normal neonate powerpoints

Slide 1

The Neonatal Period

CoordinateAdaptIntegrate

NURS 3217 Dr. Genae Strong1Begins at birth and ends at 28 days. At birth, multiple factors act as triggers responsible for newborns taking their first breath such as chemical, mechanical, thermal, & sensory triggers. During this time neonates must adapt, coordinate, and integrate changes:Physically1.) establishing respirations2.) changing circulation route3.) regulate temp4.) ingest, retain, & digest food5.) getting rid of waste6.) regulate weight

Behavioral1.) regulate arousal & sleep2.) process, store, & organize information3.) establish relationships

NURS 3217 Dr. Genae Strong2

APGARacronym for A -ppearance P -ulse G -rimace A -ctivity R -espiration

NURS 3217 Dr. Genae Strong3When? 1 minute after birth5 minutes after birthWhy?Physiologic state of the neonateRapid need assessment for resuscitationWhat?Appearance (generalized skin color- pallid, cyanotic, or pink)Pulse (heart rate)Grimace (reflex irritability)-- response to suctioning nares or nasopharynxActivity (muscle tone) -- degree of flexion and movement of extremitiesRespiration observed movement of chest wallHow? is it scored? Appearance (color):0 = blue, pale 1 = body pink, extremities blue 2 = all pinkPulse (heart rate):0 = absent1 = slow 100Grimace (reflex irritability):0 = no response 1 = grimace 2 = cryActivity (muscle tone):0 = flaccid 1 = some flexion 2 = well flexedRespiration (movement of chest wall):0 = absent 1 = slow, weak cry 2 = good cry

Scoring

Does it make sense why a systematic scoring method such as the APGAR would assist nurses in providing immediate care to infants based on signs of transitioning to extrauterine life?

What potential implications do you see when a systematic assessment is not used to provide evidence based care?NURS 3217 Dr. Genae Strong4

Ben was born one minute agoColor - completely blue

Heart rate 101

Cries when you insert a suction catheter to remove oral secretions

He quickly recoils his arms and legs after you extend them

Slight respiratory grunt, weak cry as you rub him with warm towels

Total 1 min APGAR =Total 5 min APGAR = ?7

NURS 3217 Dr. Genae Strong5What is the APGAR for this infant?A = 0rationale: blue = 0AppearanceP = 2rationale: 100 or > = 2PulseG = 2rationale: cries = 2GrimaceA = 2rationale: well-flexed = 2 ActivityR = 1rationale: cry (weak) = 1Respirations--------- 7 How do we feel about this baby? OK = 7, 8, or 9 (sufficient for fetal adaptation to extrauterine life.

Response to APGAR7-10

3-6

0-2Minimal

Moderately distressOxygen, Narcan, vigorous stimulation

Severely distressCPR, drug tx, intubate

NURS 3217 Dr. Genae Strong6[summary of interventions are not in text]Score of 7 - 10 normal, neonate in good condition; possible suctioning of mouth and nose, observationScore of 3 - 6moderately depressed neonate who will need some resuscitation and close observation oxygen -- blow by or by ambu bag, narcan if indicated (positive pressure) vigorous stimulationScore of 0 - 2severely depressed neonate who will need resuscitation, possible ventilatory assistance, intensive observation, and careCPR intubate if no respiration resuscitation drugs

Note: The change in score from 1 to 5 minutes is a useful index of the effectiveness of resuscitation efforts.

There is poor correlation between the 1 and 5 minute Apgar score and future neurologic outcome.

Correlation increases when the score is 0 - 3 at 10, 15, and 20 minutes.

Extrauterine AdaptationRespiratoryCardiovascularThermoregulationNeurologicalIntegumentMusculoskeletalGastrointestinalHepaticRenal


RespiratoryMOST critical adaptationInitiated by triggersChemicalMechanicalcompression intrathoracic pressure release of chest compression negative pressure drawing air in lungsThermalSensory Pulmonary vasculature Clamping cord blood pressure circulation, lung perfusion

NURS 3217 Dr. Genae Strong8Respiratory: Newborns are by preference NOSE breathers. Ultimately, the lungs must be established as the crucial site of gas exchange and is facilitated with clamping the cord. This causes a rise in blood pressure and an increase circulation into the lungs for perfusion. Respirations can also be stimulated by

The most critical adjustment a newborn makesThe first breath of air initiates a sequence of cardiopulmonary changesconverting from fetal to neonatal circulationemptying the lungs of fluidretention of fluid interferes with ability to maintain adequate oxygenation [c/s delivery]establishing pulmonary functionfirst breath inflates the lungs and reduces pulmonary vascular resistancediaphragm descends creating negative intrathoracic pressurealveoli are lined with surfactant which lowers surface tension so alveoli stay open with less pressure -- not every breath is a first breathchest and abdomen rise simultaneously with inspiration of air (seesaw respirations are not normal)Characteristic respiratory patterns -- shallow irregular breaths30 - 60 breaths/minshort periods of apnea window closesductus arteriosus (right to left shunt from pulmonary artery to descending aorta) -- ductus constricts when PO2 in arterial blood nears 50 mm Hg. Later it occludes and becomes a ligament.clamping of cord ----> umbilical arteries, umbilical vein, and ductus venosus (shunted blood from umbilical vein to inferior vena cava) close and become ligamentsThermoregulation: Ability to maintain balance between heat loss and heat productionNewborns and adults are homiotherms -- can maintain a constant core body temperature regardless of environmental temperature. Newborns have a much narrower range to which they can adapt without being stressed than adults.Heat production -- shivering thermogenesis -- not operable in the newbornnonshivering thermogensis -- metabolism of brown fat to produce heat. Deposits of brown fat are present for several weeks after birth and are rapidly depleted with cold stress. The less mature the infant the less reserve of brown fat.

Fetal Po2 from 27 mmHg (in utero) to 50 mmHg (extrauterine), O2 and prostaglandin E2 [PGE2] closes the ductus arteriosus. Can reopen in response to hypoxia, asphyxia, or prematurity. Cardio (cont)By clamping and cutting the cord, the arteries, vein, and ductus venosus close. Pulmonary pressure drops in pressure of right atrium. pulmonary blood flow from the left side of heart pressure in the left atriumcausing the foramen ovale to close. (for a few days, crying can reverse closure mild cyanosis.


Anatomic and physiologic characteristics place newborns at risk for hypothermia and hyperthermiaThermoregulationNormal temp- 97.7 to 98.9 FNewborns have larger body surface-to-body weight (mass)Blood vessels are closer to the skin. Changes in room temp temp of the blood influencing temp regulation centers in the hypothalamus

NURS 3217 Dr. Genae Strong14Thermoregulation: Ability to maintain balance between heat loss and heat productionNewborns and adults are homiotherms -- can maintain a constant core body temperature regardless of environmental temperature. Newborns have a much narrower range to which they can adapt without being stressed than adults.Heat production -- shivering thermogenesis -- not operable in the newbornnonshivering thermogensis -- metabolism of brown fat to produce heat. Deposits of brown fat are present for several weeks after birth and are rapidly depleted with cold stress. The less mature the infant the less reserve of brown fat.Heat loss -- Convection -- body surface to cooler ambient air (wrap newborn, keep nursery warm)Radiation -- body surface to cooler solid surface not in direct contact but in relative proximity (keep cribs away from windows)Evaporation -- loss of heat when liquid is converted to a vapor (dry infant directly after birth and bathing)Conduction -- body surface to cooler surface in direct contact (warm crib when admitted to nursery, skin to skin contact with mother)

Therm (cont)To conserve heat energy, newborns assume a position of flexion.Constrict peripheral blood vesselsBrown fat is used for non-shivering thermogenesis (located in superficial deposits in interscapular region, axillae, thoracic inlet, vertebral column, and kidneys.


Cold Stress

Effects of cold stress -- fig.25-3 page 640 in textOxygen consumption increases as oxygen and energy are diverted from maintaining normal function and growth to thermogenesis for survivalRespiratory rate increases because of demand for oxygenVasoconstriction to insure blood flow to vital organs jeopardizes pulmonary perfusion -- may reopen shunt across the ductus arteriosusBMR increases and may result in anaerobic glycolysis -- increased acid productionPO2 and pH decreaseExcess fatty acids displace the bilirubin from albumin-binding sites ---> increased level of circulating unbound bilirubin that increases the risk of kernicterus.


NeurologicalNeurological

NURS 3217 Dr. Genae Strong17Neurological: see newborn reflexes table 23-4 pages 546-547development follows cephalocaudal and proximodistal patternsCephalocaudal- (conception to 5 months prenatal) infants use upper limbs before lowerProximodistal- (from 5 months to birth) growth from inside the body outwardMotor skills develop from center of the body outwardsMyelin, which increases the speed and accuracy of nerve impulses, develops earliest in the brain and sensory transmitters.Acute sense of hearing, smell, tastebreathing and maintaining acid-base balanceBrain requires glucose as a source of energy and a large supply of oxygen for adequate metabolismassessment of airway and respiratory statusmonitoring of infants who may become hypoglycemicNewborn reflexes indicate the maturity and intactness of the developing nervous system -- therefore we assess reflexes

RenalRenal

NURS 3217 Dr. Genae Strong18Renal: 75% of body weight consists of water

urinary system is structurally complete but physiologically immature -- unable to concentrate urinewater losses are greaterwater requirements per kilogram of body weight are greater (125 -150 mL/KG per day will produce 100 mL of urine per 24 hours)decreased ability to remove waste products from the blood (GFR 30% compared to 50%)decreased ability to handle high osmolarity40% of body weight is extracellular (adult = 20%)bladder capacity is ~30 mL -- May not void for 12 - 24 hours. 1st 2nd day 2-6 times per dayafter that- 5-25 times per day.

