Download care of the newborn

st
1
The
24 hours
of Life
The first 24 hours of life is a very
significant and a highly vulnerable
time due to critical transition from
intrauterine to extrauterine life
Immediate
Care of the
Newborn
• Airway
• Breathing
• Temperature
Airway & Breathing
• Suction gently & quickly
using bulb syringe or
suction catheter
• Starts in the mouth then,
the nose to prevent
aspiration
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Airway & Breathing
• Stimulate crying by rubbing
• Position properly- side lying /
modified t-berg
• Provide oxygen when
necessary
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Temperature
• Dry immediately
• Place in infant warmer or use droplight
• Wrap warmly
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APGAR Scoring
•
•
•
Standardized evaluation of the newborn
Perform 1 minute and 5 minutes after
birth
Involves (5) indicators:
1.
2.
3.
4.
5.
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Activity
Pulse
Grimace
Appearance
Respirations
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Care of the Newborn
in the Nursery
Components
•
•
•
•
•
•
•
•
•
Anthropometric Measurements
Bathing – Oil bath/ warm water bath
Cord Care
Dressing/ Wrapping - mummified
Eye prophylaxis – Crede’s
Foot printing / Identification
Get APGAR score – 1 & 5 mins
HR, RR, Temp, BP
Injection of Vitamin K
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Components
1.
2.
3.
4.
Proper identification –tag/bracelet
Oil bath/ Warm water bath
Cord Care/ Dressing
Measurements
1. Weight
2. Anthropometric measurements
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6. Crede’s Prophylaxis
7. Vitamin K Administration
8. Foot printing/ marking
9. Vital signs
10.Dressing/ wrapping
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Proper Identification
• After delivery, gender
should be determined
• Pertinent records should
be completed including
the ID bracelet
• Before transferring to
nursery, ID tag should
be applied.
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Bathing
• Oil bath or complete
warm water bath
• From cleanest to
dirties part
• DO NOT remove
vernix caseosa
vigorously
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Cord Care
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Weight/ Anthropometric
Measurements
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Crede’s Prophylaxis
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Vitamin K Administration
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Foot Printing
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Vital Signs
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Dressing/ Wrapping
• “Mummy”
• Wrap in warm
blanket
• Cover head with
stockinette cap
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Daily Care
1.
2.
3.
4.
Nutrition/ Feeding
Elimination
Weight
Bathing & Hygiene/
Grooming
5. Obtain vital signs
6. Rooming-in
7. Note for any
abnormalities
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NEWBORN ASSESSMENT
Assessment of the newborn is
essential to ensure a successful
transition
Major Time Frames
1. Immediately after birth
2. Within the 1st 4 hours after birth
3. Prior to discharge
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APGAR Scoring System
A
P
G
A
R
ctivity/ Muscle Tone
ulse/ Heart Rate
rimace/ Reflex Irritability/ Responsiveness
ppearance/ Skin Color
espiration/ Breathing
1
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2
3
Neonatal Care
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4
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INDICATORS
Activity
Pulse
2
1
0
Active,
spontaneous
Some flexion
of extremities
No movement
(flaccid, limp)
>100 bpm
< 100 bpm
Absent
Pulls away,
Facial grimace
sneezes, coughs only
No response
with stimulation
Appearance
Completely pink
Acrocyanosis
Bluish-gray or
pale all over
Respiration
Good vigorous
cry
Slow, irregular
Weak cry
Absent
Grimace
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Score
Interpretation
7 to 10
Well baby
4 to 6
0 to 3
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Nursing Interventions
Rarely needs resuscitation
Requires resuscitation
At risk
Suction
INFANT NEEDS Dry immediately
INTENSIVE CARE Ventilate until stable
Careful observation
Intensive resuscitation
ET/ Ambu bag
Sick baby
Ventilate with 100% O2
PROGNOSIS FOR CPR
NB IS GRAVE
Maintain body temperature
Parental support
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General Guidelines
•
•
•
•
Keep warm during examination
From general to specific
Least disturbing first
Document ALL abnormal findings &
provide nursing care
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GENERAL APPEARANCE
Posture
• Full term:
– Symmetric
– Face turned to side
– Flexed extremities
– Hands tightly fisted with thumb
covered by the fingers
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Special Concerns
• Asymmetric
– Fractured clavicle or humerus
– Nerve injuries (Erb-Duchenne’s Paralysis)
• Breech Presentation
– Knees and legs straightened or in FROG
position
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VITAL SIGNS
TEMPERATURE
•
•
•
