Newborn Care and Assessment

Newborn Care and Assessment
Kim Martin RN, MSN Nursing Instructor HACC, Pennsylvania’s Community College Nursing 101; Summer 2012 Today we will talk normal newborn. Some of you are already assessing babies and others will be starting soon, so we will start with this and work our way through pediatrics. Mrs. Leib covered OB information with you. She covered all information about baby before birth, through transition from intrauterine to extrauterine life. We will begin our discussion with the delivered newborn. The newborn is now several hours old and has successfully transitioned to extra-uterine life.

Newborn Assessment Begins immediately after birth
Continues throughout hospital stay APGAR score at one minute and 5 minutes Gestational age assessment within 2 hours Complete assessment within 24 hours Wear gloves until 1st bath Infant delivered by midwife, OB, and sometimes nurse. Gestational Age Assessment to determine age of fetus. Appendix F Pg 448 in text. We will talk more about this later. Complete assessment is performed by NP or Ped Wear gloves if touching infant WHY? Contamination with maternal body fluids

Newborn Assessment Health History Physical Assessment
Hand washing and warm hands Sleeping newborn Where get this vital info? Mother’s chart Maternal Hx can tell you areas that you need to address like Hep B, HIV, Prenatal Care, Drug use, Family Hx, etc. Find info: Labor and Delivery summary = Pregnancy complications, labor and delivery complications, ROM, length of labor Prenatal records = Prenatal history, history of other pregnancies, labs, family HX May have copies of these in infant’s chart Hand washing again (prior to touching any baby and between babies) Can also use this to warm hands (baby’s really do not like cold hands = cry and heat loss) Quiet (sleeping), begin assessment with things that require infant to be quiet What things should you do while infant is sleeping?

Temperature Normal Abnormal Axillary = 36.5 - 37.5° C (97.7 - 99.5° F)
Rectal = ° C ( ° F) Axillary is preferred Rectal done first in some institutions Abnormal Decreased Elevated KNOW NORMAL TEMPS We must maintain temp in normal range Cold baby? WARM ASAP. Babies have difficultly maintaining temp, can occur quickly from just being uncovered in normal temp Hot baby? Question infection = septic work up with CBC and blood cultures Initial temp rectal to assess patency of rectum and more accurate Axillary after initial NO TYMPANIC TEMP = inaccurate d/t vernix and amniotic fluid in ear canals; probe does not fit well enough to accurately assess ear drum Low temp = cold environment, hypoglycemia, infection, CNS problems Elevated temp = infection, too warm environment, labor epidural

Heart Rate and Pulses Abnormal Normal Tachycardia
Bradycardia PMI to right Murmurs and arrhythmias Absent or unequal pulses Normal Heart rate = BPM PMI 3rd - 4th intercostal space Brachial, femoral, and pedal pulses present and equal bilaterally Listen at apex for one minute MUST KNOW NORMAL RATE. Much faster than adult. 100 when sleeping 180 when crying Regular rhythm – rate may vary greatly depending on activity level, but should always be regular Rate of 70 to 80 is ABNORMAL, report immediately Tachycardia = (170 or greater when not crying or sustained above ) respiratory problems, anemia, infection, cardiac problems Bradycardia = (less than 100 when alert; less than 90 when sleeping) asphyxia, neuro problems, or increased ICP PMI to right = dextrocardia, pneumothorax Murmurs and arrhythmias Absent or unequal pulses = coarctation of aorta

Respirations Normal Abnormal Rate = 30 - 60 per minute
Irregular, shallow, unlabored Chest movement symmetric Breath sounds present and clear in all lobes Abnormal Tachypnea after 1st hour Slow respirations Nasal flaring, grunting, retractions Apnea with color changes Asymmetric or decreased chest expansion Abnormal lung sounds Bowel sounds in chest Watch and count for 1 full minute, because so irregular Much faster than adult; if infant’s resp rate = adult they are in serious trouble Respiratory rate may be elevated as infant adapts to extra-uterine life, but should slow to normal level after one hour REPORT RESP RATE < 30, IMMEDICATELY REPORT Slow respirations= maternal medications Nasal flaring, grunting, retractions (EXPLAIN) pg. 74 in text = Respiratory Distress Syndrome Apnea with changes in color = respiratory depression, sepsis, cold stress Asymmetry or decreased chest expansion = pneumothorax

Weight Abnormal Normal LGA 2,500 to 4,000 grams SGA
LBW VLBW ELBW Weight loss > 10% Normal 2,500 to 4,000 grams (5 lbs 8 oz to 8 lbs 130z) Weight loss < 10% in first 2 weeks KNOW NORMS Most procedures done on and medications given to newborns are based on weight (LGA protocol for blood sugars) High = LGA = maternal diabetes = high glucose environment = high weight and high risk for hypoglycemia after birth Low = SGA, preterm, multiple pregnancy, fetal infection, maternal smoking, other medical conditions in mother that affect intrauterine growth smoking and teenage pregnancy WHY? LBW = < 2500 gm (5-6) VLBW = < 1500 gm (3-5) ELBW = < 1000 gm (2-3) Weight loss < 10% of body weight in first 2 weeks Weight loss above 10% = dehydration, feeding problems observe feedings, nurse fed infant to check feeding ability, lactation consult, frequent outpt follow-up

Weighing Done daily at same time each day; baby must be naked
Most institutions weigh after midnight Wt. in grams is recorded. Convert into lbs/oz for parents Most scales automatically convert

Length Normal Abnormal 45 - 55 cm 17.75 - 21. 5 inches
Measure from crown to heel Abnormal Below normal Above normal Below normal = SGA, congenital dwarfism Above normal = LGA, maternal diabetes

Head Circumference Abnormal Normal Small 31 to 33.8 cm Large
12.2 to 15 inches Measured over prominent part of occiput and just above eyebrows Small = SGA, microcephaly, anencephaly Large = LGA, hydrocephalus, increased ICP

