New Born P.p. Outline

•

American Academy of Pediatrics Recommendations

•

Newborns should be nursed when they show signs of hunger

•

No supplements should be given unless there is a medical indication

•

Exclusive breastfeeding is sufficient for approximately six months

•

American Academy of Pediatrics Recommendations (continued)

•

Gradual introduction of iron-rich solids should begin after six months

•

Breastfeeding should continue for at least 12 months

•

Nutrients in Breast Milk

•

Protein

•

•

–

Source of amino acids for growth

–

Whey fraction more easily digested and promotes gastric emptying

–

Greatest concentration in hind milk

–

Necessary for brain development

Fat

Carbohydrates –

Enhance immunity and brain development

•

Nutrients in Breast Milk (continued)

•

Water and electrolytes

•

Minerals

•

Trace elements

•

Fat-soluble and water-soluble vitamins

•

Anatomy of the Breast

•

Lactogenesis

•

Estrogen and progesterone levels fall

•

Prolactin triggers milk production

•

Oxytocin elicits the let-down reflex

•

Milk production depends on supply and demand –

Feed often (every two to three hours)

–

Avoid supplements

–

Encourage night feedings

•

Interferences with Lactation

•

Poor nutrition, inadequate fluid intake

•

Maternal anxiety

•

Medical conditions

•

Pendulous breasts

•

Flat or inverted nipples

•

Postoperative pain

•

Deficient knowledge

•

Promoting Successful Breastfeeding

•

Maternal comfort and relaxation

•

Positioning of mother and infant

•

Correct latching on of the infant

•

Removal of the infant from the breast

•

Burping

•

Promoting Successful Breastfeeding (continued)

•

Timing –

Feed immediately after delivery if possible

–

Offer both breasts at each feeding

–

15 minutes on each breast

–

Offer the breast every two to three hours

•

Positioning for Breastfeeding

•

Techniques for Successful Breastfeeding

•

Benefits of Breastfeeding

•

Maternal benefits –

Contraception

–

Less anemia

–

Weight loss

–

Involution of the uterus

–

Prevention against breast and ovarian cancer

•

Benefits of Breastfeeding (continued)

•

Infant benefits –

Bonding between mother/infant

–

Optimal nutrition

–

Prevention against infection

–

Enhanced cognitive development

–

Prevention against disease (diabetes, SIDS, asthma)

•

Nursing Implications: Barriers to Successful Breastfeeding

•

Maternal barriers

•

–

Diet, medications, smoking, fatigue

–

Prior breast surgery

–

Nipple abnormalities

–

Contraceptives

–

Psychologic issues, modesty

Infant barriers –

Prematurity

–

Illness and disability

–

Hypoglycemia

–

Jaundice

•

Assessment for Insufficient Lactation

•

Low urination pattern

•

Low stooling frequency

•

Minimal breast changes after delivery

•

Irritable or sleepy infant

•

Nursing less than seven times a day

•

Weight loss of more than 10% of the birth weight

•

Continued weight loss after day 10 of life

•

Contraindications to Breastfeeding

•

Maternal disease –

Hepatitis B, C

–

HIV

•

Maternal medications

•

Infant –

Severe illness

–

Inborn errors of metabolism

•

Common Breastfeeding Problems

•

Cracked or sore nipples

•

–

Change positions

–

Assess for proper latching on

–

Apply breast milk after nursing

–

Cabbage leaves, tea bags

Mastitis –

Antibiotics

•

Common Breastfeeding Problems (continued)

•

Engorgement

•

–

Feed frequently, avoid supplements

–

Good support bra

–

Apply warmth (towels, shower) before nursing

Breast Pumps

•

Resources for Breastfeeding Mothers

•

Lactation consultants

•

La Leche League

•

International Lactation Consultant Association

•

Formula Feeding

•

Available in powder, concentrate, ready-to-feed forms –

Ensure that parents know how to mix formula

–

Ensure cleanliness in preparation

•

Cow- or soy-based preparations

•

Monitor for food allergy symptoms –

Rash, colic, diarrhea, bloody stool, respiratory symptoms

•

Formula Feeding (continued)

•

Solids usually introduced at about four months –

One new food at a time

–

Wait at least three days between new foods

•

NUR251 Nursing Theory & Science III

•

NEWBORN

•

Pulmonary System Transition

•

Function of respiration switches from the placenta to the lungs

•

Factors responsible for onset of breathing –

Hypercapnia

–

Hypoxia

–

Acidosis

–

Environment (cold, light, noise)

•

Fluid in the lungs must be cleared

•

Pulmonary arterioles dilate, PVR level falls

•

Cardiac System Transition

•

Pressure in right side of the heart falls and pulmonary venous return to left atrium increases –

Foramen ovale closes due to these changes

•

Ductus arteriosis constricts and closes functionally by 96 hours

•

Ductus venosis constricts and closes functionally by two to three days

•

Thermoregulation

•

Body heat lost easily due to large body surface area in relation to weight

•

Limited neonatal fat stores

•

Limited capacity for heat production –

Brown-fat metabolism is primary heat source

•

Thermoregulation (continued)

•

Normal axillary temperature is 97°F–99.5°F –

Hypothermia is <97.0

•

Goal is to keep infant in a neutral thermal environment

•

Nursing Interventions to Prevent Hypothermia

•

Dry infant, remove wet blankets

•

Apply a hat and warm blankets

•

Avoid placing infant on cold surfaces

•

Avoid placing infants in drafts

•

Nursing Interventions to Prevent Hypothermia (continued)

•

Use heat source when bathing infants

•

Place under radiant warmer if temperature is unstable

•

Metabolic Transition

•

Infant’s source of nutrition from the placenta terminates at birth

•

Blood sugar reaches its lowest point one to three hours after birth

•

Glucose stabilizes by four to six hours after birth

•

Range of 45–80 mg/dl is normal

•

Gastrointestinal System

•

At birth abdomen is flat and bowel sounds are absent

•

Abdomen becomes rounded and soft with onset of respirations

•

Bowel sounds usually audible within 15 minutes of birth

•

First Period of Reactivity

•

First minutes after birth

•

Characteristics –

•

Alert, active, sucking activity, tachycardia, tachypnea, transient rales and nasal flaring

Implications for the family –

Infant alert and responsive

–

Allow quiet time for family to be together

–

Introduce breastfeeding

•

Period of Decreased Activity

•

Follows first period of reactivity

•

Characteristics –

Less alert and active, sleep may occur, vital signs normalize

•

Period of Decreased Activity (continued)

•

Implications for the family –

Family may stay together or infant may be taken to nursery for assessment

–

Opportunity for parents to have quiet time

–

Mother may use this time to rest

•

Second Period of Reactivity

•

Infant awakens and shows increased responsiveness to the environment

•

Characteristics –

•

Peristalsis increases and meconium may be passed, gagging, spitting up

Implications for the family

–

Allow time together if mother is rested

–

Parents may begin to have questions or need assistance with newborn care

•

Asphyxia

•

Arises from inadequate or absent respiration

•

–

Impairment of oxygen/carbon dioxide exchange

–

Hypoxemia, hypercarbia, respiratory acidosis

Assessment findings –

Poor tone, gasping or absent respirations, bradycardia, cyanosis, low Apgar score

•

Asphyxia (continued)

•

Management –

Tactile stimulation

–

Positive pressure ventilation with 100% oxygen

•

Meconium Staining

•

Caused by distress, usually asphyxia

•

Risk is that fetus/infant may aspirate –

•

Assessment findings –

•

Obstruction, chemical pneumonia may result

Respiratory distress, hypoxemia

Prevention –

Suctioning nose/mouth before delivery of the chest

–

Appropriate suctioning post delivery

•

Transient Tachypnea of the Newborn

•

Characteristics –

•

Risk factors –

•

Grunting, retracting, tachypnea

Cesarean delivery, precipitous delivery

Management

–

Oxygen therapy

–

IV fluids

–

Short-term ventilation

–

Antibiotics if sepsis is suspected

•

Hypoglycemia

•

Plasma glucose level below 40 mg/dl

•

Assessment findings –

•

Jitteriness, tremors, apnea, cyanosis, lethargy

Risk factors –

SGA, preterm, perinatal stress, IDM, sepsis

•

Hypoglycemia (continued)

•

Management –

Early feeding of infants at risk

–

Keep infant warm

–

Glucose by nipple, gavage, or IV

–

Recheck blood glucose 30 minutes after feeding

•

Transition of the Premature Infant

•

Pulmonary system –

•

Inadequate alveolar development, lack of surfactant •

May require ventilatory support

•

Administration of surfactant

Cardiac system –

Persistent ductus arteriosis (PDA) •

Indomethacin given to facilitate closure

•

Resuscitation and Stabilization in the Delivery Room

•

Dry and provide warmth, tactile stimulation

•

Clear airway

•

Resuscitation for compromised infants –

Place under radiant warmer, stimulate

–

Position to ensure a patent airway

–

Suction using appropriate technique

–

Evaluate respirations, heart rate, color

•

Resuscitation and Stabilization in the Delivery Room (continued)

•

Resuscitation for compromised infants (continued) –

Administer oxygen if indicated

–

Bag-mask ventilation if apneic

–

Medications may be indicated if infant does not respond

•

NUR251 Nursing Theory & Science III

•

NEWBORN

•

Assessment After Transition

•

Temperature –

•

Normal axillary temperature 97°F–99.5°F

Cardiovascular system –

Normal heart rate 120–150 bpm

–

Observe color, pulse, murmurs

•

Assessment After Transition (continued)

•

Respiratory system –

Normal rate is 30–60/minute

–

Nose-breather

–

Observe for flaring, grunting, retracting

–

Auscultate for rales

•

General Nursing Care

•

Eye prophylaxis –

Prevents gonorrhea and chlamydia

– •

•

Erythromycin or tetracycline ointment

Vitamin K prophylaxis (0.5–1.0 mg) –

IM into lateral thigh

–

Prevents bleeding due to Vitamin K deficiency

First bath –

Institute measures to prevent hypothermia

•

General Assessment

•

Position

•

–

Flexion of upper and lower extremities

–

Symmetrical movement

Color –

Acrocyanosis

–

Jaundice

•

Body size

•

Reactivity

•

Identification

•

Physical Examination

•

Weight

2,500–4,300 g •

Length

45–54 cm •

Head circumference

33–38 cm •

Vital signs

•

Gestational Age Assessment

•

Neuromuscular maturity –

Posture

–

Square window

•

–

Arm recoil

–

Popliteal angle

–

Scarf sign

–

Heel-to-ear

Physical maturity –

Skin

–

Lanugo

–

Plantar surface

–

Breasts

–

Eye and ear

–

Genitalia

•

Skin Assessment

•

Normal findings: color pink

•

Common variations

•

–

Milia

–

Erythema toxicum

–

Mongolian spots

–

Birthmarks

Common problems –

Petechiae

–

Blisters, lesions

–

Plethara

–

Abnormal hair distribution

•

Head, Eyes, Nose, and Throat Assessment

•

Normal findings –

Symmetry in appearance, normal placement

–

Anterior fontanel open

•

•

Common variations –

Molding

–

Caput succedaneum

–

Cephalhematoma

–

Teeth

Head, Eyes, Nose, and Throat Assessment (continued)

Caput succedaneum •

Head, Eyes, Nose, and Throat Assessment (continued)

•

Common problems –

Low-set ears

–

Discolored sclera (yellow, bluish)

–

Cleft lip, palate

–

Absent red reflex

–

Microcephaly, hydrocephaly

–

Craniostenosis

–

Features characteristic of FAS

•

Respiratory System Assessment

•

Normal findings –

•

•

•

Symmetrical expansion

Common variations –

Accessory nipples

–

Gynecomastia

Common problems –

Retractions

–

Tachypnea

–

Rales

Cardiovascular Assessment

•

•

Normal findings –

Color pink

–

Normal rate and rhythm

Common variations –

Murmurs

–

Acrocyanosis

•

Cardiovascular Assessment (continued)

•

Common problems –

Persistent murmurs

–

Cyanosis

–

Tachycardia, bradycardia

•

Abdominal Assessment

•

Normal findings

•

–

Round, full, symmetrical, plus bowel sounds

–

Two arteries, one vein in cord

Common variations –

Hernia

•

Abdominal Assessment (continued)

•

Common problems –

Two-vessel cord

–

Distension, absent bowel sounds

–

Discharge/leakage from the cord

–

Abdominal mass

•

Genital and Anal Assessment

•

Normal findings –

Patent anus

–

Testes descended

–

Stool and urine by 24 hours after birth

•

Common variations –

Hydrocele

–

Hymenal tag and vaginal discharge

•

Genital and Anal Assessment (continued)

•

Common problems –

Undescended testes

–

Epispadius, hypospadius

–

Imperforate anus

•

Circumcision

•

Risks –

•

•

Bleeding, infection, adhesions, pain

Benefits –

Decreased incidence of UTIs

–

Prevention against penile cancer

Nursing care after circumcision –

Observe for bleeding

–

Observe for voiding difficulties

•

Musculoskeletal Assessment

•

Normal findings –

•

Normal tone, flexion, symmetrical movement

Common variations –

Hip click

–

Club foot

•

Musculoskeletal Assessment (continued)

•

Common problems –

Fracture (clavicle most common)

–

Hip dysplasia

–

Syndactyly/polydactyly

–

Asymmetrical movement

–

Simian crease

•

Neurologic System

•

Normal findings –

•

Normal reflexes (suck, rooting, grasp, Moro, Gallant, gag, Babinski’s)

Common problems –

Brachial plexus injury (Erb’s palsy)

–

Spina bifida

–

Anencephaly

–

Absent or abnormal reflexes

–

Seizure activity

•

Periodic Shift Assessment

•

Vital signs

•

Weight

•

Feeding and elimination

•

Hydration status

•

Respiratory and cardiac function

•

Hip movements

•

Factors Placing the Infant at Risk

•

Physical –

•

Birth injuries, congenital conditions, temperature control

Psychological –

Interferences in interaction between parents, newborn

•

Family

•

Environment

•

Illness and infection

•

NUR251 Nursing Theory & Science III

•

NEWBORN

•

Intrauterine Growth Restriction

•

Infants <10th percentile for weight at birth

•

May be symmetric or asymmetric

•

Factors may be fetal, maternal, or placental

•

Complications –

Hypoxia, hypothermia, hypoglycemia, polycythemia, hyperbilirubinemia, meconium aspiration

•

Intrauterine Growth Restriction (continued)

•

Nursing implications –

Prevent heat loss

–

Monitor blood glucose, feed early

–

Monitor for respiratory complications

–

Management of hyperbilirubinemia

•

Triplets Manifesting Different Rates of Growth

•

Large for Gestational Age Infant

•

Infants >90th percentile for weight at birth

•

Factors –

•

Complications –

•

Maternal diabetes, parental obesity

Difficult delivery, birth trauma, hypoglycemia

Nursing implications –

Assess for birth injury

–

Monitor for hypoglycemia

•

The Premature Infant

•

Delivery prior to 37 weeks’ gestation

•

Factors –

Multiple gestation, PROM, incompetent cervix

•

The Premature Infant (continued)

•

Assessment –

Gestational age assessment

–

Neurologic assessment

–

Physical characteristics •

Thin skin, soft cartilage, absent plantar creases

•

Abundant lanugo and vernix

•

Genitalia characteristic of prematurity

•

Review of Systems and Potential Complications

•

Cardiovascular

•

•

•

–

Patent ductus arteriosis

–

Hypotension

Central nervous system –

Intraventricular hemorrhage

–

Posthemorrhagic hydrocephalus

Hematologic system –

Anemia

–

Polycythemia

Hepatic system –

Hyperbilirubinemia

•

Review of Systems (continued)

•

Gastrointestinal system

•

–

Dysmotility

–

Necrotizing enterocolitis

–

Gastroesophageal reflux

Immune system –

Infection

•

Integumentary system –

Epidermal stripping

–

Absorption of chemical agents

•

Review of Systems (continued)

•

Ophthalmologic system –

•

•

Retinopathy of prematurity

Renal system –

Oliguria

–

Glycosuria

Respiratory system –

Respiratory distress syndrome

–

Bronchopulmonary dysplasia

–

Apnea of prematurity

–

Pneumonia

•

Nutrition and Fluid Management

•

Fluids –

•

Strict I&O, weigh diapers

Electrolyte management –

Management of sodium and potassium levels

•

Glucose homeostasis

•

Feeding –

Gavage or nipple method

–

Types: formula or breast milk

•

Developmental Care of the Preterm Infant

•

Light

•

Sound

•

Temperature

•

Positioning and containment strategies

•

Handling and touching

•

Nonnutritive sucking

•

NUR251 Nursing Theory & Science III

•

NEWBORN

•

Spina Bifida

•

Etiology–failure of the spinal cord to close

•

Assessment findings –

•

Diagnosis possible before birth –

•

May be mild to severe

MSAFP screening and ultrasound

Management –

Surgical closure of open defects

•

Spina Bifida (continued)

•

Nursing implications –

Cover defect, position to avoid pressure

–

Administer antibiotics, monitor for infection

–

Prevent stasis of urine

•

Choanal Atresia

•

Separation between nose and pharynx

•

Assessment findings –

•

Respiratory distress

Management –

Surgery

•

Diaphragmatic Hernia

•

Diaphragm fails to close and abdominal organs are displaced into the chest

•

Prenatal diagnosis

–

Ultrasound

•

Diaphragmatic Hernia (continued)

•

Assessment findings

•

–

Severe respiratory distress

–

Scaphoid abdomen

–

Absent breath sounds

Management –

Surgical repair

•

Congenital Heart Defects

•

100 different types –

•

Transposition of the great vessels and coarctation of the aorta most common life- threatening

Assessment findings –

Respiratory distress, cyanosis, murmurs, diminished femoral pulses

•

Congenital Heart Defects (continued)

•

Management –

•

Medical and/or surgical interventions

Nursing interventions –

Careful monitoring, administer oxygen

–

Minimize crying

–

Gavage feeding

•

Cleft Lip and Palate

•

Failure of the maxillary and premaxillary processes to fuse

•

Diagnosis –

Prenatal diagnosis possible with ultrasound, examination of the palate during the initial assessment

•

Cleft Lip and Palate (continued)

•

Management –

Surgical repair

•

Nursing interventions –

Feeding a major issue until the defect is repaired

•

Various Gastrointestinal Anomalies

•

Various Gastrointestinal Anomalies (continued)

•

Genitourinary System Anomalies

•

Hypospadius –

•

Epispadius –

•

Urethral meatus on ventral surface of the penis

Urethral opening on the dorsal surface of the penis

Exstrophy of the bladder –

Absent abdominal wall so bladder lies open on the lower abdomen

•

Genitourinary System Anomalies (continued)

•

Ambiguous genitalia –

External genitalia not defined as male or female

–

May be caused by congenital adrenal hypoplasia

•

Developmental Dysplasia of the Hip

•

Malformation of the hip

•

Assessment findings

•

–

Uneven gluteal folds (A.)

–

Hip click with legs are abducted (B., C.)

Management –

Hips flexed and abducted position

–

Casting or surgery may be required

•

Talipes Equinovarus (Club Foot)

•

Portions of the foot and ankle are twisted out of normal position (A.)

•

Management

–

Manipulation of the foot (B.)

–

Casting

–

Surgery

•

Trauma and Birth Injuries

•

Fractures –

Clavicle, long bones, skull most common

–

Risks •

–

Assessment •

–

Large infant, breech, difficult labor

Impaired mobility

Management •

Immobilization, traction, casting

•

Trauma and Birth Injuries (continued)

•

Facial Palsy –

•

Usually related to use of forceps

Brachial Palsy –

Usually related to difficult delivery such as shoulder dystocia

–

Assessment •

–

Impaired mobility of arm

Paralysis may be temporary or permanent

•

Infants of Diabetic Mothers

•

Risk factors

•

–

Congenital anomalies

–

Macrosomia (>4,000 gm)

–

Hypoglycemia

–

Respiratory distress syndrome

Infants of Diabetic Mothers (continued)

•

Prevention of complications –

Normoglycemia during gestation and labor

–

Deliver when lungs are mature

–

Prepare for delivery of large infant

–

Monitor for hypoglycemia

•

Hyperbilirubinemia

•

Excess bilirubin in the blood resulting in jaundice

•

Can be caused by physiologic or pathologic processes –

Normal RBC breakdown

–

Rh or ABO incompatibility

•

Hyperbilirubinemia (continued)

•

Complications

•

–

Kernicterus

–

Erythroblastosis fetalis

–

Hydrops fetalis

Assessment findings –

Jaundice, elevated bilirubin levels

•

Management of Hyperbilirubinemia

•

Encourage frequent feedings

•

Exposure to sunlight

•

Phototherapy

•

–

Shield infant’s eyes

–

Monitor body temperature

–

Monitor weight

–

Monitor fluid intake

–

Weigh diapers

–

Note frequency of stools

Sepsis

•

Risk factors –

Maternal infection (group B streptococcus most common)

–

Long labor, prolonged rupture of the membranes

–

Maternal fever, chorioamnionitis

–

Fetal distress, aspiration

•

Sepsis (continued)

•

Assessment findings –

•

Unstable temperature, poor tone, poor sucking

Management –

Antibiotics

–

Supportive care