U2L1: Caring for Hospitalized Children

timing of major newborn assessments

1. after birth

2. adm to newborn nursery

3. at time of discharge

newborn assessment after birth (4)

- APGAR score

- measurements

- transition

- meds

newborn assessment when adm to newborn nursery

head to tow -> during 2 to 4 hrs of life

newborn assessment at time of discharge (2)

- screening

- measurements

when preparing for birth & resuscitation what is important to consider? (3)

- review pregnancy & labor hx

- anticipate need for more advanced resuscitation

- safety checks for newborn resuscitation

what is required to need no advanced resuscitative needs? (3)

- full term

- good muscle tone

- breathing & crying

what newborn resuscitation tools should be checked before birth? (3)

- preheated warmer

- oxygen

- suction

how often should you check temp after birth?

every 30 mins for first 2 hrs or until temp is stabilized then q8 hrs till dishcarge

temp regulations for discharge

temp must be stable for 12 hrs before discharge

thermistor probe

attached to newborn skin & records body temp on monitor

nursing considerations to maintain thermoregulation in newborn (4)

- axillary temp soon after birth -> baseline

- place newborn in radiant warmer

- hat after dried

- delay initial bath for 6-24 hrs

APGAR score

conducted 1 min & 5 mins after birth to assess newborn status

- score

measurements for APGAR score

- color/appearance

- pulse

- grimace/response to stimuli

- tony/activity

- resp effort

what apgar score is required to not need further intervention?

8-10

what does an apgar score of 4-7 indicate?

moderate difficulty w transition

what does an apgar score of 0-3 indicate

severe distress

initial assessment nursing interventions (3)

- maintain airway patency (possible suctioning)

- ensure infant identification

- newborn meds

when should initial infant identification occur?

before baby leaves delivery room -> typically has band on wrist & ankle

newborn meds (3)

- vit K

- eye abx

- hep B

vit K purpose

prevents hemorrhage

how is vit K given to newborns?

single IM inj of 0.5-1 mg in thigh

eye abx purpose

precaution against ophthalmia neonatorum which can cause corneal perforation & blindness

eye abx types (3)

- erythromycin

- tetracycline

- silver nitrate

how is heb b given to newborns?

IM at birth -> requires consent

when are abdominal circumferences indicated?

if GI issues are suspected

newborn length measurement

baby is unclothed & measured from head to heel -> must manually extend leg

avg newborn length

50 cm

newborn weight measurment

done naked & completed immediately after birth & then daily

avg newborn weight

5-8 lbs

typical newborn OFC

1/4 of length + 10 cm

AGA

appropriate weight for gest age -> 80% of newborns

LGA

large weight for gest age -> >90 percentile

SGA

small weight for gestation age ->

LGA & SGA care

at risk for certain complications & require closer monitoring & follow up care -> identify cause

ballard tool purpose

used to determine gestational age when unknown -> accurate for 20-44 wks

how does the ballard tool work?

composed of 2 domains w subdomains:

- neuromuscular maturity within 24 hrs

- physical maturity within 2 hrs

when is the newborn physical exam done?

within 24 hrs once newborn completes extrauterine transition -> postpone until stable & calm

what does the newborn physical assessment begin w?

general survey

normal newborn temp range

87.7-99.5 F

why are rectal temps contraindicated in newborns?

risk for perforation

BP in newborns

usually not assessed unless clinical indication -> use oscillometer (dinamap)

normal newborn BP

50-80/30-55

- MAP should correlate w gest age

acrocyanosis

cyanosis of fingers, hands, toes, & feet -> typical in first few weeks of life

problematic signs during skin assessment (2)

- jaundice

- signs of trauma

variations during skin assessment (8)

- milia

- erythema toxicum

- vernix

- hemangioma

- stork bite

- mongolian spots

- acrocyanosis

- nevus flammeus

milia

white or pale yellow unopened sebaceous glands on nose, chin, or forehead

erythema toxicum

newborn rash on face, chest & back

vernix

thick white substance that protects skin of fetus when delivered

hemangioma

non-cancerous red birth mark

mongolian spots

blue gray birthmarks on lower back, buttocks, or shoulders

nevus flammeus

purple/red birthmark on head & neck w sharp demarcations

normal head & face assessment (4)