Characteristics of the Newborn

Normal Skin Variations
Vernix Vernix Vernix = difficult to wash off; don’t try; will be absorbed in several days Acrocyanosis Lanugo

Milia = caused by obstruction in sebaceous glands; resolve in several weeks
Looks like little pimples

Erythema toxicum = reddened area with yellowish-white wheal in center; Common on trunk. Seen from 24 hours to 10 days of age Resolve over several weeks

Mongolian spots = bluish discolorations seen on lumbosacral region of buttocks
Most common in infants with dark complexion (African, Negro, Mediterranean, and Native American) Resolves late in infancy or early childhood

Tel-ang-ec=tatic nervi = stork bites,
Small red or pink spots on neck, eyelids, bridge of nose, chin, lips, and back of neck Blanche with pressure, usually disappear in infancy, but can persist into adulthood Become brighter when crying, paler when sleeping Seen more on pale skinned infants

Mottling Harlequin Sign
Mottling, Harlequin sign The condition is simply caused by an immature nervous system’s inability to regulate the dilation of blood vessels in the skin.Full-term babies will sometimes have Harlequin Color Change when they are first born and it will go away in just a few minutes. In babies who have a low birthweight, Harlequin Color Change is more prevalent and may appear frequently. Harlequin Color Change is completely harmless and is not associated with any permanent disorders. Harlequin sign = vasomotor instability, one side of body red and other side pale can also be upper ½ pale and lower ½ of pink Mottling = areas of blue/red/white with a lace-like appearance caused by vasomotor instability = immature circ system. Cover and warm infant if you see this Mottling Harlequin Sign

Abnormal skin variations

Excessive Vernix Cyanosis Cyanosis bluish tinge/color Jaundice

Petechiae Forceps Marks
Petechiae = pressure, low platelets, infection (clotting ) most are from labor process; increased pressure breaks small blood vessels on presenting part; OK, if small amount on face or head; will disappear in several days Abnormal, if all over body and numerous Petechiae

Nevus flammeus Cafe’ au lait spots Nevus vascularis
Nevus flammeus = very red area/burgundy color. Vascular malformation of mature capillaries. Do not ever fade. Port-wine stain = may be associated with other problems (syndromes) with a deficiency or absence in the nerve supply to the blood vessels of the affected area. These nerves control the diameter of the blood vessels. If the nerves are absentor defective, the vessels will continue to dilate and blood will pool or collect in the affected area. The result will be a visible birth mark. This is important to know because laser therapy which is used to remove a port wine stain will only be temporary. Since the deficiency is in the nervous system, in time the blood will repool in the affected area and the birthmark will once again appear. Nevus vascularis = dark red, rough, elevated. Found on face, head. Grow for several months. Then shrink spontaneously by 7 – 10 years. Some require surgery. They can get very large and interfere with vision, hearing, eating, and speaking Café’ au lait = flat brown like coffee with cream; could indicate neurofibromatosis, if there are 6 or more that are greater than 1.5 cms in size neurofibromatosis a genetic condition that affects neural cell growth Cafe’ au lait spots Nevus vascularis

Skin tags

? jaundice

What is normal? Head and face

See cone shape of head Area is firmer than caput Molding

See some molding and caput
Caput and Molding

Cephalhematoma Cephalhematoma is firmer than caput
Does not cross suture lines Blood collects between bone and thin membrane that covers skull = periostium Page 52 & 53 in Peds. text Cephalhematoma

Ear Placement An imaginary line is drawn from inner to outer canthus of eye and then to ear; line should intersect with area where upper ear joins head.

Preauricular sinus Usually benign

Think “Ears and Kidneys”
REMEMBER, if you see malformed ears, monitor I&O closely to ensure proper kidney fx Need to assess hearing also Think “Ears and Kidneys”

Asymmetric face = Bell’s Palsy = eyelid and face droop on affected side; may impair sucking
May occur with forceps and can be permanent Trisomy 18 Down’s These may be very subtle

Transient strabismus Normal in first few months of life; should improve by 4 – 6 months

Choanal Atresia See boney obstruction at back of nose; can be bone or tissue Newborns are nose breathers, so a blocked nasal passage will effect their breathing pattern and ability to eat. Maybe very fussy or have significant respiratory distress Choanal Atresia Symptoms include: Chest retracts unless the child is breathing through mouth or crying Difficulty breathing following birth, which may result in cyanosis (bluish discoloration), unless infant is crying Inability to nurse and breathe at same time Inability to pass a catheter through each side of the nose into the throat Persistent one-sided nasal blockage or discharge

Mouth – Normal Precocious teeth Epstein’s pearls
Some babies born with teeth; remove to avoid choking Epstein’s pearls are blocked sebaceous glands in mouth = oral milia The pearls are protein-filled cysts. The condition is harmless, although it sometimes worries new mothers. No treatment Epstein’s pearls

Cleft Lip and Palate There are many causes for of cleft lip and palate. Problems with genes passed down from one or both parents, drugs, viruses, or other toxins can all cause such birth defects. Cleft lip and palate may occur along with other syndromes or birth defects. A cleft lip and palate can affect the appearance of one's face, and may lead to problems with feeding and speech, as well as ear infections. Problems may range from a small notch in the lip to a complete groove that runs into the roof of the mouth and nose. These features may occur separately or together. Risk factors include a family history of cleft lip or palate and other birth defect. About 1 out of 2,500 people have a cleft palate Poor feedinFailure to gain weight Feeding problems Flow of milk through nasal passages during feeding Misaligned teeth Poor growth Recurrent ear infections Speech difficulties

What is normal? Chest and abdomen

Abnormal Asymmetrical Supernumerary nipples
Normal for nipples to be engorged (swollem=n) Asymmetrical = diaphragmatic hernia, pneumothorax Supenumerary nipples=clinically non significant

Umbilical Hernia

Omphalocele Defect in umbilicus and cord
Midline defect = results in herniation of bowel and intra-abdominal contents into umbilical cord. Contents are limited by membrane Approximately % of infants with an omphalocele have other birth defects. They may include genetic problems (chromosomal abnormalities), congenital diaphragmatic hernia, and heart defects. Omphaloceles are repaired with surgery, although not always immediately. A sac protects the abdominal contents and allows time for other more serious problems (such as heart defects) to be dealt with first, if necessary. To fix an omphalocele, the sac is covered with a special man-made material, which is then stitched in place. Slowly, over time, the abdominal contents are pushed into the abdomen. When the omphalocele can comfortably fit within the abdominal cavity, the man-made material is removed and the abdomen is closed.

