Week 9 Normal Newborn PDF

Normal Newborn BNUR 414 – AY 2024_2025- Semester 1 Physiological adaptation of the newborn from intrauterine to extrauterine Assessment and immediate care of the11/15/22 normal newborn & Apgar scoring Birth Injuries  Part...

Normal Newborn BNUR 414 – AY 2024_2025- Semester 1 Physiological adaptation of the newborn from intrauterine to extrauterine Assessment and immediate care of the11/15/22 normal newborn & Apgar scoring Birth Injuries  Part I Physiological adaptation of the newborn from intrauterine to extrauterine Normal Newborn 2  Objectives At the end of this presentation the student will be able to identify: Initiations of Respirations in the newborn Newborn Cardiovascular Adaptation Newborn Neurological Adaptation Effect of Cold Stress on the Newborn Newborn Hematological adaptation Newborn Gastrointestinal adaption Newborn Hepatic adaption and jaundice Newborn Urinary system adaptation Initiations of Respirations (Ch. 19 P. 517) ▪ The first vital task the newborn must accomplish ▪ Development of lungs ▪ During fetal life the alveoli produce fetal lung fluid that expands the alveoli ▪ The lung fluid is continuously produced at a rate of 4 to 5ml /kg/hr ▪ As the fetus nears term, the amount of fetal lung fluid begins to decease in preparations for birth, when the fluid must be clear for the infant to breathe air. ▪ Absorption is accelerated by secretion of fetal epinephrine and corticosteroids but may be delayed by C birth, without labor. ▪ The removal of the fluid helps reduce pulmonary resistance to blood flow that is present before birth and enhance the advent of air breathing. Initiations of Respirations Surfactant A slippery detergent-like combination of lipoproteins is detectable by 24-25 weeks of gestations. Surfactant lines the inside of the alveoli and reduces surface tension within alveoli, allowing the alveoli to remain partially open when the infant begins to breathe at birth. Without the surfactant the alveoli collapse as infant exhales. By week 34 to 36 weeks of gestations, sufficient surfactant is usually produced to prevent respiratory distress syndrome. Increased secretion of surfactant during labor, and immediate after birth to enhance the transition from fetal to neonatal life. Steroids given to a woman in preterm labor help increase surfactant production and speed maturation of the lungs. Initiations of Respirations Causes of Respirations At birth the infant’s first birth must force the remaining fetal lung fluid out of the alveoli to allow air to enter lungs. Caused by: Chemical factors chemoreceptors in aorta and carotid arteries respond to hypoxemia. A decrease in the partial PO2, and Ph and increase in Pco2 which stimulate respiratory centers in brain. Mechanical factors When the pressure against the chest is released at birth, recoil of the chest draws a small amount of air into the lungs and helps remove some of the viscous fluid in the airways. Initiations of Respirations Causes of Respirations Thermal factors The infant moves from the warm, fluid-filled uterus into an environment where the temperature may be much cooler. Sensors in the skin respond to this sudden change in temperature by sending impulses to the medulla that stimulate respiratory center and breathing. Sensory factors ▪ Auditorily, tactile, visual and other sensory factors stimulate respiratory center to continue breathing. ▪ Nurses hold, dry, and place infant skin-to-skin with the mother or wrap them in blankets, providing further stimulation to skin sensors. ▪ The stimulation of the light, sound, smell, and pain at delivery also may aid in initiating respirations.  Initiations of Respirations Continuation of Respiration ▪ Approximately 20-30 ml of air from the first breaths remains in lungs to become the functional residual capacity (FRC). ▪ Within first hour, 80-90 % of FRC is established. ▪ Because the alveoli remain partially expanded with this residual air, subsequent breaths require much less effort than the first one. ▪ As infant cries pressure in lungs the fluid moves out of the lungs and absorption may take several hours. Cardiovascular Adaptation During fetal life, three shunts-the ductus venous, foramen ovale and ductus arteriosus carry much of the blood away from the lungs and away from the liver. ▪ At birth, the shunts close and the pulmonary vessels dilate in response to: ▪ Increases in blood oxygen ▪ Shifts in pressure within the heart, pulmonary, and systemic circulations ▪ Clamping of the umbilical cord The alterations necessary for transition from fetal to neonatal circulation