Exam 3_ Notes PDF

I. Newborn: (13) A. Infant Feeding 1. Feeding Cues a) Rapid eye movement under eye lids b) Suckling movements c) Hand to mouth movements d) Body movements e) Small...

I. Newborn: (13) A. Infant Feeding 1. Feeding Cues a) Rapid eye movement under eye lids b) Suckling movements c) Hand to mouth movements d) Body movements e) Small sounds f) Rooting g) Crying is the LAST hunger cue 2. Types of Milk  a) Colostrum (1) First 2-3 days (2) Yellow (3) Thick, high in protein, fat soluble vitamins, minerals, and immunoglobulins b) Transitional Milk (1) 3-4 days to 2 weeks (2) Higher concentration of fat, lactose, and water soluble vitamins c) Mature Milk (1) After 2 weeks (2) 10% carbs, protein, and fat (3) 90% water (4) Foremilk (a) High in water, vitamins, and protein (5) Hind Milk (a) Higher in fat 3. Types of Feeding a) Direct breastfeeding b) Breast Milk fed (1) Pumping milk and feeding in a bottle c) Formula fed 4. Breast changes a) Colostrum development begins as early as 12-16 weeks b) Milk is produced in alveoli of breasts (1) Most is made during infant sucking c) Hormones: (1) Prolactin (2) Oxytocin d) Supply and demand (1) Human milk removal (2) If milk is not removed then negative feedback will happen 5. Breastfeeding Benefits for infant a) Reduces allergies, infection, and lowers risks of various diseases b) Tailored to meet specific needs c) Easily digestible (1) Reduces constipation d) Promotes healthy portion control e) Not reliant on clean water access 6. Breastfeeding Benefits for Person a) Oxytocin release (1) Enhances uterine involution, reduces blood loss, and delays of the return of menses and ovulation B. Is baby getting enough C. Discharge Teaching 1. For breastfeeding clients a) Wear nonbinding bra to prevent clogged ducts b) Breastfeed on demand, 8-12 times daily c) Allow feeding until breast softens, offer both breasts per session d) Use warm showers/compresses pre feeding and cold compresses post feeding e) Ensure complete breast emptying f) Nipple care g) Hydration 2. For non breastfeeding clients a) Lactation suppression (1) Where supportive bra continuously for 72 hours (2) Avoid breast simulation and warm water b) Engorgement relief (1) Use cold compress and fresh cabbage leaves (2) Take analgesics or antiinflammatories as needed D. Normal Newborn Transition 1. Vitals: a) 120-160 BPM (1) Check apical for 1 full min (2) Usually we check brachial but for this instance apical so we can also hear heart sounds b) 30-60 respiration per min (1) Diaphragmatic breathing and brief periodic breathing is normal (a) Intercostal muscles aren’t super strong so lots of belly breathing c) Axillary temp of 36.4-37.2 C or 97.5 - 98.9°F d) Initially BP of 60-90/40-50 (1) 100/50 by day 10 (2) Leg cuff 2. Timing and Types of Assessments a) Initial  (1) APGAR (a) Scores: (i) 0-3 is critical (ii) 4-6 is below normal (iii) 7-10 is normal (b) Performed at 1 and 5 min after birth (c) If less than 7 (i) Repeat apgar every 5 min for up to 20 min (2) Airway clearance (3) Dry newborn (a) This stimulates crying and breathing (4) Stability (5) Initiate attachment (a) Skin to skin (i) Warms up (ii) Exposes to mom’s flora (iii) Leads to breast feeding b) 1 - 4 hours (1) Adaptation to extrauterine life (2) Head to toe assessment (a) Eyes and thighs golden hour (1st period of reactivity for about 1-2 hrs), baby is most alert  (i) erythromycin eye ointment (ii) Vitamin K injection in thigh (a) Needed for clotting factor synthesis (b) Newborn lacks intestinal bacterial flora to produce vitamin k (c) Give within 1 hour of birth (3) Gestational size/age (ballard score) (4) High risk problem assessment (5) Nursing assessments and interventions (a) Vitals every 30 min, then hourly (b) Identify infant, security system and name band (c) Obtain weight, length, head circumference (i) Length is needed until