Gastroschisis Intestine protrudes out of abd through hole in wall beside umbilicus; Normally on right NURSIING CARE cover with wet sterile saline dsg and keep covered and moist until surgery can be done Both of these can be seen on ultrasound and would indicate need for C-Section May use a silo until stable for surgrey

Bladder Exstrophy Bladder outside of body
Surgically repaired . Management at birth is directed to stabilizing the patient and preparing him or her for the initial closure of the bladder, posterior urethra, and abdominal wall, and reapproximation of the pubic symphysis. What position should infant be placed in prior to surgery? Side lying to promote bladder drainage

Ambiguous Genitalia

What is normal? Extremities

Polydactyly

Syndactyly Syndactyly is treated by surgically separating the joined fingers. In general, the skin is split evenly between the two fingers with zig-zag incisions. Skin grafts to provide skin coverage of the newly separated fingers are usually taken from the lower abdomen and leave minimal scars.

Seen with Down’s syndrome

Brachial Plexus Injury
Diminished movement of arm with extension and pronation of forearm (Erb-Duchenne paralysis) Brachial plexus injury = usually from birth process Injury to 5th and 6th spinal nerves – see limp arm with internal rotation BUE movement is not symmetrical The brachial plexus is a network of nerves that conducts signals from the spine to the shoulder, arm, and hand. Brachial plexus injuries are caused by damage to those nerves. Symptoms may include a limp or paralyzed arm; lack of muscle control in the arm, hand, or wrist; and a lack of feeling or sensation in the arm or hand. Brachial plexus injuries can occur as a result of shoulder trauma, tumors, or inflammation. Some brachial plexus injuries may heal without treatment. Many children who are injured during birth improve or recover by 3 to 4 months of age. Treatment for brachial plexus injuries includes physical therapy and, in some cases, surgery Treatment is immobilization to prevent further injury to nerve

Abnormal Lower Extremities
Ortolani and Barlow signs positive unequal leg length Malposition of feet = position in uterus, talipes equinovarus Congenital Hip Dysplasia The maneuver is easily performed by adducting the hip (bringing the thigh towards the midline) while applying light pressure on the knee, directing the force posteriorly.[1] If the hip is dislocatable - that is, if the hip can be popped out of socket with this maneuver - the test is considered positive. The Ortolani maneuver is then used, to confirm the positive finding (i.e., that the hip actually dislocated). Ortolani Test (steps 1-5) Ortolani test or Ortolani Maneuver is a physical examination for congenital hip dysplasia or developmental hip dysplasia. The test was named after Marino Ortolani, the person who developed it in The maneuver is performed by abducting the infant’s hip an assessing for a clicking sound. This test is used to detect the posterior dislocation of the hip. A positive Ortolani’s sign is noted when a clicking or distinctive “clunk” is heard when femoral head re-enters the acetabulum. Ortolani maneuver is performed before 2-3 months of age. The maneuver is done in early infancy because after 2-3 months the development of soft tissue contracture prevents the hip from being relocated, thus, no clicking or clunking sound will be assessed in children with congenital hip dysplasia. Barlow Test (steps 6 and 7) Barlow test is a maneuver performed by bringing the thigh towards the midline of the body. Feeling of femoral head slipping out of the socket postolaterally, is considered as a positive Barlow’s sign. The Ortolani test is then used to confirm that the hip is actually dislocated

Newborn reflexes These need to be present to be normal.
If any problem with them, the child may have neurological problem Newborn reflexes

Moro/Startle Reflex Moro = startle to movement – abduct and extend – c shape to hands; disappears at 6 months Startle = startle to sound – different from MORO, even though they maybe called the same reflex – infant will flex then abduct and hands are clasped

Grasp Reflex Grasp – Plantar = toes curl around finger with pressure to base on toes; persists until months Palmar = fingers curl around examiner’s finger; diminished by 3-4 months

Rooting Reflex Sucking Reflex Swallowing Reflex
Rooting – stroke infant’s cheek or corner of mouth and head will turn to that side; may persist for a year; extremely important to initiate feedings Sucking – should be well developed by term; use gloved hand and place pinky in infant’s mouth; should feel strong suck; also good time to check palate Swallowing – swallows without gagging or chocking All 3 MUST be intact for baby to eat successfully

Tonic Neck/Fencing Reflex
Tonic neck/Fencing – turn head to side and arm and leg on that side extend/flex on opposite side ; disappears by 3-4 months

Babinski Reflex Babinski – toes will flare open when lateral plantar surface is stroked; Normal until 1 year, then becomes sign of neurological problem

Stepping and Placing Reflex
Stepping – or dance – hold infant upright and put feet down on a firm surface; infant will step up; lasts for up to 6 weeks Placing – touch top of foot against a surface and infant will step up

