Normal Infant Care PDF

Normal Infant Care Growth and Development The Consumers of Infant Care – Neonate - Infant  Outline Normal Infancy Framework – Age-Group: Generalities – Assessment: Normal Growth and Development, Head-to-toe assessment – Diagnosis: Common Problems – Implementation of me...

Normal Infant Care Growth and Development The Consumers of Infant Care – Neonate - Infant  Outline Normal Infancy Framework – Age-Group: Generalities – Assessment: Normal Growth and Development, Head-to-toe assessment – Diagnosis: Common Problems – Implementation of measures to address common problems – Summary of the Age-group  GENERAL PRINCIPLES Definition of Terms A. Growth: increase in size of a structure. Human growth is orderly and predictable, but not even; it follows a cyclical pattern.  GENERAL PRINCIPLES Definition of Terms B. Development: maturation of physiologic and psychosocial systems to more complex state.  GENERAL PRINCIPLES C. Cephalocaudal: head-to-toe progression of growth and development – Development proceeds from head down to the toes – Infants achieve control of the head before the trunk  GENERAL PRINCIPLES D. Proximodistal: trunk-to-periphery (fingers and toes) progression of growth and development – Development proceeds from the midline of the body to the extremities  General principles Growth and development are continuous processes from conception until death. Growth and development proceed in an orderly sequence. Different children pass through the predictable stage at different rates. All body systems do not develop at the same rate Development is cephalocaudal  General principles Development proceeds from proximal to distal body parts. Development proceeds from gross to refined skills. There is an optimum time for initiation of experiences or learning. Neonatal reflexes must be lost before development can proceed. A great deal of skill and behavior is learned by practice.  Rates of Development A. Fetal period and infancy: the head and tissue grow faster than other tissues. B. Infancy and adolescence: fast growth periods C. Toddler through school-age: slow growth periods D. Toddler and preschool periods: the trunk grows more rapidly than other tissue. E. The limbs grow most during school-age period. F. The trunk grows faster than other tissue during adolescence.  Stages of growth and development 1. Pre-natal period 2. Neonate- birth to TWENTY-EIGHT days 3. Infancy- One month to 12 months 4. Toddler- 1 year to 3 years 5. Pre-school- 3 years to 6 years 6. School-aged- 6 years to 12 years 7. Adolescence- 12 years to 18 years  The Personality Development 1. Psychosexual theory- Psychoanalytical theory 2. Psychosocial theory 3. Cognitive theory 4. Interpersonal theory 5. Moral development theory  Psychosexual/Psychoanalytical Five Stages of psychosexual development 1. Oral 2. Anal 3. Phallic or Oedipal 4. Latency 5. Genital Psychosexual/Psychoanalytical Freud proposes that the underlying motivation to human development is an energy form or life instinct called LIBIDO. Unconscious mind is the mental life of a person of which the person is unaware. Proposed concepts like: ID, EGO, SUPER EGO ID – developed during infancy – "I know what I want and I want it now!” – Pleasure principle EGO – developed during toddler period – "I can wait for what I want!" – Reality principle – balances the id and superego SUPEREGO – developed during preschool period – "I should not want that!” – Conscience- Morality principle  Psychosexual/Psychoanalytical Phase Age Focus Oral 0- 1 yr Site of gratification: Mouth Anal 1 - 3 yrs Site of gratification: Anus Phallic 3- 5 years Site of gratification: Genitals Latency 6- 12 Site of gratification: (School years Activities) Genita 12 & Site of gratification: Genitals l above  Psychosexual/Psychoanalytical Phase Age Focus Oral 0-1 year Major task: Weaning Anal 1- 3 Major task: Toilet training years Phallic 3- 5 Major task: Oedipal & Electra years complex Latenc 6- 12 Major task : y years School/Academics Genital 12 & Major task: Sexual intimacy above  Psychosexual model (Freud) 1. Oral a. 0-12 months b. Pleasure and gratification through mouth c. Behaviors: dependency, eating, crying, biting d. Distinguishes between self and mother e. Develops body image, aggressive drives  Psychosexual model (Freud) 2. Anal a. 1 year - 3 years b. Pleasure through elimination or retention of feces c. Behaviors: control of holding on or letting go d. Develops concept of power, punishment, ambivalence, concern with cleanliness or being dirty  Psychosexual model (Freud) 3. Phallic/Oedipal a. 3 - 6 years b. Pleasure through genitals c. Behaviors: touching of genitals, erotic attachment to parent of opposite sex d. Develops fear of punishment by parent of same sex, guilt, sexual identity  Psychosexual model (Freud) 4. Latency a. 6 - 12 years b. Energy used to gain new skills in social relationships and knowledge c. Behaviors: sense of industry and mastery d. Learns control over aggressive, destructive impulses e Acquires friends  Psychosexual model (Freud) 5. Genital a. 12 - 20 years b. Sexual pleasure through genitals c. Behaviors: becomes independent of parents, responsible for self d. Develops sexual identity, ability to love and work  Erikson’s Psychosocial theory Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority Identity versus role confusion Intimacy versus isolation Generativity versus stagnation Ego integrity versus despair  Erikson’s Psychosocial theory Age Task Achievements 0- 1 yr Trust vs Mistrust Optimism 1- 3 yrs Autonomy vs S/D Self-Control 3- 5 yrs Initiative vs Guilt Direction and purpose 6- 12 Industry vs inferiority Competence and yrs method 12- 18 Identity vs Role Devotion and Confusion fidelity  Psychosocial Model (Erikson) 1. Trust vs mistrust a. 0 - 18 months b. Learn to trust others and self vs withdrawal, estrangement  Psychosocial Model (Erikson) 2. Autonomy vs shame and doubt a. 18 months - 3 years b. Learn self-control and the degree to which one has control over the environment vs compulsive compliance or defiance  Psychosocial Model (Erikson) 3. Initiative vs guilt a. 3 - 5 years b. Learn to influence environment, evaluate own behavior vs fear of doing wrong, lack of self-confidence, overrestricting actions  Psychosocial Model (Erikson) 4. Industry vs inferiority a. 6 - 12 years b. Creative; develop sense of competency vs sense of inadequacy  Psychosocial Model (Erikson) 5. Identity vs role confusion a. 12 - 20 years b. Develop sense of self; preparation, planning for adult roles vs doubts relating to sexual identity, occupational career  Psychosocial Model (Erikson) 6. Intimacy vs isolation a. 18 - 25 years b. Develop intimate relationship with another; commitment to career vs avoidance of choices in relationships, work, or life-style  Psychosocial Model (Erikson) 7. Generativity vs stagnation a. 21 - 45 years b. Productive; use of energies to guide next generation vs lack of interests, concern with own needs 8. Integrity vs despair a. 45 years to end of life b. Relationships extended, belief that own life has been worthwhile vs lack of meaning of one’s life, fear of death  Piaget Sensori-motor (birth to 2 ) Pre-operational (2-7) – Preoperational preconceptual (2-4) – Preoperational intuitive (4-7) Concrete operational (7-12) Formal operational (12 to adulthood)  Cognitive Theory (Piaget) A. 0 - 2 years: sensorimotor -reflexes, repetition of acts B. 2 - 4 years: preoperational/preconceptual -no cause and effect reasoning; egocentrism; use of symbols; magical thinking C. 4 - 7 years: intuitive/preoperational -beginning of causation  Cognitive Theory (Piaget) D. 7 – 12 years: concrete operations - uses memory to learn - aware of reversibility E. 12 - 15 years: formal operations -reality, abstract thought -can deal with the past, present and future  Interpersonal theory This concept focuses on interaction between an individual and his environment Personality is shaped through “interaction” with significant