occur simultaneously within the first few minutes after birth. Neurological Adaptation Thermoregulation Methods of Heat loss Evaporation The maintenance of body temperature. Is air drying of the skin that result in cooling. The temperature drops up to 0.2 to 1 C Conduction per minutes if the infant is not kept Placing infants on cold surfaces or touching them with cool warm. objects. Convection Neonates must produce and maintain Transfer of heat from the infant to color surrounding air in enough heat to prevent cold stress, convection. which can have serious and even fatal Radiation effects. Infants in incubators transfer heat to the walls of the incubator >> Use a radiant warmer. Methods of Heat loss Effect of Cold Stress Increased oxygen need Decreased surfactant production Respiratory distress Hypoglycemia Metabolic acidosis Jaundice Hematological adaptation Factors that affect the blood The blood volume of the term newborn is 80 to 100 ml /kg. Blood values Hgb is higher in infants (15-24 g/dL) than adults. Hct is 44%- 70% WBC 15000/mm3 in term infant. Risk of clotting deficiency Low vitamin K put infants at risk that why infants are given vitamin k. Gastrointestinal system Stomach-> newborn’s stomach capacity is 6 ml/kg at birth. Intestines-> are longer in infants to enhance absorption but it can put infants for risk of water loss if they have diarrhea. Air enter the bowels after birth sounds can be heard 15 minutes after birth. Digestive enzymes-> pancreatic enzymes is deficient for the first 4-6 months after birth. Pancreatic Amylase is present in breast milk. Stools-> meconium a greenish black stool, and is the first stool that infant pass after birth, usually passed within first 12h, and 99% of infants passed them by 24 hrs. There is a difference in breastfeed infants' stool-> are seedy, mustard color, four or more daily. The formula fed infants a pale yellow. Hepatic system Blood glucose maintenance (primary source of energy) ▪ Glucose concentration is low by 60-90 min after birth but rise and stabilize in 2-3 hrs. ▪ In term infant glucose level should be 40-60 mg/dl in the first day. ▪ Many infants are at risk of hypoglycemia, if they are preterm, low weight, as adequate stores of glycogen has not yet developed. ▪ Also, large of gestational age and those with diabetic mothers have excessive insulin production consuming glucose quickly. Hepatic system-conjunction of bilirubin The newborn's liver may not be mature enough to prevent jaundice during first week of life. Hyperbilirubinemia An excessive bilirubin in blood, it occurs in 60 % of term newborns, and 80% of preterm infants. Factors that increase risk of hyperbilirubinemia Hemolysis of excessive erythrocytes Short RBCs lifespan Lack of albumin binding sites Liver immaturity Breastfeeding Delayed or inadequate feeding Blood incompatibility Preterm infants Male gander Maternal diabetes or preeclampsia. Hyperbilirubinemia Excessive level of accumulated bilirubin in the blood and is characterized by jaundice, a yellowish discoloration of the skin, sclerae, mucous membranes and nails  Physiological Jaundice Is a transit hyperbilirubinemia and is considered normal. The jaundice is not present during the first 24 hrs. of life in term infants but appears on 2-3 day after birth. Maximum intensity by 4th-5th day in term & 7th day in preterm. jaundice become visible when bilirubin level is > 5 mg /dl. ▪ Normal values of unconjugated bilirubin are 0.2 to 1.4 mg/dL. Non physiological Jaundice (pathological) Time at which jaundice appears is one of the important factor to distinguish physiological and and pathological jaundice. Pathological jaundice occurs in first 24 hrs of age, when bilirubin rises higher and stays longer than expected. Increase of bilirubin > 5 mg / dl / day Jaundice persisting after 14 days Stool clay / white colored Breastfeeding or Early Onset Jaundice Bilirubin levels greater than 12 mg/dL develop in 13% of breastfed infants by 1 week of age True breast milk jaundice occurs after 5 days of birth and could stays several months and some infants reach TSB 20-30 mg/dl  Causes ▪Appearing within 24 hours of age  Hemolytic disease of NB : Rh, ABO  Infections: bacterial ▪Appearing between 24-72 hours of life  Physiological  Sepsis  Polycythemia  Intraventricular hemorrhage  Increased entero-hepatic circulation Causes After 72 hours of age Sepsis. UTI, Cephalhaematoma Neonatal hepatitis Breast milk jaundice Metabolic disorders (G6PD). Hypothyroidism, Urinary system  Kidney are developed by 34-36 weeks of gestation  Voiding occurs within the first 12 hours for 50% of newborn , 99% void within 48 hrs after birth.  