Routine procedures and care

Thermoregulation Keeping infant warm.
Remember effects of cold stress on newborn? Hypoglycemia Respiratory distress Hyperbilirubinemia Increased Metabolic Rate Result: Decreased Surfactant Production and hypoxemia leading to respiratory distress When the metabolic rate of a neonate is increased, the need for oxygen also increases. A 2 degree centigrade drop in environmental temperature can double the newborn’s oxygen need. As cold stress progresses, surfactant production also diminish thereby impeding lung expansion. As a result hypoxemia will be noted and mild respiratory distress can become severe hypoxia if oxygen must be used for heat production. Result: Increase consumption of glucose resulting to hypoglycemia When the metabolic rate rises for the body to produce heat, glucose requirement also increases. As the demand of glucose surges the body compensates to this need by converting glycogen stores to glucose. When glycogen stores are converted to glucose, they may be quickly used up resulting to hypoglycemia. Result: Failure to gain weight Infants who must use glucose for temperature regulation and maintenance have less available supply for growth and development. Metabolism of brown fat Result: Metabolic Acidosis; increases the risk of jaundice When brown fats are metabolized in the presence of insufficient oxygen supply increased acid production will result. Rising amount of acids causes metabolic acidosis, which can be a life-threatening condition. Aside from that, elevated fatty acids in the blood can interfere with the transport of bilirubin to the liver for conjugation, thus, increasing the risk of jaundice in a newborn. image from fullmoonsdaughter.com

Prevention of Infection
Hand washing Standard Precautions Gloves must be worn Until first bath Heel stick Diaper changes Breastmilk Regurgitation Suctioning Infection prevention through proper hand washing; SINGLE MOST IMPORTANT METHOD USED 3 minute scrub at beginning of shift; includes hands and arms to elbow 15 second scrub before/after contact with each newborn Regurgitation usually with burp is normal Suctioning is done with bulb syringe KNOW PROCEDURE (SHOW USE OF BULB SYRINGE) Will use standard precautions with starting an IV

Infant ID ID band will be placed on baby’s wrist and ankle. Mother is banded at same time with same number. ID MUST be on before leaving DR. Father may also have band. Some institutions also place security band at this time. Foot prints are also taken. Any identifiable features or characteristics are also noted in infant’s chart (birth marks, Mongolian spots)

Prevent Hemorrhagic Disease
AquaMephyton (Vit K) 1 mg IM in vastus lateralis Vit K can be 0.5 or 1 mg, typically 1 mg. Infants lack bacterial flora to make Vit K, so give injection at birth Safest location for injection in newborns and young children

Eye Prophylaxis E-mycin ointment to prevent blindness from gonococcal opthalmis neonatorum or chlamydia trachomatis Apply only after eye exam is complete Can use silver nitrate 1%, tetracycline 1%, or 0.05% erythromycin OPTHALMIC OINMENTS E-mycin used most often because it is most effective against Chlamydia (most frequently seen infection) Tell parents that this is to prevent infection

Prevent Hepatitis B Infection
HepB vaccine O.5 ml IM Hepatitis B vaccine prior to hospital discharge Then at 1-2 months and 6 – 18 months of age Moms with + HbsAG: baby also gets Hep B immune globulin (HBIG) What site would you use for Hep B? Same as Vit K vastus lateralis; Vit K in one leg and Hep B in other Hep B recommended CDC and AAP at birth

Newborn Hearing Screening
Many different devices on the market Mandatory screening and reporting in PA for last several years.

Lab Tests Cord blood Blood type and Rh Coombs’ prn State law mandates screening for inborn errors of metabolism PKU Hypothyroidism Some states include Sickle cell, galactosemia, and MSUD Mandated in PA CAH = Cong. Adrenal Hyperplasia CH = Cong. Hypothyroidism Galactosemia MSUD PKU Sickle Cell Supplemental Screen is also offered includes 24 other tests for inborn metabolic diseases; CF, Infant must be > 24 hrs old for testing to be accurate (especially PKU)

Labs continued… Bilirubin (total and direct) Microglucose, if at risk
Perinatal stress SGA LGA Maternal DM Post term (> 41 wks.) Pre term (< 37 wks.) NORMAL = > 40 mg/dl Bilirubin is done, if jaundiced Some institutions do initial glucose on all newborns as part of initial assessment right after birth. May do more if infant has any risk factors Discuss why risk with each.

Infant Heel Stick Blood is usually drawn from infants with heel stick
Use shaded areas to stay away from nerves and arteries in infant’s foot. If hit nerve/artery, may cause damage.

Umbilical Cord Assess daily for infection Keep clean and dry
Triple dye/alcohol promotes healing and drying Clamp removed at 24 hours Falls off about 8 – 21 days May have some bleeding as healing takes place Heals like a scab; pulling away from sides Assess for oozing, redness, foul odor Clean and dry = prevent infection Dry = diaper folded down and away from cord No tub bath until cord off and healed Wash daily with soap and water May use alcohol 3 – 4 times/day or may use only soap and water

Circumcision Surgical removal of foreskin of penis Controversial
Nursing Care Assess for bleeding Assess for signs of infection Voiding At birth foreskin is not retractable = normal When older can develop problem called phimosis = cannot retract foreskin = leads to infection, CA, pain Circumcision was thought to be needed to prevent infection and inflammation of penis, improve hygiene, reduce incidence of penile and cervical CA Used to be done to most male infants in 50’s to 80’s Newer research has shown that circumcision is not necessary. If young boy is taught and practices good hygiene the risk of phimosis, infection, inflammation, and CA is not statically different between uncircumcised and circumcised men. Now it is parent’s choice. ADVANTAGES: No need for special hygiene, have same look as father, friends/peers; sometimes culture dictates choice DISADVANTAGES: potential hemorrhage and infection, pain Must be stable; usually 12 to 24 hours old and has voided at least once Need written consent from parents usually mother signs consent form Infant maybe kept NPO for several hours prior to prevent aspiration Several different methods used: Gomco, Mogan, or plastibell

Newly circed penis Tip of penis will be red and raw for 24 to 48 hours Small amount of bleeding is normal Heals quickly Cover with Vaseline gauze for first 24 to 48 hours to prevent tip of penis from sticking to diaper and to promote healing Healed in 5 to 7 days Use only water to cleanse area NO BABY WIPES OR POWDER = Irritation and pain

Plastibell Plastic bell is places around penis under foreskin
Foreskin and bell fall off after several days No special care Wash with soap and water Watch for infection

Health Promotion and Safety
General Hygiene Complete bath 2 – 3 times/week Mild soap and water; no powder Wash hair with bath, brush while washing to prevent cradle cap (seborrheic dermatitis) Cut nails straight across while infant is asleep Diapering and diaper rash Suctioning prn Instruct parents to change diaper when soiled or wet. If stools become hard or loose REPORT TO PED Diaper rash = expose to air for 30 min several times/day; use A&D ointment or Vaseline Clean girls front to back Boys= clean under scrotum, DO NOT attempt to retract foreskin unless circumcised. Bulb syringe must be in crib for all newborns.