others We internalize approval or disapproval from our parents  Interpersonal theory Personality has three SELF-SYSTEM 1. “Good Me” develops in response to behaviors receiving approval by parents/SO 2. “Bad Me” develops in response to behaviors receiving disapproval by parents/SO 3. “Not Me” develops in response to behaviors generating extreme anxiety in parents/SO and this is denied as part  Interpersonal Model (Sullivan) 1. Infancy a. 0 - 18 months b. Others (Caregivers) will satisfy needs 2. Childhood a. 18 months - 6 years b. Learn to delay need gratification 3. Juvenile a. 6 - 9 years b. Learn to relate to peers  Interpersonal Model (Sullivan) 4. Preadolescence a. 9—12 years b. Learn to relate to friends of same sex 5. Early adolescence a. 12—14 years b. Learn independence and how to relate to opposite sex 6. Late adolescence a. 14—21 years b. Develop intimate relationship with person of opposite sex KOHLBERG’S STAGES OF MORAL DEVELOPMENT  Moral Theory Pre-Conventional Stage 1 Stage 2 Conventional Stage 3 Stage 4 POST Conventional Stage 5 Stage 6  PRECONVENTIONAL LEVEL Stage 1 Age Group: 2-3 years Description of morality: – Punishment or obedience (heteronomous morality) – A child does the right things because a parent tells him or her to avoid punishment – Child is UNABLE to understand other’s viewpoint  PRECONVENTIONAL LEVEL Stage 2 Age Group : 4-7 years Description of morality: – Individualism- Hedonism – Child carries out actions to satisfy own needs rather than society’s. – The child does something for another if that person does something for him in return- “an eye for an eye’  CONVENTIONAL LEVEL level 2 Stage 3 Age Group : 7-10 years Description of morality: – Orientation to interpersonal relations of mutuality- CONFORMITY – A child follows rules because of a need to be a good person in own eyes and in the eyes of others – “Good boy or Good girl”  CONVENTIONAL LEVEL level 2 Stage 4 Age Group : 10-12 years Description of morality: – Maintenance of social order, fixed rules and authority – Child FOLLOWS RULES of authority figures as well as parents to keep the system working – LAW and ORDER POSTCONVENTIONAL LEVEL level 3 Stage 5 Age Group : 12 and above Description: – social contract, utilitarian law making perspective – child FOLLOWS STANDARDS OF SOCIETY for the good of all people  POSTCONVENTIONAL LEVEL level 3 Stage 6 Age :older than 12 Descriptions: – universal ethical principle orientation – Respect and dignity of humanity  Spiritual Development- Fowler Stage Age Group Description Undifferentiated 0-3 years No concept Intuitive-Projective 4-6 years Imaginations Mythic-literal 7-12 years Stories and Myths Synthetic-Conventi Adolescent Expectations onal Individuating-reflect Adult- after 18 One’s system ive Paradoxical-consoli Adult- after 30 Various dating viewpoints UNIVERSALIZING MAYBE never Love and justice  Death Concepts (Kozier) AGE Beliefs Infancy to 3 years old NO clear concept of Death 3 years to 4 years It is Reversible, temporary sleep 5 to 9 years Understands DEATH is FINAL but can be AVOIDED 9-12 years Death is INEVITABLE, everyone will die someday Understands own mortality 12-18 years Fears a lingering Death 18-45 Attitude is influenced by religion 45-65 years Experiences peak of death anxiety 65 and above Death as multiple meanings  Child’s Response to Death 1. Infants and toddlers - toddlers may insist on seeing a significant other long after that person’s death. 2. Preschoolers - may see death as temporary; a type of sleep or separation. 3. School-age – See death as a period of immobility. - Feel death is punishment. 4. Adolescents - Have an accurate understanding of death. CARE OF THE NEWBORN Immediate Care of the Newborn Airway Breathing Temperature  The st 1 24 hours of Life The first 24 hours of life is a very significant and a highly vulnerable time due to critical transition from intrauterine to extrauterine life  Immediate Newborn Care 1. Establish and maintain a patent airway –Never stimulate to cry unless secretions have been drained out. –Head lower than the rest of the body (except in increased ICP) –Suction secretions properly  Immediate Newborn Care 1. Establish and maintain a patent airway – MOUTH before NOSE (prevent inhalational reflex) – AVOID PROLONGED and DEEP SUCTIONING (stimulates vagus nerve)→ BRADYCARDIA – OCCLUDE ONE NOSTRIL AT A TIME – Newborns are obligate nasal breathers!  Airway & Breathing Suction gently & quickly using bulb syringe or suction catheter Starts in the mouth then, the nose to prevent aspiration 051104 Neonatal Care 55 051104 Neonatal Care 56  Airway & Breathing Stimulate crying by rubbing Position properly- side lying / modified t-berg Provide oxygen when necessary 051104 Neonatal Care 57  Immediate Newborn Care 2. Maintain appropriate body temperature. – Body temperature is about 37.2°C at the moment of birth (confined in an internal body organ) – There is heat loss due to immature temperature-regulating mechanisms. – COLD STRESS → due to large losses of heat (Convection, Conduction, Radiation, Evaporation)  Immediate Newborn Care 2. Maintain appropriate body temperature Effects of Cold Stress: Metabolic acidosis (breakdown of brown fat found in INTRASCAPULAR AREA, THORAX and PERIRENAL REGIONS) Hypoglycemia (due to use of glucose stored as glycogen)  Immediate Newborn Care 2. Maintain appropriate body temperature. Prevention Place the newborn near the mother’s skin Dry the newborn immediately Wrap him with warn sheets Put him under a droplight Close windows and door  Temperature Dry immediately Place in infant warmer or use droplight Wrap warmly 051104 Neonatal Care 61  NEWBORN ASSESSMENT Assessment of the newborn is essential to ensure a successful transition  Major Time Frames 1. Immediately after birth 2. Within the 1st 4 hours after birth 3. Prior to discharge 051104 Neonatal Care 64  NEONATAL ASSESSMENT Initial assessment Ongoing assessment Physical assessment Sensory assessment Behavioral assessment 2 forms of neonatal assessment 1. IMMEDIATE ASSESSMENT APGAR scoring Ballard scoring Gestational Age assessment: BESTS 2. SECONDARY ASSESSMENT Head-to-toe physical assessment Neonatal Reflexes Sensory and Behavioral  APGAR Score Virginia Apgar  APGAR Scoring System A ctivity/ Muscle Tone P ulse/ Heart Rate G rimace/ Reflex Irritability/ Responsiveness A ppearance/ Skin Color R espiration/ Breathing 1 2 3 4 5 051104 Neonatal Care 68 INDICATORS 2 1 0 Activity Active, Some flexion No movement spontaneous of extremities (flaccid, limp) Pulse >100 bpm < 100 bpm Absent Grimace Pulls away, Facial grimace No response sneezes, coughs only with stimulation Appearance Completely pink Acrocyanosis Bluish-gray or pale all over Respiration Good vigorous Slow, irregular Absent cry Weak cry 051104 Neonatal Care 69 Score Interpretation Nursing Interventions 7 to 10 Well baby Rarely needs resuscitation Requires resuscitation 4 to 6 At risk Suction INFANT NEEDS Dry immediately INTENSIVE CARE Ventilate until stable Careful observation Intensive resuscitation ET/ Ambu bag 0 to 3 Sick baby Ventilate with 100% O2 PROGNOSIS FOR CPR NB IS GRAVE Maintain body temperature Parental support 051104 Neonatal Care 73 Baby’s Apgar scores (1 min & 5 mins.) Interpretation: 7-10 the baby is in the best possible health 4-6 the baby’s condition is guarded, he needs more extensive clearing of airway-suctioning and monitoring 0-3 the baby is in serious danger and needs immediate resuscitation.  