HepaticHepatic

NURS 3217 Dr. Genae Strong19Hepatic:Liver is enlarged and occupies 40% of abdominal cavity at birthLiver began storing iron in utero. If mother had adequate iron intake iron stores will last until 4-6 month of life. If preterm iron stores will last 2-3 monthsLiver conjugates bilirubin [fig. 25-4 page 644]. Bilirubin is the by-product of the destruction of RBCs. Bilirubin is released in an unconjugated form (indirect bilirubin) which binds to plasma proteins. Unbound bilirubin can leave the vascular system and permeate other tissues (skin, sclera, mucous membranes). Yellow coloring is jaundice. When it crosses the blood brain barrier it is called kernicterus.The conjugated form of bilirubin is excreted as a constituent of bile (direct bilirubin). Direct bilirubin is converted to urobilinogen and stercobilin which is excreted in urine and feces. Total bili is the sum of direct and indirect bili. Adequate binding sites are available in the newborn unless the infant is asphyxiated, has cold stress, or hypoglycemia. Maternal ingestion of drugs (aspirin, sulfa) prebirth can reduce binding sites.Physiologic jaundice -- normal in 50% of newbornshigher rate of bilirubin productionshorter life span of fetal RBC (90 days compared to 120)reabsorption of bilirubin from small intestine -- need early feeds to increase passage of meconium and stoolCriteria -- well infant, appears after 24 hrs and disappears by end of 7th day; unconjugated (indirect) bili not >12 mg/100 mL; conjugated not > 1 -1.5 mg/100 mL; daily increments not > 5 mg/100 mL

Formation and Excretion of Bili


GastrointestinalGastrointestinal

NURS 3217 Dr. Genae Strong21Breastfeeding jaundice -- appears day 3, no other clinical causeearly frequent feedings will decrease bili level8 or more feedings per daycolostrum is a natural laxativeGastrointestinal:born with the capacity to swallow, digest, metabolize and absorb proteins and simple carbohydrates. Limited ability to digest fats -- no lipase from pancreasMotility and sphincteric control are immature -- regurgitation, gas distention, flatus and wide variety of stool patterns are commonBacteria not present in the GI tract at birth. Normal intestinal flora help synthesize vitamin K.Bowel sounds are heard within 1 hour of birthFirst stool is meconium passed in first 24-48 hours. No stool in 72 hours is indicative of an obstruction; transitional stools -- watery, loose, green-brown to yellow-brown by day 3; milk stools by day 4 -- vary in consistency, color, and frequency by feeding method (breast or bottle).Feeding behaviors -- vary; some nurse right away. Others require a learning period of up to 48 hrs.

MusculoskeletalMusculoskeletal


Musculoskeletal:head is 1/4 the body length; arms slightly longer than legscranial size and shape are distorted by moldingcheck base of spine for dimpling -- spina bifida occultaextremities should be symmetric and of equal lengthOrtolanis maneuver to check for hip dysplasiaFingernails and toenailsCreases cover sole of foot in term infant

IntegumentIntegument

NURS 3217 Dr. Genae Strong23Integument and Reproductive system:vernix caseosa -- white, cheesy substance fused with the epidermis that serves as protective coatingerythematous (beefy red) skin for a few hours after birth. The blotchy or mottled especially over extremities. Acrocyanosis -- cyanotic hands and feet from vasomotor instability, capillary stasis, and a high hemoglobin level. Transient. Persists 7 to 10 days.Lanugo -- fine hair on face, shoulders, backecchymosis and edema -- from face presntation or forceps birthpetechia -- in areas of increased pressure; report generalized petechia; may be sign of low platelet count or infection.Caput succedaneum -- scalp edema from sustained pressure of presenting vertex against the cervix. Extends across suture lines and disappears spontaneously within 3 - 4 days.[fig.25.5 page 647 caput vs cephalo]Cephalohematoma -- blood between skull bone and periosteum; never crosses a suture line; soft, fluctuating, irreducible fullness that doesnt pulsate or bulge when the infant cries; appears several hours after birth, largest on day 2 or 3, spontaneously resolves in 3 to 6 weeks. May cause hyperbilirubinemia as hemolysis of RBCs occurs.Desquamation -- peeling of skin a few days after birth. Indicates postmaturityMilia -- white spots on chin and nose; distended sebaceous glandsMongolian spots -- bluish-black areas of pigmentation commonly appearing on back and buttocks in dark-skinned individuals. Fade over period of months or yearsNevi -- stork bites are pink and blanch easily. Appear on eyelids, nape of neck, nose, upper lip. Fade by first or second year. [Differentiate these from strawberry mark or port wine stain]erythema toxicum -- transient rash of macules, papules, or small vesicles. Appears suddenly anywhere on body within first 3 weeks after birth. No clinical significance, no treatment.Pseudomenstruation -- slight bloody spotting, mucoid vaginal discharge resulting from drop in estrogenWitches milk -- swelling and discharge from nipples from increase in estrogen during pregnancy.

Caput, Cephalhematoma, & Subgaleal


Extrauterine AdaptationPhysical CharacteristicsVital SignsWeightHeadChestLength

NURS 3217 Dr. Genae Strong25Physical characteristics:vital signs -- HR = 110 160 (first 30 minutes- HR 160-180 then 110-120)R = 30 60 (first 30-60 mins- Resp 60-80 then 60 breaths per minute)T = 97.5 - 99weight -- >2500 grams but

normal neonate powerpoints

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