Newborn Care PDF

NEWBORN CARE  A. Essential Concepts: 1. In the postpartal period, the newborn experiences complex bio- physiologic and behavior change related to the transition to extrauterine life. 2. Nursing care of the newborn is based on knowledge of these changes and of t...

NEWBORN CARE  A. Essential Concepts: 1. In the postpartal period, the newborn experiences complex bio- physiologic and behavior change related to the transition to extrauterine life. 2. Nursing care of the newborn is based on knowledge of these changes and of the newborn’s impact on the family unit. 3. The first few hours after birth represent a critical period of adjustment for the newborn. In most setting, the nurse provides direct care to the newborn immediately after birth. 4. After the transition period, the nurse continues to evaluate the newborn at periodic intervals and to alter nursing plans according to ongoing findings. 5. The nurse must be skillful in balancing the family’s need for privacy and time to interact without interruptions with the need to closely monitor the newborn’s transition to extrauterine life.  B. GOALS OF NEWBORN CARE 1. For the initial postpartal period a. Establish and maintain an airway and support respirations. b. Maintain warmth and prevent hypothermia. c. Ensure safety to prevent injury or infection. d. Identify actual or potential problems that might require immediate attention. 2. For continuing care a. Continue to protect from injury or infection and identify actual or potential problems that could require attention. b. Facilitate development of a close parent-infant relationship. c. Provide parents with information about newborn care. d. Assist parents in developing healthy attitudes about childrearing practices.  C. FACTORS AFFECTING NEWBORN ADAPTATION 1. Antepartal experiences of mother and newborn (e.g., exposure to toxic substances, parental attitude toward childbearing and childrearing) 2. Intrapartal experiences of mother and newborn (e.g., length of labor, type of intrapartal analgesia or anesthesia) 3. Newborn’s physiologic capacity to make the transition to extrauterine life. 4. Ability of health care providers to assess and respond appropriately in the event of potential problems.  D. NURSING RESPONSIBILITIES 1. Support the neonate’s physiologic adaptation to extrauterine life 2. Prevent or minimize potential complications 3. Facilitate parent-infant interaction  IMMEDIATE NEWBORN CARE After the birth of the infant, every effort should be exerted to support him in his first minutes, hours and days of life. The quality of the immediate care afforded the newborn will spell his later state of health or well-being.  1. Establishment and maintenance of patent airway Right after the extension of the newborn’s head before the chest is delivered the mouth and nose should right away be cleared. This measure is the best prevention to meconium aspiration which results to lung infection: ASPIRATION PNEUMONIA a. Suction the newborn observing the following considerations:  Start with the mouth, then the nose – stimulation of the nerve receptors in the nose can cause reflex inhalation of oropharyngeal secretions into the trachea and bronchus and aspirate the secretions.  Press or deflate the rubber ball of the bulb syringe before inserting its tip into the mouth and nostrils of the newborn  Suction shallowly by using bulb syringe – deep suctioning can cause vagal stimulation leading to bradycardia and laryngospasm. Suction briefly – to avoid suctioning needed oxygen. ☺Preterm: less than 5 seconds per suction time ☺Full-term: 5 to 10 seconds per suction time Suctioning is a critical intervention in the newborn period. Which of the following statements about suctioning in the immediate newborn period is WRONG? A. Tachycardia can result when suctioning is not gentle B. Bulb syringe can be used for suctioning if secretions are not copious. C. Oropharyngeal suctioning, when needed, is done before nasal suctioning. Give oxygenation judiciously when necessary- giving more than 40% oxygen concentration can result to damage to the retina causing neonatal blindness called RETROLENTAL FIBROPLASIA Position in SLIGHT TRENDELENBERG position (10 to 15 degrees angle) – to drain secretions from the oro-naso- pharynx.  