•
•
Site: Axillary NOT Rectal
Duration: 3 mins
Normal Range: 36.5 – 37.6 C
Stabilizes within 8-12 hrs
Monitor q 30 mins until stable for 2 hrs
then q 8 hrs
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Heat Loss Mechanisms
• Convection – the flow of
heat from the body
surface to cooler
surrounding air
– Eliminating drafts such
as windows or air con,
reduces convection
• Conduction – the
transfer of body heat to
a cooler solid object in
contact with the baby
– Covering surfaces with a
warmed blanket or towel
helps minimize
conduction heat loss
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• Radiation – the transfer
of heat to a cooler
object not in contact
with the baby
– Cold window surface or
air con; moving as far
from the cold surface,
reduces heat loss
• Evaporation – loss of
heat through conversion
of a liquid to a vapor
– From amniotic fluid; NB
should be dried
immediately
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Nursing Considerations
• Keep dry and well-wrapped
• Keep away from cold objects or outside
walls
• Perform procedures in warm, padded
surface
• Keep room temperature warm
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Pulse
• Awake: 120 – 160 bpm—120 – 140
bpm
• Asleep: 90-110 bpm
• Crying: 180 bpm
• Rhythm: irregular, immaturity of cardiac
regulatory center in the medulla
• Duration: 1 full minute, not crying
• Site: Apical
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Nursing Considerations
•
•
•
•
•
•
Keep warm
Take HR for 1 full minute
Listen for murmurs
Palpate peripheral pulses
Assess for cyanosis
Observe for CP distress
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Special Concerns
• (+) Prominent radial pulse = CHD
• (-) Femoral pulse = Coarctation of aorta
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Respiration
• Characteristics:
Nasal breathers, gentle, quiet, rapid
BUT shallow; may have short periods of
apnea (<15 secs) and irregular without
cyanosis—periodic respirations
• Rate: 30-60 cpm
• Duration: 1 full minute
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Nursing Considerations
•
•
•
•
Position on side
Suction PRN
Observe for respiratory distress
Administer oxygen via hood PRN and
as prescribed
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Silverman-Anderson Index
• Perform to observe for signs of
respiratory distress
– Chest lag
– Retractions
– Nasal flaring
– Expiratory grunting
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Silverman Scoring System
0
1
2
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Example
0
1
2
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Score Interpretation
Score
Interpretation
0-3
No RDS
4-6
7-10
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Moderate RDS
Severe RDS
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Blood Pressure
• NOT routinely measured UNLESS
in distress or CHD is suspected
• At birth:
80/46 mmHg*
• After birth: 65/41 mmHg*
• Using Doppler UTZ
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ANTHROPOMETRIC
MESUREMENTS
Body Measurements
• Weight:
– 5.5 to 9.5 lbs (2500-4300 gms)
– 70-75% TBW is water
– LBW = below 2500 gms; regardless
of AOG
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• Length:
– 45 to 55 cm (18-22 inches)
– Average: 50 cm
– Techniques: using tape measure
• Supine with legs extended
–Crown to rump
–Head to heel
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• Head Circumference (HC):
– 33 to 35.5 cm (13-14 inches)
– Technique: using tape measure
• From the most prominent part of
the OCCIPUT to just above the
EYEBROWS
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– 1/3 the size of an adult’s head
– Disproportionately LARGE for its
body
– HC should be = or 2cm > CC
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• Chest Circumference (CC):
– 30 to 33 cm (12-13 inches)
– Technique: using tape measure
• From the lower edge of the
SCAPULAS to directly over the
NIPPLE LINE anteriorly
– CC should be = or < 2 cm than HC
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SKIN
Nursing Considerations
• Under natural light
• Assess for:
–Color
–Hair distribution
–Turgor/ Texture
–Pigmentation/ Birthmarks
–Other skin marks
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Skin Color
• Velvety smooth and puffy esp. at the
legs, dorsal aspects of hands & feet and
in the scrotum or labia
• Pinkish red (light skinned) to pinkish
brown to yellow (dark skinned)
• “Ruddy” or reddish due to increased
RBC concentration and decreased
subQ tissues
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Skin Color
•
•
•
•
Cyanosis/ Acrocyanosis
Pallor
Jaundice
Meconium Staining
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Acrocyanosis
• Bluish discoloration of palms of hands
& soles of feet
• Due to immature peripheral circulation
• Exacerbated by cold temperatures
• Normal within 1st 24 hrs
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Pallor/ Cyanosis
• May indicate hypothermia, infection,
anemia, hypoglycemia, cardiac,
respiratory or neurological problems
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Jaundice
• Under natural light