- soft & flat fontanels

- sutures approximated

- symmetric facial features

- intact soft & hard palate

head & face assessment variations

- molding

- epstein pearls -> milia in mouth

molding

elongated head shape to accommodate passage thru birth canal

problematic signs of head & face assessment (4)

- caput succedaneum

- facial nerve paralysis

- full/bulging fontanels

- malformed/blocked nare

caput succedaneum

swelling of scalp in a newborn due to increased pressure from birth

- crosses suture lines

cephalohematoma

pressure on the head ruptures small BV causing fluctuating swelling -> does not cross suture lines

most common cause of cephalohematoma

vacuum assist births

chest variations (3)

- breast buds

- whitish discharge

- protruding xiphoid process

problematic signs during neck assessment (4)

- restricted movement

- crepitus

- clavicular fractures

- torticollis

problematic signs during chest assessment (3)

- asymmetrical movement

- barrel shaped

- retractions

abdominal variations (3)

- 2 vessel cord

- umbilical hernia

- diastasis recti

problematic signs during abdominal assessment (3)

- distended & tender

- dusky color

- absent BS

normal male genitalia assessment (2)

- smooth glands

- meatus at tip

normal female genitalia assessment

swollen labia majors & minora

variations in male genitalia

edematous scrotum

variations in female genitalia

pseudo menstruation -> vaginal discharge of mucus & blood

problematic sign during male genitalia assessment

hypospadias -> urinary meatus on ventral surface instead of at tip

problematic signs during female genitalia assessment (2)

- labial bulge -> indicates inguinal hernia

- ambiguous genitalia

extremity variations (2)

- polydactyly -> too many digits

- syndactyly -> fused figits

problematic signs during spine assessment (3)

- tuft og hair

- pilonidal dimple midline

- cyst or mass

problematic signs during extremities assessment (3)

- abnormal creases

- asymmetric gluteal folds

- positive ortolani & barlow maneuvers

how to you perform ortolani maneuver?

abduct thighs & lift femur forward -> clunk heard is abnormal

how do you perform barlow maneuver?

adduct thighs & apply outward & downward pressure -> clunk heard is abnormal

when should bathing be delayed till?

temp is stable

elimination & diaper care (2)

- don't force foreskin back

- 6 diapers/day -> adequate hydration

cord care (3)

- should fall off within 7-10 days

- clean & dry w soap & water

- remove clamp after 24 hrs unless still moist

cord abnormalities (2)

- bleeding -> clamp could be loosened

- drainage -> indicates inf

circumcision benefits

decreases risk of UTIs & STIs

circumcision care (3)

- apply jelly coat

- assess for bleeding q30 mins for first 2 hrs

- document 1st void after procedure

preop preparation for circumcision (4)

- baby must me 12 hrs old

- received vit K prophylaxis

- voided at least once

- analgesics must be used

how often should you breastfeed?

q2-3 hrs for 10-20 mins

how often should you formula feed?

q3-4 hrs of 1/2-1-2 oz

combination feeding

preferred by some parents & recommended if weight gain or glucose issues

breastfed stool characteristics

yellow & soft/loose w seed like particles

formula fed stool characteristics

tan brownish w pasty consistency

how many newborns experience hypoglycemia?

40%

signs & symptoms of hypoglycemia in newborns (5)

- jitteriness

- sweating

- hypothermia

- lethargy

- apnea

what babies should have regular glucose screenings? (5)

- infant w DM or overweight parents

- preterm

- babies w FGR

- c/s

- neonatal hypothermia

newborn screenings (4)

- state screen

- bilirubin screening for jaundice

- hearing screening

- congenital heart screening

state screen

mandatory after 24 hrs of life -> PKU, congenital hypothyroidism, galactosemia, sickle cell

discharge rdy checklist (5)

- follow up appointment schedules

- safe home env

- supplies needed for newborn

- car seat safety

- education

what happens at follow up pediatric appointments?

- developmental milestones

- parent teaching/education

- vaccinations

timeline for followup peds appointments (4)

- 2-4 days

- 2-4 weeks

- 2, 4, 6, 9, 12, 15-18 months

- 2 yrs