nursing care and neonate family

transition to extrauterine life

- neonatal period: first 28 days of life

- transtition begins when umbilical cord is cut and baby takes first breath

- nureses role is to assess, monitor, and support neonates as they undergo changes

- families support infant transition

resp system newborn

• lungs filled w fetal fluid → fetuses practice breathing w fluid

• vag delivery helps w reabsorption of fetal lung fluid

• surfactant: produced in utero 24-28 wks → fully efficient at 38 wks → prevents alveoli from collapsing

• crackles are heard at birth → cleared up by 1 hr of age

triad signs of resp distress in infant

• grunting

• nasal flaring

• retractions

transition to extrauterine pulm fx

• mechanical stimuli - infant chest is compressed through vaginal canal w/ vaginal deliver

• chemical stimuli - occurs as infant gets closer to delivery and through labor

• sensory stimuli - going from warm to cold environment → helps take 1st breath

circulatory system of fetus

• clamping of umbilical cord - increases BP, dilates pulm vessels

• three shunts used for circulation

• pressure w/in heart → R>L → lungs are filled w/ fluid → has to fight harder to push blood through

ductus venousus

- located by the liver

- bypasses liver bc dont need all fx in utero

- goes through placenta to umbilical vein → bypasses liver → into inferior vena cava

foramen ovale

- between R and L atria

- right side of the heart has more pressure than the left

ductus arteriosis

- between pulmonary artery and aorta

changes in fetus at birth

• closure of shunts

  • ductus venous - shuts at clamping of cord

  • foramen ovale - closes once fluid starts to be reabsorbed → pressure switches to L>R

  • ductus arterioles - shunt should close with rising pO2 levels → w/in 1st 72 hrs → as it closes, blood flow gets turbulent through it → can cause temporary murmur

• brachiocephalic branch

  • goes to arm and brain

  • right hand or wrist of baby for placement of pulse ox during delivery → right hand has same amount of oxygen that is going to brain

neonate responds to cold by

- increasing activity and metabolic rate

- peripheral vascular constriction

- metabolism of brown fat

what is metabolism of brown fat

• brown adipose tissue → only if full term → made around 26-30 wks

• non-shivering thermogenesis → metabolize fat → blood circulates and warms → releases heat

• rapidly depletes reserves if cold stressed

what should babys temp be in first 2-3hrs

97.7-98.6

methods of heat loss

• conduction

• convection

• evaporation

• radiation

what is conduction

- direct contact of cold objects/surfaces

- ex: cold hands, scales, equipment

- warm blankets, warm stethoscope, blanket on scale

convection

- drafts transfer heat to cooler air

- ex: open doors, fans, movement of people

what is evaporation

- air drying of skin

- ex: wet skin at birth, wet linens, insensible water loss

- dry infant off immediately → remove wet towels/blankets

what is radiation

- indirect transfer to cooler objects

- ex: windows, outside walls

fx leading to cold stress

• physical characteristics

  • large body surface area

  • rate of heat loss greater

normal response to cold for healthy term newborn

- activity

- acrocyanosis - shunting blood to middle of body

- flexed body posture decreases surface area exposed to environment

what is cold stress

• excessive heat loss leads to hypothermia

  • increased RR and HR → compensation

  • increased O2 & glucose consumption → hypoglycemia and desaturations can occur bc O2 is utilized for brown fat metabolization → metabolization and glucose consumption can cause lactic acidosis

  • decrease in surfactant → resp distress syndrome

risk fx for cold stress

- prematurity, sga → can’t flex arms → prev by swaddling

- hypoglycemia

- prolonged resuscitation efforts, sepsis

- neuro, endocrine, cardiac, resp problems

s/s cold stress

- axillary temp <96.6

- cool skin

- lethargy

- pallor or cyanosis

- tachypnea

- grunting

- hypoglycemia

- hypotonia

- jitteriness

- weak suck

- bradycardia

nursing actions cold stress

• proacticve

  • dry baby off very first thing

  • skin to skin

  • swaddling help

  • hat on head

  • make sure rooms aren't cold

• reactive

  • put under radiant warmer (probe on skin, slowly warms them)

  • skin-to-skin if not too cold

  • assess O2 and glucose

  • assist w/ feeds

glucose values in neonate

• normal is 40-60

• hypoglycemia → below 40-45

risk hypoglycemia

• cold stress

• dm moms → sugars cross placenta, but insulin doesn’t → infant’s pancreas making insulin for large ants of sugar being passed → w/ cutting of cord, you cut off sugar passage → but pancreas still making insulin for it