• Blanch skin over the chest or tip of
the nose
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• Physiologic
– FT: after the 1st 24 hrs (2-7 days)
– PT:after the 1st 48 hrs
– Peaks at 5-7 days & disappears by
the 2nd week
– Due to immaturity of liver
– Usually found over the face, upper
body and conjunctiva of eyes
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• Pathologic
– Within 1st 24 hrs
– May indicate early hemolysis of RBC
or underlying disease process
– Duration:
• FT: 1 wk
• PT: 2 wks
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Management of Jaundice
• Monitoring serum bilirubin levels
– Physiologic: not more than 5 mg/dl
per day
– Pathologic: more than 15-20 mg/dl
(critical levels)
• Maintain hydration
• Place in bilirubin lights as needed
• Provide emotional support to parents
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Phototherapy units
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Nursing Responsibilities:
-cover eyes and sex organ
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Meconium Staining
• Over the skin, fingernails & umbilical
cord
• Due to passage of meconium in utero r/t
fetal hypoxia
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Lanugo
• Found after 20
weeks of gestation
on the entire body
except the palms &
soles
• Fine downy hair that
covers the
shoulders, back &
upper arms
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Nursing Considerations:
• More mature, less lanugo
• May disappear within 2 weeks
• Preterm: woolly patches of lanugo on
skin and head
• Post term: parchment-like skin w/o
lanugo
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Vernix Caseosa
• Protective cheesy-like, gray-white
fatty substance
• FT: skin folds under the arms and
in the groin under the scrotum or in
the labia
• Nursing Considerations:
– Use baby oil
– DO NOT attempt to remove
vigorously
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Desquamation
• Dryness/ peeling of the skin
• Usually occurs after 24-36 hours
• Marked scaliness & desquamation =
signs of postmaturity
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Milia
• Multiple, yellow or pearly
white papules approx. 1
mm wide
• Due to enlarged or
clogged sebaceous gland
• Usually found on the nose,
chin, cheeks, eyebrows
and forehead
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Birthmarks
Mongolian Spots
• Blue-green or gray
pigmentation
• Lower back,
sacrum & buttocks
• Disappears by
4 years of age
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Salmon Patches
• Seen commonly in NB
• AKA: Naevus simplex,
"angel kisses" (when on
the forehead or
eyelids), and "stork
bites" (over the nape of
the neck)
• midline malformations
consisting of ectatic
capillaries in the upper
dermis with normal
overlying skin.
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Stork bites
• Telangiectatic Nevi
• Flat red or purple
lesions
• Back of neck, lower
occiput, upper eyelid
and bridge of the
nose
• After 2 years of age
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Strawberry marks
• Nevus Vasculosus or
Capillary Hemangioma
• Dark red, raised
lobulated tumor
• Head, neck trunk &
extremities
• After 7 to 9 years of
age
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Large capillary hemangioma
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Cavernous Hemangioma
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Port-wine stain
• Nevus Flammeus or
Capillary Angioma
• capillary malformation
• Flat Red to purple,
sharply demarcated
dense areas beneath the
capillaries
• Face
• Does not fade with time
• Associated with SturgeWeber
syndrome
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Sturge-Weber syndrome
• PWS involving the forehead (V1 area of
the trigeminal nerve), eye abnormalities
(choroidal vascular abnormalities,
glaucoma), and leptomeningeal and
brain abnormalities (vascular
malformations, calcification, or cerebral
atrophy)
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Other Skin Marks
Mottling
• Cutis marmorata
• reticulated pattern of
constricted capillaries
and venules due to
vasomotor instability in
immature infants
• Bluish mottling or
marbling of skin in
response to chilling,
stress or
overstimulation
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Erythema toxicum
• Newborn rash
• Small, white,
yellow, or pink to
red papular rash
• Trunk, face &
extremities
• Within 48 hrs
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Petechiae
• Pinpoint hemorrhages
on skin
• Due to increased
vascular pressure,
infection or
thrombocytopenia
• Within 48 hrs
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Ecchymosis
• Bruises
• As a result of rupture of
blood vessels
• May appear over the
presenting part as a result
of trauma during delivery
• May also indicate infection
or bleeding problems
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Harlequin Sign
• When on side,
dependent side
turns red and upper
side/ half turns pale
• Due to gravity and
vasomotor instability
or immature
circulation
• Skin resembles a
CLOWN’S SUIT
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Café-au-lait spots
