Week 10 331 - Care of the Healthy Newborn Lecture Notes PDF

CARE OF THE HEALTHY NEWBORN NURS 331: Nursing Care of Childbearing Women and Families Monday, November 4, 2024 STAGES OF TRANSITION 2 Can be impacted by: Gestational age Placental health and condition Maternal health or chronic illness...

CARE OF THE HEALTHY NEWBORN NURS 331: Nursing Care of Childbearing Women and Families Monday, November 4, 2024 STAGES OF TRANSITION 2 Can be impacted by: Gestational age Placental health and condition Maternal health or chronic illness Physical defects or anomalies RESPIRATORY SYSTEM From Surfactant production occurs pulmonary artery between 24-28 weeks Considered adequate between 35- 37 weeks Reduces the surface tension of fluid in the lungs and helps make the small air sacs in the lungs (alveoli) more stable To pulmonary vein ESTABLISHING RESPIRATION 4 BEFORE BIRTH Reduced production of fetal lung fluid and decreased alveolar fluid volume Cortisol and catecholamine surge occurs which stimulates surfactant and promotes fluid clearance from the lungs Transient hypoxia and acidosis caused by contractions stimulate the respiratory center of the brain Fluid is moved out of the lungs by sodium INITIATION OF RESPIRATION 5 Fluid shifts out and the lungs fill with oxygen. Intrathoracic compression can play a role in this. First breath (“gasp”) is triggered by increased PCO2 and decreased pH and PO2 (acidosis) Initiation of respiration occurs with pulmonary alveoli expansion  This process is supported by the presence of surfactant which reduces the tension of the alveolar surface CARDIOVASCULAR SYSTEM 6 Ductus Venosus Hepatic system Foramen Ovale Between the right and left atrium Ductus Arteriosus Connects pulmonary artery to the descending aorta IMMEDIATE ASSESSMENT 7 Skin-to -skin immediately as long as mom and baby are stable Dry, stimulate, keep warm ABC’s & neonatal resuscitation Breathing and airway clearance  Suction if necessary HR with umbilical cord or apically Note color and tone  8 APGAR SCORING Assigned at 1 minute and 5 minutes of life Peripheral cyanosis is an expected finding May help determine response to and success of resuscitation Does not predict future neurologic outcome of the newborn  RESPIRATION AND PERFUSION 9 Normal respiratory rate of 30-60 breaths per minute  Periodic, shallow breathing  Abdominal in nature Transient Tachypnea of the Newborn (TTN)  Usually resolves within 48-72 hours  Primarily caused by retained fetal lung fluid Acrocyanosis  Bluish discoloration of the hands and feet  Normal finding in the first 24 hours  10 RESPIRATORY DISTRESS Nasal flaring Retractions Grunting Tachypnea Apnea Central cyanosis Lasting beyond the first 2 hours of life may indicate a more serious problem HEART RATE AND SOUNDS 11 Term newborn heart rate ranges from 110-160 bpm Can range from 80-100 bmp while sleeping or increase to 180 bpm while crying May be irregular within the first few hours of life Functional murmurs are often present and typically resolve by 6 months of age  12 HEAD-TO-TOE ASSESSMENT Skin Head, Ears, Nose, & Mouth Clavicle Abdomen Genitalia/Anus Extremities Spine Neurological/Reflexes ASSESSING THE SKIN Skin reddish in color, smooth, and puffy at birth Vernix caseosa Lanugo Congenital dermal melanocytosis (formerly called “Mongolian Spots”) Milia Erythema toxicum (newborn acne) Telangiectatic nevi (stork bites) ASSESSING THE HEAD & SCALP Fontanels Anterior Posterior Suture lines Frontal Coronal Sagittal Lambdoidal MOLDING 15 Pressure on the head as it passes through the birth canal results in an oblong shape The bones of the neonatal skull are soft and flexible and often overlap during the birth process CAPUT SUCCEDANEUM Scalp swelling extending across the midline and over suture lines Associated with head molding Does not usually cause complications and usually resolves over the first few days CEPHALOHEMATOMA Collection of blood between the periosteum and the skull, but does not cross suture lines. More common with assisted delivery Often not visible until 24-48 hours post delivery Occasionally may be indicative of skull trauma or  18 ASSESSING THE EARS Placement Shape/malformation Flexibility Skin tags  