What is this? How do you use this? Why would you use this? Wash with soap and warm water, air dry and discard when plastic starts to deteriorate

Diaper Rash Cause? Allergy Poorly washed diapers
Infrequent diaper changes Ammonia formation from urine Prevention is best frequent diaper changes meticulous cleansing with mild soap or diaper wipes no plastic pants or plastic covers on diapers use absorbent diapers May use Vaseline, A&D ointment, Desitin

Never leave infant alone Hold during feedings Prevent heat loss Support head at all times Always use seatbelt in carriers, swings, strollers, etc. DO NOT leave alone with young siblings Clothing In mother’s room; nursery; house; tub; car Not on changing table, bed, scale, or sofa Infants need touch so holding is essential; decreased risk for aspiration DO NOT leave alone with young children; Nat wanting to play ball with sister; watch pet reactions Clothing = dress as you are comfortable plus one light layer. Avoid direct sunlight. No sunscreen until 6 months. Hat at all times (keep in heat; protect from sun). Rinse clothing thoroughly when washing

BACK TO SLEEP BACK to SLEEP = SIDS prevention; use back only; side maybe OK, if infant is closely supervised or has special medical condition

Car Seats Car Seat necessary for all infants Federally approved
Must have seat to leave hospital Law in all 50 states Rear-facing until one year AND 20 lbs. Car seat in back/rear seat only, center, and tightly secured according to manufacturer’s instructions AAP now recommending rear-facing until 2 yrs of age or maximum weight recommended for seat.

Increased frustration Smoking Domestic Violence Sexual Abuse CPR Increase frustration should be addressed at hospital and every well child visit. Parenting is stressful. Teach to recognize own frustration and anger. Remove self from situation. Call someone, support groups are good help. Give 24 hour hotline numbers. Shaken baby syndrome will discuss in infant lecture. Smoking = increases risk of baby developing URI’s, ear infections, SIDS, allergies, asthma (small airways; smoke irritates and increases secretions; closes off airways Domestic violence = all women should be screened during pregnancy. Usually escalates during pregnancy and early parenting. If present in home, increased risk of child abuse. Talk about child abuse in later lecture. Sexual Abuse = REMEMBER 80% of time abuser is a family member. Requires careful observation and immediate action. Genitals should be examined at every well child visit. More later. CPR = all families should know this. Especially important with preterm infant or family Hx of SIDS or apnea

Shaken Baby Syndrome Shaken baby syndrome can occur from as little as 5 seconds of shaking. When an infant or toddler is shaken, the brain bounces back and forth against the skull. This can cause bruising of the brain (cerebral contusion), swelling, pressure, and bleeding in the brain. The large veins along the outside of the brain may tear, leading to further bleeding, swelling, and increased pressure. This can easily cause permanent brain damage or death. Shaking an infant or small child may cause other injuries, such as damage to the neck, spine, and eyes Injuries are most likely to happen when the baby is shaken and then the baby's head hits something. Even hitting a soft object, such as a mattress or pillow, may be enough to injure newborns and small infants. Children's brains are softer, their neck muscles and ligaments are weak, and their heads are large and heavy in proportion to their bodies. The result is a type of whiplash, similar to what occurs in some auto accidents. Shaken baby syndrome does not result from gentle bouncing, playful swinging or tossing the child in the air, or jogging with the child. It also is very unlikely to occur from accidents such as falling off chairs or down stairs, or accidentally being dropped from a caregiver's arms. Short falls may cause other types of head injuries, although these are often minor. The characteristic injuries of shaken baby syndrome are subdural hemorrhages (bleeding in the brain), retinal hemorrhages (bleeding in the retina), damage to the spinal cord and neck, and fractures of the ribs and bones. These injuries may not be immediately noticeable. Symptoms of shaken baby syndrome include extreme irritability, lethargy, poor feeding, breathing problems, convulsions, vomiting, and pale or bluish skin. Shaken baby injuries usually occur in children younger than 2 years old, but may be seen in children up to the age of 5.

Signs of Illness Change in skin color Difficulty breathing or absence of breathing Axillary temp. > 37.8° C (100° F) Projectile vomiting Refuses 2 consecutive feedings Excessive crying, fussiness, lethargy, or difficulty waking infant Stool or urine changes S&S of infection from cord or circ site Appears or act ill Dusky, blue around mouth, whites of eyes yellow If absence of breathing for >15 sec. Projectile vomiting 2 or more times in several hours 2 or more green, watery stools; hard stools; infant urinates < 6 X’s in 24 hours S&S on infection from cord or circ site

Newborn nutrition

Maternal Choice Many factors influence mother’s preference to breast or bottle feed Breastfeeding is almost ALWAYS BEST for infant, but may not be best choice for mother Factors = physical, psychosocial, social. Issue must be discussed prenatally for mother to make a good decision for herself and her child.

Breastfeeding Assess latch Listen for suck/swallow
Observe infant and mother for comfort level Count wet and soiled diapers In order to assist a mother in this process you must understand what is a good latch, suck/swallow, good position of mother and infant, and how to assess if infant is getting enough.