• Tan or light brown
macules or patches
• NO pathologic
significance, if <3cm
in length and <6 in
number
• If > 3 or 6 =
Cutaneous
neurofibromatosis
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Neurofibromatosis
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HEAD
What to assess
• For symmetry, shape, swelling,
movement
–Soft, pliable, moves easily
–With some molding (if VSD);
round & well-shaped (if CS)
• Measure HC; HC = or > CC
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• Fontanelles “soft spot”
–BAD (12-18 mos)
–LPT (2-3 mos or 8-12 wks)
–Bulging or sunken
• Sutures
–Overriding or separated
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• Head lag
– Common when pulling newborn to a
sitting position
– When prone, NB should be able to lift
the head slightly and turn head from
side to side
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Caput Succeedaneum
• Swelling of soft
tissues of the
scalp
• Due to pressure
• Crosses the
suture lines
• Presenting part
• 3 days after birth
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Cephalhematoma
• Subperiosteal
hemorrhage with
collection blood
• Due to rupture of
capillaries as a result
of trauma
• Does not crossed
suture lines
• Several weeks
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Molding
• Overlapping of skull
bones
• Due to compression
during labor and
delivery
• Disappears in few
days
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Forcep Marks
• U –shaped
bruising usually
on the cheeks
after forcep
delivery
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Craniotabes
• Localized softening of the cranial bones
• Can be indented by pressure of fingers
• MOST common among 1st born babies,
pathological in older child—metabolic
disorder
• Caused by pressure of the fetal skull
against the mother’s pelvic bone in
utero
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Craniosynostosis
• Premature closure of the fontanelles
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Face/Eyes/Ears/
Nose /Mouth
What to Assess
• Facial movement & symmetry
• Symmetry, size, shape and spacing of
eyes, nose and ears
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Eyes
• Color:
– white sclera
– Slate gray, brown or dark blue
– Final eye color: after 6-12 months
• Symmetrical
• Pupils equal, round, reactive to light
• (+) Blink reflex
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• (+) transient strabismus due to weak
EOM
• Able to move and fixate momentarily
• (+) Red reflex – if (-), cataract
• (+) Edema on eyelids r/t pressure
during delivery or effects of medication
• (-) Tear formation (begins @ 2-3 mos)
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Nursing Considerations
• Administer eye medication within 1 hr
after birth to prevent Ophthalmia
neonatorum
• DOC: Erythromycin 0.5%
Tetracycline 1%
Silver Nitrate 1%
• From inner to outer canthus of the eye
(conjunctival sac)
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Nose
•
•
•
•
•
•
•
Small & narrow
Flattened, midline
Nasal breathers
(+) Periodic sneezing
Reactive to strong odors
(+) Flaring = respiratory distress
(+) Low nasal bridge = Down’s syndrome
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Ears
• Soft and pliable; with firm cartilage
Pinna should be at the level of outer
canthus of the eye
• (+) Low set ears = renal or
chromosomal abnormalities
• May be congested and hear well after
few days
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Low set ears
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Accessory tragus:
remnant of 1st branchial
arch
Congenital preauricular sinus:
ends blindly
risk for infection
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Mouth
• Pink, moist gums
• Intact soft & hard palates
– (+) Epstein’s pearls
• Uvula midline
• Tongue moves freely, symmetrical with
short frenulum
• (+) Extrusion & Gag reflexes
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• Small mouth or large tongue =
chromosomal problems
• (+) white patches on tongue or side of
the cheek = Oral thrush
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Neck
• Short, thick, in midline
• Able to flex and extend but cannot
support the full weight of head
• Creased with skin folds
• Trachea midline
• Thyroid gland not palpable
• Intact clavicle
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Chest
•
•
•
•
CC = or < 2cm than HC
Cylindrical; equal AP:T diameters
Symmetrical
Abdominal breathers
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• (+) Bronchial sounds
• (+) Breast engorgement ;
subsides after 2 wks
• (+)Prominent/ edematous nipple
• (+) Accessory nipples
• (+) “Witch Milk”
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Abdomen
• Umbilical Cord
– 2 arteries; 1 vein
– White & gelatinous immediately after
birth
– Begins to DRY between 1-2 hrs
following birth
– Blackened or shriveled between 2-3
days
– Dried & gradually falls off by 7 days
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Daily Cord Care
• Keep cord dry and clean & clamp secured
• Apply 70% isopropyl alcohol to the cord
with each diaper change and at least 2-3x
a day.