child can stand independently (2-3 yrs old) (ii) BMI is taken after 2 years of age (iii) Measure from supraorbital ridges to most prominent part of occiput for head circumference (a) Every visit until 2 yrs (b) Then measure as needed after (d) Assess and monitor skin color (i) Acrocyanosis is normal  (a) blue/grayish hands and feet (e) Assess suck/swallow ability with feeding (f) Assess newborn reflexes and movement (g) Assess for anomalies c) First 24 hours, basically before discharge (1) Full physical exam (a) Depends on hospital policy (2) Nutritional status and feeding ability (3) Complete all screenings (4) Newborn Metabolic Screening (a) Heel stick after 24hrs of age, before discharge E. Initiation of respiration 1. Fetal lung fluid a) Expands alveoli b) Aids in lung dev c) 65% is absorbed by time of birth (1) 80-100cc remain 2. Surfactant a) Detectable by 24-25 weeks gestation 3. Baby’s first breath a) C-section (1) Slows down process of getting fetal lung fluid (a) There is less time for squeezing b) Forces remaining fetal lung fluid out of alveoli (1) Mechanical factors (a) Fetal chest compression due to vaginal birth (b) Recoil of the chest draws in a small amount of air into lungs (2) Chemical factors (a) Increased partial pressure of CO2 and decreased pH (3) Thermal factors (4) Sensory factors F. Fetal Circulation a) High resistance and pressure in lungs is what allows all bypasses to stay open (1) Pulmonary resistance will decrease as alveoli are able to open up so blood vessels will dilate there since it can be oxygenated there, leading to bypasses to close 2. Placenta 3. Patent foramen ovale a) Connects 2 atrium b) Provides brain perfusion 4. Ductus arteriosus  a) Bypass lungs b) Provides lower limb perfusion 5. Ductus venosus a) Bypasses liver 6. Lungs G. Periods of Reactivity 1. Golden hour a) First hour, baby is born and most alert b) Eyes and thighs c) Skin to skin contact d) Initial assessment 2. Period of relative inactivity a) 2-3 hours after birth 3. Increase sleepiness, decreased HR (100-14) and RR (40-60) 4. 2nd period of reactivity is at 4-6 hours a) 10 mins to several hours lasting H. Infant Size 1. Small for gestational age (SGA) a) 90th percentile I. Caput Succedaneum vs. Cephalohematoma 1. Caput succedaneum a) Localized edema over sagittal suture b) Disappears over a few days 2. Cephalohematoma a) Does Not cross suture line b) Blood under scalp caused by pressure c) Reabsorbed slowly d) Increases risk of jaundice J. Newborn Reflexes K. Newborn Genitalia L. Voiding 1. 93% of infants void 24 hours after birth, 99% by 48 hrs a) If newborn doesn’t void within 24 hrs, nurse should assess adequacy of fluid intake, bladder distention, restlessness, and symptoms of pain 2. Initial bladder volume a) 6-44 mL 3. Assess feeding as you assess voiding a) Day 1-2 (1) Void 2-6 times a day b) Day 3-4 (1) Void 6-8 times a day c) Day 5+ (1) Void 6-8 times a day M. Elimination 1. Breastfed a) Yellow, gold, soft or mushy, seedy  b) Odor may be sweet-sour c) Typically 3+ stools/day until 6 weeks 2. Formula fed a) Pale yellow to light brown b) Formed and pasty c) Odor is typical d) Frequency varies but usually less than breast fed babies N. Jaundice 1. Assess for jaundice every 8-12 hrs a) Visual assessment (1) Universal predischarge bilirubin screening (a) Serum - blood test through heel stick (b) Transcutaneous (i) Greater than 12 or 15 mg/dL (ii) Get a serum level 2. Adequate feeding is essential a) First feed 1-2 hrs post birth b) Fed 8-12 times every 24 hrs c) Colostrum laxative to promote stooling (1) This gets rid of bilirubin to prevent jaundice (2) Meconium has a lot of bilirubin so we want to get rid of it d) Bottle fed 8-12 times in 24 hours 3. Types of Jaundice in newborns a) Physiologic Jaundice (1) Normal process (2) Occurs 3-5 days after birth (a) Bilirubin levels peak at 5-6 