Test patency of the airway by occluding one nostril at a time – newborns are nasal breathers Position in slight Trendelenberg (10-15 degrees angles) – promote drainage of oro-naso-pharyngeal secretions. Avoid the acute Trendelenberg position – can cause abdominal contents to exert pressure unto the diaphragm leading to difficult breathing Head-down position is contraindicated in the presence of signs of increased intracranial pressure: vomiting; bulging/tensed fontanels; abnormally enlarged head; increased BP; decreased PR and RR; widening pulse pressure; shrill, high-pitched cry – place baby in Semi- Fowler’s position.  RESUSCITATION MEASURE Airway – make sure that the mouth and nasopharynx are free of secretions; remove secretions by suction, small finger, or gentle milking of trachea Breathing – if neonate does not make effort to breathe, start your mouth-to-mouth resuscitation. Pinch the nose and cover the baby’s mouth entirely with your mouth, and breath into him and notice the chest move Circulation – if there are no heart sounds, apply index and middle fingers/thumb on the infant’s mid-sternum and apply 1 inch downward pressure. Do 5 chest compressions followed by mouth-to-mouth resuscitation. LOOK, LISTEN, AND FEEL. * Oxygen deprivation of more than 5 minutes can result to the death of the baby or permanent damage of sensitive brain cells *Continue resuscitation until breathing is established or the heart stops beating and the baby is pronounced dead *Stop resuscitation when pupils have remained dilated for 30 minutes  2. Maintenance of appropriate body temperature The newborn temperature at birth is 37.3oC & drops quickly to 35.5oC owing to the mechanisms of heat loss. Dry the newborn immediately after birth to prevent heat loss by evaporation. Wrap the body and promote flexion and apply cap to head to minimize the body surfaces exposed to cool air or cool surfaces; never place newborn on cold and unlined surfaces. – to prevent heat loss by conduction and radiation. Most of newborn’s heat is lost by RADIATION.  Use a thermoregulator, such as a radiant warmer, or a temperature-controlled incubator to control environmental temperature until the neonate’s temperature stabilizes ❖Radiant warmer – maintains the neonate’s temp. by radiation. ❖Incubator – maintains the neonate’s temp. by conduction and convection. ✓ Make sure the warmer is set to the desired temperature ✓ Warm blankets, washcloths, or towels under a heat source ✓ Keep the neonate under the radiant warmer until his temperature remains stable ✓ When an incubator is used, keep it away from cold walls or objects, and perform all required procedures quickly, closing the portholes in the hood after completion  The warm abdomen of the of the mother ca be a good place to keep the newborn warm immediately after birth. The initial temperature of the newborn is taken per RECTUM – to detect for IMPERFORATE ANUS. After the initial temperature taking, all other temperature taking should be per AXILLA – to minimize potential risk to traumatizing the mucus membrane of the rectum; every 15-30 min. until it stabilizes and then every 4 hours to ensure stability Avoid exposing infant to drafts, wetness, and direct or indirect contact with cold surface. Maintain normal body temperature (97.7 to 98.6 oF) (36.5 to 37oC)  Temperature is stabilized within 8 to 12 hours at 36.8oC (98.2oF). During the entire immediate care procedures, place newborn under the floorlamp – to keep him warm. Subjecting the newborn to COLD STRESS can cause: 1.Increased brown fat metabolism causing an increased in fatty acids in the circulation thus METABOLIC ACIDOSIS. 2.Increased activity/metabolic rate causing more utilization of glucose and oxygen thus HYPOGLYCEMIA and RESPIRATORY DISTRESS.  3. Do immediate Assessment of the Newborn APGAR SCORING - Is the standardized evaluation of the newborn’s condition at birth done at: 1 min. after birth – to determine the general condition; & 5 min. after – to determine how well the newborn is adjusting to extrauterine life. - The scoring system is named after DR. VIRGINIA APGAR, an anesthesiologist, who studied the observations in the newborn. - The normal infant should have an APGAR of 7 or more; the higher the APGAR score, the better is the prognosis.  