Newborn Assessment and Care PDF

PPN301 Class 6: Newborn Assessment and Care 1 Learning Outcomes Describe the physiological adaptations the newborn must make during the period of transition from intrauterine to extrauterine environment. Describe the physical and behavioural adaptations that are characteristic of the newborn duri...

PPN301 Class 6: Newborn Assessment and Care 1 Learning Outcomes Describe the physiological adaptations the newborn must make during the period of transition from intrauterine to extrauterine environment. Describe the physical and behavioural adaptations that are characteristic of the newborn during the transition period. Explain the mechanisms of thermoregulation in the newborn and the potential consequences of hypothermia and hyperthermia. Discuss the sensory and perceptual function of the newborn. Identify signs that the newborn is at risk related to problems with each body system. 2 Physiological Adaptation of the Newborn Physiological adjustments Establishing and maintaining respirations Adjusting to circulatory changes Regulating temperature 3 Establishing and maintaining respirations Chemical factors: Activation of chemoreceptors in the carotid arteries and aorta due fetal hypoxia Contraction temporary decrease uterine blood flow and transplacental gas exchange-transient fetal hypoxia ↓Po2 and ↑Pco2, ↓blood pH Stimulation of the respiratory centre Thermal factors ↓extrauterine environment stimulates receptors in the skin, resulting in stimulation of the respiratory centre in the medulla. Note: Cold stress may be important for initializing breathing, but prolonged exposure should be avoided Mechanical factors: Changes in intrathoracic pressure from compression of the chest during vaginal birth. Relieve of the pressure result in a negative intrathoracic pressure, which helps draw air into the lungs. Crying of baby increases the distribution of air in the lungs, promotes expansion of the alveoli. creates positive pressure which helps to keep the alveoli open. Sensory factors handling or drying the newborn, lights, sounds, and smells of the new environment can also be involved in stimulation of the respiratory centre. Pain associated with birth can also be a factor constant cold stress has impact on metabolic state if prolonged mechanical mens pressure 4 Circulatory changes after birth Expansion of the lungs increases the baby's blood pressure Resulting in a major decrease in the pulmonary pressures and the changes in pressure result in ↓shunting of blood to the ductus arteriosus and closure of the ductus arteriosus ↑ pressure in the left atrium of the heart and lower pressure in the right atrium causing the foramen ovale to close. Failure may result in patent foramen ovale (hole in heart) and surgical repair is required Circulatory Adjustment shunting is where blood is mixed first one if the opening 5 Thermoregulation Heat regulation is most critical to the newborn’s survival. Anatomical and physiological characteristics of newborns place them at risk for heat loss-hypothermia Larger body surface to body weight Less adipose tissue & fat in newborn Underdeveloped sweating and shivering mechanisms Blood vessels closer to skin surface – contribute to heat loss Environmental factors -temperature and humidity of the air, flow and velocity of the air, and the temperature of surfaces in contact with and around the newborn. Goal of care is to maintain a neutral thermal environment in which heat balance is maintained. To allow the newborn to maintain a normal body temperature to minimize oxygen and glucose consumption. conduction - direct contact 6 Evaporation: Loss of heat when water evaporates from the skin and respiratory tract heat loss is intensified by failing to completely dry after bathing Dry baby quickly and remove wet towels/blankets Conduction: Heat loss from the body surface to cooler surfaces in direct contact Prewarm incubator/radiant warmer to ensure warm mattress Cover x-ray plates and scales Prewarm hands, stethoscopes, blankets and other equipment weighing the newborn should have a protective cover to minimize conductive heat loss  Radiation: Heat lost to