1. 1

2. 2 Normal Newborn

3. 3 التوقعات

4. 4 Physical characteristics of the newborn Systematic adjustment to extra uterine life Define the neonatal period 1 2 3 Out lines Immediate care of newborn 4 Neonatal reflexes 5 Applying nursing process 6

5. 5

6. 6 The term ''newborn'' refers to the infant in the first minutes to hours following birth. In contrast, the neonatal period is defined as the first four weeks subsequent to birth.

7. 7 Neonatal Period: Birth --> 28 days of life Term Infant: 38 - 42 weeks of gestation Transition Period: Phases of instability during the first 6-8 hours after birth Terms:

8. 8 Fetal circulation

9. 9 As a baby enters the world, many body systems change dramatically from the way they functioned during fetal life. The newborn must begin to adjust to life outside the uterus.

10. 10 I- Systematic Adjustment To Extra Uterine Life

11. 11 Metabolic Processes Voluntary Muscle Activity Peripheral Vasoconstriction Nonshivering Thermogenesis Temperature Regulation

12. 12 Temperature Regulation Non-Shivering thermogenesis: brown fat is the primary source of heat production. Brown fat is broken down into glycerol & fatty acids producing heat. Brown fat is found @ the nape of the neck, axillae, around the kidneys and in the mediastinum.

13. 13 No shivering thermo-genesis The distribution of brown adipose tissue (brown fat)

14. Possible Sources of Heat Loss

15. 15 Convection Radiation Evaporation Conduction

16. 16 The Four modalities by which the infant lost his/ her body temperature: 1- Evaporation: Heat loss that resulted from expenditure of internal thermal energy to convert liquid on an exposed surface to gases, e.g.: amniotic fluid, sweat. Prevention: Carefully dry the infant after delivery or after bathing.

17. 17 2- Conduction: Heat loss occurred from direct contact between body surface and cooler solid object. Prevention: Warm all objects before the infant comes into contact with them.

18. 18 3- Convection: Heat loss is resulted from exposure of an infant to direct source of air draft. Prevention: · Keep infant out of drafts · Close one end of heat shield in incubator to reduce velocity of air.

19. 19 4- Radiation: It occurred from body surface to relatively distant objects that are cooler than skin temperature.

20. 20

21. 21 Transitional Circulation = acrocyanosis Five major changes:- -↑ aortic pressure----↓venous pressure -↑ systemic pressure---- ↓pulmonary artery - Closure of foramen oval by 3months - Closure of ductus arterious—4months - Closure of ductus venosus ----immediatly Circulatory :

22. 22 Before birth O 2 needs met by placenta. The alveoli are in state of total collapse called Telecasts, the first breath taken 30 second. Oxygenation improved during the first 2 weeks. 35-50 cycle/min Respiratory

23. 23 Immature at birth, reaches maturity at 2-3 years of age stomach capacity 50-60ml sucking becomes coordinated @32 wks little saliva until 3 months of age bowel sounds after 1 hour of birth Gastrointestinal System

24. 24 NB have difficulty digesting complex starches and fat Abdomen becomes easily distended after eating Initial fecal material = meconium within 12- 48hr. Gastrointestinal System

25. 25 passage of meconium

26. 26 Limited specific and Non-specific immunity at birth passive immunity(from mom- IgG) for the first 3 months of life ~ this will be reduced if baby is born premature breastfeeding = ^ passive immunity (IgA) Immune System

27. 27 Liver produces substances essential for clotting of blood. Stores needed iron for the first few months. Preterm & small infants have lower iron stores than full term and heavier infants. (full term infants stores last 4-6 mo) NB at risk for Physiologic Jaundice after 24 hours of age, due to increased breakdown of RBC’s and immature liver functioning. Hepatic Function

28. 28 All neurons are present, but many are immature: uncoordinated movements poor muscle control startle easily Tremors in extremities Neurologic

29. 29 92% of all healthy infants void in the first 24 hrs of birth initial urine:-cloudy,, uric acid crystals ---> reddish stain on diaper Kidneys not fully functional until child is 2 years of age. Kidneys and Urination

30. 30 It is normal for the newborn infant to loose 5-10% of weight in the first 4 to 5 days of life. (physiological weight loss). Gain weight -------250gm/kilogram during the first month Weight Loss

31. 31 II-Assessment criteria of the newborn

32. 32 II-Assessment criteria of the newborn The initial assessment using the apgar score. Transitional assessment during the period of reactivity. Assessment of gestational age. Systematic physical examination 1 2 4 3

33. 33 The initial assessment using the apgar score. I

34. 34 The newborn's adaptation to life outside the uterus is evaluated using an apgar score.