19 ASSESSING THE EYES Color Size Equal and reactive to light Blink reflex Conjunctival hemorrhages Petechiae  20 ASSESSING THE MOUTH Lips Palate Hydration Additional normal findings:  Epstein’s pearls  Precocious teeth  Short frenulum of tongue ASSESSING THE TRUNK AND 21 ABDOMEN Clavicles Chest Breast enlargement is normal Abdomen  Soft with some distension  Obvious abnormalities such as loops of bowel visible through skin or upon palpation, sunken appearance  Umbilical cord intact and without signs of infection  ASSESSING THE GENITALIA 22 Female Labia Clitoris Vaginal opening  Hymeneal tag  Secretions Anus  ASSESSING THE GENITALIA 23 Male Penis  Location of the urethral meatus Palpable testes in scrotum Anus  24 ASSESSING THE EXTREMITIES Upper Hands Palmar creases Lower Hips Normal Palm Singular Palmar Creases Crease Feet  25 ASSESSING THE SPINAL COLUMN Palpate the spine Straight and easily flexed Sacral dimple or pigmented nevus with tuft of hair NEUROLOGICAL ASSESSMENT AND 26 REFLEXES Primitive reflexes originate in lower centers of the nervous system-usually integrate by 1 year of age Moro or Startle Palmar and Plantar grasping reflexes Rooting Sucking Babinski NEONATAL MEDICATIONS 27 Vitamin K (Phytonadione) Administered IM within 1-6 hours of birth Fat-soluble vitamin needed for blood clotting Risk for Vitamin K Deficiency Bleeding (VKDB) Erythromycin Ointment Administered within 1-2 hours of birth Bacteriostatic and bactericidal for N. gonorrhoeae N. Gonorrhoeae infection in the newborn eye can lead to blindness Required by law in most states, but IL parents can opt out New studies questioning efficacy NEONATAL MEDICATIONS 28 Hepatitis B Vaccine Administered IM before discharge Induces protective antihepatitis B antibodies Recommended for 3 doses to be fully protected Hepatitis B Immunoglobulin (HBIG) Administered IM within 12 hours of birth Only given to infants of mothers who are Hepatitis B positive or unknown Given with the Hepatitis B vaccine  In 2013, 6 infants were admitted to Vanderbilt C hildren’s Hospital in Nashville, Tennessee, with life-threatening bleeding. The infants were diagnosed with late Vitamin K deficiency bleeding (VKDB). Four of the infants had bleeding in the brain, and two had bleeding in the intestines. Although the six LET’S TALK infants survived, two required MORE ABOUT emergency brain surgery to save VITAMIN K! their lives, one has severe brain damage (a stroke with right-sided paralysis and severe cognitive WHAT DID THESE INFANTS HAVE 30 IN COMMON? All the moms had consistent prenatal care None of the mothers had high risk pregnancies or chronic histories that would increase the risk of hemorrhage for their infants Three of the infants were born in hospitals, two were born at home, one was born in a birth center All were normal vaginal births They were exclusively breastfed  31 IN EVERY CASE… They declined Vitamin K injection for their infants PARENT EDUCATION 32 Vitamin K is a fat-soluble vitamin needed for blood clotting We cannot make Vitamin K ourselves, and we don’t store it very well in our body We get Vitamin K1 (also known as phylloquinone) from leafy green vegetables Can be produced within the human body (by bacteria) but not by the body A baby who does not have enough Vitamin K can start to bleed suddenly, without warning. This is known as Vitamin K deficiency bleeding (VKDB) It is VERY rare but can be very serious. It can happen within the first few days of life or after the first week. Late VKDB can be fatal. VOIDING AND STOOLING 33 Meconium Usually the first three days Greenish black and viscous Formed from amniotic fluid, intestinal secretions, shed mucosa cells, and possible blood Urine May be pale yellow, pink, or orange tinged (uric acid) At least one wet diaper during the first 24 hours At least one every eight hours in the first CORD CARE Cleanse with plain water Observe for redness, foul smell, discharge or an increase in bleeding  35 NORMAL NEWBORN PROCEDURES CCHD Screening Hearing Test Newborn Metabolic Screening Transcutaneous Bilirubin Circumcision  36 CRITICAL CONGENITAL HEART DISEASE (CCHD) 6 of 10,000 apparently healthy term or late- preterm infants will have critical