surrounding colder solid objects (not in direct contact) but in close proximity Keep incubator, warmer, examination table, crib cot away from outside walls and windows Dress baby Care providers need to avoid exposing the newborn to direct air drafts. Convection: Heat lost from the body surface to cooler ambient air Raise surrounding 22° and 26°C Cover baby’s head Wrap and dress baby Warm O2 Skin to skin contact: Baby will gain heat if placed on warm surface Skin-to-skin keep newborns warmer than swaddled Newborn Heat Loss stethoscope should be warm anything touching baby should be warm to minimize heat loss Cold Stress Effects of cold stress. When a newborn is stressed by cold, oxygen consumption increases and pulmonary and peripheral vasoconstriction occur, thereby decreasing oxygen uptake by the lungs and oxygen to the tissues; anaerobic glycolysis increases; and there is a decrease in Po2 and pH, leading to metabolic acidosis. common cold means need of O2 increases which results in: 2 vasoconstriction mechanism pulmonary/peripheral pulmonary - less O2 on lungs peripheral - less O2 in tissues not enough o2 in tissues → anaerobic glycolysis → metabolic acidosis avoided by warming the baby 8 Newborn Assessment: Immediately after Birth Head to Toe Immediate assessment of the newborn done at 1 and 5 minutes after birth Scores of 0 to 3-indicate severe distress, Scores of 4 to 6 indicate moderate difficulty Scores of 7 to 10 indicate that the newborn is having minimal or no difficulty adjusting to extrauterine life Reassessment is at 10 and 20 minutes if the score is less than 7 at 5 minutes Resuscitation may occur at any point when the newborn is compromised and should not wait until the initial 1-minute Apgar score Immediate Newborn Assessment-Apgar Scoring 7 to move on Respirations Observe rise/fall of chest for 1 full minute Auscultate lung sounds Normal – 30-60 RR/min, shallow & irregular; apneic periods of 5-10 seconds as fluid is being absorbed/expelled Possible crackles - 1st hr. after birth Acrocyanosis (extremities blue) – normal finding during transition Look for signs of respiratory distress Chest retractions Grunting with expirations Increase use of the intercostals muscles Nasal flaring Respiratory rate < 30 or > 60 breaths/min should be reported Respiratory System heart rate between 110 and 160 beats/min Heart rate 160 re-evaluate after 30 t0 1 hour Heart murmurs heard during the first few weeks have no pathologic significance murmurs disappear by 6 months Average systolic BP is 60 to 80 mm Hg, and average diastolic BP is 40 to 50 mm Hg Fetal Hb – high affinity for oxygen to promote oxygenation while infant begins producing own Hb postnatally Hb level 14-24 g/dl Blood volume 300mls Time taken to clamp cord Sign of Cardiovascular concern Persistent tachycardia (more than 160 bpm) anemia, hypovolemia, hyperthermia, or sepsis. Persistent bradycardia (less than 100 bpm) congenital heart block, hypoxemia, normal sinus bradycardia, or hypothermia. Unequal or absent pulses, bounding pulses, and decreased or elevated blood pressure can indicate cardiovascular concerns Cardiovascular system 13 Fontanelles Anterior fontanel 5-cm, diamond shaped, increases as moulding resolves Closes within 18 months Posterior fontanel triangle 0.5x1 cm, smaller than anterior Closes within 8-12 weeks after birth Sutures (Allow for brain growth) Should be palpable and separated suture, possible overlap of sutures with moulding Widely spaced (hydrocephaly) Premature closure (fused) (craniosynostosis) Signs of Fontanel concerns: Full, bulging (tumour, hemorrhage, infection) Large, flat, soft (malnutrition, hydrocephaly, delayed bone age, hypothyroidism) Depressed (dehydration Fontanelles - soft spots Cephalhematoma is the collection of blood between the skull bone and its periosteum caused by external Pressure during L & D Forceps delivery Largest on the second or third day, Feels boggy, edemtous to touch Does not cross suture lines Resolves in 3 to 6 weeks Not aspirated due to risk of infection Increase risk of jaundice Localized edematous area of the soft tissues of the scalp. Presenting part causes compression of local vessels slowing venous return increase in tissue fluids within the skin of the scalp edematous swelling develops. Extends across the suture lines of the skull Disappears spontaneously within 3 to 4 days. Caput succedaneum Cephalhematoma 15 Lips should be symmetrical Pink, moist lips and mucosa Sucking blisters - from breastfeeding latch Saliva not excessive Intact hard and soft palate; freely moving tongue Tongue not protruding; freely movable; symmetrical movement Sucking pads inside cheeks Uvula in midline Epstein’s pearls: small, firm white cysts on gums. Resolve on its own during 1st weeks Anatomical groove in palate to accommodate nipple, disappearance by 3–4 yr of age Common conditions Thrush: White plaque – similar to milk curds, does not easily scrape off Precocious, predeciduous-presence of teeth at birth (hereditary) Cleft lip/palate Cyanosis, circumoral pallor (respiratory distress, hypothermia) Asymmetry in movement of lips (seventh cranial nerve paralysis) Short lingual frenulum (ankyloglossia- tongue-tie Mouth Natal teeth are teeth that are already present at birth. Male genitalia Hypospadias: Urinary meatus on ventral surface of penis (underside). Circumcision is contraindicated in the presence of hypospadias or epispadias since the foreskin is used in repair of these anomalies Epispadias: Meatus on the dorsal surface Phimosis: Foreskin cannot be fully retracted A tight prepuce (foreskin) is common in newborns and completely covers the glans  Hydrocele: Collection of fluid around testes Discoloration of testes – assess for testicular torsion Crepitus in groin or scrotal sac indicates hernia Undescended testes; (cryptorchidism) Failure of testes to descend into scrotal sac in term infant Female genitalia Labia – examined for size. Labia majora develops close to term Assess to ensure that labia are not fused Assess ambiguous genitalia Milky vaginal discharge- due to circulating maternal hormones Pseudomenses: blood tinged mucous – due to hormones of pregnancy Vaginal tag: (hymenal tag) usually disappears in first few weeks after birth Swelling of the breast tissue in term newborns of both sexes-due to hyperestrogenism in utero few newborns a thin discharge can be seen. Genito-urinary System Undescended After 6 months and before 12 months Ambiguous geneialia – when clitoris excessively prominent; vaginal opening not clearly patent 17 Normal infant – Pink varying with ethnic group, well perfused Perfusion assessed by capillary refill of 2 seconds or less Skin should spring back when pinched dehydration if fold of skin persisting after release of pinch) Skin is soft, dry texture. Acrocyanosis: Bluish discoloration of hands and feet 1st 6 -8 hr. post birth (due to cardiovascular immaturity) Skin Post-mature infants may have dry skin, cracking on feet and hands Loose, wrinkled skin (prematurity,) Mottling: due to temperature instability; overstimulation of autonomous nervous system Tense, tight, shiny skin (edema, extreme cold, shock, infection) Full range of motion of arms & shoulders Assess leg length – equal, with symmetrical gluteal creases Assess for club foot (talipes equinovarus) Back should be straight, flexible Pilonidal dimple - cleft at base of sacrum, generally benign Digits Extra digits: polydactyly Webbing: Syndactyly Extremities Sucking: When anything is placed in mouth or touches lips Newborn Reflexes Rooting: infant turns head when side of mouth/ cheek is stimulated. Present for 3-4 months. Aids in latching Babinski: (plantar reflex). Hyperextension of toes when the sole is stroked from heel up to ball of foot. Disappear by age 1 year. Moro: Startling infant, - response by symmetrically extending arms outward while knees flex. Can last up to 6 months Most sensitive assessment for infant’s neurological system 21 Prophylactic & Screening Measures 0.5% Erythromycin eye ointment within 1 hr. of birth vs. maternal gonococcal transmission Vitamin K injection within 1 hr. birth vs. hemorrhage Hep. B vaccine at birth (against all known Hep B subtypes), HBIG 12 hrs after birth If maternal hep. B surface antigen is positive or unknown Blood glucose monitoring – baseline at 2 