Birth through the first 2 hours
Assessment and nursing diagnoses
Apgar score
Initial physical assessment
-external
-chest
-abdomen
-neurologic
-other observations
Responsibilities After birth
Care of the infant
-promote normal respirations
-support thermoregulation (dry baby quickly and reduce heat loss)
-identify the infant (baby gets two bands & mom gets one along with support person)
APGAR score
Provides rapid assessment
5 signs that indicate physiologic state of the neonate:
1. Heart rate
2. Respiratory rate
3. Muscle tone
4. Reflex irritability
5.Generalized skin color
When do you assess APGAR score?
1 minute after birth and 5 minutes after birth
What do you suction when the baby is born?
Suction the mouth first and the nose next
What does APGAR stand for?
A = appearance
P = pulse
G = grimace
A = activity
R = respiratory effort
APGAR how is it scored
Each item is scored as 0,1, or 2
Evaluations are made at 1 and 5 minutes after birth
Score of 8 or more, no intervention needed
Score of 4-6 interventions
Score of less than 4 needs resuscitation
The Apgar score at 1 minute evaluates the status of the neonates:
Intrauterine oxygenation
At 5 minutes it evaluates the status of transition to:
Extrauteirne oxygenation
Development of the lungs
First vital task for newborn
-initiation of respirations
Surfactant lines the alveoli and reduces surface tension to keep the alveoli open
Sufficient surfactant by 34-36 weeks gestation
Surfactant secretion increases during labor and immediately after bir
Lungs Continued
Fetal lung fluid moves into the interstitial spaces before, during and after birth
Lung fluid is absorbed by the lymphatic and vascular systems
Causes of respirations:
-first breath requires much larger negative pressure (suction) than subsequent breathin
Initiation of Respirations
A number of factors combine to stimulate the respiratory center in the brain and initiate respirations at birth
-chemical
-mechanical
-thermal
-sensory
Continuation of respirations
Alveoli remain partially open
Much of air from 1st respiration become residual capacity
Subsequent breaths require less effort
As infant cries, pressure with in lungs increase, causing remaining fetal lung fluid to move into interstitial spaces
Cardiovascular adaptation
Transition form fetal to neonatal circulation
-increase in blood oxygen level
-shifts in pressure in the heart and lungs
-Closing of the umbilical vessels
-Closing of the ductus arteriosus, foramen ovale, and the ductus venosis at birth
Thermoregulation
Next to establishing respirations, heat regulation is most critical to the newborns survival
Thermoregulation
Newborn characteristic leading to heat loss
-skin with little sub q fat white
Blood vessels clots to the surface
Large skin surface
Methods of heat production
-increase activity
-flexion
-metabolism
-vasoconstriction (acrocyanosis)
-nonshivering thermogenesis (brown fat)
These factors increase O2 and glucose consumption and may cause respiratory distress, hypoglycemia, and jaundice
Nonshivering Thermogenesis
When newborn becomes cold = restless and cry, increase activity to help maintain heat
Temperature regulation - newborn thermal
Insulation is less than an adult
Effects of cold Stress
Increased O2 need
Decreased surfactant production
Respiratory distress
Hypoglycemia
Metabolic acidosis
Jaundice
Methods of heat loss
Evaporation
Conduction
Convection
Radiation
Hematologists Adaptation
Erythrocytes, hemoglobin, and hematocrit
-Higher for newborns than for adults because less oxygen was available in fetal life than after birth
Leukocytes
-elevated while blood count
Clotting
-Newborns are giving helpful levels of wits in K, which is neces
Gastrointestinal system
Stomach
Intestines
Enzymes
Stools
-progress form meconium > transitional > milk stools
-stools of breastfed infants are frequent, seedy, and mustard-colored
Blood Glucose Maintenance
The neonate uses glucose rapidly and is at risk for hypoglycemia
Infants at risk for hypoglycemia include:
Preterm and late preterm
Small for gestational age
Large for gestational age
Born to diabetic mothers
Exposed to stressors
Signs of hypoglycemia
Jitteriness, tremors
Poor muscle tone
Sweating
Tachypnea
Cyanosis
Apnea
Diaphoresis
Low temp
Poor suck
High pitched cry
Lethargy
Irritability
Seizures, coma
**Some infants may be asymptomatic
Hepatic - conjugation of Bilirubin
Bilirubin is a yellow pigment derived from the hemoglobin
-released with the breakdown of RBCs and the myoglobin in muscle cells
Hyperbilirubinemia - excessive bilirubin in the bold
Physiologic Jaundice
Occurs after the first 24 hours of life as a result of hemolysis of red blood cells and immaturity of the liver
Sources and effect of bilirubin
Principal source is hemolysis of erythrocytes
Bilirubin is toxic to the body - must be excreted
Released in unconjugated form
Risk factors for elevated bilirubin
Liver immaturity
Lack of albumin binding sites
Short red blood cell life
Blood incompatibility
Gestation
Express production of erythrocytes
Trauma
Fatty acids from cold stress or asphyxia
Family background
Delayed feeding
(Diabetic nothing, some drugs, hy
Pathological jaundice
Begins in the first 24 hours and my require treatment with phototherapy
Breast milk jaundice
Often caused by a lack of sufficient intake
True breast milk of late onset jaundice
Occurs after 3-5 days of life
3 weeks to 3 months to resolve