35. 35 Apgar Test Sign 012 Heart Rate P Absent<100 beats/min100-140 beat/min Respiratory R Effort No breathing for 1 min Slow and irregular Good respiration normal crying Muscle Tone A Limb and flaccidSome flexion of extremities Good flexion and active motion Reflex G Irritability No facial expressions Some contortions and grimacing Active crying Body color A Blue or pale body/ Extremities Body pink w/blue extremities Pink all over

36. 36 Transitional assessment (Periods of reactivity): I) First period of reactivity: Stage 1: during the first 30 min. through which the baby is characterized as Physiologically unstable ( ), very alert, cries vigorously, may suck a fist greedily, & appears very interested in the environment. 2

37. 37 Stage 2: it lasts for about 2-4 hours, through this period; all V.S & mucus production are decreased. The newborn is in state of sleep and relative calm.

38. 38 II) Second period of reactivity: it lasts for about 2-5 hours, through which the newborn is alert and responsive, heart & respiratory rate, gastric & respiratory secretions are increased & passage of meconium commonly occurs. Following this stage is a period of stabilization through which the baby becomes physiologically stable & a vacillating pattern of sleep and activity.

39. 39 Assessment of gestational age. 3- ( High-risk neonate)

40. 40 Assessment of Gestational Age: The Dubowitz and Ballard Exams - gestational age based on physical and neurologic signs-

41. 41 Infants at Risk (Warning SIGNS) “RED FLAGS” after birth include: gagging --> turning blue (esp. after fdg) generalized cyanosis weak cry grunting or respiratory distress decreased or absent movements excessive twitching or trembling OTHERS>>>>>

42. 42

43. 43 Danger signs EN- Teaching Aids: ENC 43 Not feeding well Less active than before Fast breathing (>60/ min) Moderate or severe chest in-drawing Grunting Convulsions Floppy or stiff Temperature >37.5 0 C or <35.5 0 C Umbilicus draining pus or umbilical redness extending to skin. >10 skin pustules Bleeding from umbil. Stump

44. 44 Systematic Physical examination :- 4-4- 1- growth measurement 2- physiological measurement 3- general appearance

45. 45 Systematic Physical examination: 1- growth measurement 4-

46. 46

47. 47 2- physiological measurement :- - Temperature. - Pulse. - Respiration. - Blood pressure

48. 48 Temperature

49. 49 3- general appearance. Posture: Flexion of head & extremities, taking them toward chest & abdomen

50. 50 Posture

51. 51. Skin: General description: - At birth; color: bright red, texture: soft and has good elasticity. - Edema is seen around eye, face, and scrotum or labia. - Cyanosis of hands & feet (acrocyanosis)

52. 52 General description of the skin

53. 53 Acrocyanosis

54. 54 Soft yellowish cream layer, cheese like that may thickly cover the skin of the newborn, or it may be found only in the body creases and between the labia. it formed after 32weeks of gestation The debate of wash it off or to keep it. 1- Vernix Caseosa

55. 55 Vernix Caseosa

56. 56 2. Lanugo hair: it is slightly long fine hair - Distribution - The more premature baby is, the heavier the presence of lanugo is. - It disappears during the first weeks of life

57. 57 Lanugo hair shoulders- back- extremities – forehead& temple

58. 58 3. Mongolian spots: Black coloration on the lower back, buttocks, anterior trunk, & around the wrist or ankle. They are not bruise marks or a sign of mental retardation, they usually disappear during preschool years without any treatment.