BESTS Criteria 0 to 36 weeks 37-38 weeks 39 weeks & above B- reast nodule 2 mm 4 mm 7 mm E – ar lobe No cartilage Some cartilage Thick cartilage S – calp hair Fine and fuzzy Fine and fuzzy Coarse and silky T– Testes in lower Intermediate; Testes testes/Scrotum sac; scrotum scrotum with pendulous; with no rugae some rugae scrotum with rugae S – ole creases Anterior Creases over Entire sole transverse anterior 2/3 covered with crease only creases  Assessment of Gestational Age Dubowitz Maturity Scale – Gestational rating scale – NB are observed and tested according to the criteria – Help determine whether the NB needs immediate high-risk nursery intervention 051104 Neonatal Care 76  Usher’s Criteria FINDINGS 0-36 WKS 37-38 WKS 39 WKS AND OVER Sole creases Anterior transverse Occl creases in Sole covered with crease only ant 2/3 creases Breast nodule 2 4 7 diameter (mm) Scalp hair Fine and fuzzy Fine and fuzzy Coarse and silky Ear lobe Pliable; no Some cartilage Stiffened by thick cartilage cartilage Testes and Testes in lower Intermediate Testes pendulous, scrotum canal; scrotum scrotum full; small; few rugae extensive rugae 051104 Neonatal Care 77  Ballard’s Scoring Completed in 3-4 min 2 portions: physical maturity and neuromuscular maturity 051104 Neonatal Care 78  Ballard’s Scoring Ballard's Scoring A. Neuromuscular Maturity – Posture – Square window – Arm recoil – Popliteal angle – Scarf sign – Heel to ear B. Physical – Skin – Lanugo – Plantar surface – Breast – Eye-ear – Genitalia Physical maturity 051104 Neonatal Care 80 Neuromuscular Maturity 051104 Neonatal Care 81  Scoring 051104 Neonatal Care 82 Physical maturity 051104 Neonatal Care 19 83 Neuromuscular Maturity 051104 Neonatal Care 17 84  Scoring 19+17=36 36 39 051104 Neonatal Care 85  Silverman-Anderson Index Perform to observe for signs of respiratory distress – Chest lag – Retractions – Nasal flaring – Expiratory grunting 051104 Neonatal Care 86  Silverman Scoring System 0 1 2 051104 Neonatal Care 87  Example 0 1 2 051104 Neonatal Care Score: 5 88  Score Interpretation Score Interpretation 0-3 No RDS Moderate RDS 4-6 Severe RDS 7-10 051104 Neonatal Care 89  Head-to-toe Assessment Physical Examination: Vital signs HR = 120 - 140/min (Apical) RR = 30 - 60/min (diaphragmatic and abdominal, irregular, rapid, quiet and shallow) BP = 80/46 → 1 00/50 mmHg after 10 days Temp = must be maintained at 35.5°C - 36.5°C (rectal route🡪 preferred to check patency of anus)  Newborn Screening The Newborn Screening Reference Center (NSRC) is an office under the National Institutes of Health (NIH), University of the Philippines Manila created under RA 9288– The Newborn Screening Act of 2004 Performed after 24 hours of life up to 3 days except for patient in intensive care, must be tested by 7 days 051104 Neonatal Care 91  Congenital Hypothyroidism (CH) Congenital Adrenal Hyperplasia (CAH) Galactosemia (GAL) Phenylketonuria (PKU) Glucose-6-Phosphate-Dehydrogenase Deficiency (G6PD Def) 051104 Neonatal Care 92 Disorder Screened If not screened If screened Congenital Severe mental Normal Hypothyroidism retardation Congenital Adrenal Death Alive and Normal Hyperplasia Galactosemia Death or Cataracts Alive and normal PKU Severe mental Normal retardation G6PD Deficiency Severe Anemia, Normal Kernicterus 051104 Neonatal Care 93  TEMPERATURE Site: Axillary NOT Rectal Duration: 3 mins Normal Range: 36.5 – 37.6 C Stabilizes within 8-12 hrs Monitor q 30 mins until stable for 2 hrs then q 8 hrs 051104 Neonatal Care 94  Heat Loss Mechanisms Convection – the flow of heat from the body surface to cooler surrounding air – Eliminating drafts such as windows or air con, reduces convection Conduction – the transfer of body heat to a cooler solid object in contact with the baby – Covering surfaces with a warmed blanket or towel helps minimize conduction heat loss 051104 Neonatal Care 95  Radiation – the transfer of heat to a cooler object not in contact with the baby – Cold window surface or air con; moving as far from the cold surface, reduces heat loss Evaporation – loss of heat through conversion of a liquid to a vapor – From amniotic fluid; NB should be dried immediately 051104 Neonatal Care 96  Nursing Considerations Keep dry and well-wrapped Keep away from cold objects or outside walls Perform procedures in warm, padded surface Keep room temperature warm 051104 Neonatal Care 97  Pulse Awake: 120 – 160 bpm—120 – 140 bpm Asleep: 90-110 bpm Crying: 180 bpm Rhythm: irregular, immaturity of cardiac regulatory center in the medulla Duration: 1 full minute, not crying Site: Apical 051104 Neonatal Care 98  Nursing Considerations Keep warm Take HR for 1 full minute Listen for murmurs Palpate peripheral pulses Assess for cyanosis Observe for CP distress 051104 Neonatal Care 99  Special Concerns (+) Prominent radial pulse = CHD (-) Femoral pulse = Coarctation of aorta 051104 Neonatal Care 100  Respiration Characteristics: Nasal breathers, gentle, quiet, rapid BUT shallow; may have short periods of apnea ( CC 051104 Neonatal Care 145  Fontanelles “soft spot” – BAD (12-18 mos) – LPT (2-3 mos or 8-12 wks) – Bulging or sunken Sutures – Overriding or separated 051104 Neonatal Care 146  Head lag – Common when pulling newborn to a sitting position – When prone, NB should be able to lift the head slightly and turn head from side to side 051104 Neonatal Care 147  Head-to-toe Assessment Head Fontanelles - should be flat; not indented or bulging – Anterior (diamond-shaped) closes 12-18 months – Posterior (triangular shaped) closes 2-3 months. Molding - some overlapping of sutures Craniotabes - localized softening of the cranial bones caused by pressure of fetal skull against the mother's pelvic bone; more common in firstborn infants Caput succedaneum vs. Cephalhematoma  Caput Succeedaneum Swelling of soft tissues of the scalp Due to pressure Crosses the suture lines Presenting part 3 days after birth 051104 Neonatal Care 149  Cephalhematoma Subperiosteal hemorrhage with collection blood Due to rupture of capillaries as a result of trauma Does not crossed suture lines Several weeks 051104 Neonatal Care 150  Head-to-toe Assessment Criteria Caput succedaneum Cephalhematoma Cause Scalp edema Collection of blood between periosteum and skull bone Extent of Both hemispheres Involvem (Crosses sutures) ent Does not cross sutures Absorption About 3 days Several weeks  Molding Overlapping of skull bones Due to compression during labor and delivery Disappears in few days 051104 Neonatal Care 152 051104 Neonatal Care 153  Craniotabes Localized softening of the cranial bones Can be indented by pressure of fingers MOST common among 1st born babies, pathological in older child—metabolic disorder Caused by pressure of the fetal skull against the mother’s pelvic bone in utero 051104 Neonatal Care 154  Forcep Marks U –shaped bruising usually on the cheeks after forcep delivery 051104 Neonatal Care 155 Face/Eyes/Ears/ Nose /Mouth  What to Assess Facial movement & symmetry Symmetry, size, shape and spacing of eyes, nose and ears 051104 Neonatal Care 157  Head-to-toe Assessment Eyes (Assess by putting infant in upright position) – tearless due to immature lacrimal ducts – comea is round, pupil is dark, iris is gray – temporary cross-eyed (STRABISMUS)  Eyes Color: – white sclera – Slate gray, brown or dark blue – Final eye color: after 6-12 months Symmetrical Pupils equal, round, reactive to light (+) Blink reflex 051104 Neonatal Care 159  (+) transient strabismus due to weak EOM Able to move and fixate momentarily (+) Red reflex – if (-), cataract (+) Edema on eyelids r/t pressure during delivery or effects of medication (-) Tear formation (begins @ 2-3 mos) 051104 Neonatal Care 160 051104 Neonatal Care 161  Nursing Considerations Administer eye medication within 1 hr after birth to prevent Ophthalmia neonatorum DOC: Erythromycin 0.5% Tetracycline 1% Silver Nitrate 1% From inner to outer canthus of the eye (conjunctival sac) 051104 Neonatal Care 162  Head-to-toe Assessment Ears – The level of top part of the external ear should be on a line drawn from the inner canthus to the outer canthus of the eye – Low-set ears 🡪 Down's syndrome  Ears Soft and pliable; with firm cartilage Pinna should be at the level of outer canthus of the eye (+) Low set ears = renal or chromosomal abnormalities May be congested and hear well after few days 051104 Neonatal Care 164  Low set ears 051104 Neonatal Care 165  Accessory tragus: remnant of 1st branchial arch Congenital preauricular sinus: ends blindly risk for infection 051104 Neonatal Care 166  Head-to-toe Assessment Nose – appear large for the face; no septal deviation – obligate nasal breathers  Nose Small & narrow Flattened, midline Nasal breathers (+) Periodic sneezing Reactive to strong odors (+) Flaring = respiratory distress (+) Low nasal bridge = Down’s syndrome 051104 Neonatal Care 168  Head-to-toe Assessment Mouth – should open evenly when crying – tongue appears large – palate intact; lips should have no breaks – EPSTEIN PEARLS: small, round glistening cysts on the palate (due to hypercalcemia of the mother) – NATAL TEETH: if loose, should be extracted  Mouth Pink, moist gums Intact soft & hard palates – (+) Epstein’s pearls Uvula midline Tongue moves freely, symmetrical with short frenulum (+) Extrusion & Gag reflexes 051104 Neonatal Care 170  Small mouth or large tongue = chromosomal problems (+) white patches on tongue or side of the cheek = Oral thrush 051104 Neonatal Care 171  Head-to-toe Assessment Neck – short and chubby; creased with folds – thymus is palpable (triples at 3 yrs; stops growth and recedes by 10 years old) – head should rotate freely  Neck Short, thick, in midline Able to flex and extend but cannot support the full weight of head Creased with skin folds Trachea midline Thyroid gland not palpable Intact clavicle 051104 Neonatal Care 173  Head-to-toe Assessment Chest – should be symmetrical – breasts may be engorged – WITCH'S MILK: due to maternal hormones  Chest CC = or < 2cm than HC Cylindrical; equal AP:T diameters Symmetrical Abdominal breathers 051104 Neonatal Care 175  (+) Bronchial sounds (+) Breast engorgement ; subsides after 2 wks (+)Prominent/ edematous nipple (+) Accessory nipples (+) “Witch Milk” 051104 Neonatal Care 176  Head-to-toe Assessment Abdomen – slightly protuberant; dome-shaped – if scaphoid → diaphragmatic hernia – liver, spleen and kidneys are palpable – umbilical cord - 2 arteries and 1  Abdomen Umbilical Cord – 2 arteries; 1 vein – White & gelatinous immediately after birth – Begins to DRY between 1-2 hrs following birth – Blackened or shriveled between 2-3 days – Dried & gradually falls off by 7 days 051104 Neonatal Care 178  Head-to-toe Assessment Anogenital region – Pseudomenstruation – epispadias, hypospadias, hydrocele – Foreskin should be retracted to test for phimosis and paraphimosis – testes should be descended (if not, Cryptorchidism) – "wink reflex" sign of anal patency  Head-to-toe Assessment Back – appears flat when prone – mass, hairy nebule or a dimple along axis 🡪 Spina bifida  Back Spine – Straight, posture flexed – Supports head momentarily – Arms & legs flexed – Chin flexed on upper chest – Check for protrusion, excessive or poor muscle contractions = CNS damage 051104 Neonatal Care 181  Head-to-toe Assessment Extremities – arms and legs are short and plump Side Notes: – ERB DUCHENNE'S PARALYSIS Absent Moro reflex on affected arm – Extra digits (polydactyly); fused digits (syndactyly) – Simian line: a single palmar crease → Down’s syndrome – Ortolani’s sign: congenital hip discoloration  Extremities Flexed, full ROM, symmetrical Clenched fists; flat soles With 10 fingers and toes in each hand Legs bowed Even gluteal folds 051104 Neonatal Care 183  (+) Creases on soles of feet – (-) Creases = prematurity Check for hip fractures or dysplasia – (+) Ortolani’s click & uneven gluteal folds = Hip dysplasia li ck c ! 051104 Neonatal Care 184 051104 Neonatal Care 185 051104 Neonatal Care 186  (+) inward turning of the foot = club foot or talipes equinovarus 051104 Neonatal Care 187  (+) extra digits = Polydactyly (+) web fingers = Syndactyly 051104 Neonatal Care 188  Systemic Assessment Fetal accessory Functional Adult structure structures Closure Foramen ovale 1 year Fossa ovalis Ligamentum Ductus arteriosus 1 month arteriosum Ductus venosus 2 months Ligamentum venosum Umbilical arteries Lateral umbilical 2-3 months (2) ligament Ligamentum teres Umbilical vein (1) 2-3 months (round ligament of liver)  GIT: – Capacity: 90 ml, with rapid intestinal peristalsis ( 2 ½ to 3 hrs) – Bowels sounds; (+) within 1-2 hrs after birth – Presence of mass, distention depression or protrusion – (+) Scaphoid = diaphragmatic hernia – (+) Distended = LGIT obstruction/ mass 051104 Neonatal Care 191  Anus – Check patency – First stool (Meconium) – within 1st 24 hrs Sticky, tarlike, blackish-green, odorless material 051104 Neonatal Care 192 051104 Neonatal Care 193  Systemic Assessment Meconium – within 24 hours – sticky, tarlike, blackish-green, odorless – mucus, vernix, lanugo, hormones and carbohydrates that accumulated during intrauterine life. Transitional stools - 2nd to 3rd day up to 10th day – slimy green and loose resembling diarrhea to the untrained eye  Transitional Stool Within 2- 10 days after birth Breastfed: – golden yellow, mushy, more frequent 3-4x and sweet smelling Bottlefed: – Pale yellow, firm, less frequent 2-3x, with more noticeable odor 051104 Neonatal Care 195  Meconium Staining Over the skin, fingernails & umbilical cord Due to passage of meconium in utero r/t fetal hypoxia 051104 Neonatal Care 196  Genitals Female: – Labia: edematous – Clitoris: enlarged – (+) Smegma – Pseudomenstruation possible – Visible “hymen tag” – First voiding within 24 hrs 051104 Neonatal Care 197  Male: – Prepuce covers glans penis (+) adherent foreskin = Phimosis – Scrotum: edematous (+) enlarged = Hernia – Meatus: central (+) ventral/ dorsal = Hypo/epispadias – Testes: descended (+) undescended = Cryptorchidism 051104 Neonatal Care 198  051104 Neonatal Care 199  Systemic Assessment Criteria Breastfed Infant Bottle-fed Infant Color Golden yellow Pale yellow Consistency Mushy, soft Firm Frequency of 3-4x/day 2-3x/day passage Smell Sweet-smelling Slightly Malodorous  Systemic Assessment Urine – about 15 ml of urine per void – females: form a strong stream when voiding – males: small projected stream when voiding – should void within 24 hours.  NEONATAL SENSES HEARING: – able to hear in the utero – within hrs after birth, hearing in NB becomes acute VISION: – focus on black and white objects – distance of 9-12 inches – pupillary reflex present at birth  NEONATAL SENSES TASTE: – developed before birth TOUCH: – MOST developed sense at birth – react to painful stimuli SMELL: – present as soon as the nose is cleared of mucus – ability to respond to odors can be used to document alertness  Neonatal Reflexes Reflexes Disappearance Rooting reflex 6 weeks Sucking Reflex 6 months Extrusion Reflex 4 months Palmar grasp 6 weeks-3 months Stepping 3 months (Walk-in-place/Dancing) Reflex Placing (anterior surface of leg) 3 months Plantar Grasp 8-9 months Tonic neck (Fencing/Boxer) 2-3 months Reflex  Neonatal Reflexes Reflexes Disappearance Moro reflex 4-5/6 months Babinski Reflex 3 months Magnet Reflex 3 months Crossed Extension Reflex 3 months Trunk Incurvation Reflex 2-3 months Landau Reflex (Parachute Reaction) 3 months Bauer's (Crawling) Reflex 6 weeks Blink Reflex (see objects 9-12" at Do not disappear midline) Swallowing Reflex Do not disappear  NEONATAL REFLEXES Reflex: Tonic neck Stimulus: neck flexion, neck extension Response: arm flexion, leg extension, arm extension, leg flexion Onset: birth-1month Suppression: 3-4 mos  Tonic Neck/ Fencing While the baby is falling asleep or sleeping, gently and quickly turn the head to one side As the baby faces the left side, the left arm and leg extend outward while the right arm or leg flex and vice-versa Disappears within 3-4 mos 051104 Neonatal Care 207  NEONATAL REFLEXES Reflex: Positive supporting Stimulus: tactile contact and weight bearing on sole Response:leg extension for supporting partial body weight Onset: 2 months Suppression: 3-7 mos, replaced by volitional standing  NEONATAL REFLEXES Reflex: Rooting Stimulus: stroking the corner of the mouth, upper or lower lip Response:moving the tongue, mouth and head towards the site of stimulus Onset: birth Suppression: 4 mos  Sucking/ Rooting Touch the lip, cheek or corner of the mouth