mg/dL then fall by days 5-7 (3) Occurs in 5-% of term and 80% of preterm newborns (4) Caused by accelerated destruction of fetal RBC’s and increase reabsorption of bilirubin by liver b) Early Onset breastfeeding jaundice (1) Develops in 13% of breastfed infants by 1 week of age (a) This is caused by an insufficient intake (i) Greatest risk is in infants who are sleepy, have poor suck, or nurse infrequently (ii) BF babies 3-6x more likely to develop moderate jaundice or sever (2) Interventions (a) Assist parent with breastfeeding (b) Consider pumping to stimulate milk production and increase intake c) Late Onset Breastfeeding Jaundice (1) True breast milk jaundice  (a) Occurs first 3-5 days of life and lasts 3 weeks to 3 months (b) Breastmilk substance may increase absorption of bilirubin from intestine or interfere with conjugation (i) They’re getting enough milk but something is possibly wrong with milk (2) Interventions (a) Close monitoring (b) Minimum of 8-12 feedings/day (c) If total serum bilirubin (TSB) is too high, begin phototherapy and continue breastfeeding (d) If dangerously high, pause breast feeding for 1-3 days d) Pathologic Jaundice (1) Not related to breastfeeding (2) Usually appears within 24 hours of birth (3) Result of excessive hemolysis of RBCs or bilirubin conjugation problems (a) Sepsis (b) Blood incompatibilities (c) Metabolic disorders (d) Cephalohematoma or bruising 4. Jaundice treatments a) NICU b) Phototherapy (1) Especial blue light not UV rays O. Heat Loss P. Immune System 1. Passive immunity  a) Immunoglobulin (igG) (1) Crosses placenta mainly in 3rd trimester (2) Provides immunity to stuff the mom is immune to (3) Preterm infant may be susceptible to infection b) Breastfeeding continues passive immunity for infants 2. Active Immunity a) This happens when you’re exposed to a pathogen 3. Hypothermia is more reliable indicator of infections instead of fever a) Additional signs (1) Change sin activity, tone, color, feeding II. Developmental influences and Child Health Promotion (13) A. Types of Play 1. Unoccupied: infants 2. Solitary: 0-2 yrs 3. Onlooker: ~2 years, helps them learn and observe but not engaging  4. Parallel: 2+ years, they don’t interact but they’re doing something similar next to each other 5. Associative: 3-4 years, no rules but they play together and work together, 6. Cooperative: 4+ years, playing together with rules, goal, and possibly a winner 7. Symbolic Play: pretend play, using an item and pretend it’s something else B. III. Care of infants, toddlers, and preschoolers (10) IV. Immunizations (4) V. VI. Care of School Age and Adolescents (10). A. Puberty 1. Vagina: a) Thelarche - onset (8- 13 years) - beginning of breast dev (1) Increase in estrogen breast dev (2) Secondary sex characteristics (3) Tanner stages 2-3 (a) 2=breast buds (9-13) (b) 3=breast enlargement (12-13) (4) Peak height velocity for growth spurt 1 year post Thelarche (a) so when they get that breast buds/breast enlargement, in 1 year they’ll have their major growth spurt b) Adrenarche - androgens released that are responsible for public hair development, 2-6 months post thelarche. c) Menarche - onset (12-15) by 16 (1) Increase in estrogen first menses (2) 1.5 -2 years after Thelarche (3) 1 year post peak height velocity (4) Tanner stage 4 (5) Linear growth slows d) Tanner stage 5 (1) Cycle established 2-5 years post menarche (2) Growth complete 2-2.5 years post menarche 2. Penis: a) Gonadarche: (1) testicular enlargement by age 14; Tanner 2  b) Adenarche (1) Growth of pubic, axillary and facial hair (2) Rapid increase in height c) Tanner 3 (1) Voice deepens (2) Penis growth d) Spermarche: - first sperm production (1) Nocturnal emissions e) Peak height velocity begins later than females; Tanner 4 f) Muscle deposited vs fat g) Growth complete at Tanner 5 3. Tanner Stages: a) Girl: b) Boy: