chapters 13 & 15 nursing assessment of newborn in...

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Chapters 13 & 15 Nursing Assessment of Newborn in Transition and the Normal Newborn

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Chapters 13 & 15Nursing Assessment of Newborn

in Transition and the Normal Newborn

Physiologic Adaptation

• Antenatal

– Completely dependant

– Lungs uninflated, fluid-filled

– Circulation by passes heart

– shunts

• Post natal

– Separate from maternal sources of oxygen, heat, nourishment

– Lungs air-filled

– Shunts close

Fetal vs neonatal circulation

Physiologic Changes in the Newborn

• Respiratory system

– Air-filled, low-pressure system encourages blood flow through the lungs for gas exchange

– Increased oxygen content of blood in the lungs contributes to the closing of the ductus arteriosus

– Lungs are site of gas exchange

• Circulation through the heart

– Pressures in the left atrium are greater than in the right, causing the foreman ovale to close

Physiologic Changes in the Newborn (cont.)

• Hepatic Portal Circulation

– Ductus venosus closes (becomes a ligament); hepatic portal circulation begins

• Thermoregulation

– Body temperature maintained through a flexed posture and brown fat

The Nurse’s Role in Caring for the Newborn

• Supporting the newborn as he or she adapts to life outside the womb

• Quickly recognizing the development of complications so that interventions can be initiated immediately

• Teaching the parents the skills needed to care for their newborn

Immediate Assessments of the Newborn

• Success of cardiopulmonary adaptation

– A vigorous or lusty cry

– Heart rate greater than 100 beats per minute (bpm)

– Pink color

• Apgar score

Five Parameters Assessed by the Apgar Score

• Heart rate

• Respiratory effort

• Muscle tone

• Reflex irritability

• Color

Apgar Scoring

• Heart rate: 2= HR> 100, 1= HR< 100, 0= no HR

• Respiratory effort: 2= strong, vigorous cry, 1= weak cry, slow or difficult respirations, 0= no respiratory effort

• Muscle tone: 2= maintains a position of flexion with brisk movements, 1= minimal flexion of extremities, 0= limp and flaccid

• Reflex irritability: 2= cries or sneezes when stimulated, 1=grimaces when stimulated, 0=no response

• Color: 2=Body and extremities pink, 1=body pink, extremities blue, 0= body and extremities blue or completely pale

Indications of Apgar Scores (cont.)

• Scores of 0 to 3

– Indicate severe difficulty in making the transition

– Infants require observation and care in a neonatal intensive care unit (NICU)

Indications of Apgar Scores

• Scores of 7 to 10

– Indicate a healthy baby adapting well

– Infant can be cared for in the regular newborn nursery or room-in with mother

• Scores between 4 and 6

– Indicate some difficulty in adjusting

– Infant is cared for in a special nursery with oxygen and monitoring devices

Assessments During the Transition Period

• Continue to observe newborn for signs of respiratory distress or cardiovascular compromise

• Observe the newborn closely for cold stress (body temperature of less than 97.6ºF [36.5ºC])

• Assess for hypoglycemia in the newborn

• Perform a full physical assessment, including gestational age assessment, within the first few hours of life

Adaptation and Change

• Hepatic:

– Liver is immature at birth

– Vitamin K needed to produce clotting factors

– Must process large number of “surplus” RBCs that die

– Biliruben released as cells die

– Liver conjugates bili making it water soluble for excretion in feces

– Overwhelmed liver cannot keep up

– Unconjugated biliruben builds up in bloodstream

– Jaundice present when unconjugated biliruben levels> 4-6mg/dL

– Physiologic jaundice occurs in ½ of all newborns

– Physiologic jaundice occurs after 24 hours (usually day 3-4), peaks between days 5-6.

– Pathologic jaundice occurs within first 24 hours

– Rising bilirubin levels place infants at risk for brain damage.