Turns head toward the nipple, opens mouth, takes hold of the nipple and sucks Disappears after 3-4 mos up to 1 year 051104 Neonatal Care 210  Extrusion Anything place on the anterior portion of the tongue will be “spit out’ To prevent swallowing of inedible substances Disappears after 4 months Disappearance indicates readiness for semi-solid to solid foods 051104 Neonatal Care 211  Swallowing Occurs spontaneously after sucking and obtaining fluids NEVER disappear Newborn swallows in coordination with sucking without gagging, coughing or vomiting 051104 Neonatal Care 212  NEONATAL REFLEXES Reflex: Palmar grasp Stimulus: pressure or touch on the palm, stretch of finger flexors Response:flexion of fingers Onset: birth Suppression: 4-6 mos  Palmar(Grasping)/ Plantar Place a finger in the palm of the baby’s hand, then place a finger at the base of the toes Fingers will curl or grasp the examiner’s finger and the toes will curl downward Palmar: fades within 3-4 mos Plantar: fades within 8 mos 051104 Neonatal Care 214  NEONATAL REFLEXES Reflex: Plantar grasp Stimulus: pressure on the sole just distal to the metatarsal heads Response:flexion of toes Onset: birth Suppression: 12-18 mos  NEONATAL REFLEXES Reflex: Automatic neonatal walking Stimulus: contact of the sole in vertical position tilting the body forward and from side to side Response: automatic alternating steps Onset: birth Suppression: 3-4 mos  Stepping/ Walking/ Dancing Hold baby in a standing position allowing one foot to touch a surface Simulates walking by alternately flexing and extending feet Disappears after 3-4 mos 051104 Neonatal Care 217  NEONATAL REFLEXES Reflex: Moro Reflex Stimulus: Startle the neonate with a loud noise or jarring the bassinet; hold supine and let head drop backward Response: ABDUCT and extend the arms and lega; fingers in “C” position🡪 then ADDUCT into embracing position Onset: birth Suppression: 4-5 mos  Moro Hold baby in a semi sitting position then allow the head and trunk to fall backward to at least a 30-degree angle Symmetrically abducts and extends the arms; fans the fingers out and forms a C with the thumb and the forefinger; and adducts the arms to an embracing position & returns to a relaxed state 051104 Neonatal Care 219  Present at birth; complete response at 8 weeks MOST significant singular reflex indicative of CNS problem (>6 mos) Disappears after 4-5 mos. 051104 Neonatal Care 220  Startle Best elicited if baby is 24 hrs old Make a loud noise or claps hands Baby ‘s arms adduct while elbows flex with fists clenched Disappears within 4 mos 051104 Neonatal Care 221  Babinski Gently stroke upward along the lateral aspect of the sole, starting at the heel of the foot to the ball of the foot Dorsiflexion of big toe and fanning of little toes Disappears starts a 3 mos to 1 year Disappearance indicates maturity of CNS 051104 Neonatal Care 222  BEHAVIORAL ASSESSMENT First Period of Reactivity 30 minutes after birth Awake and active VS are increased Mother infant bonding 🡪 breastfeeding Resting Period 2 to 4 hours VS returning to baseline 1 ½ sleep and difficult to be aroused Second Period of Reactivity 4 to 6 hours Care of the Newborn in the Nursery  Components Anthropometric Measurements Bathing – Oil bath/ warm water bath Cord Care Dressing/ Wrapping - mummified Eye prophylaxis – Crede’s Foot printing / Identification Get APGAR score – 1 & 5 mins HR, RR, Temp, BP Injection of Vitamin K 051104 Neonatal Care 226  Proper Identification After delivery, gender should be determined Pertinent records should be completed including the ID bracelet Before transferring to nursery, ID tag should be applied. 051104 Neonatal Care 227  Weight/ Anthropometric Measurements 051104 Neonatal Care 228  Body Measurements Weight: – 5.5 to 9.5 lbs (2500-4300 gms) Caucasian: 7 lbs Filipinos: 6.5 lbs – 70-75% TBW is water – LBW = below 2500 gms; regardless of AOG 051104 Neonatal Care 229  Length: – 45 to 55 cm (18-22 inches) – Average: 50 cm – Techniques: using tape measure Supine with legs extended – Crown to rump – Head to heel 051104 Neonatal Care 230 051104 Neonatal Care 231  Head Circumference (HC): – 33 to 35.5 cm (13-14 inches) – Technique: using tape measure From the most prominent part of the OCCIPUT to just above the EYEBROWS 051104 Neonatal Care 232  Chest Circumference (CC): – 30 to 33 cm (12-13 inches) – Technique: using tape measure From the lower edge of the SCAPULAS to directly over the NIPPLE LINE anteriorly – CC should be = or < 2 cm than HC 051104 Neonatal Care 233  – 1/3 the size of an adult’s head – Disproportionately LARGE for its body – HC should be = or 2cm > CC 051104 Neonatal Care 234  Implementation Routine Care of the Newborn: Give initial oil bath to cleanse the baby of blood, mucus and vernix. Dress umbilical cord (70% alcohol or PNSS) Crede's prophylaxis - against Ophthalmia neonatorum – 2 gtts 1 % AgN03 on lower conjunctival sac; flush with NSS – Erythromycin/Terramycin ointment  Crede’s Prophylaxis 051104 Neonatal Care 236  Implementation Routine Care of the Newborn: Vitamin KI (Phytomenadione) administration → inject at vastus lateralis, middle third – 1.0 mg → full term infants – 0.5 mg → preterm infants Identification – Bands; footprints  Vitamin K Administration 051104 Neonatal Care 238  Foot Printing 051104 Neonatal Care 239  Dressing/ Wrapping “Mummy” Wrap in warm blanket Cover head with stockinette cap 051104 Neonatal Care 240  Implementation Routine Care of the Newborn: Feeding – NSVD = within 30 mins – C/S = within 3-4 hours – Initial feeding - with sterile water only; glucose is irritating to the lungs if aspirated (1 oz) – Subsequent feeding - per demand  Implementation Composition Human Milk Cow'sMilk Calories 20 cal/oz 20 cal/oz CEO High (Lactose) Low Low CHON (Lactalbumin/ High (Casein) Whey) Same (Linoleic COOH Same Acid) Minerals Low High Iron Low Low  Implementation Bathing – done anytime but not within 30 minutes after feeding – sponge baths done until cord falls off  Bathing Oil bath or complete warm water bath From cleanest to dirties part DO NOT remove vernix caseosa vigorously 051104 Neonatal Care 244  Cord Care 051104 Neonatal Care 245  Daily Cord Care Keep cord dry and clean & clamp secured Apply 70% isopropyl alcohol to the cord with each diaper change and at least 2-3x a day. DO NOT cover with diaper Note for any signs of bleeding or drainage from the cord and other abnormalities Sponge bath until cord falls off. 051104 Neonatal Care 246  Implementation Constipation – add more fluids or carbohydrates/sugar Loose stools - management depends on cause Colic Causes: – Overfeeding, gas distention, too much carbohydrates – tense and unsure mother Mgt: – Feed by self-demand – Burp the baby twice during a feeding – feed in upright position – change milk formula if needed – reduce sugar content  Implementation Spitting up - due to poorly developed sphincter Mgt: – feed in upright position – position on right side after feeding – burp more frequently Skin irritation - may be due to poor hygiene, or irritation from urine, feces or laundry products Mgt: – expose to air – careful washing and rinsing of skin  Implementation Seborrheic dermatitis/cradle cap - involves sebaceous glands; due to poor hygiene Mgt: – apply mineral oil or Vaseline on the scalp at night – giving shampoo bath in the morning Clothing – If mother feels warm, keep the baby cool. – If the mother feels cold, keep the baby warm. Sleep patterns  Jaundice Under natural light Blanch skin over the chest or tip of the nose 051104 Neonatal Care 250  Implementation Jaundice – Use natural light and blanch skin on the chest or tip or the nose – Inability to conjugate bilirubin (decreased GLUCORONYL TRANSFERASE) – Physiologic jaundice: 2nd to 7th day – Breastfed babies have longer physiologic jaundice because human milk has PREGNANEDIOL → depresses glucoronyl transferase  Implementation Pathologic jaundice- within 24 hours Management of Pathologic Jaundice: Phototherapy (photoisomerization