hr. post-birth if gestational diabetes, LGA, or SGA; ½-1 hr. post birth if symptoms of hypoglycemia occur earlier Heel prick for bilirubin levels, phenylketonuria (PKU) & hypothyroidism (mental retardation if untreated), sickle cell, Screening for congenital heart disease: pre-ductal (right hand) and post-ductal (any foot) oxygen saturation obtained. Repeat screen if >3% difference between 2 readings or if O2 sat is less than 94% on either extremity. Hearing to assess for hearing loss 22 Newborn responses to pain Assessment of pain in the newborn Goal of newborn pain management minimize the intensity, duration, and physiological cost of the pain maximize the newborn’s ability to cope with and recover from the pain. Nonpharmacological management Pharmacological management Vital signs—Observe for variations Increased heart rate, increased blood pressure, rapid, shallow respirations Oxygenation ↑ oxygen saturation (tcPo2), ↓arterial oxygen saturation Skin—Observe colour and character Pallor or flushing, diaphoresis, palmar sweating Vocalizations Crying, whimpering, groaning Facial expression Grimaces, brow furrowed, chin quivering, eyes tightly closed, mouth open and squarish Body movements and posture Limb withdrawal, thrashing, rigidity, flaccidity, fist clenching Changes in state Changes in sleep–wake cycles, feeding behaviour, activity level, fussiness, irritability, listlessness Pain in the Newborn 23 Non-nutritive sucking on a pacifier promote comfort Oral sucrose in small amounts given with a syringe with or without a pacifier for sucking reduces pain during single events Skin-to-skin contact (kangaroo) care help reduce pain during a painful procedure Breastfeeding or breast milk helps reduce pain during heel lancing and blood collection Swaddling or snugly wrapping the newborn with a blanket aids in self-regulation, and reduces physiological and behavioural stress resulting from acute pain Safe swaddling is important Touch, massage, rocking, holding, and environmental modification (e.g., low noise and lighting). Management of Pain in the Newborn 24 Community follow-up Temperature Respirations Feeding patterns Elimination Prevention of sudden infant death syndrome (SIDS) Rashes Diaper rash Other rashes Clothing Car seat safety Non-nutritive sucking Bathing Umbilical cord care Newborn follow-up care Cardiopulmonary resuscitation Practical suggestions for the first weeks at home Recognizing signs of illness Discharge Planning and Teaching Caring High Risk Newborn Infants who are born considerably before term and survive are particularly susceptible to development of sequelae related to preterm birth. High-risk infants are most often classified according to: birth weight gestational age common pathophysiological problems Jaundice Preterm Diabetes Meconium aspiration in newborn Hyperbilirubinemia bilirubin greater than 340 mcmol/L in the first 28 days Causes Increase bilirubin level due break down in RCS Short lifespan of leads to RBC mass breakdown Immature liver to cannot break down bilirubin for excretion Hepatic obstruction Unconjugated bilirubin is highly toxic to neurons Jaundice Risk Factors Maternal fetal Rh or ABO incompatibility Sepsis Polycythemia Biliary atresia Liver impairment Hypoglycemia Pre-term birth Polycythemia Delayed passage of meconium Large cephalohematoma at birth Hypoxia Hypothermia 27 Physiological jaundice: 60% of newborns born at term and 80% of preterm infants. Appears after 24 hours of age and usually resolves without treatment. unless bilirubin levels rise higher or faster than normal Pathological Jaundice Appears within 24 hours of birth Total unconjugated bilirubin levels >100 mcmcol/L in 24 hours level exceeds >256 mcmol/L at any time Untreated ↑ unconjugated bilirubin is neuro toxic to brain Acute bilirubin encephalopathy (lethargy, hypotonia, poor sucking irritability, seizures, coma, and death Kernicterus: irreversible long-term consequences of bilirubin toxicity, (hypotonia, delayed motor skills, hearing loss, cerebral palsy, and gaze abnormalities) Types of Newborn Juandice Marandola, 2022 28 Use to reduce the level of circulating unconjugated bilirubin or to keep it