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Well Baby A Clinical Case Study Presented to Manila Doctors’ College of Nursing S.Y. 2023-2024 In Partial Fulfillment of the Requirements for the Subject MATERNAL AND CHILD NURSING Submitted by: Group 1 BSN II-1 Adecer, Denise Laureen C. Andamun, Hasrap C. Espino, Pauline Joy T. Fernandez,Kim Ashley T Gonzales, Ian Francis Kullar, Manjot K. Linao, Julia Louise J. Manzo, David Gilbert Melgar, Christian Ira V. Mendoza, Vana Kaiyah D. Prof. Abogado, Dynah Clinical Instructor Table of Contents Case Abstract 2 Nursing Health History 3 Biographic Data 3 Chief Complaint(s) 3 History of Past Illness 3 Childhood Illness(es) 3 Family History 3 Heredo-familial illnesses 4 Developmental History 5 Environmental History 6 OB/Gyne History 6 Gordon’s Typology of 11 Functional Health Pattern 7 Health Perception/Health Management Pattern 7 Nutritional/Metabolic Pattern 7 Elimination Pattern 7 Sleep-Rest Pattern 8 Self-perception/Self-concept Pattern 8 Role-relationship Pattern 8 Sexuality-reproductive Pattern 8 Coping-stress Tolerance Pattern 8 Value-belief Pattern 8 Activity-Exercise Pattern 8 Physical Assessment 9 General Survey 9 Anthropometric Measurement 9 Vital Signs 9 Physical Examination 9 Neurologic Status 18 Anatomy and Physiology 18 Laboratory Results 52 Drug Study 53 List of Prioritized problems 56 Nursing Care Plan 60 Evidence-based Nursing 70 Ongoing Appraisal 70 Health Teaching Plan 70 Discharge Plan 72 Case Abstract A well baby refers to an infant or young child who is considered healthy. The term “well baby” signifies a child who does not have any apparent health issues or concerns and is growing and developing appropriately for his age. To determine if the patient is a well baby, the health care providers conducted physical examinations and observed the patient’s cry, suck and latch. Patient B.G.C is a newborn admitted at Ospital ng Muntinlupa on September 26, 2023 at 7:40 AM one hour after her birth. The patient was a non institutional delivery baby since she was delivered at home by her mother’s aunt by normal spontaneous delivery at 6:20 AM and was admitted for further newborn care while her mother was for placental delivery. She was transferred from the emergency department to the Obstetrics ward with her mother. She was approved for discharge on September 29, 2023 but was only discharged on October 4, 2023 due to delays with billing. The patient’s chart indicated that she already had a Newborn Hearing Test (NBHT) upon admission on September 26, 2023 but the results were not yet released. The nurses on duty stated that the test results would take at least a month to be finalized. The patient does not have an APGAR score since she was delivered outside the institution only by her mother’s aunt. The basis for determining the patient’s condition were through physical assessments and information from her chart. Patient B.G.C was presented with a good cry, suck, and latch and was identified as a well baby as stated in her hospital chart. The patient was administered Erythromycin eye ointment and BCG, Hepa B, and Vitamin K vaccinations upon admission. Upon assessment for vital signs and physical examinations, all results were in the normal range without complications or abnormalities. The top three nursing diagnoses for patient B.G.C are readiness for enhanced nutrition as evidenced by strong sucking reflex, readiness for enhanced comfort as evidenced by reduced crying when swaddled, and risk for child falls related to unsafe absence of bed rails and bassinets. The health teaching plan created for the patient focused on newborn care discharge instructions after being approved for discharge on October 4 , 2023. Nursing Health History Biographic Data Client’s Initial: B.G.C. Gender: Female Age: 8 days old Date of Birth: 9/26/2023 Educational Attainment: N/A Occupation: N/A Marital Status: N/A Place of Birth: Ospital ng Muntinlupa Date of Admission: 9/26/2023 7:40:00 am No. of days in hospital: 8 days Order of Admission: Carried by the mother Source of Information: Mother Chief Complaint(s) For further newborn care (Non-institutional Delivery) History of Past Illness The following information is not applicable to newborns. Childhood Illness(es) Childhood illness(es) The following information is not applicable to newborns. Childhood/adult immunization(s) BCG Vaccination, Hepatitis B Vaccination, Vitamin K, Erythromycin eye ointment Accidents and Injuries The following information is not applicable to newborns. Previous hospitalization/surgery The following information is not applicable to newborns. Medication prior to confinement The following information is not applicable to newborns. Family History General Family Information: Name Relation Age Gender Occupation Educational Attainment Diseases/Disorder J.C. Mother 29 Female Housewife Finished Grade 3 None H.U. Father 32 Male Construction Worker Finished Grade 3 None L.J.C Sibling #1 12 Female Student Grade 6 None C.U.C Sibling #2 11 Male Student Grade 3 None N.C. Sibling #3 10 Female Not as student Not applicable Undiagnosed Special Child A.C. Sibling #4 9 Female Student Grade 3 Pneumonia E.C. Sibling #5 1y 3m Male Not as student Not applicable None Heredo-familial illnesses: According to her mother, Patient B.G.C’s maternal grandfather died due to heart attack and her maternal grandmother died due to Leukemia. On the other hand, the patient's paternal grandfather's death is attributed to a heart problem, although it is not specified, while the patient's paternal grandmother’s cause of death is undetermined. The patient’s aunts and uncles from both paternal and maternal sides are alive and well. The patient’s mother and father are alive and well. The patient has 5 siblings and all of them are alive and well but the fourth sibling has a history of pneumonia. Developmental History Theory Age Developmental Task Client Description Interpretation Psychosexual 0 Oral Stage (Between infancy and two years old) (Sigmund Freud, 1902) Patient B.G.C sucks her mother’s nipple for feeding. The developmental stage is appropriate for the patient. The patient’s need for nutrition is achieved through sucking her mother’s nipple. Psychosocial 0 Trust vs. Mistrust (Erik Erikson, 1950) Patient B.G.C puts trust in her mother to meet basic needs such as nutrition. The developmental stage is appropriate for the patient. The patient depends on her mother because of her age and lack of capabilities. When the patient cries, her mother immediately accompanies her by breastfeeding. The patient stops crying because of the bond formed by trust. Cognitive 0 Sensorimotor Stage (Jean Piaget, 1936) Patient B.G.C coordinates with her mother using verbal and motor responses such as crying. The developmental stage is appropriate for the patient. The patient uses signs to inform her mother about her needs. The baby cries when hungry and while undergoing physical examinations which shows how the patient uses actions to show her demands. Moral 0 Id an unconscious component wherein selfishness is seen to immediately alleviate stress. (Sigmund Freud, 1910) Patient B.G.C cries when she is hungry and does not stop until she is breastfed. The developmental stage is appropriate for the patient. The patient cries when she is hungry without being considerate about the time or place. Selfishness is seen with this stage; the patient’s stress must be solved immediately for her to return back to being calm. Spiritual Not Applicable to Newborns Environmental History According to the patient’s mother, patient B.G.C. will reside in Muntinlupa City in a nuclear family setup, living with the patient’s parents and siblings in the same household. Their home is conveniently located, with easy access to the hospital which is one jeep ride away, health center, wet market, and a tricycle terminal. Although their house is closely adjacent to other houses, it has minimal noise disturbances, except during events like fires which seasonally occur in summer. The family's residence is a modest bungalow built with wood, cement, and iron sheet roofing with one entrance door, one jalousie window near their entrance door for ventilation, and a single bedroom. Their living room, kitchen, and dining room are combined into a single space. Regarding utilities, the family relies on Maynilad for water supply and is connected to the Meralco grid for electricity. Their means of transportation is by public vehicle, and their means of disposal is through plastic bags that they place outside their house and is sometimes being collected once a week. Gordon’s Typology of 11 Functional Health Pattern Health Perception/Health Management Pattern The following information is not applicable to newborns. Nutritional/Metabolic Pattern Presently, the patient’s mother adheres to the standard frequency of breastfeeding 8 times a day. The patient breastfeeds every 3 hours and per demand. There are no vitamins and supplements that are being taken together with breastmilk. The patient has experienced a physiologic weight loss from 3.8 kg to 3.6 kg. The patient had a good appetite, and is breastfeeding for 15 minutes per breast. The patient has no problem swallowing and sucking. Analysis: Breast milk alone is the best nutrition for your baby for about the first six months of life. All of the nutrition that he or she will need during this time is provided by breast milk. In the beginning, breastfed babies usually need to eat every two to three hours. Your baby is probably getting enough if you find frequent wet and dirty diapers, he or she looks satisfied after feeding, and your healthcare provider says that your baby is growing well. The amount your baby eats may change from day to day and meal to meal as he or she goes through growth spurts. (Olson, n.d.). Proper infant nutrition is fundamental to a child’s continued health, from birth through adulthood. Correct feeding in the first three years of life is particularly important due to its role in lowering morbidity and mortality, reducing the risk of chronic disease throughout their life span, and promoting regular mental and physical development. (Infant Nutrition - Global, n.d.). All newborns will lose some weight after birth due to fluid shifts and limited caloric intake in the first few days of life. Infants may lose up to 10% of body weight but should regain this by 2 weeks of age. After this initial period of weight loss, newborns are expected to gain ½ ounce to 1 ounce (15–30 g) per day. Generally, infants will double their birth weight by age 6 months and triple it by 1 year. (Science Direct, 2023) Interpretation: The patient’s nutritional pattern is good and not altered as evidenced by her good sucking reflex and no difficulty in swallowing which is why the patient also has a good appetite as stated by her mother. It is normal to lose 7–10% of weight in the first week of life (physiologic weight loss) so losing weight doesn’t necessarily indicate that the patient is not receiving proper and adequate nutrition but should regain that weight within the first 2 weeks or so after birth. Elimination Pattern Presently, on the sixth day, the patient's mother reports changing the diaper five to six times a day, depending on the patient's needs, primarily due to urine and occasional stool. Over the course of three days, as per the group's rotation, a consistent pattern emerged. On the initial day, it was observed and noted on the chart that the patient changed diapers six times, with six diapers containing clear-colored urine and three diapers containing seedy yellow wet stool. Subsequently, on the second and third days, there were five diaper changes each, with two diapers containing stool and five diapers containing urine. Notably, the observed stool was described as seedy wet yellow, while the urine remained clear. Analysis: The intermittent stool pattern demonstrates the expected variability in newborn bowel movements as their gastrointestinal systems adapt to feeding patterns (AAP, 2020). Notably, the description of clear-colored urine throughout this perNewbornsiod is indicative of proper hydration, a positive sign of adequate fluid intake and renal function (American Academy of Family Physicians, 2020). Stools are meconium at birth, brown by day 2, green by day 3 or 4, and then seedy yellow on the following days. The newborn usually has one or more stools daily by day 5 (Pillitteri, A., 2014). Interpretation: The intermittent nature of stool passage aligns with the developmental variability in newborn bowel habits. The presence of seedy yellow stool is a normal and expected component of fifth to sixth day elimination for newborns. This suggests that the newborn's gastrointestinal system is undergoing the natural process of adaptation and maturation. The maintenance of clear urine throughout the observed period is a positive sign of adequate hydration, reflecting proper fluid intake and renal function Sleep-Rest Pattern Presently, the mother of patient B.G.C states that the patient sleeps for about 4 hours and wakes up to breastfeed for around 30 minutes before going back to sleep. The patient does not have a regular sleep and wake schedule but her mother states that the patient sleeps for either 20-40 minutes or 2-4 hours until waking up for breastfeeding. Analysis: The reported sleeping pattern of patient B.G.C, as described by the mother, indicates a sporadic sleep schedule without a consistent pattern of duration or timing. The infant appears to alternate between short naps lasting 20-40 minutes and longer sleep lasting 2-4 hours, followed by waking for breastfeeding sessions lasting around 30 minutes. It's important to note that newborns often have irregular sleep patterns, characterized by frequent waking for feeding due to their small stomach capacity and rapid growth needs. (Stanford Medicine Children’s Health, n.d.). Interpretation: The reported sleep pattern seems within the range of normal for a newborn. Over time, newborns gradually develop more organized sleep patterns and longer periods of sleep at night. This erratic sleep cycle is typical for infants in their early stages, as their sleep-wake cycles are not fully developed. Babies often experience shorter sleep cycles, with frequent awakenings due to hunger, discomfort, or the need for parental care and attention. Cognitive-Perceptual Pattern The following information is not applicable to newborns. Self-perception/Self-concept Pattern The following information is not applicable to newborns. Role-relationship Pattern The following information is not applicable to newborns. Sexuality-reproductive Pattern The following information is not applicable to newborns. Coping-stress Tolerance Pattern The following