Failure to void maybe result of hypovolemia and inadequate fluid intake.  Infants usually void 6 times per day.  Daily intake for newborn first 2-3 days is 60-100ml and is 150-175 ml after 5 days of birth.  Part II Immediate Assessment of the Normal Newborn Apgar Score Normal Newborn 24 Objectives ▪ At the end of the lecture the student will be able to: Explain early focused assessment of newborn Explain assessment of body systems Assessment of gestational age Discuss nursing care for newborn infant. Principles of Examination ▪ Prevention of heat loss during assessment. ▪ Rapid overall assessment done at time of birth and detailed assessment later. ▪ The nurse determines if the infant needs a recusation or not and no abnormality are present. ▪ Where possible, parents should be present during assessment. ▪ Examination should follow a sequence. Normal Newborn  Neonatal period = 1st 28 days of life  Early neonate 0-7 days of life  Late neonate 8-28 days of life 2/3rds of all deaths that occur in 1st year of life occur during neonatal period [1st 28 days of life]. Gestational Age: Pre-term: < 37 weeks Term: 37- 41 +6 weeks Post-term: ≥ 42 weeks Gestational age Gestational age can predict problems, morbidity, mortality, and can help you keep alert for certain problems Preterm infants are at a higher risk for:  Respiratory distress syndrome  Necrotizing enterocolitis  Patent ductus arteriosis  Apnea Post-term infants are at a higher risk for:  Asphyxia  Meconium aspiration  Trisomies and other syndromes Initial assessment Apgar Score The Apgar score is a rapid standardized method of assessing the clinical status of the newborn immediately after birth at one minutes and then at 5 minutes intervals. Components of the Apgar score: 1. Heart rate 2. Respiratory effort 3. Muscle tone 4. Reflex response 5. Color The Importance of Apgar score ▪ Assess condition of the newborn at birth. ▪ Identify need for resuscitation. ▪ Provide necessary care to the baby. ▪ Prevent hypothermia. Apgar Score ▪ Heart Rate: Reflex Response: No response to suction or flicking of soles ▪ Absent = 0 =0 ▪ Below 100bpm = 1 Minimal response or grimacing = 1 ▪ 100bpm or higher = 2 Responds promptly with cry or active ▪ Respiration: movement = 2 Color: ▪ No spontaneous respiration = 0 Pallor or cyanosis = 0 ▪ Slow respiration or weak cry = 1 Bluish hands or feet = 1 ▪ Spontaneous respiration with Pink or absence of cyanosis = 2 strong, lusty cry = 2 Care According to Apgar Score ▪ Apgar score of 1-3: resuscitation required. ▪ Apgar score of 4-6: stimulation required. Give oxygen and Narcan if required. ▪ Apgar score of 7-10: no action required except support of infant’s spontaneous efforts. *ACOG: ▪ a 5-minute Apgar score of 7–10 as reassuring, a score of 4–6 as moderately abnormal, and a score of 0–3 as low in the term infant and late-preterm infant Immediate and Early Care Clear airway. Clamp umbilical cord. Dry newborn- temperature regulation. Radiant warmer or wrap newborn. Identification. Records. Focused early assessment: cardiorespiratory status Airway RR: is assessed every 30 minutes then very 2 hour after birth. Normal range is 30- 60 breaths per minutes. Respiration should be normal, not labored, and chest movement should be symmetrical Breath sounds: clear in most areas, crackles (1st and 2nd hours) is not unusual. Color: assess for pallor (anemia, slight hypoxia), and ruddy color indicate polycythemia (increase RBCs). Assessments of respiration - Pauses in breathing lasting 5 to 10 seconds without other changes followed by rapid respirations for 10 to 15 seconds. This occurs in some full-term infants during the first few days but is more common in preterm infants. Apnea: is a pause in breathing lasting 20 seconds or more accompanied by cyanosis, pallor, bradycardia or decreased muscle tone. This requires a prompt intervention and notifying HCP. Focused early assessment -assessment of RD Sings of respiratory distress: Tachypnea: > 60 BPM Retraction Flaring of nose Cyanosis Asymmetrical chest expansion *** If abnormality exist rule out choanal atresia: blockage or narrowing of nasal passage by bone or tissue, nurses need to assess and watch if breathing is difficult. (p.536,ch20). Focused early assessment -Assessment of cardiorespiratory status Heart sounds: Rate should be 120-160 beats per minutes. Sleeping (100), crying (180) Regular rhythm Most murmurs in newborn are temporary and caused by incomplete transition from fetal to neonatal circulation. Blood pressure: Average is 65 – 