Behavioral and Social Adaptation

• Each infant is unique

• Communicate through behavior and controlling responses to the environment

• Recognize mother’s voice at an early age

Phases of Brazelton’s Neonatal Behavioral Assessment Scale

• Deep sleep

• Light sleep

• Drowsy

• Quiet alert

• Active alert

• Crying

Patient Goals for the Newborn

• Experience adequate cardiovascular, respiratory, thermoregulatory, and metabolic transitions to extrauterine life

• Remain free from signs and symptoms of infection

• Maintain hemostasis

• Be adequately identified before separation from the parents

Nursing Interventions for the Newborn

• Supporting cardiovascular and respiratory transition

• Maintaining thermoregulation

• Preventing injury from hypoglycemia

• Preventing infection

• Preventing imbalanced fluid volume

• Preventing misidentification of a newborn

Maintaining Thermoregulation

• Kangaroo

• Swaddling

• Avoid drafts

• Caps

• The higher ratio of body surface (proportional to heat loss) to body volume (proportional to heat production)

• The higher proportional surface area of the head

• The low amount of musculature and the inability or reluctance to shiver.

• A lack of thermal insulation, e.g. subcutaneous fat and fine body hair (especially in prematurely born children)

• The inability to move away from cold areas, air currents or heat-draining materials

• The inability to use additional ways of keeping warm (e.g. turning up a heater, drying their skin, changing clothes or performing physical exercise)

• The nervous system is not fully developed and does not respond quickly and/or properly to cold (e.g. by contracting blood vessels in the skin)

• Brown Fat—heat producing tissue found only in fetuses and newborns. Located at nape of the neck, in the armpits, between the shoulder blades, along the abdominal aorta, and around kidneys and sternum.

– Not renewable

– Lower amount in premature infants

Risk Factors for Hypoglycemia• Gestational HTN

• Maternal diabetes

• Prolonged labor

• Fetal distress during labor

• Titodrine or terbutaline administered to mother

• IUGR

• LGA

• SGA

• Prematurity

• Postmaturity

• Macrosomia

• Respiratory or cardiovascular depression

• Normal Blood glucose during 1st 24 hours: 40-60 mg/dL

• Use heel stick to obtain specimen

• Asymptomatic newborns at risk tested 2,4,6,12,24,&48 hours after delivery

• <40mg/dL: feed infant

Signs of Hypoglycemia in the Newborn

• Jitteriness or tremors

• Exaggerated Moro reflex

• Irritability

• Lethargy

• Poor feeding

• Listlessness

• Apnea or respiratory distress

• High-pitched cry

Expected Vital Signs of the Term Newborn

• Heart rate

– 110–160 beats per minute

• Respiratory rate

– 30–60 breaths per minute

• Axillary temperature

– 97.7–98.6○F (36.5–37○C)

• Blood pressure

– 60–80/40–45

Average Physical Measurement Ranges of the Term Newborn

• Weight

– 2500–4000 grams

• Length (head-to-heel)

– 48–53 cm

• Head circumference

– 33–35.5 centimeters

• Chest circumference

– 30.5–33 centimeters

Physical Characteristics of the Normal Newborn

• Skin

– Should be supple with good turgor and a pink color

• Head and face

– Molding may be present

– The hard and soft palates should be intact

• Neck and chest

– The neck is short and thick

– Webbing should not be present

– Periodic breathing episodes are normal

Characteristics of Newborn Skin

• Vernix caseosa

– A white cheese-like substance covering the body of the fetus during the second trimester to protect against skin dryness

• Lanugo

– A fine downy hair present in abundance on the preterm infant but found in thinning patches on the shoulders, arms, and back of the term newborn

Common Skin Manifestations of the Normal Newborn

• Harlequin sign

– Dark red on one side of the body, pale on the other caused by dilation and constriction of blood vessels

• Mottling

– red and white lacy pattern on the skin of fair skinned infants

• Acrocyanosis

– A bluish color to the hands and feet of the newborn; normal in the first 6 to 12 hours after birth

Erythema toxicum“Newborn rash” commonly appears on the chest, abdomen, back, and buttocks of the newborn

Milia Small white spots on the newborn’s face, nose, and chin that resemble pimples

Nevus flammeus or port-wine stain

Dark reddish-purple birthmark that most commonly appears on the face. Caused by a group of dilated vessels. Does not blanch with pressure or disappear over time

Mongolian spotBluish-black areas of discoloration on the back and buttocks or extremities of dark-skinned newborns. Not to be confused with signs of abuse. Fade by about 2 years of age.

• Telangiectatic nevi

– Pale pink or red marks found on the nape of the neck, eyelids, or nose of fair-skinned newborns. Blanch when pressed and fade by about 1 year of age.

Physical Characteristics of the Normal Newborn (cont.)

• Abdomen

– The abdomen is protuberant

– The cord should be clamped and drying at the base

• Genitourinary

– The newborn should void within the first 24 hours

– Genitalia of both sexes may be swollen

• Back

– Should be straight and free of hairy tufts, dimples, or tumors

Eyes

• Color blue-gray to dark blue

• Sclera white

• Swollen eyelids normal

• Movement uncoordinated

• Doll’s eyes reflex

• strabismus

• Can perceive light and follow movement

• 0.5% erythromycin, 1% tetracycline or 1% silver nitrate instilled in eyes to prevent opthamia neonatorum

Nose

• Flat

• Bridge may appear absent

• Obligate nose breathers

• Sense of smell present

• Nasal flaring is a sign of respiratory distress.

The Fontanels

• Two: Anterior and posterior

• Occur at junction of cranial bones.

• Anterior: Diamond shaped, larger than posterior. Flat. Normal to feel pulsations. Closes at 12 to 18 months

• Posterior: Smaller, triangular. Closes by 3 months

Ears

• Pinna flexible with quick recoil

• Top of pinna even with line from inner to outer canthus of eye

• Hearing tests done before discharge

Mouth

• Membranes pink, moist

• Uvula midline

• Epstein’s pearls: small white cysts on midline of hard palate.

• Well developed fat pads on cheeks

• Thrush

Abnormal Characteristics of the Newborn’s Mouth

• Thrush

– A fungal infection (caused by Candida albicans) in the oral cavity

• Cleft palate and cleft lip

– Non-intact palate or lip

“Normal Abnormalities”• Molding

• Cephalhematoma: bleeding under the periosteum caused by birth trauma. No treatment required. Make certain it does not cross suture line. Assess for anemia

• Caput succedaneum: swelling of the soft tissue of scalp. Will resolve in a few days without treatment.

Chest, abdomen, Genitourinary

• Chest

– Equal front to back and side to side

– Witch’s milk

• Abdomen

– Dome shaped

– Diaphragmatic breathing

– Audible bowel sounds after 2 hours

• Genitourinary

– Void within 24 hours

– Urine light colored without odor

– Genitalia may be swollen

Assessments of the Male Genitourinary Tract

• Epispadias

– The urinary meatus is located abnormally on the dorsal (upper) surface of the glans penis

• Hypospadias

– The urinary meatus is located on the ventral (under) surface of the glans

• Phimosis

– Tightly adherent foreskin

– A normal condition in the term newborn

• Cryptorchidism

Neurologic Assessments of the Newborn

• General appearance and behavior

• Reflexes

• Behavioral assessment

Goals for the Newborn After Successful Transition

• Maintain a clear airway

• Be free of infection

• Have clean intact skin

• Not be abducted from the hospital

• Respond to the environment in an organized way

• Maintain an adequate body temperature

Disorders for Which Newborn Screening is Performed

• Phenylketonuria (PKU)

• Congenital hypothyroidism

• Galactosemia

• Maple syrup urine disease

• Homocystinuria

• Biotinidase

• Sickle cell disease

• Congenital adrenal hypoplasia

• Cystic fibrosis

Measures to Prevent Transmitting Infection to the Newborn

• Perform hand washing as per agency policy

• Keep all the newborn’s belongings together in the bassinet and do not share items between newborns

• Wipe down shared equipment (such as stethoscopes) with alcohol between uses

• Encourage rooming-in

• Use universal precautions

Assessments of the Newborn Being Prepared for Discharge

• Continue to assess respiratory, cardiovascular, thermoregulatory, nutritional, and hydration status

• Monitor for signs of infection

• Check vigilantly for developing jaundice

• Watch for signs of pain, especially with circumcision

• Assess the adaptation of the mother and father to the parenting role

Newborn Conditions Contraindicating Circumcision

• Still in the transition period

• Preterm or sick

• Family history of bleeding disorder until the disorder is ruled out in the newborn

• Diagnosis of a bleeding disorder

• Congenital genitourinary disorder, such as epispadias or hypospadias

Focus of Discharge Teaching for New Parents• Handling the newborn

• Clearing the airway

• Monitoring adequate temperature

• Monitoring stool and urine patterns

• Providing skin care

• Maintaining safety

• Cord care

• Circumcision care