Lecture 6 Newborn Transition-Assessment Fall 10

7/31/2019 Lecture 6 Newborn Transition-Assessment Fall 10

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NEWBORN TRANSITIONASSESSMENT

Mary L. Dunlap MSN, APRNFall 10


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Newborn Care Period

Physical Adaptations

Newborn Assessment

Nutrition Discharge Assessment


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Neonatal Physiologic Adaptations

Respiratory

Breathing noted asearly as 11 weeksgestation

Fetal lung fluidnecessary fordevelopment and

decreases withgestational age

Functioning lungsoccurs after 26weeks gestation

Surfactant found insufficient quantityaround 35 weeks

gestation


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Respiratory Adaptations

Chemical Stimulation

Mechanical Stimulation

Sensory Stimulation Pulmonary Blood Flow


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Catecholamine surge prior to laborcorresponds to rapid drop in level offluid in lung field

Catecholamines increase the release ofsurfactant


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Decrease O2 & Increase CO2concentration along with decrease pHstimulates aortic & carotidchemoreceptors triggering themedulla to initiation of respirations


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Surfactant promotes lung expansion

by preventing the complete collapsing

of the alveoli with each expiration. Increases the lungs ability to fill with

air


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Mechanical Stimulation

Compression of the chest duringvaginal birth forces 1/3 of the fluid outof the lung fields

Once the chest is delivered the re-expansion draws air into the lungs

Crying creates positive intrathoracicpressure keeping alveoli open


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Sensory Stimulation

Tactile

Visual

Auditory


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Pulmonary Blood Flow

Pulmonary vasodilatation occurs as

O2 enters the lungs

The decrease in PVR allows foradequate gas exchange andtransition


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Established within 1 minute of birth

Respirations should be quiet

Diaphragmatic and abdominalmuscles used

Nose breathers

30-60/minute


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Acrocyanosis and circumoral

cyanosis 1-2hrs

Respiratory distress nasal flaring,grunting, costal retractions and a rateless than 30 & greater than 60


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Cardiovascular Adaptations

Fetal to neonatal circulation occurssimultaneously with the respiratory

adaptation Cessation of blood through the umbilical

vessels and placenta causes the

change from fetal to neonatal circulation


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Cardiovascular Adaptation

Closure of the ductus venosus,

foramen ovale and the ductus

arteriousus Shift to pulmonary circulation


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Fetal to Neonatal Circulation

Clamping the umbilical cord increases theSVR

Closure of the ductus venosus allows bloodflow through the portal/hepatic system

Increase pressure in the left atrium from thepulmonary venous return closes the foramenovale

Rising O2 concentration in the blood anddecreased prostaglandin levels closes theductus arteriousus


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Neonatal Circulation

Apical pulse counted for a full minute

PMI is at the 4th intercostal space to

the left of the midclavicular line Heart rate at birth 120-160

Tachycardia greater than 160

Bradycardia less than 100


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Capillary refill less than 3 sec.

Femoral/Bracial pulses palpated for

symmetry, strength and rate willprovide information about the changeto adult circulation pattern

Average systolic 60-80, diastolic 40-50


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Average blood Volume 300ml

Late clamping of the cord can lead to

polycythemia Hemoglobin 14-24g/dl

Hematocrit 44%-64%


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RBC 4.8-7.1/mm

WBC 9,000-30,00 per mm

Platelets 200,000-300,00 Factors II, VII, IX, and X are low due

to the lack of Vit. K


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Thermogenic Adaptation

Balance between heat loss and

production

Newborns ability to maintain itstemperature is controlled by externalenvironmental factors and internal

physiologic process


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Environmental Evaporation: Heat loss as water

evaporates from the skin

Convection: transfer of body heat tosurrounding air ( cold del. Room)


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Environmental Conduction: transfer of heat tosurface the newborn is lying on

Radiation: loss of heat through the airto a cooler surface ( not in directcontact with the neonate)


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Internal Newborns have limited ability to

shiver to generate heat

Heat is produced by the metabolismof brown fat

Voluntary muscle activity: flexion of

extremities, restlessness, and crying


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Effects of cold stress Increase O2 consumption can lead to

metabolic acidosis

Increase glucose utilizes leads tohypoglycemia

Production of surfactant is decreased

and respiratory distress can occur


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Signs of Cold

Stress/Hypothermia Skin cool to touch Mottling of the skin

Central cyanosis

Decreased responsiveness

Jittery Tachypnea


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Renal System

40 ml of urine at birth 2-6 voids/day for the first 2 days

5-25 voids/day after 48 hours

15-60 ml. of urine per/kg/day Urine odorless straw color

Uric crystals cause pink staining indiapers

One year to fully mature


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Gastrointestinal System

Audible bowel sounds within 1 hour

Stomach capacity 30-90 ml.