information is not applicable to newborns. Value-belief Pattern The following information is not applicable to newborns. Activity-exercise Pattern The following information is not applicable to newborns. Physical Assessment General Survey Body Built: Endomorph Grooming/Hygiene: Well-groomed Posture & Gait: Lying Body Odor and Breath Odor: No noted body odor Signs of Distress: None Obvious Signs of Illness(es) None Orientation: Time (N/A) Person (N/A) Place (N/A) Level of Consciousness: N/A Affect: N/A Mood: N/A Quantity & Quality of Speech: Strong cry per demand Organization of thoughts: N/A Anthropometric Measurements Height 47 cm Weight 3.65 kg or 3650 g IBW/BMI 16.52 Head circumference 35 cm Abdomen circumference 29 cm Chest circumference 32 cm Body length 47 cm Vital Signs Date and Time: 9/26/2023 Time Performed: 0740H Temperature: 36.9 C Fetal Heart Rate: 133 bpm Respiratory Rate: 38 cpm Date and Time: 10/2/2023 Time Performed: 1200H Temperature: 36.4 C Fetal Heart Rate: 145 bpm Respiratory Rate: 54 cpm Date and Time: 10/3/2023 Time Performed: 0800H Temperature: 36.9 C Fetal Heart Rate: 130 bpm Respiratory Rate: 45 cpm Date and Time: 10/4/2023 Time Performed: 0800H Temperature: 37.0 C Fetal Heart Rate: 140 bpm Respiratory Rate: 49 cpm Physical Examination Body Part Normal Findings Actual Findings Analysis & Interpretation Skin Newborn skin color ranges from pale white with pink, yellow, brown, or olive tones to dark brown or black. No strong odor should be evident and the skin should be lesion free. Skin is normally a warm temperature. It may also be soft and slightly moist. The newborns’ skin may contain birthmarks or moles. Skin turgor should have quick recoil. (Weber, Kelly Health Assessment in Nursing 5th edition, pg. 747-750) The skin color is light brown and it is evenly distributed without unusual discolorations. There is no strong odor noted and the skin is free from lesions. The skin is soft and warm to touch. There are no birthmarks or evident moles detected. The skin turgor is less than 2 seconds. Analysis: Newborn babies can have a wide range of skin colors, including variations of light brown. A baby's skin color at birth may not necessarily be the final or permanent skin color. Babies can have a variety of skin colors when they are born and it can change over time and should settle fully at around 20 months old. Interpretation: NORMAL Haghighi, A. S. (2021, September 10). Babies and skin color: A guide. Hair The hair is lustrous, silky, strong and elastic. Lanugo is fine, downy hair that covers parts of the body, such as shoulders back, and sacral area, may be seen in the newborn or young infant (Health Assessment in Nursing. 7th edition by Weber and Kelley pg. 729 & 749) The hair has a smooth texture. The lanugo covers most parts of the body in thin layers, especially the sacral area, shoulders and back. The color of the hair is dark. Analysis: The texture and color of an infant's hair can vary widely. Soft, fine hair is typical, often referred to as lanugo, which is more prominent in premature babies. (Health Assessment in Nursing. 7th edition by Weber and Kelley pg. 729 & 749) Interpretation: NORMAL Nails Fingernails should be soft and smooth, and extended over the fingertips. Pink tones returns immediately (less than seconds) to blanched nail beds when pressure is released (Health Assessment in Nursing. 7th edition by Weber and Kelley pg. 266-267) Fingernails are soft, smooth, and extend over the fingertips. Capillary refill of both fingers returns less than 2 seconds. Analysis: Newborns typically have soft and flexible fingernails and toenails. While their initial softness is beneficial, overly long or jagged nails can pose discomfort to the baby or those around them. (Kaneshiro, 2021). Interpretation: NORMAL (Health Assessment in Nursing. 7th edition by Weber and Kelley pg. 266-267) Head & Face The head should be normocephalic and symmetric. The anterior fontanel should not appear indented (a sign of dehydration) or bulging (a sign of increased intracranial pressure). Face is normally proportionate and symmetric. Movements are equal bilaterally. (Weber, Kelly Health Assessment in Nursing 5th edition, pg. 747-750) The head is normocephalic and is symmetric. The fontanels are felt as a soft spot and do not appear intended or bulging. Face is proportionate and symmetric. The movements are bilaterally equal. Analysis: An infant is born with two major soft spots on the top of the head called fontanels. These soft spots are spaces between the bones of the skull where bone formation isn't complete. This allows the skull to be molded during birth. It's normally slightly depressed and pulsates. Soft spots are covered by a thick fibrous layer and are safe to gently touch. Baby’s soft spots (fontanels). (2022, January 20) Interpretation: NORMAL Eyes Eye movement should be smooth and symmetric throughout all six directions. Skin on both eyelids is without redness, swelling or lesions. Eyeballs are symmetrically aligned in sockets without protruding or sinking. Sclera and conjunctiva are clear and free of discharge Pupils are brown, equal, round, and reactive to light and accommodation Eyebrows should be symmetric in shape and movement. Eyelashes should be evenly distributed and curled outward. (Weber, Kelly Health Assessment in Nursing 5th edition, pg. 308-318) Eye movement appears dysconjugate, where the eyes move independently Skin on the corners of the eyes are without lesions, redness, purulent discharge, and are not swelling. Eyeballs are symmetrical, they are aligned in the sockets. It is not protruding or sinking. Both the sclera and conjunctiva are clear, minimal discharge of clear fluid due to crying after 15 mins of assessment Pupils were dark brown, round, and were able to constrict and dilate as penlight was flashed. Eyebrows are symmetric in shape. Eyelashes are evenly distributed and are culerd outward. Analysis: During the first few months of life, newborns will frequently have disconjugate eye movements, where the eyes appear to move independently. Eyes may transiently appear crossed or divergent. This phenomena is particularly noticeable when the infant is falling asleep or being woken from sleep. Eyes. (n.d.-b). Newborn Nursery. Interpretation: NORMAL Ears Top of the pinna should cross the eye-occiput line and be within a 10° angle of a perpendicular line drawn from the eye-occiput line to the lobe. No unusual structure or markings should appear on the pinna. No excessive cerumen, discharge, lesions, excoriation, or foreign body in the external canal. A newborn will exhibit the startle (Moro) reflex and blink eyes ( acoustic blink reflex) in response to noise older infants will turn head (Health Assessment in Nursing. 7th edition by Weber and Kelley) The top of the pinna of the patient was across the eye occiput line to the lobe. Upon observation to the external ear of the patients there's no excessive cerumen, lesions, discharged or foreign body The patient exhibit the startle reflex when they hear noises Analysis: The inner ear develops during the first trimester of gestation. Therefore, maternal problems during this time such as rubella may impair hearing. Newborns can hear loud sounds at 90dB and react with startle reflexes. They respond to low-frequency sounds, such as heartbeat or a lullaby, by decreasing crying and motor reflex. They react to high-frequency sounds with an alerting reaction. (Health Assessment in Nursing. 