95 mm hg systolic, and 30-60 diastolic. Normal capillary refill. The brachial and femoral pulses should be present and equal. Focused early assessment -assessment of Thermoregulation ▪ Commonly taken by axillary method: 36.5 c to 37.5 c. ** Please refer to table 20.1, Ch20, p. 535 for vital signs assessment procedure. General Assessment: Head to Toe Head: ▪ Constitute of one fourth of the body surface. ▪ Round, symmetric, soft and moves easy from left to right and up to down. ▪ Hair should be fine with a consistent pattern; abnormal hair might indicate genetic abnormalities. ▪ Molding: normal changes in head shape that allows it to pass through birth canal. General Assessment: Head Fontanels: Areas in head where sutures between bones meet. The nurse should notice position, palpate it during sleep or when the baby is quiet and upright position.  the anterior fontanel is diamond shape (frontal and partial bone meet 4-6 cm), soft and flat;  Very sunken fontanels may be a sign of dehydration.  Bulging (increase intracranial hemorrhage and meningitis ).  It close by 18 months.  The posterior fontanel is a triangular area (occiput and partial bones meet), measures 0.5- 1 cm. closes at 2 months of age. Face should be symmetrical with abnormal masses or dropping of mouth that might be caused by trauma. Face ▪ Normal ▪ Abnormal: ▪ Eyes symmetrical.​ ▪ Injuries.​ ▪ Nose symmetrical.​ ▪ Facial palsy.​ ▪ Patent nostrils.​ ▪ Eyes asymmetrical.​ ▪ Ears normal configuration.​ ▪ Nose with nasal flaring or atresia.​ ▪ ​Mouth: Normal ▪ Low set ears. configuration, Tongue ▪ Cleft lip/palate. moving freely. ▪ Precocious teeth. ▪ Tongue tie. Neck and clavicles ▪ Assess and inspect the newborn neck for full ROM ▪ No masses ▪ No factures ▪ Fractures of the clavicle are more likely to occur in large infants, especially when shoulder dystocia occurred. Sliding the fingers along each clavicle while moving the infant’s arm helps identify a fractured clavicle. ▪ Injury to the brachial plexus may cause paralysis of the arm on the side of the fracture. Treatment of a fractured clavicle includes immobilization of the affected arm for a short time. The fracture heals quickly Chest Normal: Abnormal: Two nipples. Extra nipples. Enlarged breasts. Apnea, cyanosis, tachypnea or grunting. Normal breath sounds. Crackles, wheezes. Tachycardia or bradycardia Umbilical cord The umbilical cord should contain three vessels. Two arteries are small and may stand up at the cut end. (if only one artery is present the infant is assessed for other abnormalities). Single large vein. A two-vessel cord may be associated with renal or chromosomal defects. A yellow brown or green tinged may be a sign of meconium stained during birth. Extremities ▪ The infant should actively move the extremities equally in random manner. ▪ The term infant’s extremities should be sharply flexed and resist extension during physical exam. ▪ Poor muscle tone associated with inadequate oxygenation during birth. ▪ Examine for signs of fractures : crepitus, redness, lumps or swelling. Hands and feet: the fingers are examined for symmetry and any other extra digits (polydactyly) and webbing between digits (syndactyly)- Hips ▪ The hips are examined for signs of developmental dysplasia (instability of the hip joint occurs at the head of the femur can be moved in and out of the acetabulum). ▪ The infant’s knees should be bent with feet flat on bed to compare the height of them. ▪ Legs are extended to determine symmetry and equal height. ▪ If the hip is dislocated: the leg on the affected side is shorter. ▪ Barlow and Ortolani tests are performed to assess hip instability in newborn. Hips Barlow’s Test (Figure A) Adduct the hip, then apply a downward pressure over the knee with your thumb. If the hip is unstable, the femoral head will slip out of the acetabulum, producing the palpable sensation of the hip dislocating. If the hip is dislocatable, then Barlow’s test is positive Ortolani’s Test (Figure B) Used to confirm the hip dislocation. Flex the hips and knees to 90 degree, then apply an anterior pressure over the greater trochanter and gently adduct the leg with your thumbs. If the hip was dislocated, a distinctive clunk will be heard as the hip relocates https://www.youtube.com/watch?v=imhI6PLtGLc Vertebral column ▪ Symmetrical, no masses, or deformities. ▪ Abnormal findings: spina bifida (failure of vertebra to close) Measurements- weight Term Infant (weight classification) Large for gestational age (LGA): > 4000 g Average gestational age (AGA): 2500-4000 (normal) Small for gestational age (SGA):