of indirect bilirubin) – 10 pcs 20-watt daylight or blue fluorescent lights at 30 inches above – cover eyes and scrotum with an opaque mask – monitor temperature and adequate hydration – turn q 2H to expose all body areas – measure I & Q Exchange transfusion  Management of Jaundice Monitoring serum bilirubin levels – Physiologic: not more than 5 mg/dl per day – Pathologic: more than 15-20 mg/dl (critical levels) Maintain hydration Place in bilirubin lights as needed Provide emotional support to parents 051104 Neonatal Care 253  Pathologic – Within 1st 24 hrs – May indicate early hemolysis of RBC or underlying disease process – Duration: FT: 1 wk PT: 2 wks 051104 Neonatal Care 254  Phototherapy units 051104 Neonatal Care 255 Nursing Responsibilities: -cover eyes and sex organ 051104 Neonatal Care 256  Physiologic – FT: after the 1st 24 hrs (2-7 days) – PT:after the 1st 48 hrs – Peaks at 5-7 days & disappears by the 2nd week – Due to immaturity of liver – Usually found over the face, upper body and conjunctiva of eyes 051104 Neonatal Care 257  Infancy Age group: 1 month to 12 months  Infancy FIRST "period of rapid growth and development" 1 month to 12 months  Infancy: PHYSICAL GROWTH Weight – Average weight: male -10 kg (22 lbs) and female 9.5 kg (lbs) – birth weight doubles at 6 months of age – birth weight triples at 12 mos – weight gain is approximately 1 lb/month or 6-8 oz/week for the 1st 6 mos; slightly less for the next 6 mos  Infancy: PHYSICAL GROWTH Height – 50% increase of the birth length during the 1st year – average height: 30 inches (76.2 cm) at 1 year old – should be taken with the child lying supine or standing erect against measuring board.  Infancy: PHYSICAL GROWTH Height Summary of height pattern: 0-3 mos 9 cm 3-6 mos 8 cm 6-9 mos 5 cm 9-12 mos 3 cm 25 cm  Infancy: PHYSICAL GROWTH Weight in GRAMS Less than 6 months: Age (mons) x 600 + B Wt 6 to 12 months: Age (mons) x 500 + B Wt Weight in KILOGRAMS 2 years and up: Age (yrs) x 2 + 8  Infancy: PHYSICAL GROWTH Height/Length Age in years x 5 + 80 = height in centimeters Age in years x 2 +32= height in inches  Infancy: PHYSICAL GROWTH Head Circumference – a reflection of rapid brain growth – at the end of 1 st year, brain has already reached 2/3 of adult size – Pattern of growth: 1 to 4 mos ½ inch per month 5 to 12 mos ¼ inch per month Infancy: Pertinent Systemic Assessment CVS: Physiologic anemia occurs because – fetal RBC's life span is through and new replacement is not adequate yet – serum iron levels decrease – fetal hemoglobin is converted to adult hemoglobin (5-6 mos)  Infancy: Pertinent Systemic Assessment Dentition 1st tooth erupts at 6 months (LOWER CENTRAL INCISORS) RULE of thumb No. of teeth = (age in months) - 6  Neonate and Infants A. Physical tasks Neonate (Birth to 1 month) a. Weight: 6 - 8 lb (2750 - 3629 g); gains 5 - 7 oz (142 - 198 g) weekly for first 6 months b. Length: 20 inches (50 cm); grows 1 inch (2.5 cm) monthly for first 6 months  Neonate and Infant A. Physical tasks Neonate (Birth to 1 month) Head growth 1) head circumference 33 - 35 cm (13 - 14 inches) 2) head circumference equal to or slightly larger than chest circumference 3) increases by 1/2 inch (1.25 cm) monthly for first 6 months  Neonate and Infant A. Physical tasks Neonate (Birth to 1 month) Vital signs 1) pulse: 110 - 160 and irregular; count for a full minute apically 2) respirations: 32 - 60 and irregular; neonates are abdominal breathers, obligate nose breathers 3) blood pressure: 75/49 mm Hg  Neonate and Infant A. Physical tasks Neonate (Birth to 1 month) Motor development 1) behavior is reflex controlled 2) flexed extremities  Neonate and Infant A. Physical tasks Neonate (Birth to 1 month) Sensory development 1) hearing and touch well developed at birth 2) sight not fully developed until 6 years a) differentiates light and dark at birth b) rapidly develops clarity of vision within 1 foot c) fixates on moving objects d) strabismus due to lack of binocular vision  Neonate and Infant B. Psychosocial tasks Neonatal period a. Cries to express displeasure b. Smiles indiscriminately c. Receives gratification through sucking d. Makes throaty sounds  Neonate and Infant C. Cognitive tasks Neonatal period: reflexive behavior only  Infant A. Physical tasks 1 - 4 months Head growth: posterior fontanel closes Motor development 1) reflexes begin to fade (e.g., Moro, tonic neck) 2) gains head control🡪 3 months 3) rolls from back to side🡪 4 months 4) begins voluntary hand-to-mouth  Infant A. Physical tasks 1 - 4 months Sensory development 1) begins to be able to coordinate stimuli from various sense organs 2) hearing: locates sounds by turning head and visually searching 3) vision: follows objects 180°  Infant A. Physical tasks 1 - 4 months Language development 1) Crying and gurgling sounds🡪 1 month 2) Makes cooing sounds🡪 2 months 3) Laughs and Squeals🡪 3-4 months  Infant 1 - 4 months Social development 1) Crying and gurgling sounds🡪 1 month 2) Makes cooing sounds🡪 2 months 3) Laughs and Squeals🡪 3-4 months  Infant B. Psychosocial tasks 1 - 4 months a. Crying becomes differentiated at 1 month 1) decreases during awake periods 2) ceases when parent in view b. Vocalization distinct from crying at 1 month 1) coos, babbles, laughs; vocalizes when smiling  Infant B. Psychosocial tasks 1 - 4 months c. Socialization 1) stares at parents’ faces when talking at 1 month 2) smiles socially at 2 months 3) shows excitement when happy at 4 months 4) demands attention, enjoys social interaction with people at 4 months  Infant C. Cognitive tasks 1 - 4 months a. Recognizes familiar faces b. Is interested in surroundings c. Discovers own body parts  Infant A. Physical tasks 3. 5 - 6 months Weight: birth weight doubles; gains 3-5 oz (84-140 g) weekly for next 6 months Length: gains 1/2 inch (1.25 cm) for next 6 months  Infant A. Physical tasks 3. 5 - 6 months Eruption of teeth begins 1) lower incisors first 2) causes increased saliva and drooling 3) enzyme released with teething causes mild diarrhea, facial skin irritation 4) slight fever may be associated with teething, but not a high fever or seizures  Infant A. Physical tasks 3. 5 - 6 months Motor development 1) supports weight on arms 2) sits with support  Infant A. Physical tasks 3. 5 - 6 months Sensory development 1) hearing: can localize sounds above and below ear 2) vision: smiles at own mirror image and responds to facial expressions of others 3) taste: sucking needs have decreased and cup weaning can begin; chewing, biting, and taste preferences begin to develop  Infant B. Psychosocial tasks 3. 5 - 6 months a. Vocalization: begins to imitate sounds b. Socialization: recognizes parents, stranger anxiety begins to develop; comfort habits begin  Infant C. Cognitive tasks 5 - 6 months a. Begins to imitate b. Can find partially hidden objects  Infant A. Physical tasks 7 - 9 months a. Teething continues 1) 7 months: upper central incisors 2) 9 months: upper lateral incisors b. Motor development 1) Crawls 🡪 8 to 9 months may go backwards initially 2) pulls self to standing position 3) develops finger-thumb opposition (pincer grasp)  Infant B. Psychosocial tasks 7 - 9 months a. Vocalization: verbalizes all vowels and most consonants b. Socialization 1) shows increased stranger anxiety and anxiety over separation from parent 2) exhibits aggressiveness by biting at times 3) understands the word “no”  Infant C. Cognitive tasks 7 - 9 months a. Begins to understand object permanence; searches for dropped objects b. Reacts to adult anger; cries when scolded c. Imitates simple acts and noises d. Responds to simple commands  Infant A. Physical tasks 10-12 months a. Weight: birth weight tripled b. Length: 50% increase over birth length c. Head and chest circumference equal d. Teething 1) lower lateral incisors erupt 2) average of six to eight deciduous teeth  Infant A. Physical tasks 10—12 months Motor development 1) walks with help or cruises (10 months) 2) may attempt to stand alone  Infant