Breastfeeding Supplements maybe recommended for breastfed infants
Vitamin D Vitamin K Iron Fluoride Mother should continue prenatal vitamins Mother needs proper diet

Formula Closely resembles human breastmilk Provides essential vitamins
Should be Iron enriched WIC (Women, Infant, Children) = state/federal supplemental food program If formula not prepared with fluorinated water, infant needs fluoride supplement by 6 months WIC is program for pregnant/breastfeeding/postpartum women and their children up to 5 years of age For low income population; must meet income guidelines Will get formula for little or no cost, if eligible Get cheese, eggs, milk, cereal, juice, nutritional counseling, breastfeeding support (info and pumps), iron testing, weight and growth assessments for children

Formula Teach parents importance of following directions Types: Forms:
Cow milk based Soy based Predigested Forms: Ready to feed Liquid concentrate Powdered Teach parents importance of following directions Soy used, if allergy to cow's milk or lactose intolerance Soy = protein that is base for formula. Used instead of cow’s milk protein. Add sucrose instead of lactose (in cow’s milk) for carbs needed. Predigested = Nutramagen, easier to digest; used if infant cannot tolerate soy based (preterm or other GI problems); Follow directions for formula prep; must mix correctly to get correct ratio of fluid, carbs, and nutrients.

Bottle Feeding Positioning Held in semi-upright position
Lying down predisposes to: Middle ear infections Aspiration Nipple filled with formula to avoid air Burp every ½ oz. Avoid lying down Burp every 5 minutes Should hold, cuddle, and talk to infant during feedings; helps with psychological as well as cognitive development

Bottle Feeding After feedings, position on back
Give feedings at room temperature Warm cold formula or breastmilk in pan of warm water DO NOT MICROMAVE formula or breastmilk Clean bottles with soap/water or dishwasher If well water, boil water 5 – 10 minutes May use right side to promote movement of food through stomach and away from cardiac sphincter (IN HOSPITAL) Teach parents on back Why no microwave? DISCUSS Never keep left-overs; discard any formula or breastmilk in bottle after infant is finished. WHY? Contaminated!!! Holding infant during feedings is important for their psychological development. Use this as time to interact and talk to infant.

High-risk newborn

Infant born prior to 37 weeks gestation is considered pre-term
The Preterm Infant

Appearance of Preterm Infant
“Winkled old man” Lacks subcutaneous fat Skin delicate, thin, transparent Covered with lanugo Prominent fontanels/suture lines Weak cry Abundant vernix Few creases on soles of feet Always has “worried look” Weak cry with decreased respiratory effort Resp system not mature until 35 weeks gestation

Appearance of Preterm Infant
Abdomen protrudes Short nails Genitals small Testicles high in scrotum No rugae until after 36 weeks Clitoris exposed Labia majora opened Ears lack shape/cartilage Small chest with protruding abd.

Limbs extended Lax easily manipulated joints

Thermoregulation for Preterm Infant
Problems Decreased brown and subcutaneous fat Large body surface area in relation to weight Poor muscle tone Thin skin Blood vessels close to surface Warmer or isolete Monitor skin temperature with sensor HUGH PROBLEM = ability to conserve heat limited by these factors and immature temp regulation center in brain Must continually monitor temp and respond immediately to changes Avoid changes in core temp (too high and too low)

Complications of prematurity

Respiratory System Functionally and structurally immature
Insufficient surfactant Chest muscles not fully developed Abdomen distended = pressure on diaphragm Respiratory centers in brain immature Irregular pattern; apnea Predisposed to respiratory distress and infection Not mature until 35 weeks By 35 weeks surfactant is usually sufficient to enable infant to breathe without collapse of alveoli when exhaling Often preemie has irregular breathing. This places them at danger for periodic apnea. You will see pause in respirations longer than 10 – 15 sec. prolonged apnea = bradycardia and cyanosis. Apnea monitor = stimulate with tactile stimulation suction, head up, position change and continue to monitor

Respiratory Complications

RDS (Respiratory Distress Syndrome)
Hyaline Membrane Disease Membrane forms around alveoli and prevents exchange of O2 and CO2 Lack of surfactant Synthetic or natural surfactant introduced into neonate’s endotracheal tube 10% of all preterm infants will develop this problem Risk increases if less than 1500 gms Hyaline membrane that develops prevents exchange of O2 and CO2. Membrane caused by lack of surfactant

RDS Chest X-Ray Lungs fields appear patchy (salt and pepper)

Bronchopulmonary Dysplasia (BPD)
Supplemental O2 for extended period of time causes: Thickening of alveolar sacs Atelectasis and scaring Results in long term dependence on oxygen Prevention Monitor O2 concentrations closely Maintain lower O2 saturations Results from PPV and O2 toxicity (too much O2) think oxidation S&S = tachypnea, retractions, tachycardia, irritability Treatment = long term O2 and pulse Ox, supportive care

Swiss cheese appearance on chest X-Ray
BPD Chest X-Ray

Retinopathy of Prematurity (ROP)
Also Called Retrolental Fibroplasia Prolonged high concentrations of O2 cause proliferation and rupture of retinal blood vessels Blindness Prevention Monitor O2 carefully Decrease lighting in NICU Reduce stress to infant Time when too much of a good thing can be BAD. Too much O2 is as damaging as not enough. Stress = fluctuations in BP and O2 needs = more rupture of retinal blood vessels Retinal blood vessels are extremely fragile. Hypoxemia, acidosis, sepsis, and shock can also contribute See ped ophthalmologist = treat with laser surgery or cryotherapy

Circulatory system

PDA (Patent Ductus Arteriosus)
S&S = systolic murmur, active precordium, bounding peripheral pulses Medical Management indomethacin (Indocin) inhibits prostaglandin synthesis diuretics surgical ligation Nursing Care Accurate I&O, O2 sats, ABG’s They are predisposed to congenital cardiovascular problems due to nonclosure or delayed in change from fetal circulation. Mrs. Leib talked about fetal circulation in great detail Remember that the placenta provides O2 prior to birth During fetal life most of the blood bypasses the nonfunctioning lungs and liver There are 3 shunts that allow for this bypass and must close after delivery PDA means that Ductus Arteriosus does not close Indocin causes vasoconstriction of ductus; leading to closure Diuretics to tx HF Surgical closure, if needed