59. 59 Mongolian spots

60. 60 Mongolian spots

61. 61 Mongolian spots

62. 62 - Peeling of the skin over the areas of bony prominence that occurs within 2-4 weeks of life because of pressure and erosion of sheets. 4. Desquamation:

63. 63 Desquamation It appear on nose, knee, elbow,

64. 64 5-Physiological Jaundice

65. 65 Physiological Jaundice

66. 66 6. Milia : - Small white or yellow pinpoint spots. - Common on the nose, forehead, & chin of the newborn infants due to accumulations of secretions from the sweat & sebaceous glands that have not yet drain normally. -They will disappear within 1-2 weeks, they should not expressed

67. 67 6- Milia

68. 68 The Anterior fontanel: is diamond in shape, located at the junction of 2 parietal &2 frontal bones. It is 2-3 cm in width & 3-4 cm in length. It closes between 12-18 months of age. The posterior fontanel: is triangular in shape, located between the parietal & occipital bones. It closes by the 2 nd month of age. 7. Head :

69. 69 Fontanels should be flat, soft, & firm. It bulge when the baby cries or if there is increased in ICP. Two conditions may appear in the head: Caput succedaneum & cephlhemtoma

70. 70 Caput succedaneum An edematous swelling on the presenting portion of the scalp of an infant during birth, caused by the pressure of the presenting part against the dilating cervix. The effusion overlies the periosteum with poorly defined margins. Caput succedaneum extends across the midline and over suture lines. Caput succedaneum does not usually cause complications and usually resolves over the first few days. Management consists of observation only.

71. 71

72. 72 Caput succedaneum

73. 73 Caput succedaneum

74. 74 Caput succedaneum

75. 75 Cephalhematoma: Cephalhematoma is a subperiosteal collection of blood secondary to rupture of blood vessels between the skull and the periosteum, in which bleeding is limited by suture lines (never cross the suture lines).

76. 76 Cephalhematoma

77. 77 Cephalhematoma

78. 78 - Usually edematous eye lids - Gray in color. True color is not determined until the age of 3-6 months. - Pupil: React to light - Absence of tears - Blinking reflex is present in response to touch - Can not follow an object (Rudimentary fixation on objects ). 8. Eyes :

79. 79 Normal Eye

80. 80 Eyelid Edema

81. 81 Dysconjugate Eye Movements

82. 82 Subconjunctival Hemorrhage

83. 83 Congenital Glaucoma

84. 84 Congenital Cataracts

85. 85 9. Ears: Position: Pinna flexible, cartilage present.

86. 86 Normal Ears

87. 87 Ear Tag

88. 88 10. Nose: Nasal Patency (stethoscope). Nasal discharge – thin white mucous

89. 89 Normal Nose

90. 90 Dislocated Nasal Septum

91. 91 11. Mouth & Throat: - Intact, high arched palate. - Sucking reflex – strong and coordinated - Rooting reflex - Gag reflex - Minimal salivation

92. 92 12. Neck : Short, thick, usually surrounded by skin folds.

93. 93 Neck

94. 94  System assessment of the neonates: 1. Gastrointestinal System: Mouth should be examined for abnormalities such as cleft lip and/or cleft palate. Epstein pearls are brittle, white, shine spots near the center of the hard palate. They mark the fusion of the 2 hollows of the palate. If any; it will disappear in time.( several days to weeks)

95. 95 Cleft Palate

96. 96 Cleft Lip

97. 97 Cheeks: Have a chubby appearance due to development of fatty sucking pads that help to create negative pressure inside the mouth which facilitates sucking.

98. 98 Epstein Pearls & cheeks

99. 99 Normal Tongue Ankyloglossia

100. 100 Ankyloglossia

101. 101 Gum: May appear with a quite irregular edge. Sometimes the back of gums contain whitish deciduous teeth that are semi-formed, but not erupted

102. 102 Irregular edges with Natal Teeth

103. 103 Natal Tooth

104. 104 13- Abdomen Cylindrical in Shape

105. 105 Normal Umbilical Cord Bluish white at birth with 2 arteries & one vein.

106. 106 Meconium Stained Umbilical Cord

107. 107 14. Circulatory system : Heart: Apex- lies between 4 th & 5 th intercostal space, lateral to left sternal border.

108. 108 15. Respiratory system : Slight substernal retraction evident during inspiration

109. 109 15. Respiratory system Cont. : Xiphesternal process evident

110. 110 15. Respiratory system Cont. : Respiratory is chiefly abdominal Cough reflex is absent at birth, present by 1-2 days postnatal. Possible signs of RDS are: - Cyanosis other than hands & feet. - Flaring of nostrils. - Expiratory grunt-heard with or without stethoscope.

111. 111 16. Urinary System : Normally, the newborn has urine in the bladder and voids at birth or some hours later.