APGAR SCORE CHART SIGN 0 1 2 COLOR Generalized Body pink, Pink all over pallor or extremities blue (Appearance) bluish (Acrocyanosis) HEART RATE Absent < 100/min 100/min or more (Pulse) REFLEX IRRITABILITY None; No Grimace, weak Cry; sneezing; response cry coughs (Grimace) MUSCLE TONE Limp, Some tone in Active flexion of flaccid limbs; some limbs; well flexed (Activity) flexion of ext. extremities BREATHING None slow, irregular; Regular, with good weak cry strong cry (Respiratory Effort) O – 3 = severely depressed with HR slow, inaudible and reflex response are depressed or absent. The baby is in serious danger and NEEDS IMMEDIATE RESUSCITATION. 4 – 6 = mildly to moderately depressed infants; demonstrates depressed respiration, flaccidity, and pale to blue color. HR and reflex irritability are good. Condition is guarded and NEEDS AIRWAY CLEARANCE AND SUPPLEMENTAL OXYGEN. 7 – 10 = excellent condition and require no aid other than simply nasopharyngeal suctioning; absence of difficulty ; SURVIVES IN EXTRAUTERINE ENVIRONMENT  Score the following babies. Which of them are experiencing moderate difficulty? BABIES HR/min. RESP. MUSCLE REFLEX COLOR EFFORT TONE IRRITABILITY 110 Strong cry Well flexed Strong, loud Completely Grace cry pink Miriam 90 Irregular, Some Weak cry Body pink, slow flexion extremities blue Rodrigo 105 Good, strong Well flexed Strong cry Body pink, cry extremities blue Mar 80 Weak Limp Grimace Blue and pale Jojo 120 Strong cry Well flexed Strong cry Completely pink  COLOR. Many babies may be blue when they are delivered, but they usually regain color and become pink soon. If the newborn remains bluish, the baby may not be breathing well, or may be cold, or may have infection, or a congenital heart problem – refer the newborn immediately to the doctor. HEART RATE. The heart rate of a newborn is between 120 to 160 beats every minute – count the HR in 1 full minute; if outside the normal rate, refer immediately. MUSCLE TONE. A newborn with his arms and legs bent has good muscle tone. A limp baby with his arms and legs loose has poor muscle tone. A baby with poor/weak muscle tone may have trouble breathing. – try rubbing his back so the baby will wake up; or refer immediately.  BREATHING. Babies who cry after birth are usually breathing well. However, some newborns may have breathing problems. The following are bad signs: The nostrils are flaring when the baby breathes The skin between the ribs retracts on breathing Very rapid breathing – mote than 60 per min. Very slow breathing – less than 30 per min. The baby grunts when he breathes - A baby who is not breathing or is gasping needs immediate help.  If the baby has lots of secretions, use the bulb syringe to clear the airway. Turn the baby on his side for few minutes. Rub your hand firmly on his back. Never hit the baby nor hold him upside down to make him cry. Give oxygen inhalation if there is one available. Refer immediately.  Silverman-Anderson Scoring -An index of respiratory distress or is a useful tool in the evaluation of status of the newborn’s respiration to determine degree of respiratory distress syndrome (RDS). signs 0 1 2 No difficulty Moderate difficulty Maximum difficulty Upper chest Synchroniz Chest lag See-saw movement ed breathing breathing Lower chest No minimal Marked movement retractions  signs 0 1 2 No difficulty Moderate difficulty Maximum difficulty Xiphoid No minimal Marked process retractions retractions Nasal flaring No flaring Just visible Marked Expiratory Quiet Expiratory Grunting on grunting breathing grunts on bare ears auscultation  Silverman-Anderson Scoring Interpretation 0 = (-) respiratory distress 4 – 6 = moderate respiratory distress 7 – 10 = severe respiratory distress  Initial assessment and action to be taken: Initial assessment Action Pink Dry and wrap baby HR > 120 bpm Baby stays with mother Breathing regularly Blue Dry and wrap HR >100 bpm Clear the airway Breathing inadequate Blue or pale Dry and wrap HR