from increasing bilirubin level begin to decrease within 4 to 6 hours after; within 24 hours decrease by 30 to 40% to discontinue therapy is based on a definite downward trend in bilirubin values Precautions Newborn’s eyes must be protected by a shield to prevent retinal damage Temperature should be closely monitored at least every 2 hours Possibility of heat loss and dehydration (feeding is critical ) No ointments- heath absorption and cause burns Loose stool due to bilirubin breakdown-buttocks must be cleaned after each stool to maintain skin integrity Phototherapy 29 Preterm-born before completion of 37 weeks of gestation regardless of the weight of the infant Organ and systems are immature Lack of adequate physiological reserves to function in the extrauterine environment. Is the leading cause of newborn deaths globally accounting for almost 40% in Canada Low birth weight (LBW)-newborns weighing 2 500 g or less Increase risk for health issues, Extremely low birth weight (ELBW)-birth weight of less than 1000 g (2 lb, 3 oz) Practical and ethical dimensions of resuscitation of extremely low-birth-weight infants (ELBW Causes of preterm birth multifactorial poverty (which can contribute to suboptimal health care and prenatal nutrition) maternal infections previous preterm birth multiple pregnancies pregnancy-induced hypertension, placental conditions that interrupt the normal course of gestation Smoking Advanced maternal age Fetal disorders intrauterine growth restriction (IUGR) (associated with LBW) Preterm 30 Risk Respiratory distress Thermal instability Hypoglycemia Jaundice’ Feeding difficulties Neurodevelopmental issues (speech, behavioural, and cognitive) Infection Complications Respiratory distress syndrome (RDS) Patent ductus arteriosus Periventricular-intraventricular hemorrhage Necrotizing enterocolitis - inflammatory bowel disease seen in preterm infants, involving intestinal damage that may lead to perforation Pretem Risk and Complications Respiratory support Oxygen therapy Nasal cannula Continuous distending pressure Mechanical ventilation Weaning from ventilatory support Cardiovascular support Assess heart rate and rhythm, skin colour, blood pressure, perfusion, peripheral pulses, oxygen saturation Thermoregulation Maintaining a neutral thermal environment (NTE) Kangaroo care Neurological Monitor for seizure activity, hyperirritability, CNS depression, elevated intracranial pressure, and abnormal movements. Nutrition and Hydration Breastfeed if sucking and swallowing reflexes are adequate and no other contraindications. Gavage feeding (nasogastric or orogastric tube) Gastrostomy feeding (surgical placement of a tube through abdomen into the stomach. Supplemental parenteral fluids to supply additional calories, electrolytes, or water. Nursing Care 32 Renal support Assess acid–base and electrolyte balance serum levels of medication for adequate therapeutic range for treatment and to prevent toxicity Hematological support Signs of bleeding, anemia Nurturing environment Avoid slamming doors (including isolette portholes), listening to radios, talking loudly, and handling equipment (e.g., trash containers), jarring chairs Monitoring sound levels in the nursery Shielding newborns’ eyes from bright lights Clustering of care and assessments to enable undisturbed sleep periods Skin care Care must be taken to avoid damage to the delicate structure. Use skin products (e.g., alcohol, chlorhexidine, povidone-iodine) with caution Rinsed with water afterward to prevent severe irritation and chemical burns in VLBW and ELBW infants. Minimal use of adhesive tape, backing the tape with cotton, and delay removal adhesive until adherence is reduced Protection from infection Strict hand hygiene is the single most important measure to prevent infections Nursing Care Large for gestational age LGA: Newborn birth weight is above the ninetieth percentile on growth charts Higher incidence of birth injuries Asphyxia Congenital anomalies such as heart defects. Causes of LGA Maternal diabetes in the mother (most common cause)  Maternal obesity Having had previous LGA babies Genetic abnormalities or syndromes Excessive