Uncoordinated peristaltic activity in the

esophagus for a few days Immature cardiac sphincter

Enzymes able to digest CHO, protein & fats

1 st meconium passed 12-24 hrs Transitional stool passed for 1-2 days


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Hepatic Adaptation

In utero iron is stored for use in hemoglobinproduction after birth. If adequate will last till 5thmonth without needing supplement.

Glucose is stored as glycogen for neonatal

metabolic demands Due to the rapid depletion of glycogen during the

first 24 hours the glucose level will be between 50to 60 mg/ml

Feedings will help stabilize the glucose levels,which after day 3 will be between 60-70 mg/ml


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Immune System Adaptation

Neonate depends on threeimmunoglobins: IgA, IgG, and IgM

IgG crosses the placenta and is found inthe fetus by the 3rd trimester. It protectsthe newborn against bacterial and viral

infections the mother has developedantibodies for ( tetanus, measles,

mumps)


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Immune System Adaptation

IgM is found in the blood and lymph and isthe first immunoglobulin to respond toinfection. Production starts at birth. If

elevated at birth may indicate exposure tointrauterine infection

IgA is found in colostrum and can

contribute to passive immunity. It limitsbacterial growth in the GI tract and isproduced gradually.


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Normal Newborn Assessment

Evaluate the newborns adjustment

to Extrauterine.

Assess for possible birth trauma The assessment should progress

from head to toe.


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Initial Assessment

Apgar score determined Assess for gross abnormalities

Apply cord clamp

Obtain foot prints

Apply identification bands

Administer Vit. K & eye prophylaxis Promote bonding


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Transition to Extrauterine LifeFirst period of Reactivity

Birth to 30 minutes

Heart rate160 to 180 beats/min

Returns to 110-160 after 30 min Resp. rate 60-80/crackles may be present

Reactive to stimuli

After this period newborn could sleep up to60-100 min.


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Transition Second Period

4-8 hours after birth

10 min to several duration

Brief periods of Tachycardia andTachypnea

Increase muscle tone and color

changes

Meconium may be passed


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Newborn Assessment

Length-19 to 21 inches Weight- average 7lb 8oz (10th to 90th %)

SGA less than 5lb 8 oz (Less thanthe 10th %)

LGA greater than 9 lb ( greaterthan the 90th %)

Newborns can loose up to 10% of birth weight

Head circumference- 33-38 cm Chest circumference-31-36 cm


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Newborn Assessment

Temperature

Normal axillary temperature 97F

99.5F Cardiovascular system

Normal heart rate 110160 bpm

Observe color, pulse, murmurs


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Newborn Assessment

Respiratory system

Normal rate is 3060/minute

Nose-breatherObserve for flaring, grunting,

retracting

Auscultate for rales


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Head

Measure circumference Anterior fontanel diamond shaped closes in 18months

Posterior fontanel triangle shaped closes in 8-12 weeks

Fontanels need to be open and soft

Depressed fontanel indicates dehydration

Bulging fontanel may indicate increasedintracranial pressure


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Head

Molding result of fetal position in utero andpressure from passage through birth canal( resolves in 24-48hrs)

Cephalhematoma result from trauma(resolves in few weeks)

Caput succedaneum pressure from

delivery ( resolves in 1-2 weeks)


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Head

Inspect face for symmetry of eyes, nose, lips,mouth and ears

Eyes usually blue or gray, permanent colorestablished in 3-12 months

Red reflex present cornea intact

Can see up to 2 feet clearest vision is 8 to12 inched

Subconjunctive hemorrhages may bepresent due to the pressure from delivery


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Head

Nose midline with patent nares Ears aligned with outer canthus of eyes;

pinna well formed, open auditory canal ( low

set ears associated with chromosomalabnormalities)