Remember that the ductus arteriosus shunts blood from pulmonary artery to the aorta, bypassing the fetal lungs. As pulmonary artery dilates in response to increase O2 needs of lungs at birth, the ductus arteriosus constricts and closes completely.\ Functional closure occurs at 15 – 24 hours of age Anatomical closure with fibrous tissue 3 – 4 wks of age Blood flow from high pressure aorta flows into low pressure pulmonary artery and R side of heart = increased blood flow in pulmonary artery and R side of heart. Can occur because of underdeveloped musculature or hypoxia in preterm infant If untreated = pulmonary edema and heart failure S&S = systolic murmur, active precordium, bounding peripheral pulses Medical Management = Indometacin (Indocin) prostaglandin synthesis inhibitor – constricts to close; diuretics; surgical ligation Nursing Care = Accurate I&O, O2 sats, ABG’s

Nervous System Immature
Suck, gag, and swallow reflexes uncoordinated or absent before 34 to 35 weeks gestation Intraventricular Hemorrhage If no suck or gag reflex = feeding tube May be fed by nipple if coordinated suck and gag reflex are present. Use soft nipple (usually red in color) to prevent fatigue – maximum time is 20 minutes Use pumped breast milk – provides immunoglobulins necessary to protect against infection. Helps prevent NEC Intraventricular Hemorrhage is caused by asphyxia – most vulnerable between 28 and 32 weeks

GI System Weak sucking and swallowing Delayed stomach emptying
Reduced intestinal motility Small capacity Poor fat absorption Stomach sphincter immature – vomiting Tire easily – feeding uses a lot of energy Usually tube fed or IV nutrition only Preterm infant can take only limited nourishment. Limited stomach size, increased risk of GE reflex. Increased risk of aspiration = poor gag reflex and increased risk of reflux = right side after feedings With delayed stomach emptying and reduced intestinal motility you will see abdominal distention, rigidity, and failure to absorb liquids Predisposes to NEC

May po feed for X number of minutes and then finish feeding by gavage
If gavage feeding, must check placement, residual, and assess patency prior to each feeding Adequate intake, if gaining 20 – 30 gms/day

Necrotizing Enterocolitis (NEC)
Ischemia of bowel Cells stop secreting protective mucus Intestinal cell damage and death Intestinal wall becomes invaded by bacteria Untreated, it can be fatal Exact cause unknown Acute inflammatory disease Mostly preterm infant who have intestinal ischemia, bacteria in area, and have started ingestion formula Less incidence among breastfed infants = so strongly encourage pumping of breastmilk for initial feedings

Necrotizing Enterocolitis
Prevention is best Recommend breastmilk for initial feedings to prevent this. TREATMENT: NG with suction to decompress bowel IV antibiotics Parenteral nutrition = TPN to rest gut

Urinary System Kidneys are immature
At risk for fluid retention and/or over hydration Should have greater than 1ml/kg/hr urinary output Subtract dry weight of diaper from wet weight of diaper to determine UO 1 gm = 1 ml Fasten diapers securely, especially in warmer to prevent leakage or evaporation.

Immune System Preterm at high risk for infection
Invasive procedures Fragile skin Decreased immunity acquired from mom Meticulous hand washing and good aseptic technique Most maternal immunity is transferred to infant in last trimester

Endocrine System Hypoglycemia due to inadequate brown fat and glycogen stores Increased glucose needs for growth and needs of heart and brain Microglucose done Very young and small preemies are not held to same guidelines as full term infants If < 2500 gms considered Hypoglycemic if glucose is < 20 – 25 mg/dL during first 72 hours then must be above 40 mg/dL to be normal

Caregiver Role Strain Family may need to grieve loss of “perfect” baby
May initially be afraid to become attached Encourage visits and involvement in care ASAP Allow verbalization Parents need teaching, guidance, and emotional support May not be prepared to accept a preterm infant Need to grieve and work through emotions and feelings of guilt Encourage to begin the process of attachment Nurse is constant assistant to family and support to family A lot of sophisticated overwhelming equipment Encourage daily visits from family May need place to stay, if long distance from home

Thanks to nursing research, we have learned a great deal about the importance of touch for all infants, especially premature infants. Kangaroo care = skin to skin contact between parent and infant 2 components to success 1. Sensory touch – encourage to touch and hold and care for infant 2. Care-taking – feeding What we have found is that with Kangaroo care infant is more relaxed We see less crying, more quiet sleep, less apnea and more regular breathing Less irregular HR, better temp regulation, decreased mortality, decreased hospital stay, Decreased infection, and decreased cost Because they don’t spend energy warming self or on purposeless movement and active sleep, they conserve energy and you see wt gain. Gain faster and leave hospital earlier Also makes parents feel closer attachment with infant and more involved in infant care

Cuddling Twins Eat better Sleep better THIVE
This same technique applies to twins and other multiples. Current NICU research by nursing is proving that these babies do much better if kept together. Need to be careful that they don’t pull out each other’s feeding tubes or IV lines, but benefits outweigh risks When they are first put together they explore each other, touching, rubbing each other in a dance that says “OHH! There you are. Where have you been?” They will then settle, sleep better, thrive and continuously touch each other. Never underestimate the POWER of TOUCH REMEMBER – NURSING discovered this through our research. We may not be finding the cure for cancer, but we do find the HUMAN component of healing. THIS IS THE ART OF NURSING AT ITS BEST. Cuddling Twins Eat better Sleep better THIVE