B. Psychosocial tasks 10 - 12 months a. Vocalization: imitates animal sounds, can say only 4 - 5 words but understands many more (ma, da) b. Socialization 1) begins to explore surroundings 2) plays games such as pat-a-cake, peek-a-boo 3) shows emotions such as jealousy,  Infant C. Cognitive tasks 10—12 months a. Recognizes objects by name b. Looks at and follow pictures in book c. Shows more goal-directed actions  Nursing Considerations Breastfeeding can usually begin immediately after birth Bottlefeeding may be started with sterile water to 4 hrs after birth prior to formula feeding Burp during and after feeding Position properly during and after feeding 051104 Neonatal Care 304  Infant D. Nutrition Birth to 6 months a. Breast milk is a complete and healthful diet; supplementation may include 0.25 mg fluoride, 400 IU vitamin D, and iron after 4 months. b. Commercial iron-fortified formula is acceptable alternative; supplementation may include 0.25 mg fluoride if water supply is not fluoridated. c. Juices may be introduced at 5-6 months,  Infant D. Nutrition 6 - 12 months a. Breast milk or formula continues to be primary source of nutrition. b. Introduction of solid foods starts with cereal (usually rice cereal), which is continued until 18 months. Cereal 🡪 fruits 🡪 vegetables🡪 meat🡪 egg yolk  Infant D. Nutrition 6 - 12 months c. Introduction of other food is arbitrary; most common sequence is fruits, vegetables, meats. 1) introduce one new food a week. 2) decrease amount of formula to about 30 oz. as foods are added. d. Iron supplementation can be stopped.  Infant D. Nutrition 6 - 12 months e. Finger foods such as cheese, meat, carrots can be started around 9-10 months. f. Chopped table food or junior food can be introduced by 12 months g. Weaning from breast or bottle to cup should be gradual during second 6 months.  Infant E. Play (Solitary) Birth to 4 months a. Provide variety of brightly colored objects, different sizes and textures. b. Hang mobiles within 8-10 inches of infant’s face.  Infant E. Play (Solitary) 5 - 7 months a. Provide brightly colored toys to hold and squeeze. b. Allow infant to splash in bath. c. Provide crib mirror.  Infant E. Play (Solitary) 8 - 12 months a. Provide toys with movable parts and noisemakers; stack toys, blocks; pots, pans, drums to bang on; walker and push-pull toys. b. Plays games: hide and seek, pat-a-cake.  Infant Care Skills Holding the baby – Football Hold – Cradle Hold – Shoulder Hold 051104 Neonatal Care 314  Football Hold Purpose: to carry on one hand free A holding technique in bathing a baby Use for small babies Procedure: 1. slide forearm under his back 2. support neck and head with your hand 3. press his arm firmly against your side 4. his head faces you 5. infant’s feet tucked under your elbow 051104 Neonatal Care 315  Cradle Hold Purpose: use for feeding and cuddling a baby Procedure: support head in the crook of your arm encircle the body with your arm press baby firmly against your side use other hand to support bottom and thigh 051104 Neonatal Care 316  Shoulder Hold Purpose: use for burping Procedure: draw baby towards your chest with one forearm bracing his back and your hand cradling his head support your baby’s bottom and thighs with your other arm gently press his head against shoulder 051104 Neonatal Care 317  Infant F. Fears 1. Separation from parents a. Searches for parents with eyes. b. Shows preference for parents. c. Develops stranger anxiety around 6 months, peak at 8 months 2. Pain a. hold and comfort infant b. reduce painful procedures if possible  Infant PROMOTING SENSORY STIMULATION VISION – Teach parents to make eye-to-eye contact with the infant to stimulate vision and to promote socialization. – Infants enjoy mobiles and crib mirror – Photos of family members may be posted near the baby's crib.  Infant HEARING – Infant's toys should have soft, musical or cooing sounds. – An audiotape of family voices might be soothing reminder of their presence when they are not around.  Infant TOUCH – Clothes should feel comfortable and diaper should always be dry. – Teach parents to handle the infant with assurance and with gentleness. – “Kangaroo hold" promotes close physical contact.  Infant TASTE – Infants turn away or spit out a taste they do not enjoy. – Urge parents to make a mealtime for fostering trust as well as supplying nutrition. – Feedings should be at the infant's pace and the amount should fit the child's needs – New foods should be introduced one at a time so that the child can become accustomed to one new taste before another is tried. – This also lets parents detect adverse reactions, such as allergy to a new food.  Infant SMELL Infants smell accurately within 1-2 hours after birth. Infants draws back from irritating smell and enjoys pleasant odors like that of the breast milk teach parents to be alert to substances that cause sneezing when sprayed into the air  Implementation INFANT’S DAILY ACTIVITIES BATHING Bath serves many functions: – a. to promote cleanliness. – b. to provide opportunity for the baby to exercise – c. to give parents time to talk, touch and communicate with the baby. – d. to give the baby the opportunity to learn different textures and sensations.  Implementation DIAPER – AREA CARE Good diaper-area hygiene means not to allow an infant to wear soiled diapers for a lengthy time. Diapers should be changed frequently. Skin should be washed thoroughly with water and mild soap.  Implementation CARE OF THE TEETH Fluoride is important in proper tooth development and prevention of tooth decay. Teach parents to begin "brushing" even before teeth erupt by rubbing a piece of gauze over the gum pads. Toothpaste may not be necessary.  Implementation DRESSING Clothes should be easy to launder and simply constructed Type of clothing should suit infant’s activity level  Implementation SLEEP Infants need 10-12 hours of sleep a night and one or several naps during the day. Caution parents not to place pillows to avoid possibility of suffocation.  Implementation EXERCISE The infant benefits from outings in a carriage or stroller, as sunlight provides a natural source of vitamin D. Early mornings and late afternoons are the best times for the infant to be outside.  Implementation PARENTAL CONCERNS AND PROBLEMS RELATED TO INFANCY 1. Teething🡪 use of cool teething rings 2. Thumb sucking🡪 reassure parents, provide sucking pleasures 3. Use of Pacifiers🡪 ensure cleanliness 4. Head Banging🡪 pad rails and reassure parents  Implementation PARENTAL CONCERNS AND PROBLEMS RELATED TO INFANCY 5. Sleep Problems🡪 provide soft toys and music 6. Constipation🡪 increase fluid intake and fiber 7. Loose Stools🡪 assess and intervene 8. Colic🡪 assess, burp, make feeding stimulating  Implementation PARENTAL CONCERNS AND PROBLEMS RELATED TO INFANCY 9. Spitting up 🡪 upright position feeding, burp baby, bib during feeding 10. Diaper Dermatitis🡪 frequent change, air dry 11. Miliaria🡪 bathing with baking soda 12. Baby bottle syndrome 🡪avoid bottle during sleep  Implementation IMMUNIZATION BCG – Infants.05 ml – Intradermal 0.1 ml Right deltoid School Entrants  Implementation BREAST FEEDING ADVANTAGE Readily available Economical Promotes facial muscles, jaw and teeth Mother infant bonding Reduced incidence of allergies Reduced incidence of maternal breast cancer Transfer of maternal antibodies  Implementation BREAST FEEDING DISADVANTAGES Prevents other from feeding the infant Limits paternal role in feeding Compels the mother to monitor her diet carefully Maybe difficult to a working mother Digest quickly 🡪 more feeding  Implementation BREAST FEEDING ADEQUATE feeding? Wets 6 to 8 diapers a day Gaining weight Sleeps well  Implementation BOTTLE FEEDING ADVANTAGE Permits the father to feed Mother 🡪 can take medications Fewer feedings Feeding 🡪 public 🡪 little embarrassment  Implementation BOTTLE FEEDING DISADVANTAGES Cost Greater preparation and effort Hands 🡪 should be clean Requires refrigeration and storage