• DO NOT cover with diaper
• Note for any signs of bleeding or drainage
from the cord and other abnormalities
• Sponge bath until cord falls off.
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• GIT:
– Capacity: 90 ml, with rapid intestinal
peristalsis ( 2 ½ to 3 hrs)
– Bowels sounds; (+) within 1-2 hrs
after birth
– Presence of mass, distention
depression or protrusion
– (+) Scaphoid = diaphragmatic hernia
– (+) Distended = LGIT obstruction/
mass
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• Anus
– Check patency
– First stool (Meconium) – within 1st 24
hrs
• Sticky, tarlike, blackish-green,
odorless material
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Transitional Stool
• Within 2- 10 days after birth
• Breastfed:
– golden yellow, mushy, more frequent
3-4x and sweet smelling
• Bottlefed:
– Pale yello, firm, less frequent 2-3x,
with more noticeable odor
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Nursing Considerations
• Breastfeeding can usually begin
immediately after birth
• Bottlefeeding may be started with sterile
water to 4 hrs after birth prior to formula
feeding
• Burp during and after feeding
• Position properly during and after
feeding
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Genitals
• Female:
– Labia: edematous
– Clitoris: enlarged
– (+) Smegma
– Pseudomenstruation possible
– Visible “hymen tag”
– First voiding within 24 hrs
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• Male:
– Prepuce covers glans penis
• (+) adherent foreskin = Phimosis
– Scrotum: edematous
• (+) enlarged = Hernia
– Meatus: central
• (+) ventral/ dorsal = Hypo/epispadias
– Testes: descended
• (+) undescended = Cryptorchidism
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•
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Back
• Spine
– Straight, posture flexed
– Supports head momentarily
– Arms & legs flexed
– Chin flexed on upper chest
– Check for protrusion, excessive or
poor muscle contractions = CNS
damage
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Extremities
• Flexed, full ROM, symmetrical
• Clenched fists; flat soles
• With 10 fingers and toes in each
hand
• Legs bowed
• Even gluteal folds
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• (+) Creases on soles of feet
– (-) Creases = prematurity
• Check for hip fractures or dysplasia
– (+) Ortolani’s click & uneven gluteal
folds = Hip dysplasia
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• (+) inward turning of the foot = club foot
or talipes equinovarus
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• (+) extra digits =
Polydactyly
• (+) web fingers =
Syndactyly
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Neurologic System
Reflexes
Sucking/ Rooting
• Touch the lip, cheek or corner of the
mouth
• Turns head toward the nipple, opens
mouth, takes hold of the nipple and
sucks
• Disappears after 3-4 mos up to 1 year
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Extrusion
• Anything place on the anterior portion of
the tongue will be “spit out’
• To prevent swallowing of inedible
substances
• Disappears after 4 months
• Disappearance indicates readiness for
semi-solid to solid foods
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Swallowing
• Occurs spontaneously after sucking and
obtaining fluids
• NEVER disappear
• Newborn swallows in coordination with
sucking without gagging, coughing or
vomiting
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Tonic Neck/ Fencing
• While the baby is falling asleep or
sleeping, gently and quickly turn the
head to one side
• As the baby faces the left side, the left
arm and leg extend outward while the
right arm or leg flex and vice-versa
• Disappears within 3-4 mos
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Palmar(Grasping)/ Plantar
• Place a finger in the palm of the baby’s
hand, then place a finger at the base of
the toes
• Fingers will curl or grasp the examiner’s
finger and the toes will curl downward
• Palmar: fades within 3-4 mos
• Plantar: fades within 8 mos
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Moro
• Hold baby in a semi sitting position then
allow the head and trunk to fall
backward to at least a 30-degree angle
• Symmetrically abducts and extends the
arms; fans the fingers out and forms a C
with the thumb and the forefinger; and
adducts the arms to an embracing
position & returns to a relaxed state
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• Present at birth; complete response at
8 weeks
• MOST significant singular reflex
indicative of CNS problem (>6 mos)
• Disappears after 4-5 mos.