weight gain during pregnancy Large for gestational age LGA Infants of Diabetic Mothers Clinical Manifestations Macrosomia or Large for gestational age Very plump and full faced Abundant vernix caseosa Plethora (ruddy complexion - polycythemia) Listless and lethargic Possibly meconium stained at birth Hypotonia Complications Hypoglycemia, hypocalcemia, hypomagnesemia, polycythemia, hyperbilirubinemia, cardiomyopathy, Respiratory Distress Syndrome CNS anomalies-anencephaly, spina bifida, and holoprosencephaly-abnormal development of the forebrain Cardiac anomalies- ventricular septal defects and coarctation of the aorta Sacral agenesis and caudal regression Increased risk for birth injuries Higher Risk of Hypoglycemia High maternal blood glucose levels during fetal life stimulate the fetal islet cells to produce insulin Leads to hypertrophy and hyperplasia of the pancreatic islet cells-transient state of hyperinsulinism Sudden removal of newborn’s glucose supply after birth + continued production of insulin depletes the blood of circulating glucose creating a state of hyperinsulinism and hypoglycemia within 0.5 to 4 hours Quick drops in blood glucose levels leads to neurological damage or death Young, 2022 Feedings with breast milk or formula initiated within the first hour after birth if cardiorespiratory status stable If enteral supplementation failed or infant unable to feed continuous IV infusion of 10% dextrose at 4 to 6 mg/min/kg If blood blood glucose is below 1.8 mmol/L, a one-time bolus infusion of 10% dextrose (200 mg/kg) should be given over 2 to 4 minutes, followed by a continuous IV infusion of 10% dextrose Evaluation of serum glucose 30 minutes pharmacological agents (glucagon and diazoxide) may be required Monitoring for symptoms of hypoglycemia in an IDM include jitteriness or tremors, cyanotic episodes, seizures, intermittent apneic episodes difficulties feeding Assess for congenital anomalies, signs of possible respiratory or cardiac issues Maintenance of adequate thermoregulation Monitoring of serum blood glucose levels. Monitored closely for hyperbilirubinemia. ; Management and Nursing Care Parents should be given the opportunity to room-in and spend a night or two providing care Home care needs of infant's parents are assessed. Referrals for appropriate resources Assistance with medical supplies Parent teaching include bathing and skin care, infection prevention Nutritional requirements for meeting nutritional needs Parent education and opportunity for return demonstrations care skills Age-appropriate car seat Health care provider contact Appropriate immunizations, metabolic screening, hematology assessment, and evaluation of hearing and for retinopathy of prematurity (ROP) before discharge Transport to a regional centre Discharge Planning for High-Risk Infants Interprofessional and family-centred approach-Medical, nursing, social services, and other professionals (physiotherapy, occupational therapy, developmental follow-up specialist) are critical for successful transitioning and long term neurocognitive development Ontario government site: http://www.health.gov.on.ca/en/pro/programs/immunization/schedule.aspx http://www.health.gov.on.ca/en/public/programs/immunization/static/immunization_tool.html Immunizations 39 References Images courtesy of Elsevier Additional images source from Google images for learning purpose Marandola, J. (2022a). Nursing care of the newborn and family. Chapter 26. In L. Keenan-Lindsay, C.A. Sams, C.L. O’Connor, S.E. Perry, M.J. Hockenberry, D.L. Lowdermilk and D. Wilson (Eds). Maternal child nursing care in Canada (5th ed.). Elsevier Canada. Marandola, J. (2022b). Physiological adaptations of the newborn. Chapter 25. In L. Keenan-Lindsay, C.A. Sams, C.L. O’Connor, S.E. Perry, M.J. Hockenberry, D.L. Lowdermilk and D. Wilson (Eds). Maternal child nursing care in Canada (5th ed.). Elsevier Canada. Young, J. (2022). Infants with gestational age–related conditions. Chapter 28. In L. Keenan-Lindsay, C.A. Sams, C.L. O’Connor, S.E. Perry, M.J. Hockenberry, D.L. Lowdermilk and D. Wilson (Eds). Maternal child nursing care in Canada (5th ed.). Elsevier Canada.