No transfer of maternal antibodies Doesn’t benefit mother physiologically  Summarizing the INFANT 1 month to 1 year Double weight at 6, triple weight at 12 months First tooth at 6 months GROSS: lift chest at 2, sits at 6-8, creeps at 9, cruise at 10, walks after 12 FINE: transfers object at 7, pincer grasp at 9-10 LANGUAGE: Cries at 2, “Mama-Dada” at 9 VISION: Past midline at 3, focus object at 6 PLAY: Solitary, toy: mobile, rattles, mirror Theory: Oral, Id, Trust vs Mistrust, Sensori-motor  INFANCY (0 to 1 yr) I – ron supplement (4 to 6 months), Immunization N – o choking hazard F – ear of stranger peaks at 8 months A – llow to use a pacifier if NPO N – ote the weight changes T – rust V.S. mistrust S – olitary play  INFANCY (0 to 1 yr) COMMON ACCIDENTS P – revent further absorption O – ff, shower or wash off I - dentify S - upport O – ngoing safety education N – otify local poison control center  Key to Success! Confidence Test taking strategies Ample test preparation and study habits Review of frequent board examination topics Focus on your goals Above all- PRAYERS  Toddler Considered as the age from age 1 – 3 years Terrible “two”  Toddler (12 months to 3 years) Physical tasks: this is a period of slow growth 1. Weight: gain of approximately 11 lb (2.5 to 5 kg) during this time; birth weight quadrupled by 2 1/2 years 2. Height: grows 20.3 cm (8 inches) 3. Head circumference: 19½ - 20 inches (49 - 50 cm) by 2 years Anterior fontanel closes by 12-18 months  Toddler (12 months to 3 years) Physical tasks: this is a period of slow growth Weight gain pattern – 2x 🡪 6 months – 3x 🡪 1 year – 4x 🡪 2 ½ year Body Contour- Prominent LORDOSIS and wide stance gait Toddler (12 months to 3 years) Developmental Milestones: Gross 15 months🡪 walks alone well 18 months🡪 walks upstairs, runs 21 months🡪 walks upstairs and downstairs, runs well 2 years 🡪 runs, walks up and down, jumps 3 years🡪 rides TRIcycle, balance on one foot briefly Toddler (12 months to 3 years) Developmental Milestones: fine 15 months🡪 drinks from a cup 18 months🡪 scribbles spontaneously 21 months🡪 imitates vertical line 2 years 🡪 imitates a circle at 2 1/2 3 years🡪 wiggles thumb Toddler (12 months to 3 years) Developmental Milestones: language 15 months🡪 18 months🡪 uses ONE word in a sentence (usually three words other than mama or dada) 21 months🡪 2 years 🡪 uses TWO words in a sentence  Toddler (12 months to 3 years) Vitals Pulse 110; respirations 26; blood pressure 99/64 Dentition Primary dentition (20 teeth) completed by 2 1/2 years Control Develops sphincter control necessary for bowel and bladder control  Toddler (12 months to 3 years) Psychosocial tasks 1. Increases independence; better able to tolerate separation from primary caregiver. 2. Less likely to fear strangers. 3. Able to help with dressing/undressing at 18 months; dresses self at 24 months. 4. Has sustained attention span. 5. May have temper tantrums during this period; should decrease by 21/2 years. 6. Vocabulary increases from about 10 - 20 words to over 900 words by 3 years.  Toddler (12 months to 3 years) Psychosocial tasks 7. Has beginning awareness of ownership (my, mine) at 18 months; shows proper use of pronouns (I, me, you) by 3 years. 8. Moves from hoarding and possessiveness at 18 months to sharing with peers by 3 years. 9. Toilet training usually completed by 3 years. a. 18 months: bowel control b. 2 - 3 years: daytime bladder control c. 3 - 4 years: nighttime bladder control  Toddler (12 months to 3 years) Cognitive tasks 1. Follows simple directions by 2 years. 2. Begins to use short sentences at 18 months to 2 years. 3. Can remember and repeat 3 numbers by 3 years. 4. Knows own name by 12 months; refers to self, gives first name by 24 months; gives full name by 3 years. 5. Able to identify geometric forms by 18  Toddler (12 months to 3 years) Cognitive tasks 6. Achieves object permanence; is aware that objects exist even if not in view. 7. Uses “magical” thinking; believes own feelings affect events (e.g., anger causes rain). 8. Uses ritualistic behavior; repeats skills to master them and to decrease anxiety. 9. May develop dependency on “transitional object” such as blanket or stuffed animal.  Toddler (12 months to 3 years) Sense of Autonomy Favorite word: “NO” Child learns to be independent Understanding love of the child is shown by: – giving him all the freedom he can safely use – giving him all the love and help he needs to keep him safe in an environment beyond his control  Toddler (12 months to 3 years) Negativism Gives the child opportunity to make choices Regulating the toddler’s activities which is an important part of his training is a challenge to the adult Providing safe environment for a gradually expanding area of growth Avoiding use of pain and ridicule as a means of punishment or of prevention of forbidden activities Allowing the child to have certain amount of defiance, which is normal  Toddler (12 months to 3 years) Toilet Training The child must begin accepting the “reality principle” (giving up an immediate pleasure in order to gain another pleasure later.) Toddler must give up the pleasure of excreting where and when he wishes in order to gain his mother ‘s approval.  Toddler (12 months to 3 years) Requisites for Toilet Training 1. Physiologic readiness – Sphincter control – myelination of nerve tract occurs at around 15 – 18 months of age (MOST IMPORTANT REQUIREMENTS) – Recognizes the urge and with ability to stand and walk to the bathroom and manage clothing 2. Psychological readiness – Understands the act of elimination – Ability to verbally communicate need to defecate or urinate – Mother or caretaker must be able to recognize verbal behavior  Toddler (12 months to 3 years) Schedule/Timing of Training 15 – 18 moths start of training 18 mos – 24 mos bowel control 2 –3 years daytime bladder control 3 – 4 years nighttime bladder control  Toddler (12 months to 3 years) Principles of Toilet of Training Bowel training should be started before bladder training. Bladder training is done 1 or more months after fairly well established bowel training. Training should not be accomplished during illness. Consistency – observe usual time for defecation  Toddler (12 months to 3 years) Principles of Toilet of Training Positive maternal attitude – when successful, the child should be praised and cuddled; if not, she should not show any disapproval. Child should feel secure when seated on the chair or toilet bowl NEVER FLUSH TOILET WHILE CHILD IS SITTING ON IT! Child should not be given food or toy during training as it distracts him. High Risk Conditions COMMON PROBLEMS, DISORDERS AND DISEASES IN INFANTS A. PREMATURITY: - birth before 37th week of gestation 1. Associated Medical Problems Maternal – Placenta previa – Abruptio placenta – Cervical incompetence – Hypertensive disease of pregnancy  Fetal Assessment - Weight - Gestational age - Fontanels - Multiple gestations - Infections - Respiratory distress - Tachypnea - Arterial blood gases - Urine integrity - Abnormal breath sounds - Skin integrity - Vernix caseosa - Apgar scoring - Signs of birth trauma  Nursing Interventions Feed slowly Keep infant warm Maintain clear airway Rub back or soles of feet to stimulate infant’s breathing. Transport infant to special care facility as soon as possible. Avoid handling infant more than necessary for feeding and changing of diapers.  Necrotizing Enterocolitis Acute inflammation of the small and large intestine caused by Clostridium Perfringens Results from ischemia or poor perfusion of blood vessels in sections Risk factors: immaturity, history of anorexia or shock, enteral feedings and infections Management: includes IV or total parenteral nutrition and surgery.  Clinical Focus Infections – Conjunctivitis Inflammation of the conjunctiva Viral vs. bacterial – Neonatal Gonorrheal Ophthalmia Severe form of conjunctivitis Affects babies delivered via NSD from an infected mother High risk for blindness Treatment: Silver Nitrate