  Gastrointestinal tract- absorbs nutrients and expels waste after first feed  Renal system- excretes waste and maintains chemical balance  Liver- metabolizes and excretes toxins  Immunologic system- immature until vaccines are given  Vital signs  First period occurs after delivery- SNS changes (tachycardia, rapid respirations, grunting, flaring, retractions, falling body temp, hypertonus, alertness). PNS changes (bowel sound initiation, oral mucus production)  Second period after an interval of sleep: oral mucus production more evident, HR more labile, newborn becomes more responsive to endogenous and exogenous stimuli, and meconium is passed Copyright © 2021 by Elsevier, Inc. All rights reserved. 4  Anatomy and Physiology Assessment  History: Past maternal, past obstetric (number of previous pregnancies, newborns, abortions, C sections, healthy status of living children), family history (three generation pedigree including genetic/congenital conditions), obstetric history (current maternal health, maternal age, prenatal care, medications, infections, alcohol/drug use, heavy metal exposure, hypertension, glucose intolerance, labor duration, anesthesia, delivery route, polyhydramnios, oligohydramnios, stained meconium, foul smell amniotic fluid, fever), social history (emotional stressors, unplanned pregnancy, financial, emotional support, educational background, anticipated involvement of partner)  Physical Examination  At birth  APGAR- indicated how well the resuscitation efforts succeeded. Determines long term health outcomes (Activity, Pulse, Grimace, Appearance, Respiration). 0-2 score of each.  Gestational Age- based on physical exam. Done within 2 hours of birth to confirm maternal gestational dates. > 90th percentile (LGA), < 10th percentile (SGA). Between 10-90 th percentile (AGA)  Temperature- heat loss rate in newborn is 4x that of an adult. Can fall in a cool, drafty environment. Towel dry newborn after birth and place skin to skin with mom. Use a radiant warmer, warp in warm blanket, cover head when being held by parents  Lungs- Further expulsion of amniotic fluid and high pulmonary vascular resistance ensure with newborn’s first breaths. Careful bulb suctioning. With C section, more intervention required since no squeezing motion to help with respiratory efforts. Newborn lung sounds are bronchovesicular or bronchial sounds. Fine crackles during first few hours of life are normal.  Umbilical cord- has two arteries and one vein.  After Stabilization-after initial assessment in OR, physical assessment is done (gestational age, age in hours, stage of transition)  Screening- done before discharge. Lab data includes maternal syphilis/hepatitis B/HIV, newborn blood type, Coombs test, Hearing screening by 1 month old, CHD and bilirubin screening tests. Administer first Hep B dose. 5  Management Strategies  Initial Care  Establishing Feeding: follow up in 2-3 days to ensure nutrition  Prophylaxis for ophthalmia neonatorum with ointment and vitamin k IM  Anticipatory Guidance Before Discharge  Physical Care  Umbilical cord- leaving cord to air dry and place diaper below cord until it separates. Separation occurs at 10-14 days old. Slight blood discharge will be seen for 1-2 days. Avoid bellybands/coins to cover the navel which can increase infection. Foul smelling discharge around umbilicus, evaluate immediately for sepsis. Apply silver nitrate for a granuloma  Circumcision- decision rests with parents. AAP states no evidence for routine circumcision, but benefits are greater than risks. Lowers chance for UTIs, keeps glans penis cleaner, penile cancer reduction, phimosis, balanitis, adhesions, and urethral meatus occlusion reduction. Gentle cleaning around gential area, don’t force foreskin back, cleanse penis daily with cotton swabs dipped in tap water with a small amt of petroleum jelly on tip of penis for first 2-3 days post procedure with each diaper change  Bathing, Oils, and Powders- do not require dial baths. Mild cleansing agents like Dove, Caress, Neutrogena, Bases, are gentle enough. Avoid oils and powders. Use Keri, Eucerin, Aveeno or Cetaphil for lotion.  Diapers- Frequent changing and proper cleanisng Copyright © 2021 by Elsevier, Inc. All rights reserved. 6 Early Discharge and Follow-up  The Newborns' and Mothers' Health Protection Act Vaginal delivery- 48 hrs in hospital before discharge C section- 96 hours Copyright © 2021 by Elsevier, Inc. All rights reserved. 7 Common Neonatal Conditions Normal skin in newborn- pallor, cyanosis plethora, jaundice, or grey. Copyright © 2021 by Elsevier, Inc. All rights reserved. 8 Head, Face, and Eye Conditions  Both Caput Succedaneum and Cephalohematoma result from prolonged vaginal labor/delivery  Caput Succedaneum- diffuse, superficial swelling of soft tissue on scalp, usually crosses suture lines. Originates from trauma as baby descend through canal.  Clinical Findings- See obvious swelling/bruising in parietal scalp regions, superficial swelling that crosses suture lines, associated with molding/traumatic delivery  Differential Diagnosis- cephalohematoma, subgaleal hemorrhage  Management- no treatment, resolves over first few days of birth  Cephalohematoma- deep collection of blood in the subperiosteal area of the scalp that does not cross suture lines. No surface bruising, results from trauma in a difficult delivery.  Clinical Findings- swelling in parietal area that doesn’t cross suture lines, primigravida history or traumatic delivery, rarely associated with skull fracture, coagulopathy, or intercranial hemorrhage  Differential Diagnosis- caput succedaneum, subaleal hemorrhage, cranial meningocele  Management- no treatment, resolves within a few weeks to months  Craniotabes- thinning of the bone of the scalp seen in premature. This is anormal variation of the parietal bone  Clinical Findings- ping pong ball effect when pressing parietal bone  Management- no treatment, resolves spontaneously. 9  Head, Face, and Eye Conditions  Jaundice- accumulation of bilirubin in skin  Clinical Findings- when bilirubin exceeds 5-7 mg/dL, a cephalocaudal pattern.  Physiologic jaundice- rise in bilirubin from 1-3 mg/dL to 5-6 mg/dL on third day, declining to normal adult level of