Mouth mucosa pink and moist; tongue

mobile, strong suck, hard/soft palate intact(Epsteins pearls may be noted on the gumsor hard palate)


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Neck

Shape typically short with deep folds of skin

Webbing associated with Down Syndrome

Assess for full range of motion

Palpate for abnormal masses

Note the position of the trachea


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Chest

Shape should be cylindrical (bell shaped could be asign of underdeveloped lungs)

Palpate clavicle bones and ribs

Assess nipples for size, placement and number

Evaluate respiratory effort and movement

Auscultate the lung fields and heart sounds

Unequal breath sounds could be a pneumothorax


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Abdomen

Umbilical cord, 2 arteries 1 vein

Cylindrical with some protrusion

Flat abdomen indicates diaphragmatic hernia

Auscultate for bowel sounds Suprapubic area palpated for bladder

distention

Femoral pulses palpated, if unable to locatecould signify coarctation of the aorta


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Female Genital and AnalAssessment

Term newborn labia majora covers

labia minora and clitoris

Mucoid vaginal discharge due tomaternal hormones

Hymental tag may be present

Annus patent


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Male Genital and AnalAssessment

Rugae present on the scrotum

Scrotal edema may be present due tomaternal hormones

Testes descended Check for placement of the meatus

Dorsal surface- epispadias

Ventral surface-hypospadias Anus should be patent


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Extremities

Assess for full range of motion, symmetry andsigns of trauma

Spontaneous motion of all extremities should

be present Assess muscle tone

Hyperflexibility of joints associated with Down

Syndrome Hips assessed for dislocation


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Extremities

Nail beds pink- persistent cyanosis associatedwith hypoxia

Palms should have normal creases

Simian crease (transverse palmer) suggestsDown syndrome

Count digits on extremities (more than fivedigits polydactyl-Digits fused togethersyndactyl


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Spine

Straight

Flat

Shoulders, scapulae and iliac crestsline up in same plane

Evaluate for dimpling or fissures

Dimpling associated with spina bifida


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Skin

Assess color

Check for birth marks, trauma, rashes orbruises

Presence of lanugo

Palpate texture ( ranges from smooth to

peeling) Turgor ( elasticity)


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Skin Assessment

Common variations

Milia

Mongolian spots

Birthmarks

Common problems

Petechiae

Blisters, lesions

Abnormal hair distribution

Port wine stains


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Neurological System

Infant alert, responsive, strong lusty cry ina flexed position

Reflexes provides information on the

system and maturity Reflexive behaviors are necessary for

survival and safety

Absence, weakness or asymmetryindicates abnormalities


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Neurological Reflexes

Sucking

Rooting

Grasping

Extrusion

Tonic neck

Moro

Stepping

Crawling

Babinski

Truncal incurvation

Blinking


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Neurologic System

Common problems

Brachial plexus injury (Erbs palsy)

Spina bifida

Anencephaly

Absent or abnormal reflexes

Seizure activity


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Behavioral Assessment

Sleep-wake cycles

Activity

Social interactions

Response to stimuli

P i A


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Pain Assessment

Most common sign crying

Changes in heart rate

Intracranial pressure

Respiratory rate and oxygen saturation

P i M


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Pain Management

Nonpharmacologic management:containment (swaddling),nonnutritive sucking and

distraction: visual, oral, auditory,tactile

Pharmacologic management:

local and topical anesthesia,Nonopioid analgesia and opioids

G i l A A


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Gestational Age AssessmentBallard Score

Neuromuscularmaturity

Posture

Square window

Arm recoil

Popliteal angle

Scarf sign

Heel-to-ear

Physical maturity

Skin

Lanugo

Plantar surface

Breasts

Eye and ear

Genitalia

I f t N t iti


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Infant Nutrition

American Academy of Pediatrics (AAP)recommends infants be breastfedexclusively for first 6 months of life

Breastfeeding should continue for at least 12months

If infants are weaned before 12 months, they

should receive iron-fortified infant formula

I f t t iti


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Infant nutrition

Human milk designed specifically for humaninfants; nutritionally superior to any alternative

Breast milk considered living tissue because it

contains almost as many live cells as blood Bacteriologically safe and always fresh

Nutrients in breast milk more easily absorbed

than those in formula

Contraindications of


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Contraindications ofBreastfeeding