Hepatic - Physiologic Jaundice
Neonatal jaundice or hyperbilirubinemia
Appears when levels reach 5-6 mg/dL
Appears in cephalocaudal manner
Dissipates in reverse order
Early frequent feeding keeps it in a safe zone
Asians & Native Americans & Hispanics are at a higher risk
Hepatic - Kernicterus
Kernicterus
Most serious complications not neonatal hyperbilirubinemia
Occurs when bilirubin levels are less than
Hepatic - Jaundice associated with breastfeeding
Incidence of jaundice
Caloric and fluid intake
Hepatic clearance of bilirubin
Less frequent stooling Amy allow for extended time for reabsorption of bilirubin from stools
Urinary system - Kidney function
The ability of the newborn kidneys to filter, reabsorbed and maintain fluid and electrolyte balance is less than that of the adult kidney
Fluid balance
The newborn body is composed of a greater percentage of water
The void should occur with 24 hours
Absence fo stool or urine for 48 hours may signify an abnormality
Immune system
Neonates are less effective at fighting off infection than the older child or adult
-IgG crosses the placenta in uterus and provides a newborn with passive immunity
-IgM and IgG are produced to protect against infection
Psychosocial Adaptation
First period of reactivity
-wide awake, alert, and seems interested in their surroundings
-temp may be decreased and heart rate may be elevated
Period of sleep or decreased activity
-falls into a deep sleep
Second period of reactivity
-become interested i
Behavioral States
Deeper quiet sleep
Light or active sleep
Drowsy
Quiet alert
Active alert
Crying
Assessment
Asses immediately after birth to detect abnormalities
Cardiorespiratory statue
-history, airway, color, heart sounds, pulses, and blood pressure
-cyanosis, acrocyanosis
Thermoregulation
-axillae temperatures are preferred over rectal temperatures
Normal Vital Signs in the Newborn
Temp-
Axillary: 97.7-99.1 F
Rectal: 97.7-99.8 F
Skin-
95.9-97.7 F
Vital signs
Apical : 120-160 bpm
(100 sleeping , 180 crying)
Respirations : 30-60 bpm
(Average 40-49)
Assessing for Anomalies
Head
-molding
-Fontanels (soft)
-caput (cone shaped head)
-cephalhematoma (blood collection underneath)
-facial symmetry
Integumentary system
Marks on the skin should be documented, including location size and a general description
-vernix (cheesy stuff over them)
-lanugo (hair)
-milia (white dots on nose)
-erythema toxicum (looks like flea bites)
-birthmarks
-marks from delivery
Caput Succedaneum
Is a generalized , easily identifiable edematous area of the scalp most commonly found on the occiputal
Usually disappears spontaneously within 3-4 days
Infants born with the assistance of vacuum extraction usually have a caput (and bruising) in the area
Cephalhematome **
Is a collection of blood between a skull bone and its periosteum
-therefore cephalhematoma does not cross a cranial suture line
Caput succedaneum and cephalhematoma often occur simultaneously
Spontaneously resolves in 2 weeks to 3 months
As the hematoma r
Desquamation
peeling" of the skin of the term infant
Occurs a few days after birth
If present at birth is an indicator of post maturity
Sweat and Oil glands
Present at birth
Do not respond to increases in ambient or body temperature
Vernix caseosa
Milia
Integumentary - Signs of risk
Close observation of the newborn's skin color can lead to early detection of potential problems
Nursing may lead to increased bilirubin levels
Petechiae may be present
Reproductive system
-female
-male
-swelling of breast tissue (both sexes)
-signs of risk for reproductive system problems
Female
-labia Majora should be large and completely covered the clitoris and labia Minorca
-genitalia may be darker
-vagina discharge normal
Male
Scrotum at term pendulous
Genitalia may be dark brown
Palpate scrotum
Assessing for anomalies (Continued)
Neck
Clavicles
Cord
Extremities
-hands and feet
-hips
Skeletal system
Undergoes rapid development in 1st year
Due to cephalocaudal development, looks somewhat out of proportion
At term, head is 1/4 of total body length
Skeletal deformities may be congenital or drug indcued
Weight
Ranges from : 2500 g - 4000 g (5 lbs 8 oz - 8 lbs 13 oz)
Average full term is 3400 g
Expected to loose up to 10% of birth weight during first few days of life
Regain or exceed birth weight by 14 days of life
Length
Measure form top of head to heel of outstretched leg
Normal length in full term = 48-53cm (18-22 in)
Head
Measure around occupy, just above eyebrows
Normal range: 32-38 cm (12.5 - 15in)
Chest
Measured at level of nipples
Usually 2-3cm smaller than head
Normally : 30-36 cm (12-14in)
Gestational Age Assessment
Neuromuscular characteristics
-posture
-square window
-arm recoil
-popliteal angle
-scare sing
-heal to ear
Physical characteristics
-skin
-lanugo
-plantar surface
-breasts
-eyes and ears
-genitals
Neuromuscular system
Newborn reflexes
Signs of risk for neuromuscular problems
Neurological assessment
Behavioral Characteristics
Sensory behaviors
Vision - prefer patterns rather than plain surfaces; prefer complex patterns to simple ones
Hearing - responds to mom's voice
Smell - have highly developed sense of smell
Taste - can distinguish among taste
Touch - responsive to touch
Responses to environmental stimuli
Temperament
Habituation
Consolability
Cuddliness
Irritability
Crying; may signal hunger, pain, desire for attention, or fussiness