Neonatal Period
-Defined as the first 28 days after birth
-Newborn adapts to a brighter & cooler environment
-Physiologic & behavioral changes occur
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-The nurse & parents must be aware of any deviations from the norm for early identification & prompt interventions
Assessment Findings
-Transition
-6-10 hours
-Physiological changes
-Periods of reactivity
-Physical assessments
-Reflexes
Umbilical cord
Vein carries oxygenated blood from placenta to uterus
Ductus Venosus
permits most of umbilical vein blood to bypass liver & merge with blood in vena cava
-Reaches heart sooner
Foramen ovale
allows blood entering right atrium to cross to left atrium
Ductus Arteriosus
connects the pulmonary artery to the aorta, allowing for bypass of the pulmonary circuit
Placenta
supplies oxygen, nutrients & removes waste products
Cardiovascular Adaptations
...
At birth
-Fetal circulation must convert to newborn
-Placental pulmonary exchange
-Release of epinephrine & norepinephrine
-Stimulate increased cardiac output
Cont..
-Umbilical cord is clamped
-First breath taken & lungs begin to function
-Pressure changes occur
-Left atrium> right atrium
-Foramen ovale closes
-Oxygenated & non-oxygenated blood no longer mixes
Cont..
-Ductus Arteriosus becomes functionally closed within the first few hours after birth
-Closure is signaled by high oxygen content of aortic blood
-Results from gas exchange in the lungs
-Pulmonary vascular resistance decreases
-Pulmonary blood flow increases & oxygen exchange occurs in the lungs
Cont..
-Ductus Venosus closes within a few days after birth
-Due to activation of functional liver
-Liver takes over functions of placenta
-Two umbilical arteries & one vein constrict at birth & become ligaments
Additional CV Changes
...
After birth
-Heart Rate- 120-180bpm
-Will decrease to 120-130bpm
-Crying, movement & wakefulness will cause an increase in HR & blood pressure
Cont..
-Difficulty compensating
-Tachycardia may reflect:
-Dehydration, CV disease, drug withdrawal
-Bradycardia may reflect:
-Apnea, hypoxia
-Delayed cord clamping may improve newborn's CV/pulmonary adaptation
Respiratory Adaptations
-Hypercapnia, hypoxia & acidosis from normal labor trigger 1st breath & subsequent respirations
-Also environmental factors e.g. noise & light
-Surfactant provides the lungs with stability for gas exchange
-Tension-reducing lipoprotein
-Prevents alveolar collapse
-Reduces the risk of atelectasis
Cont...
-Chest wall is "floppy"
-Passage through birth canal helps to eliminate amniotic fluid in lungs
-Thorax is intermittently compressed
-If fluid is not removed, will result in tachypnea
-RR> 60bpm
-E.g. Cesarean Section
After birth
-Respirations are shallow & irregular
-30-60bpm (may have short period of apnea; <15 sec.)
-More active= the higher the RR
Signs of Respiratory Compromise
-Cyanosis
-Tachypnea
-Expiratory grunting
-Sternal retractions
-Nasal flaring
-Labored breathing
Periodic Breathing
cessation of breathing that lasts 5-10 seconds without other s/s
Requires close monitoring
Thermoregulation
-Process of maintaining balance between heat loss & heat production
-Newborns at greatest risk within 12 hours of life
-Pre-term greater risk
-Range:
36.5-37.5°C
97.9-99.7°F
Heat Loss
-Lack inability to shiver
-Limited use of voluntary muscles
-Large body surface area
-Lack subcutaneous fat
-Unable to change position (can't conserve heat)
-Inability to communicate temperature extremes
-Limited metabolic stores (e.g. fat)
Conduction
Heat fluctuation between body surface when in contact with another
-e.g. cold mattress
-Use blankets
Convection
Flow of heat from body surface to cooler air
-e.g. cool breeze flows over newborn
-Warm oxygen, work inside isolette, move away from open doors/windows/fans
Evaporation
Loss of heat when liquid is converted to vapor
-E.g. Amniotic fluid evaporates off of baby after birth
-Keep cap on baby's head & dry after bathing with warm blankets
Radiation
Loss of heat to cooler, solid surfaces (not in direct contact with newborn)
-E.g. Newborn placed in isolette next to cool window
-Become cold, even though in isolette
-Keeps cribs/isolette away from windows/walls/ac units
Role of Brown Fat
-Ability to produce heat
-Through metabolic activity; oxidized
-Found between scapulae, nape of neck, mediastinum, kidneys & adrenal glands
-When a newborn is subjected to a cold environment:
-Norepinephrine is released
-Brown fat metabolism is stimulated
-Cardiac output increases
-Blood flow increases through brown fat
-Blood becomes warmed d/t increased metabolic activity