congenital cardiac disease Non-invasive screening performed using a pulse oximetry Can detect some critical congenital heart defects that present with hypoxemia Pulse ox done on the right hand and either foot SIGNS AND SYMPTOMS OF 37 CONGENITAL HEART DISEASE Tachypnea with or without respiratory distress Tachycardia Higher B/P in right arm than lower extremities Central or peripheral cyanosis Capillary refill time > 3 seconds Weak peripheral pulses, cool/cold extremities, and mottling Cold sweat on forehead/scalp  NEWBORN HEARING SCREEN 38 Significant hearing loss is the most common disorder at birth Affects approximately 1.6 out Sound of every 1000 infants stimulus travels to born in the US the brain and the electrical activity generated by the nerve can be recorded by the electrodes and is represented as waveforms on a computer screen NEWBORN METABOLIC SCREENING 39 Commonly referred to as the PKU  Tests for phenylketonuria, the enzyme needed to use phenylalanine Also checks for other metabolic, endocrine, hemoglobinopathies and amino acid disorders  Hypothyroidism, sickle cell anemia, cystic fibrosis, etc. TRANSCUTANEOUS BILIRUBIN 40 Non-invasive screening for jaundice Jaundice is the yellowing of a baby’s skin or eyes caused by a build up of bilirubin Occurs in 60% of term and 80% of preterm neonates; however, significant jaundice occurs in 6 % of term babies Risk factors include  Preterm  Breastfeeding  Rh- or ABO incompatibility  Bruising related to birth trauma  41 CIRCUMCISION Surgical procedure in which the skin covering the end of the penis is removed May be done for religious, social, and cultural reasons Not essential to a child’s health NURSING CARE OF A CIRCUMCISION Apply petroleum jelly to the penis for the first 24 hours to keep the diaper from adhering to the circumcision site Administer Acetaminophen as needed for pain Observe the penis for bleeding and adequate urination Cleanse the penis with warm water and apply the diaper loosely COMMON PROBLEMS 43 SEEN IN TRANSITION Cold Stress Hypoglycemia Neonatal Hyperbilirubinemia Acidemia Pulmonary Congenital Anomalies Cardiovascular Hemodynamics Metabolic Problems Infection  THERMOREGULATION  Normal range: 97.7F - 99.0F axillary  Newborns are not able to shiver and depend on brown fat  Skin-to-skin is best practice  Radiant warmer or isolette if skin-to-skin is contraindicated  Delay bathing  Cold stress can increase O2 consumption and result in metabolic acidosis and hypoglycemia HYPOGLYCEMIA Maternal source of glucose is eliminated when the umbilical cord is clamped Transient decrease in glucose levels to as low as 30 mg/dL during the first 1 to 2 hours after birth  Baseline glucose obtained at 30 mins to 1 hour of age for high risk infants Goal glucose levels  >40 ml/dl on first day  >50 ml/dl thereafter  46 HYPOGLYCEMIA RISK FACTORS Cold stress Respiratory distress Sepsis Premature, SGA, or LGA Infants of mother with diabetes or Gestational diabetics  47 BIRTH WEIGHT Average human birth weights reflect the diversity of human biology AND the effects of social disadvantage The prenatal grown rate is generally measured in relation to what weight is expected for gestational age Average birth weight is about 3389g or 7lb, 7.5oz NEONATAL HYPERBILIRUBINEMIA Physiologic A normal phenomenon during transition that occurs is every newborn to some degree Progressive rise in total bilirubin between 48 and 120 hours of life (peaks at 72-96 hours) Becomes concerning when bilirubin levels continue to rise Visual assessment is subjective and inaccurate  TCB vs TSB NEONATAL 49 HYPERBILIRUBINEMIA Pathologic Occurs within the first 24 hours after birth or lasts for more than 2 weeks Can result in kernicterus and cause permanent neurological damage PRE TERM AND 50 HYPERBILIRUBINEMIA Pre-term infants at higher risk due to further reduced activity of liver conjugating enzymes Pre-term infants can develop encephalopathy or kernicterus at lower total bilirubin levels  51 PHOTOTHERAPY Transforms bilirubin into water- soluble isomers that can be eliminated without conjugation in the liver through urine and stool Infants undergoing phototherapy often have frequent and loose stools QUESTIONS