• SGA/LGA

• Post or Pre Term

• infection

• resp distress/resucitation

• birth trauma

s/s hypoglycemia

- lethargy

- poor feeding

- jittery

- tremors

- irritable

- s/s resp distress

- hypothermia

nursing actions hypoglycemia

- assess

- blood glucose checks

- if low → dextrose gel inside cheek, can get 3 times then go to NICU for iv dextrose

hepatic system

- slow carb metabolism → doesn’t help stabilize hypoglycemia

- slow blood coagulation: vit k → injection at birth for clotting cascade

- conjugation of billirubin → jaundice (risk: vaucum, bruising)

- insufficient storage of fat soluble vitamins (a, d, e, k, iron)

- slow detoxification: increased toxicity w meds

gi system

• stomach capacity: 6ml/kg at birth (cherry)

• bowel sounds present w in 15-30min of life

• stools

  • meconium - w/in 8-24hrs

  • transitional stools

  • breast milk (yellow) or formula stool (pasty green)

  • 1-10 times/day

gi problems

- failure to pass meconium w in 48-72hrs of age

- fistula or imperforate anus (rectal temp to check)

- abdominal distention

- vomiting after feeds (not gaining weight)

renal system

• first void occurs w/in 24 hrs, if not → assess for adequacy of intake, bladder distention, restlessness, pain

• at risk for fluid/electrolyte imbalance

• output starts little and increases → should void at least 4-5 times/day by 4th day of life

  • 1st day → 1 diaper

  • 2nd day → 2 diapers

  • 3rd day → 3 diapers

  • 4th day → 4-5 diapers

immune system

• immature

• signs of infection very subtle

• breastmilk transfers IgA → protects against infection

• IgM shouldn’t be present immediately after birth → indicates exposure to infection from mom

active acquired immunity

• Pregnant woman’s exposure to illness and immunizations - infant acquires through placenta or if exposed after birth

• Direct exposure

passive acquired immunity

antibodies passed through placenta/milk by way of IgG

key fx neonatal assessment

- general survey

- physical assessment

- gestational assessment

- pain assessment

neonatal assessment - posture and measurements

• observe calm newborns posture → clenched hands

• measure

  • head circumference

  • chest circumference → nipple line around chest, 2-3cm less than chest

  • length - crown to heel

  • weight - naked → zero out scale

• all measurements once at delivery → weighed every day

key features weight

- 2500-4100 grams (term)

- <2500 g is sga

- >4100 g is lga

- should not lose >10% birth weight in 3 days

- back to birth weight by 2 wks

vital signs

• hr: 110-160

  • can be <110 if sleeping

  • >16p if angry

  • murmurs first few days → still get echo to make sure

• rr: 30-60, irregular and pausing

  • a pause > 20 sec w color change and desats → apnea

• temp: 97.7-99 after 1st 3 hrs

skin assessment

- pink and warm w acrocyanosis

- milia present on bridge of nose and chin

- langugo present on back, shoulders, forehead, vernix present at delivery

- peeling or cracking noted on post term neonates

- slate gray patches on back of buttocks (mongolian spots)

- other birthmarks may be noted

- may see jaundice

- post term: wrinkly dry skin

head assessment

• assess fontanels

  • anterior - diamond shape → closed by 18 mos

  • posterior - small triangle → closed by 2-4 most

• molding of head may be present

• assess suture lines

  • approximating (flat) or overriding (overlapping)

  • seperated in pre term

• assess for caput or cephalohematoma

what is caput succedaneum**

- localized edema from pressure against cervix → whole head squishy

- crosses suture lines → if lay on one side, it is more squishy on that side

- soft, dependent

- resolves quickly

what is cephalohematoma**

- bleeding between skull and periosteum

- one or both sides

- does not cross suture lines → only on one side entire time

- firm, dev w in 1-2 days

- takes wks or months to resolve

- increases risk for jaundice → when RBC get destroyed, bilirubin gets released

assesment of the eyes, mouth, nose, and neck

• assess eyes for drainage, symmetry, shape, size, coordinated movement of lids

  • sub-conjunctival hemorrhage in the outer canthus of the eyes from pressure during delivery → goes away

• asses shape or nose and opening of nares

• assess mouth for color, moisture, neonatal teeth, hard and soft palate, tongue movement

  • tongue tie → somtimes clipped for better latch

• assess neck for webbing and range of motion

assessing the ears

• assess shape, size, placement (low set), soft and pliable, instant recoil (ear stays folded if pre term), ear pits

• hearing screen

  • performed on all ky newborns after 6hrs of age → can do 2 hearing screen in pt → have to wait 12hrs after failing 1st test

  • if fail both screens, need follow up w in one month

  • early intervention important

assessing chest and lungs

• symmetry, chest movement, signs of distress, breathing effort, placement and size of breast tissue, nipple placement

• prominence of xiphoid process normal

• lungs auscultated anterioly and posteriorly, lung sound clear and equal bilaterally

