1. Nursing Care of the Newborn

2. عمل الطالبات • ريمان ضهير • امتياز ضهير • عندليب ضهير • أريج شعث • اسراء القاضي • بسمة الفرع • خضرة العفش • دينا البلعاوي

3. Immediate Baby Care • Airway - Clean mouth and nose • Thermoregulation - Warmth • APGAR • Gross assessment • Identification • Bonding – safety against infection • Medications

4. Fetus to Newborn: Respiratory Changes • Initiation of respirations • Chemicalsurfactant reduces surface tension 34-36wksdecrease in oxygen concentration • Thermalsudden chilling of moist infant • Mechanicalcompression of fetal chest during delivery normal handling

5. Nursing Process for Respirations • Assess for respiratory distress • Plan: Maintain patent airway • Interventions- Positioning infant – head lower - Suction secretions – bulb, keep near head, mouth first, avoid trauma to membranes • Evaluation – rate 30-60, no distress

6. Fetus to Newborn: Neurological adaptation: Thermoregulation Methods of heat loss Evaporation – wet surface exposed to air Conduction – direct contact with cool objects Convection- surrounding cool air - drafts Radiation – transfer of heat to cooler objects not in direct contact with infant

7. Convection Radiation Evaporation Conduction

8. Nonshivering thermogenesisThe distribution of brown adipose tissue (brown fat)

9. Nursing Care – Cold Stress • Preventing heat loss – radiant warmer • Providing immediate care - dry quickly, cover head with cap, replace wet blankets • Providing on going prevention - safety • Restoring thermoregulation – if becoming chilled - intervene

10. Effects of Cold Stress • Increased oxygen need • Decreased surfactant production • Respiratory distress • Hypoglycemia • Metabolic acidosis • Jaundice

11. APGAR • Heart rate – above 100 • Respiratory Effort – spontaneous with cry • Muscle tone – flexed with movement • Reflex response – active, prompt cry • Color – pink or acrocyanosis • 0-3 infant needs resuscitation • 4-7 Gentle stimulation – Narcan • 8-10 – no action needed

12. Early Assessments • Assess for anomalies • Head – anterior fontanelle closes 12-18 mo posterior fontanelle closes 2-3 months • Neck and claviclesfracture of clavicle – large infant, lump, tenderness, crepitus, decreased movement • Cord • Extremitiesflexed and resist extensionassess fractures, clubfeethipsvertebral column

13. Not crossing suture line Cephalhematoma is a collection of blood between the surface of a cranial bone and the periosteal membrane.

14. Crossing suture line Caput succedaneum is a collection of fluid (serum) under the scalp.

15. A, Congenitally dislocated right hip B, Barlow’s (dislocation) maneuver. C, Ortolani’s maneuver

16. Measurements • Weight – loss of 10% normal • Length • Head and chest circumference • Normal VStemp 97.7-99.5F axillaryapical pulse 120-160bpm respirations 30-60/min

17. head larger A, Measuring the head circumference of the newborn. B, Measuring the chest circumference of the newborn.

18. Assessment of Cardio-respiratory Status • History • Airway • Assessrateq 30minX2hrssymmetrybreath sounds - moisture for 1-2 hrs

19. Assessment of Thermoregulation • Check soon after birth • Set warmer controls • Take temp q 30 min until stable • Rectal for first temp • Insert only 0.5 inch • Axillary route rest of time

20. Axillary temperature measurement. The thermometer should remain in place for 3 minutes.

21. Assessment of Hepatic Function • Blood GlucoseSigns of hypoglycemia jitteriness respiratory difficulties drop in temp poor suckingTx- feed infant if glucose below 40-45 mg/dl • Bilirubinphysiologic jaundice peaks 2-4 days of lifeearly onset may be pathologic

22. Jaundice • Hemolysis of excessive erythrocytes • Short red blood cell life • Liver immaturity • Lack of intestinal flora • Delayed feeding • Trauma resulting in bruising or cephalhematoma • Cold stress or asphyxia

23. Potential sites for heel sticks. Avoid shaded areas to prevent injury to arteries and nerves in the foot.

24. Assessment of Neuro System • Reflexes • BabinskiGraspMoroRootingSteppingSuckingTonic neck reflex “fencing” • Cry • Infant response to soothing

25. Assessment of Gastrointestinal System • Mouth • Suck • Abdomen • Initial feeding • Stoolsmeconium – within 12-48 hours of birth dark greenish blackbreastfed – soft, seedy, mustard yellowformula-fed – solid, pale yellow

26. Assessment of Genitourinary System • Umbilical cord vessels • Urine – within 24 hours of birth • Voiding – 6 to 10 times a day after 2 days • Genitaliafemale – edema normal, majora covers minora, pseudomenstruationmale – pendulous scrotum, descended testes by 36 wks gest., placement of meatus

27. Assessment of Integumentary System • Vernix – white covering • Lanugo – fine hair • Milia • Erythema toxicum – red blotchy with white • BirthmarksMongolian spots – sacral areaTelangiectatic nevus “stork Bite” - blanches Nevus flammeus “port wine stain” - no blanchingNevus vasculosus “strawberry hemangioma” usually on head, disappears by school age

28. Port Wine Stain Erythema toxicum

29. Fetus to Newborn: Psychosocial adaptation • Periods of Reactivityactive – 30-60 minsleep – 2-4 hoursalert – 4-6 hours • Behavioral Statesquiet sleepactive sleepdrowsy statequiet alert – best for bondingactive alertcrying state

30. Gestational Age Assessment • Assessment tool – Dubowitz, Ballard • Weeks from conception to birth • Used to identify high risk infants • Neuromuscular characteristicsPosture – more flexionSquare window – more pliableArm recoil - activePopliteal angle - lessScarf Sign – less crossing Heel to ear – most resistance

31. Gestational Age Assessment • Physical characteristicsSkin- deep cracking, no vessels seen, post-leatheryLanugo – less as agePlantar creases – more with ageBreasts – larger areola Eyes and Ears – stiff with instant recoilGenitals – deep rugae, pendulous, covers minora • Gestational Age & Size – may not correspondsmall SGA <10% for weight large LGA >90% for weightappropriate AGA between 10-90%

32. Ongoing Assessment and Care • Bathing • Cord care • Cleansing diaper area • Assisting with feedings • Protecting infantidentifying infantpreventing infant abduction – alert to unusualpreventing infection • Review beige cue cards in center of book for teach

33. One method of swaddling a baby.

34. Common Breastfeeding Positions

37. Infant in good breastfeeding position : tummy-to-tummy, with ear, shoulder, and hip aligned.

38. Other Concerns • ImmunizationsHepatitis B – begin vaccine at birth • Screening testsHearingPhenylketonuria – by law

39. Further Assessments • Complications r/t poorly functioning placentahypoglycemiahypothermiarespiratory problems • Complications r/t LGA infanthypoglycemiabirth injury due to size

40. Shoulder Dystocia • Risk factorsdiabetes; macrosomic infantobesityprolonged second stageprevious shoulder dystocia • Morbidity- fracture of clavicle or humerus,brachial plexus injury • Management – generous episiotomy

41. Neonatal morbidity by birth weight and gestational age.

42. High Risk Infants • Preterm – before 38 weeks gestation • IUGR – full term but failed to grow normally • SGA - • LGA • Infants of Diabetic mothers • Post mature babies • Drug exposed

43. Preterm infants • Survive - Weight 1250 g -1500 g – 85-90%500-600g at birth 20% survive • Ethical questions • Characteristics – frail, weak, limp, skin translucent, abundant vernix & lanugo • Behavior – easily exhausted, from noise and routine activities, feeble cry

44. Nursing Care of Preterm Infants • Inadequate respirations • Inadequate thermoregulation • Fluid and electrolyte imbalance – dehydration sunken fontanels <1ml/kg/hr or over hydration bulging, edema and urine output >3ml/kg/hr • Signs of pain – high-pitched cry, >VS • Signs of over stimulation - >P, >RR, stiff extended extremities, turning face away • Nutrition – signs of readiness to nippleresp <60/m, rooting, sucking, gag reflex

45. Measuring gavage tube length.

46. Auscultation for placement of gavage tube.

47. Complications of Preterm Infants • Respiratory Distress Syndrome -RDS • Bronchopulmonary dysplasia – chronic lung disease • Periventricular-Intraventricular Hemorrhage30% infants <32 wk gest or <1500 g • Retrolenthal fibroplasia – visual impairment or blindness from O2 & ventilator • Necrotizing Enterocolitis (NEC) – distention, increased residual, Tx - rest bowel

48. Respiratory Distress Syndrome • RDS also know as “hyaline membrane disease” • Cause – besides preemie, C/S, diabetic mothers, birth asphyxia – interfere with surfactant • S & S tachypnea - over 60/min retractions- sternal or intercostal nasal flaring cyanosis- centralgrunting- expiratoryseesaw respirationsasymmetry

49. Evaluation of respiratory status using the Silverman-Andersen index.

50. Therapeutic Management of RDS • Surfactant replacement therapy • Installed into the infant’s trachea • Improvement in breathing occurs in minutes • Doses repeated prn • Other treatmentmechanical ventilationcorrection of acidosisIV fluids