7th edition by Weber and Kelley pg. 729 and 752) Interpretation: NORMAL Nose Nose is midline in face, septum is straight, and nares are patent. No discharge or tenderness is present. The nasal septum should be straight and both nares should be patent. Turbinates are pink and free of edema. Milia are small, white papules found on the nose, forehead, and chin. They develop from retention of sebum in sebaceous pores. They usually resolve spontaneously within a few weeks. (Weber J., Kelly J., Health Assessment in Nursing 7th edition. pg.753) Nose is in the midline and is symmetric. Septum is straight and not deviated. No discharge and lesions are present in the nose The nares do not have any discharge and the turbinates are equally pink in color. Analysis: Newborns are obligatory nose breathers and, therefore, have significant distress when their nasal passages are obstructed. Milia is a normal finding present at birth and usually goes away on its own after a few weeks without treatment. (Weber J., Kelly J., Health Assessment in Nursing 7th edition p.753) Interpretation: Normal Mouth & Pharynx Mouth should open evenly when he or she cries. Epstein pearls (small, yellow-white retention cysts on the hard palate and gums) are common in newborns and usually disappear in the first weeks of life. Drooling persists for a few months until the infant learns to swallow the saliva. Gums appear pink and moist. Teeth may begin erupting at 4-6 months. Tonsils should not be visible. Frenulum must be in midline. (Weber J., Kelly J., Health Assessment in Nursing 7th edition, pg. 729) (JoAnne Silbert-Flagg, Adelle Pillitteri, Maternal & Child Health Nursing 8th edition, Care of the childbearing and childrearing family, pg. 996) The mouth opens evenly when the patient cries. There is a presence of epstein pearls on the hard palate. There is minimal saliva. The gums are pink in color. No lesions and edema were observed during the assessment of gums and tongue. Tonsils are not visible. The frenulum is in the midline. Analysis: Saliva is minimal at birth, but drooling is evident by 3 months. Tonsils and adenoids are small in relation to body size and are hard to see at birth. Epstein pearls have no other symptoms. They cause no other symptoms with feeding or teething. (Weber J., Kelly J., Health Assessment in Nursing 7th edition, p. 729) Interpretation: NORMAL Neck The neck should be symmetric, with the head centered and without any bulging masses. The neck is usually short with skinfolds between the head and shoulder during infancy. Lymph nodes are usually non-palpable in infants. There is no swelling or enlargement, no hardness, and no tenderness of lymph nodes. Trachea should be midline The neck should have no signs of bruising or any lesions, clear and smooth skin. Clavicles should be symmetrical and intact. (JoAnne Silbert-Flagg, Adelle Pillitteri, Maternal & Child Health Nursing 8th edition, Care of the childbearing and childrearing family, pg. 997) (Weber, Kelly Health Assessment in Nursing 5th edition, pg. 751) Neck is symmetric without masses or lesions. Lymph nodes are not palpable. Trachea is located midline. No scars or lesions or redness noted on the neck. Clavicles are symmetric. Analysis: The neck is usually short during infancy lengthening at about 3-4 years of age. Lymphoid tissue is well developed at birth and reaches adult size by 6 years. Lymph nodes are usually non palpable in infants. (Weber J., Kelly J., Health Assessment in Nursing 7th edition, p. 729) Interpretation: NORMAL Spine Spine is flexible with convex dorsal and sacral curves; No unnatural spinal curvatures. Spine should be straight (when observed from behind) without signs of infantile scoliosis. Posture is lying (JoAnne Silbert-Flagg, Adelle Pillitteri, Maternal & Child Health Nursing 8th edition, Care of the childbearing and childrearing family, pg. 1001) There are no unnatural spinal curvatures. The spine is straight when viewed from behind and not deviated; C-shaped(round) viewed from the side. Posture is lying, with hips flexed and knees bent with the legs and feet crossed; legs and feet curved inward. Analysis: In infants younger than 3 months, children have a C-shaped spine(rounded spine); viewed from the side. Secondary curves in the cervical and lumbar spine develop as infants become able to lift their heads, sit up, crawl, stand, and walk. During the first several weeks, babies tend to keep their fists clenched, elbows bent, hips and knees flexed, and arms and legs held close to the front of their body. This position is similar to their position in the womb during the last months of pregnancy. (Experts, K. M. (Ed.). (2023a, January). Getting to know your newborn (for parents) - nemours kidshealth. KidsHealth.) (Spine problems. Spine Problems | Boston Children’s Hospital. (n.d.). ) Interpretation: NORMAL Thorax/Lungs Posterior: Hyperresonance is the percussion tone elicited over normal lung tissue. Flatness is detected over muscles and bones Infant’s thorax is smooth, rounded, and symmetric The lungs are clear bilaterally No adventitious sound should be heard Anterior Hyperresonance is the percussion tone elicited over normal lung tissue. Percussion elicits flat tones over the scapula The lungs are clear bilaterally No adventitious sound should be heard (Weber, Kelly Health Assessment in Nursing 5th edition, pg. 753-754) Posterior: Upon percussion, flat sound on areas of bone, dull on areas of organs, hyperresonant on lungs Shape of thorax is symmetric Upon auscultation, breath sounds are clear Adventitious sounds not present Anterior: Upon percussion, flat sound on areas of bone, dull on areas of organs, hyperresonant on lungs Upon auscultation, breath sounds are clear Adventitious sounds not present Analysis: Hyperresonance is a low-pitched but is more of a booming sound in terms of sound quality and has a longer duration. Hyperresonance can be a normal lung sound in infants with thin chest walls when percussing because of the round anatomical shape of their thorax. (Lapim, J. (2021, January 1). Percussion. Pressbooks.) Interpretation: NORMAL Cardiovascular/Heart The apical pulse is at the fourth ICS until the age of 7 years, when it drops to the fifth, it is to the left of the MCL until age 4 Innocent murmurs, which are common throughout childhood, are classified as systolic; short duration; no transmission to other areas; grade III or less; loudest in pulmonic are; low-pitched, musical, or groaning quality that varies in intensity in relation to position, respiration, activity, fever, and anemia. No other associated signs of heart disease should be found. Pulse is regular and within a range of 120-140 beats/min while at rest. The rate may rise to 180 beats/min when crying or fall to 100 beats/min when sleeping. (Weber J., Kelley J., Health Assessment in Nursing (7th Edition) p. 740, pp. 754-755) Jugular vein not distended No bruits Carotid artery palpable and not distended No visible pulsations S1 and s2 heard No s3 and s4 All pulse points felt Epitrochlear lymph node not palpable No varicosities Fetal Heart Rates: 138 bpm (9/26/23 - 0740H) 145 bpm (10/2/23 - 1200H) 130 bpm (10/3/23 - 0800H) 140 bpm (10/4/23 - 0800H) Analysis: The first and second heart sounds are normally clear and well defined. The