Maternal cancer therapy/ radioactive isotopes

Active tuberculosis

HIV Maternal herpes simplex lesion

Galactosemia in infant

Cytomegalovirus (CMV)

Maternal substance abuse

Ch i F di M th d


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Choosing a Feeding Method

Nurse must provide information toparents in nonjudgmental mannerand respect their decision

Provide Factual information about nutritionaland immunologic needs met by human milk

Potential benefits to infant and mother

Inherent risks with infant formulas

Ch i F di M th d


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Choosing a Feeding Method

Cultural beliefs and practices are asignificant influences

Immigrants from poorer countries often

choose to formula feed because theybelieve it a better, modern method

Others formula feed because they want to

adapt to American culture and perceive itthe custom to bottle feed

L t ti


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Lactation

Female breast composed of 15 to 20segments (lobes) embedded in fat andconnective tissues, well supplied with bloodvessels, lymphatic vessels, and nerves

Within each lobe are alveoli, the milk-producing cells, surrounded by myoepithelialcells that contract to send the milk forward into

the ductules

L t ti


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Lactation

Ductules enlarge into lactiferous ducts andsinuses, where milk collects behind nipple

Each nipple has 15 to 20 pores through which

milk is transferred to the suckling infant After birth, precipitate decrease in estrogen

and progesterone levels triggers release of

prolactin from anterior pituitary gland

L t ti


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Lactation

Prolactin highest first 10 days Gradually decline, but remain above

baseline levels for duration of lactation

Prolactin produced by infant suckling andemptying of the breasts

Breasts never completely empty

Milk production supply/demand

Lactation


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Lactation

Oxytocin: other hormone essential tolactation

As nipple is stimulated by suckling infant,

posterior pituitary prompted byhypothalamus produces oxytocin

Responsible for milk-ejection reflex

(MER), or let-down reflex Nipple-erection reflex is integral to

lactation

Lactation


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Lactation

Colostrum, a clear yellowish fluid birth to48hrs.

More concentrated than mature milk

Extremely rich in immunoglobulins

Higher concentration of protein andminerals

Less fat than mature milk

Coates and protects the stomach andintestines from invading organisms

Lactation


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Lactation

Transition milk 48-72hrs

High levels of fat, lactose and water

soluble vitamins Higher calorie content

Larger volume

Lactation


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Lactation Mature milk produce by 10th to 15th day

Two types of milk: foremilk and hind milk

Hind milk higher in fat which is needed forgrowth

90% water which maintains newborns fluidbalance

Remaining 10% contains carbohydrates,

proteins and fats

Lactation Frequency/Duration


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A newborns stomach is the size of a

small marble and can hold 5-7 ccs.

This is matches the amount ofcolostrum produced

From 7-10 days it increases to the

size of a golf ball and can hold 1.5 to2 oz



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Newborns nurse on average 8-12

times/24hrs

Feed by cue signs about every 1-3hours

Should have no more than one 4 hr

period

Lactation Education


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Lactation Education

Positioning

Latch-on

Let-down

Frequency offeedings

Pumping

Milk storage

Duration offeedings

Supplements,

bottles, andpacifiers

Diet

Breast care

Breast feeding Special


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Breast feeding SpecialConsiderations

Sleepy baby- use gentle stimulate to

bring to alert state

Fussy baby- use calming techniques

Slow weight gain- evaluate

breastfeeding

Breastfeeding


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Breastfeeding

Engorgement noted when milk comes in andis bilateral (increase feedings to q2hrs)

Sore nipples usually result of poor

latch on Plugged milk ducts result of inadequate

emptying or underwire bra/apply warm

compresses prior to nursing Mastitis infection characterized by sudden

flu like symptoms usually effects only onebreast

Formula Feeding


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Formula-Feeding

Personal preference

Influence by significant family

members Lack of familiarity with breastfeeding

Contraindications present

Formulas


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Formulas

Ready to feed Concentrated

Powdered

Cows milkbased Soy-based

Casein/ whey

Amino acid

Formula Feeding Education


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Formula-Feeding Education

Types of formula

Formula Preparation

Feeding patterns Feeding techniques

Bottles preparation

Discharge Assessment


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Discharge Assessment

Determine knowledge deficits Educate on car safety

Importance of Immunizations

Follow care

Newborn hearing screen

Collect blood for PKU

Lecture 6 Newborn Transition-Assessment Fall 10

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