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Startle
• Best elicited if baby is 24 hrs old
• Make a loud noise or claps hands
• Baby ‘s arms adduct while elbows flex
with fists clenched
• Disappears within 4 mos
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Babinski
• Gently stroke upward along the lateral
aspect of the sole, starting at the heel of
the foot to the ball of the foot
• Dorsiflexion of big toe and fanning of
little toes
• Disappears starts a 3 mos to 1 year
• Disappearance indicates maturity of
CNS
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Stepping/ Walking/ Dancing
• Hold baby in a standing position
allowing one foot to touch a surface
• Simulates walking by alternately flexing
and extending feet
• Disappears after 3-4 mos
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Assessment of Gestational
Age
• Dubowitz Maturity Scale
– Gestational rating scale
– NB are observed and tested
according to the criteria
– Help determine whether the NB
needs immediate high-risk nursery
intervention
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Usher’s Criteria
FINDINGS
0-36 WKS
Sole creases
Anterior transverse Occl creases in
crease only
ant 2/3
Sole covered with
creases
Breast nodule
diameter (mm)
2
4
7
Scalp hair
Fine and fuzzy
Fine and fuzzy
Coarse and silky
Ear lobe
Pliable; no
cartilage
Some cartilage
Stiffened by thick
cartilage
Testes and
scrotum
Testes in lower
canal; scrotum
small; few rugae
Intermediate
Testes pendulous,
scrotum full;
extensive rugae
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39 WKS AND
OVER
151
Ballard’s Scoring
• Completed in 3-4 min
• 2 portions: physical maturity and
neuromuscular maturity
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Physical maturity
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Neuromuscular Maturity
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Scoring
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Physical maturity
19
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Neuromuscular Maturity
17
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Scoring
19+17=36
36
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Other Nursing
Responsibilities
• Identification band
• Birth Registration
• Birth record and
documentation
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Newborn Screening
• The Newborn Screening Reference Center
(NSRC) is an office under the National
Institutes of Health (NIH), University of the
Philippines Manila created under RA 9288–
The Newborn Screening Act of 2004
• Performed after 24 hours of life up to 3 days
except for patient in intensive care, must be
tested by 7 days
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•
•
•
•
•
Congenital Hypothyroidism (CH)
Congenital Adrenal Hyperplasia (CAH)
Galactosemia (GAL)
Phenylketonuria (PKU)
Glucose-6-Phosphate-Dehydrogenase
Deficiency (G6PD Def)
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Disorder Screened
If not screened
If screened
Congenital
Hypothyroidism
Severe mental
retardation
Normal
Congenital Adrenal
Hyperplasia
Death
Alive and Normal
Galactosemia
Death or Cataracts
Alive and normal
PKU
Severe mental
retardation
Normal
G6PD Deficiency
Severe Anemia,
Kernicterus
Normal
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Infant Care Skills
• Holding the baby
– Football Hold
– Cradle Hold
– Shoulder Hold
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Football Hold
Purpose: to carry on one hand free
A holding technique in bathing a baby
Use for small babies
Procedure:
1. slide forearm under his back
2. support neck and head with your hand
3. press his arm firmly against your side
4. his head faces you
5. infant’s feet tucked under your elbow
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Cradle Hold
Purpose: use for feeding and cuddling a baby
Procedure:
• support head in the crook of your arm
• encircle the body with your arm
• press baby firmly against your side
• use other hand to support bottom and thigh
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Shoulder Hold
Purpose: use for burping
Procedure:
• draw baby towards your chest with one forearm
• bracing his back and your hand cradling his head
• support your baby’s bottom and thighs with your
other arm
• gently press his head against shoulder
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QUESTIONS
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• 1.Within what period of time baby
should pass meconium?
• 2.Bilirubin level above what range is
dangerous?
• 3.By what period mongolian spots
disappear?
• 4.Stork bites are seen on which part of
the body?
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• 5.silverman score of what number is
considered as severe respiratory
distress?
• 6.normal head circumference in a
newborn?
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