second sound is somewhat higher in pitch and sharper than the first. Heart rates normally fluctuate between 120 and 160 beats per minute. In agitated states, a rate of 200 beats per minute may occur transiently. (O’Brien, J, Rinehart, T, et al, Glob. libr. women's med., 2009) Interpretation: NORMAL Abdomen The abdomen is prominent in supine position in a cylindrical shape. Umbilicus is pink, with no discharge, odor, redness, or herniation. The liver is palpable at 1 to 2 cm below the right costal margin. Abdomen is soft to palpation and without masses or tenderness. Spleen tip and tip of the right kidneys may be palpable during inspiration Bladder may slightly be palpable Normal bowel sounds occur every 10-30 seconds. (Weber J., Kelley J., Health Assessment in Nursing (7th Edition) p. 755 - 756) The abdomen is symmetrical in supine position with a cylindrical shape. The umbilicus is pink with the remnant of the cord appearing dry and black in color. Liver is palpable. The abdomen is soft to palpation without the presence of lesions, masses, tenderness, and redness. Spleen tip, tip of the right kidneys, and bladder were slightly palpable during inspiration Bowel sounds occur every 25 seconds. Analysis: The edge of the liver is normally palpable below and often as far as 3 cm inferior to the right costal margin. The tip of the spleen can sometimes be felt in normal infants. (The Global Library of Women’s Medicine’s, n.d.) Interpretations: NORMAL Musculoskeletal Full ROM and no swelling, redness, or tenderness. Feet and legs are symmetric in size, shape, and movement. Extremities should be warm and mobile, with adequate capillary refill. All pulses (radial, brachial, femoral, popliteal, pedal) should be strong and equal bilaterally. There is an inward (pointing toward center of the body) positioning of the forefoot with the heel in normal straight position; it resolves spontaneously. Tibial torsion, also common in infants and toddlers, consists of twisting of the tibia inward or outward on its long axis and is usually caused by intrauterine positioning; this typically corrects itself by the time the child is 2 years old. Equal gluteal folds and full hip abduction are normal findings Negative Ortolani sign is normal. Negative Barlow sign is normal. In newborns, the spine is flexible, with convex dorsal and sacral curves. In infants younger than 3 months, the spine is rounded Muscle size and strength should be adequate for the particular age and should be equal bilaterally. (Weber J., Kelly J., Health Assessment in Nursing 7th edition, pg. 757-759) Full ROM and no swelling, redness, or tenderness. Feet and legs are symmetric in size, shape, and movement. Extremities are warm and mobile, with adequate capillary refill. All pulses (radial, brachial, femoral, popliteal, pedal) are strong and equal bilaterally. There is an inward (pointing toward center of the body) positioning of the forefoot with the heel in normal straight position and resolves spontaneously. Full hip abduction Negative Ortolani sign Negative Barlow sign Muscle size and strength is adequate and equal bilaterally. Analysis: For the Barlow maneuver, the clinician adducts the hip (ie, the knee is drawn across the body) while pushing the thigh posteriorly. A felt but not heard clunk indicates that the head of the femur has moved out of the acetabulum; the Ortolani maneuver then relocates it and confirms the diagnosis. For the Ortolani maneuver, the hip is returned to the starting position; then the hip being tested is abducted (ie, the knee is moved away from the midline toward the examining table into a frog-leg position) and gently pulled anteriorly. A palpable clunk of the femoral head with abduction signifies movement of an already dislocated femoral head into the acetabulum and constitutes a positive test for hip dysplasia (Consolini, 2023) Interpretation: Normal Neurologic Status Cranial Nerves Reflexes Sensory Function I Not tested IX Not tested Biceps Reflex Not tested Touch: +2 II Not tested X Not tested Triceps Reflex Not tested Pain: Not tested III, IV, VI (intact) Brachioradialis Reflex Not tested Temperature: Not tested V Not tested XI Not tested Patellar Reflex Not tested Position: Not tested VII Not tested XII Not tested Achilles Reflex Not tested Tactile Discrimination: Not tested VIII Not tested Plantar/Babinski Reflex 2+ Rooting Reflex +2 Sucking Reflex +2 Palmar Grasp +2 Tonic Neck Reflex +2 Moro Reflex +2 Landau Reflex * Scoring (+1, +2…) Anatomy and Physiology Integumentary system consists of the skin and accessory structures, such as hair, glands, and nails. integument means covering and the integumentary system covers the outside of the body and is easily observed. The skin is made up of two major tissue layers: the epidermis and the dermis. Functions of the Integumentary System Protection. The skin provides protection against abrasion and ultraviolet light. it also prevents microorganisms from entering the body and reduces water loss, thus preventing dehydration Sensation. The integumentary system has sensory receptors that can detect heat, cold, touch, pressure, and pain. Vitamin D production. When exposed to ultraviolet light, the skin produces a molecule that can be transformed into vitamin D, an important regulator of calcium homeostasis. Temperature regulation. The amount of blood flow beneath the skin’s surface and the activity of sweat glands in the skin both help regulate body temperature. Excretion. Small amounts of waste products are lost through the skin and in gland secretions. Epidermis Most superficial layer of the skin. The epidermis is stratified squamous epithelium and rests on the dermis, which is a layer of dense connective tissue. The many cells of the epidermis prevent water loss and resist abrasion. The outermost cells protect the cells underneath, and the depper, replicating cells replace cells lost from the surface. During their movement, the cells change shape and chemical composition, a process called keratinization. The term keratinization reflects the fact that the cells become filled with the protein keratin, which makes them more rigid and durable. As keratinization proceeds, epithelial cells eventually die and form an outer layer of dead, rigid cells that resists abrasion and acts as a permeability barrier. Although keratinization is a continuous process, distinct cellular characteristics can be recognized. These characteristics are used to divide the epidermis into layers called strata. Strata From the deepest to most superficial layers, the five strata are: stratum basale stratum spinosum stratum granulosum stratum lucidum stratum corneum Stratum Basale Consists of cuboidal or columnar cells that undergo mitotic divisions every 19 days. Stratum Spinosum This takes on a flattened appearance and accumulates lipid-filled vesicles called lamellar bodies. Stratum Granulosum Flat and diamond shaped. The cells accumulate more keratin and release the contents of the lamellar bodies to the extracellular space. Stratum Lucidum A thin, clear zone between the stratum granulosum and stratum corneum. The stratum lucidum is present in certain areas of the body. the cells of this stratum no longer have nuclei or organelles, and as a result, the cells stain more lightly. Stratum Corneum Most superficial stratum of the epidermis. It consists of dead squamous cells filled with keratin. Keratin gives the stratum corneum its structural strength. The stratum corneum cells are also coated and surrounded by lipids released from the lamellar bodies of the skin cells. These lipids act as waterproofing material, thereby preventing fluid loss through the skin. Dermis The dermis is composed of dense collagenous connective tissue containing fibroblasts, adipocytes, and macrophages. Nerves, hair follicles, smooth muscles, glands, and lymphatic vessels extend into the dermis. Collagen and elastic fibers are responsible for the strength of the dermis. The collagen fibers of the dermis are oriented in many different directions and can resist stretch. Subcutaneous Tissue The skin rests on the subcutaneous tissue, or hypodermis. The subcutaneous tissue is not part of the skin but instead attaches the skin to underlying bone and muscle and supplies it with blood vessels and nerves. The subcutaneous tissue is loose connective tissue, including adipose tissue that contains about half the body’s stored lipids. Hair In humans, hair is found everywhere on the skin, except on the palms, the soles, the lips, the nipples, parts of the genitalia, and the distal segments of the fingers and toes. In neonates, lanugo is soft, fine hair covering the fetus while inside the uterus. Lanugo helps protect them and keeps them warm while they grow. Each hair arises from a hair follicle, an invagination of the epidermis that extends deep into the dermis. The shaft of the hair protrudes above the surface of the skin, whereas the root is below the surface. The hair bulb is the expanded base of the root. A hair has a hard cortex, which surrounds a softer center, the medulla. The cortex is covered by the cuticle, a single layer of overlapping cells that holds the hair in the hair follicle. Because the hair follicle is composed of epithelial tissue, hair follicles can play an important role in repair of the skin. Hair is produced in the hair bulb, which rests on the hair papilla. The hair papilla is an extension of the dermis that protrudes into the hair bulb. Blood vessels within the papilla supply the hair bulb with the nourishment needed to produce hair. Hair is produced in cycles of growth and rest. During the growth stage, a hair is formed by epithelial cells within the hair bulb. These cells, like the cells of the stratum basale in the skin, divide and undergo keratinization. The hair grows longer as these cells are added to the base of the hair within the hair bulb. Thus, the hair root and shaft consists of columns of dead keratinized epithelial cells. During the resting stage, growth stops and the hair is held in the hair follicle. When the next growth stage begins, a new hair is formed and the old hair falls out. Hair color is determined by varying amounts and types of melanin. The production and distribution of melanin by melanocytes occurs in the hair bulb by the same method as in the skin. Sebaceous Glands Sebaceous glands are simple, branched acinar glands. Most are connected by a duct to the superficial part of a hair follicle. They produce sebum, an oily, white substance rich in lipids. The sebum is released by holocrine secretion and lubricates the hair and the surface of the skin, which prevents drying and protects against some bacteria. Eccrine Sweat Glands Simple, coiled, tubular glands and release sweat by merocrine secretion. Eccrine glands are located in almost every part of the skin but most numerous in the palms and soles. They produce a secretion that is mostly water with a few salts. Eccrine sweat glands have ducts that open onto the surface of the skin through sweat pores. Apocrine Sweat Glands Simple, coiled, tubular glands that produce a thick secretion rich in organic substances. These substances are released primarily by merocrine secretion, though some glands demonstrate holocrine secretion. They open into hair follicles, but only in the armpits and genitals. Nails The nail is a thin plate, consisting of layers of dead stratum corneum cells that contain a very hard type of keratin. The visible part of the nail is the nail body, and the part of the nail covered by the skin is the nail root. The cuticle, or eponychium, is a stratum corneum that extends onto the nail body. The nail root extends distally from the nail matrix. The nail also attaches to the underlying nail bed, which is located distal to the nail matrix. The nail matrix and bed are epithelial tissue with a stratum basale that gives rise to the cells that form the nail. The nail matrix is thicker than the nail bed and produces most of the nail. A small part of the nail matrix, the lunula, can be seen through the nail body as a whitish, crescent-shaped area at the base of the nail. Muscular System Functions of the Muscular System Movement of the body. Contraction of skeletal muscles is responsible for the overall movements of the body Maintenance of posture. Skeletal muscles constantly maintain tone Respiration. Contraction of the skeletal muscles of the thoracic cage, as well as the diaphragm, helps us breathe Production of body heat. When skeletal muscles contract, heat is given off as a by-product. This released heat is critical to the maintenance of body temperature Communication. Skeletal muscles are involved in all aspects of communication which includes gesturing and facial expressions for newborns Constriction of organs and vessels. The constriction of smooth muscle within the walls of internal organs and vessels causes those structures to constrict. This constriction can help propel and mix food and water in the digestive tract, propel secretions from organs, and regulate blood flow through vessels Contraction of the heart. The contraction of cardiac muscle causes the heart to beat, propelling blood to all parts of the body Microscopic Anatomy of Skeletal Muscle Sarcolemma Many oval nuclei can be seen just beneath the plasma membrane, which is called the sarcolemma in muscle cells. Myofibrils The nuclei are pushed aside by long ribbonlike organelles, the myofibrils, which nearly fill the cytoplasm. Light and dark bands Alternating dark and light bands along the length of the perfectly aligned myofibrils give the muscle cell as a whole its striped appearance. Sarcomeres The myofibrils are actually chains of tiny contractile units called sarcomeres, which are aligned end to end like boxcars in a train along the length of the myofibrils. Myofilaments There are two types of threadlike protein myofilaments within each of our “boxcar” sarcomeres. Thick filaments The larger, thick filaments, also called myosin filaments, are made mostly of bundled molecules of the protein myosin, but they also contain ATPase enzymes, which split ATP to generate the power for muscle contraction. Cross bridges Notice that the midparts of the thick filaments are smooth, but their ends are studded with thick projections; these projections, or myosin beads, are called cross bridges when they link the thick and thin filaments together during contraction. Thin filaments The thin filaments are composed of the contractile protein called actin, plus some regulatory proteins that play a role in allowing (or preventing) myosin-bead binding to actin; the thin filaments, also called actin filaments, are anchored to the Z disc (a disclike membrane). Sarcoplasmic reticulum Another very important muscle fiber organelle is the sarcoplasmic reticulum, a specialized smooth endoplasmic reticulum; the interconnecting tubules and sacs of the SR surround each and every myofibril just as the sleeve of a loosely crocheted sweater surrounds your arm, and its major role is to store calcium and to release it on demand. General Properties of Muscle Tissue Contractility. The ability of muscle to shorten forcefully, or contract. Skeletal muscle contraction causes the structures to which they are attached (such as a bone) to move. Smooth muscle contraction increases pressure inside hollow organs, such as intestines. Cardiac muscle contraction increases pressure inside the heart. On the other hand, muscles can lengthen passively. Forces that oppose contraction cause muscle to lengthen. Excitability. The capacity of muscle to respond to a stimulus. For skeletal muscle, the stimulus to contract is from nerves that we consciously control. smooth and cardiac muscle fibers contract spontaneously, but also receive involuntary neural signals and hormonal signals to modulate force or rate of contraction. Extensibility. Means that a muscle can be stretched beyond its normal resting length and still be able to contract. Elasticity. The ability of muscle to recoil to its original resting length after it has been stretched Skeletal Muscle with its associated connective tissue, constitutes approximately 40% of body weight. Skeletal muscle is so named because many of the muscles are attached to the skeletal system. However, some skeletal muscle attaches to the skin or connective tissue sheets. Skeletal muscle is also called striated muscle because transverse bands, or striations, can be seen in the muscle under the microscope. Connective Tissue Coverings Each skeletal muscle is surrounded by several connective tissue layers that support the muscle during contraction. A skeletal muscle has three layers of connective tissue: Epimysium: forms a connective tissue sheath that surrounds each skeletal muscle. The protein fibers of the epimysium gradually merge with a layer of connective tissue between adjacent muscles and connect the skin to superficial muscles. These outer layers of connective tissue separate the muscles from nearby structures. Perimysium: subdivides each whole muscle into numerous, visible bundles of muscle fibers called fascicles. The perimysium is a loose connective tissue serving as passageways for blood vessels and nerves that supply each fascicle. Endomysium: is a delicate layer of connective tissue that separates the individual muscle fibers within each fascicle. The endomysium serves as passageways for nerve fibers and blood vessels that supply each separate muscle fiber. Electrical Component Structures Sarcolemma: the cell membrane of muscle fibers. Transverse tubules: tubelike inward folds of sarcolemma. At regular intervals along the muscle fiber, the sarcolemma forms T tubules by projecting and extending into the interior of the muscle fiber. The T tubules carry electrical impulses into the center of the muscle fiber so that the muscle fiber contracts as a whole. Sarcoplasmic reticulum: a highly specialized smooth endoplasmic reticulum in skeletal muscle fibers that stores high levels of Ca2+ from the sarcoplasmic reticulum is a “switch” for muscle contraction.T tubules lie next to enlarged portions of the sarcoplasmic reticulum called terminal cisternae. Two terminal cisternae and their associated T tubule form a critical structure for muscle contraction called a triad. Mechanical Component Structures Myofibrils bundles of protein filaments. Each muscle fiber has numerous myofibrils in its sarcoplasm. The myofibrils are long threadlike structures that extend the entire length of the muscle fiber. The diameter of each myofibril is approximately one-sixth that of a human hair. It is the protein filaments in the myofibrils that interact to shorten the muscle fiber during contraction. Myofilaments The actin and myosin filaments are arranged into highly ordered units called sarcomeres. The sarcomeres are the structural and functional units of skeletal muscles. The myofilaments in the sarcomere provide the mechanical aspect of muscle contraction. Sarcomeres Sarcomeres join end to end, forming the myofibrils. The sarcomere is the smallest portion of a muscle that can contract. Each sarcomere has a precise boundary. Structures called Z disks form a stationary anchor for actin myofilaments. One sarcomere extends from one Z disk to the next Z disk. It is the arrangement of actin and myosin filaments within sarcomeres that gives skeletal muscle its striated appearance. Actin Myofilaments Each actin myofilament is composed of three separate proteins: (1) actin, (2) tropomyosin, and (3) troponin. Each actin has an attachment site for the myosin myofilaments during muscle contraction. In a sense, we can think of the attachment sites on the actin as receptor sites for a portion of the myosin myofilament, the myosin head. Myosin Myofilaments Composed of many elongated myosin molecules shaped like golf clubs. Each myosin molecule consists of a rod portion lying parallel to the myosin myofilament and two myosin heads that extend laterally. The myosin heads have 3 important properties: (1) The heads bind to active sites on the actin molecules to form cross-bridges to contract the muscle; (2) the heads are attached to the rod portion by a hinge region that bends and straightens during contraction; (3) the heads break down adenosine triphosphate, releasing energy. Part of the energy is used to bend the hinge region of the myosin molecule during contraction. Resting Membrane Potential Electrically excitable cells are specialized to respond to electrical stimuli. At rest, these cells have an electrical charge difference across the cell membrane. In actuality, all cells in the body have this electrical charge difference, but neurons and muscle fibers contain specialized components that allow them to utilize this charge difference. In an unstimulated cell, this charge is called Resting membrane potential. It is the result of 3 factors: (1) The concentration of K+ inside the cell membrane is higher than that outside the cell membrane, (2) The concentration of Na+ outside the cell membrane is higher than that the inside cell membrane, and (3) the cell membrane is more permeable to K+ than to Na+. Action Potentials An action potential occurs when the excitable cell is stimulated. The action potential is a reversal of the resting membrane potential such that the inside of the cell membrane becomes positively charged compared with the outside. This charge reversal occurs because ion channels open when a cell is stimulated. The diffusion of ions through these channels changes the charge across the cell membrane and produces action potential. An action potential lasts from approximately 1 millisecond to a few milliseconds, and has 2 phases: (1) depolarization and (2) repolarization. Neck Muscles The deep neck muscles include (1) neck flexors and (2) neck extensors. Neck flexors originate on the anterior surface of the vertebral bodies. Neck extensors originate on the posterior surface of vertebral bodies. Lateral and posterior neck muscles rotate and laterally flex the head. The prime mover of the lateral muscle group is the sternocleidomastoid muscle. Contraction of both sternocleidomastoids can either flex or extend the head and neck. Vertebral Column Muscles In humans, the maintenance of erect posture is due to very strong back muscles. The erector spinae group of muscles on each side of the back are primarily responsible for keeping the back straight and body erect. Deep back muscles, located between the spinous and transverse processes of adjacent vertebrae, are responsible for several movements of the vertebral column including extension, lateral flexion, and rotation. Thoracic Muscles The muscles of the thorax are involved almost entirely in the process of breathing. The external intercostals elevate the ribs during inspiration. The internal intercostals depress the ribs during forced expiration. However, the major movement produced in the thorax during quiet breathing is accomplished by the dome-shaped diaphragm. When it contracts, the dome is flattened, causing the volume of the thoracic cavity to increase, resulting in inspiration. Abdominal Wall Muscles The anterior abdominal body wall muscles flex and rotate the vertebral column, compress the abdominal cavity, and hold in and protect the abdominal organs. In a relatively muscular person with little fat, a vertical indentation, extending from the sternum through the navel to the pubis, is visible. Pelvic Diaphragm and Perineal Muscles The pelvis is a ring of bone with an inferior opening that is closed by a muscular foot, through which the anus and the urogenital openings penetrate. The pelvic floor is called the pelvic diaphragm. It consists of the coccygeus muscle and the levator ani muscle. Just inferior to the pelvic diaphragm is a diamond-shaped area called the perineum. The anterior half of the perineum is the urogenital triangle, and the posterior half of the perineum is the anal triangle. Vanputte C., Regan J., Russo A., Seeley’s Essentials of Anatomy and Physiology 11th Edition (pp. 173-204) Skeletal System The skeletal system in newborns is a complex framework of approximately 270 bones (Saladin, K. S., 2018), providing structural support, protection, and the foundation for movement. This system comprises the axial skeleton, which includes the skull, vertebral column, and rib cage, and the appendicular skeleton, consisting of the limbs and their girdles. At birth, the newborn's skeletal structure is characterized by a degree of flexibility and pliability. Fontanelles, or soft spots, are present on the skull, allowing for easier passage through the birth canal and accommodating the rapid growth of the brain during infancy. These fontanelles eventually close as the bones of the skull gradually fuse over time. Many of the bones in a newborn's body are not fully ossified and remain in a cartilaginous state. Ossification, the process of transforming cartilage into bone, continues throughout infancy and childhood. Long bones, found in the limbs, undergo endochondral ossification, contributing to the overall growth and development of the skeletal system. The axial skeleton, essential for maintaining the body's central axis, plays a crucial role in protecting vital organs. The vertebral column, composed of individual vertebrae, provides support and flexibility, while the rib cage safeguards the thoracic organs, such as the heart and lungs. The appendicular skeleton comprises the limbs and their associated girdles. Limb bones, including those in the arms and legs, are present but still developing. Joints in newborns are notably flexible, allowing for a wide range of movements, and some, like the sutures in the skull, permit adjustments during the birthing process. Red bone marrow in newborns is actively involved in hematopoiesis, the formation of blood cells. As the child grows, some red marrow transitions to yellow marrow, which stores fat. This shift in bone marrow composition is part of the ongoing maturation of the skeletal system (Saladin, K. S., 2018). Description of Bones Skull The skull is the bony structure that houses and protects the brain. In newborns, the skull is not a single solid bone but rather a collection of bones connected by soft spots or fontanelles. This allows for the flexibility required during childbirth and accommodates the rapid brain growth in early infancy. Vertebral Column The vertebral column, or spine, is composed of individual vertebrae that protect the spinal cord and provide support for the upper body. In newborns, the vertebral column is in the early stages of development, with the vertebrae separated by intervertebral discs. Rib Cage The rib cage consists of ribs and the sternum. In newborns, the rib cage protects the developing organs in the thoracic cavity, including the heart and lungs. The ribs are relatively soft and flexible at birth, allowing for compression during childbirth. Limbs The limbs include the bones of the arms (humerus, radius, and ulna) and legs (femur, tibia, and fibula). These long bones are crucial for movement and support. At birth, the bones in the limbs are present but still in the process of ossification, with cartilage forming the initial structure. Hands and Feet The hands and feet contain numerous small bones that contribute to dexterity and mobility. In newborns, the bones in the hands and feet are in the early stages of development, and some bones may not be fully ossified. Joints Joints allow for movement between bones. In newborns, joints are characterized by their flexibility, enabling a broad range of movements. As the child grows, some joints will become more stable, while others, such as the fontanelles in the skull, will gradually close. Bone Marrow Red bone marrow is found within the cavities of certain bones and is responsible for hematopoiesis, the formation of blood cells. In newborns, red bone marrow is actively involved in producing red and white blood cells. Microscopic Anatomy of Newborn Bone Hyaline Cartilage This is the most prevalent type of cartilage in the newborn skeletal system. It serves as a precursor to bone formation and is present in areas where bones are still developing. For example, in the long bones of the limbs, the initial structure is cartilaginous, and over time, it undergoes ossification. Calcified Cartilage Calcified cartilage serves as a temporary structure during the initial stages of bone development. Before bone tissue fully replaces cartilage, a transitional phase occurs where the cartilage matrix becomes mineralized (calcified). This process allows for the formation of a more rigid structure while the bone is still developing. Osteoblasts These are specialized cells responsible for bone formation. In newborns, osteoblasts are actively engaged in the process of ossification, where they lay down bone matrix. The matrix initially consists of collagen fibers and other substances that provide the framework for the bone. Osteocytes As osteoblasts continue to build bone, some become embedded in the matrix and differentiate into osteocytes. Osteocytes play a role in maintaining bone tissue by sensing mechanical strain and regulating bone remodeling. Osteoclasts These cells are involved in bone resorption, breaking down bone tissue. While the primary focus in newborns is on bone formation, osteoclasts become more prominent later in development during the remodeling process. Epiphyseal Plates Found at the ends of long bones, these plates consist of cartilage a

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