Post-term Infant Born after 42 weeks gestation
Placenta does not function well after 40 weeks Decreased O2 In labor, O2 reserve is limited Higher risk of fetal distress and meconium aspiration Decreased nutrients Increased risk of hypoglycemia Look thin with loose skin Decreased vernix Skin dry and cracked Have wasted physical appearance d/t intrauterine malnutrition. Infant has used up subcutaneous and brown fat and glycogen stores. Need to monitor closely regardless of size Risk for asphyxia, meconium aspiration, hypoglycemia, birth trauma, seizures from hypoxia, polycythemia (increased RBC’s d/t chronic intrauterine hypoxia) No vernix to protect skin, so skin becomes dry and cracked

Neonatal complications

Hypoglycemia Plasma glucose levels < 40 mg/dL At risk Preterm LGA
Infants born to mothers with DM

Hypoglycemia Common signs Treat immediately Lethargy Poor feeding
Hypotonia Tachypnea Jitteriness Apnea Sweating Shrill cry Low temperature Seizures Treat immediately KNOW COMMON SIGNS: you will likely see this. Treatment: Feed ASAP May require IV with sugar (D10W) Frequent blood glucose assessments (hourly for severe or ac for minor) Why treat immediately? Brain needs constant supply of glucose to function.

Neonatal Sepsis Generalized bacterial infection in blood stream
Caused by Staph aureus Staph epidermidis E-coli Haemophilus influenzea Group B strep Can occur any time in first month of life Infection can result from transplacental, transvaginal, or nosocomial transmission Diagnosis based on clinical signs and symptoms and + blood cultures Usually polymicrobial (more than one pathogen)

Neonatal Sepsis Signs of sepsis Treatment Lethargy Prevention
Hypothermia Respiratory distress Cyanosis, pallor Jaundice Poor sucking and feeding Vomiting Diarrhea Treatment Prevention Antibiotic therapy O2 therapy Careful regulation of fluids and electrolytes May see resp distress with apnea, irregular resp with grunting, and retractions See low temp because thermoregulation center in brain is immature Need proper handwashing and standard precautions Proper care of and cleaning of equipment If mother + Group B strep = antibiotics (2 doses during labor, prior to delivery) O2 if needed May need nutritional support if unable to suck and eat properly

Hyperbilirubinemia Excessive level of bilirubin in blood
Characterized by jaundice Common in newborn Destroyed or dead RBC’s release bilirubin as they breakdown RBC’s broken down into heme and globin Globin (protein portion) is reused by body Heme is converted to unconjugated bilirubin (an insoluble substance bound to albumin) In liver unconjugated bilirubin is changed into soluble conjugated bilirubin Conjugated bili is excreted into bile and into intestines In intestines, bacteria reduces it into urobilinogen (pigment that gives stool its color) Excreted with feces

Hyperbilirubinemia Physiological Jaundice Common Self-limiting
Peaks 3 – 4th day of life Screening tool: Cutaneous bilimeter Blood test: Direct Bili Physiological jaundice is common and self limiting may be associated with breastfeeding occurs at 2 – 4 days of age from normal RBC death and immature liver Newborns have high number of RBC’s at birth Numerous RBC’s die in first several days of newborn’s life In newborn high number of dying RBC’s, immature liver, and limited intestinal bacteria cause build up of unconjugated bili

Hyperbilirubinemia Pathologic Jaundice Occurs within 24 hours of birth
Total serum Bili 12 mg/dl or > in term infant Formula fed < 12 mg/dl Breast fed < 14 mg/dl Total serum Bili of 16 mg/dl or > in preterm infant Primary cause is Rh and ABO incompatibilities This can lead to extremely high levels of bilirubin in blood

Rh and ABO Incompatibility
First Pregnancy Next Pregnancy Rhogam has greatly reduced incidence of this Mrs. Leib has already talked about this. Remember mother must be given Rhogam injection within 72 hours of delivery of Rh+ baby and at 28 weeks gestation to limit complications. Can also see similar type problem with ABO incompatibility Mother has O blood type and baby has A, B, or AB Mother’s blood contains no A, B, or AB antigens and can develop anti A and anti b antibodies Milder form of hemolysis occurs = rarely causes significant anemia, but can cause significant jaundice Rhogam = Prevention

Hyperbilirubinemia Bilirubin encephalopathy
CNS damage from deposits of unconjugated bilirubin High levels of bilirubin may cause Decreased activity Poor feeding Lethargy Long-term effects Mental retardation Behavior disorders Motor dysfunction Why we worry about bili levels.

Hyperbilirubinemia Diagnostic Tests
Total serum bili: Measures conjugated (direct) and unconjugated (indirect) bili Direct Coombs: Measures antibody coated Rh + RBC’s in infant’s blood Performed to ID hemolysis Indirect Coombs: Measures Rh + antibodies in mother’s blood Jaundice in newborn is usually unconjugated (indirect) bili d/t immature liver. High direct or conjugated bili is usually in adults and d/t bile duct obstruction, gallstones, tumor, inflammation, scarring Coombs done on umbilical cord blood POSITIVE result = Rh or ABO incompatibility

Phototherapy Protect eyes and skin; maintain temp and fluid balance
Treatment Will decrease serum bili because light oxidizes unconjugated bili in skin, so it becomes soluble in H2O and is excreted in stool and urine MUST shield eyes to prevent retinal damage genitals covered to protect gonads (male) maximum exposure occurs if unclothed (diaper only) turn frequently for maximum exposure and to prevent skin breakdown obtain serum bili 8 – 12 hours to assess effectiveness stop when bili within normal range (9 – 12 mg/dL) feed Q 2 – 3 hours to increase excretion and maintain adequate fluids observe for S&S of hypothermia, hyperthermia, hypoglycemia, or dehydration skin care = change positions frequently monitor I&O carefully Phototherapy Protect eyes and skin; maintain temp and fluid balance

Newborn Care and Assessment

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Newborn Care and Assessment

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