112. 112 Female genitalia

113. 113 Female genitalia Cont. Labia & Clitoris are usually edematous. Urethral meatus is located behind the clitoris. Vernix caseosa is present between labia

114. 114 Normal Male genitalia Urethral opening is at tip of glans pens. Testes are palpable in each scrotum. Scrotum is usually pigmented, pendulous & covered with rugae.

115. 115 17. Endocrine system : Swollen breasts: Appears on 3 rd day in both sex, & lasts for 2-3 weeks and gradually disappears without treatment. N.B: The breasts should not be expressed as this may result in infection or tissue damage.

116. 116 Maternal hormonal withdrawal Female genitalia, normal with vaginal discharge

117. 117 Infantile menstruation

118. 118 Extremities Nail beds pink

119. 119 Extremities Cont. Meconium Stained fingernails

120. 120 Extremities Creases on anterior two thirds of sole.

121. 121 Common feet abnormalities Club Feet

122. 122 18. The Central Nervous system : Reflexes: Successful use of reflex mechanism is a strong evidence of normal functioning CNS.

123. 123 Reflexes

124. 124 -protective Reflexes:- -blinking/corneal reflex -sneezing /cough reflex -Gag reflex - Yawn reflex - Extrusion reflex - Crying Reflex Reflexes

125. 125 Feeding Reflexes:- - Rooting Reflex - Sucking Reflex - Swallowing Reflex

126. 126 Other Reflexes Babkin reflex:- pressure applies to both palms while baby lying on his back causes eyes closed, mouth open, and head turned to center position, disappear in 3-4 months. Babinski:fanning of toes when foot stroked –should disappear by end of first year; absent in lower spinal defects Palmar, Darwinian or automatic hand grasp –replaced by voluntary grasping at 3-4 months; weak or absent in depressed/distressed babies Moro reflex: startle reflex –disappears by 3-4 months; absent in neurologically depressed babies Stepping or swimming reflex –disappears at 3-4 months; absent in lower spine defects, depressed babies

127. 127

128. 128

129. 129 Babniski Reflex

130. 130 Extrusion Reflex

131. 131 Rooting reflex

132. 132 Sucking reflex

133. 133 Immediate Care of the Newborn:

134. 134

135. 135

136. 136 Immediate Care of the Newborn: 1. Clear airway. 2. Established respiration. 3. Maintenance of body temperature. 4. Protection from Hge. 5. Identification.

137. 137 Dry the Baby Hypothermia is common Wet newborns rapidly lose heat Use a warm, dry, soft towel Any absorbent material: –Shirt –T-shirt –Socks –Battle dressings

138. 138 Position the Baby Keep the baby on its’ back or side, not on its’ stomach Neither extend nor flex the head. Either may obstruct the airway. Newborn babies normally make this adjustment themselves. If depressed, however, you may need to position the head to get a good airway.

139. 139 Suction the Airway May need to help them clear mucous and amniotic fluid from the airway Use a bulb syringe Use it gently If bulb syringe is not available, use any suction device, including a small hypodermic syringe without the needle.

140. 140 Color Most newborns have acrocyanosis (body is centrally pink, but hands and feet are blue Cyanosis requires treatment: –Oxygen –Airway –Ventilation Pink Acrocyanosis Cyanosis

141. 141 IMMEDIATE CARE COLOR PULSE SUCTION TEMPERATURE

142. 142 Nursing Diagnosis: Ineffective Airway Clearance R/T excessive oropharyngeal mucus Ineffective Thermoregulation R/T newborn transition to extrauterine life High Risk for infection R/T maturational factors, immature immune system

143. 143 Position of sleep/prevent SIDS Back to sleep Feet to foot of bed No stuffed animals or excessive blankets in bed Don’t cover head in stroller Don’t keep house too warm No smoking around infant

144. 144 Cleanliness No tub baths until cord off and healed Clean around organs of elimination and mouth after soiling to prevent skin break down Daily head to toe bath not necessary fold diapers away from umbilicus NEVER leave child alone in tub!!

145. 145 * General management: 1- Infant should be warmed quickly by wrapping in a warm towel. 2- Uses extra clothes or blankets to keep the baby warm. 3- If the infant is in incubator, increase the incubator’s temperature. 4- Use hot water bottle (its temperature 50 °C). 5- Food given or even intravenous solution should be warm. 6- Avoid exposure to direct source of air drafts. 7- Check body temperature frequently. 8- Give antibiotic if infection is present.

146. 146 Thank you