• crackles can be heard at birth, but should clear over the next hr

• breast tissue may be enlarged

cardiac assessment

- cap rf: <3sec

- brachial and femoral pulse

- auscultate apical pulse one full min

- transient murmurs common

congenital heart defect screening

• every baby gets screening

• pre-ductal (r hand) and post-ductal (r or L foot) → o2 sats compared after 24 hrs of age → big gap between = defect → further testing

abdomen assessment

- soft, rounded, symmetrical

- bowel sound should be present but may be hypoactive for first few days

- skin around umbilical cord should be assessed for infection

assessing umbilical cord

- 2 arteries 1 vein (AVA)

- fewer vessels present warrants further evaluation

- whartons jelly: protective substance around the vessels

- facilitate drying of cord stump → keep dry as possible → fold diaper underneath

- cord falls off 7-10 days (ok by 3 wks)

gu male assessment

- foreskin completely covers and adheres to glans for 1st 3-4 yrs

- urethral opening should be at tip of penis

- testes palpable at 40 wks

- position of testes and amt of rugae on scrotum used in gestational age

gu female assessment

- pseudo-menstruation and or vaginal discharge normal

- external genitalia usually edematous, vaginal tags common

- labia majora completely cover labia minora in full term female

- urinary meatus midline

muscoloskeletal assessment hips and spine

• hips assessed for dysplasia (risk: breech)

  • assess leg length, gluteal folds, thigh creases

• spine assessed for closure, position, and visible defects

  • lack of closure may be severe or occult

  • dimple or tuft of hair at scrotum

assessing neuro

• Posture, tone, and reflex

• Reflexes

  • Palmar grasp

  • plantar grasp

  • babinski reflex - toes fan out and dorsiflex of big toe

  • tonic neck - hand is turned → arm is extended on the side the head is turned, other arm is flexed

  • rooting reflex

  • sucking reflex

  • stepping reflex - pressure against feet → will step against it

  • moro reflex - startle → arms fling out and they come back to center

periods of reactivity 

Early stages of activity 

• First period of reactivity - Active, alert wakefulness → lasts about 30 minutes right after birth → want to initiate breastfeeding

• Period of inactivity and sleep - Decreased muscle activity and is difficult to awaken → recovering from stress of birth → usually several hours

• Second period of reactivity - Newborn awakens and becomes alert again and eager to feed → mins - sev hours

nursing care of the neonate → fourth stage of labor

• Preparation

• Stabilization - Dry, position, suction, stimulate & provide warmth (30 seconds)

• Assessment - Airway, Breathing, Circulation

• Assignment of APGAR

cardiorespiratory statys

• Airway - Bulb syringe for secretions (mouth first, then nose)

• Breathing - Respiratory rate, breath sounds, signs of distress, color (look, listen, feel)

• Circulation - HR, heart sounds, rhythm & murmurs, pulses, blood pressure, cap refill

immediate care of newborn after delivery

• Head to toe assessment 

• Vital signs, weight, length and head circumference

• ID newborn & mother

• Administer newborn prophylactic medications

  • Erythromycin (opthalmic ointment)

  • Vitamin K

APGAR SCORE

• measured at 1 and 5 min of life

• can be contained after in situation where infant needs advanced resuscitation 

• scoring - <7 is concern

  • 7-10 → little difficulty transitioning

  • 4-6 → moderate Amt of difficulty → some resuscitation

  • 0-3 → severe distress → full resuscitation

neonatal resuscitation

• after initial stabilization & baby isn’t breathing effectively or HR <100 → begin bag/mask ventilation (PPV)

• continue until baby begins breathing spontaneously and HR >100

• >30 seconds & HR <60 → CPR

• after 1 min → check HR → >60 and rising → stop compressions → continue PPV

• if still <60 → consider intubation and placement of umbilical venous catheter

nursing care of neonate → 4 hours to discharge

• Perform assessment once per shift

• Assess vital signs per hospital policy

• Bathing (6 to 24 hours)

• Promote parent-infant attachment

• Promote sibling attachment

• Assist parents with feeding

• Perform screening tests and discharge teaching

screening tests

• Newborn screening

• State standards for genetic, metabolic, and infectious disease screenings

• Hearing screening

• Hyperbilirubinemia screen

• Critical congenital heart defect screen

circumcision

• Contraindications - Preterm, defects, bleeding problems, compromise (ex. RDS)

• Risks - Hemorrhage, infection, pain, adhesions

• Benefits - Decreased incidence of UTI, STI 

• Postoperative care

  • V/S q15 mins for first hour

• Assess for bleeding (quarter-size of blood on diaper and should not drip actively), swelling, voids, pain, infection

• Vaseline gauze with each diaper change, if no plastibell

immunizations

• Hepatitis B vaccine (series, administered IM)

• HBIg (If mother is HBsAG positive)

• Give parents information sheet

• Document date, time, location

• Made aware of risks and benefits if declines vaccine