Hepatic System Adaptations
-Liver assumes its normal function at birth
-Iron is released & stored by liver until new red cell production
-Liver releases glucose from glycogen stores for first 24 hours after birth for energy
-Feedings help stabilize glucose
Bilirubin
-Liver is responsible for conjugation of bilirubin
-Produced by breakdown of RBC's
-Normally, circulates in plasma, taken up by liver cells, changed to water-soluble pigment & excreted in bile
-Newborns produce twice as much as adults
-Declines 10-14 days after birth
Total bilirubin
-Combination of direct (unconjugated; not soluble) & indirect (conjugated; water soluble)
-Failure of liver cells to break down & excrete bilirubin lead to jaundice or icterus
-Yellowing of skin, sclera, mucus membranes
-Buildup of bilirubin levels in the blood
-Kernicterus bilirubin induced brain dysfunction
-Extreme high levels in blood
Jaundice
Risk Factors:
-Fetal-maternal blood incompatibility
-Prematurity
-Breastfeeding
-Drugs
-Gestational Diabetes
-Male gender
-Trauma in birth
-TORCH infection
-Previous sibling
-Asian or Native American decent
GI System Adaptations
At birth the newborn can:
-Swallow, metabolize, absorb & digest food
Bacterial Colonization
-GI tract is sterile prior to delivery
-During delivery newborn's gut is colonized with mother's & surrounding environments intestinal flora
-C-Section patient's may take 6 months for flora to develop
-initially obtain flora from environment
Mucosal Barrier
-Epithelial lining of intestines that prevents passage of harmful substances (e.g. bacteria)
-Developed within in first week of life
-Provides an environment where necessary flora can survive & harmful cannot
-Human breast milk provides antibodies & additional substances that can also help protect the neonate against harmful substances
Bowel
...
Meconium
-First stool passed
-Greenish black
-12-24 hours post birth
Sterile
Once feedings are initiated
-Transitional stool occurs
-Greenish-yellowish brown
-Seedy
Milk Stool
-BF- yellow gold, loose, sour smelling
-Formula- vary based on type, yellow-green, loose, unpleasant odor
Renal System
-Normally void immediately post delivery
-Urine becomes concentrated ~ 3mos
-6-8 voids/day is expected
-Indicates adequate fluid intake
-Additional Characteristics:
-Low GFR
-Limited excretion
-Affect ability to excrete salt, water & drugs
Immune System Function
Poor immune function well into neonate period
-Previously depended on intrauterine environment
Natural Immunity
Responses or mechanisms that do not require previous exposure to function appropriately
-E.g. Newborn's skin & mucus membranes
Acquired Immunity
-Two processes
-1- development of antibodies
-2- Formation of lymphocytes to destroy harmful substance
-Absent until first invasion of harmful substance
-Newborn relies on immunoglobulin's for defense mechanisms
-Antibodies
-IgG, IgA, IgM
-IgA found in human break milk
Integument System Adaptations
-Epidermis fully formed by 32 weeks gestation
-Newborn skin:
-Risk of injury from tape, monitors
-handling increases risk
-Sweat glands not fully functional until 2-3 years
-Exposure to air after birth accelerates hair growth
-Color changes with environment & health status
-Birth
-Skin is dark purple
-With first breath Red
-Should fade over first 24 hours
Neurologic System Adaptations
At birth:
-Hear
-Smell (mother's milk vs. others)
-Touch (sensitivity to pain)
-Vision (focus 7-12 inches away)
-Smell develops over 72 hours (sour vs. sweet)
-Reflex testing
-Involuntary muscular response
-Will indicate normal functioning CNS or reveal abnormalities
First Period of Reactivity
Birth to 30 minutes
-Heart rate: 120 to 180
-Respirations: Irregular 60-80-activity; alert watching
-Responsiveness: Reacts vigorously
-Reflexes: rooting, sucking, moro, chewing, fine tremors
-A time for parents/caregivers to interact with newborn & enjoy close contact
-Initiation of breastfeeding
Period of Decreased Responsiveness
30-120 minutes
-Color: stabilizing, pink all over
-Heart rate : slows to 120-130bpm
-Respirations: slows to 30-50bpm
-Responsiveness: Sleepy, decrease in activity & movements less frequent
-A time for parents/caregivers to remain close & rest together after labor/birthing experience
Second Period of Reactivity
2 to 8 hours
-Color: quick color changes with crying/movement
-Heart rate: varies with activity
-Respirations: irregular with activity
-Responsiveness: Reactive; shows interest in environment. Motor coordination increases
-Meconium: Peristalsis increases, may pass
-A good time for parents/caregivers to examine their newborn & ask questions
Neurobehavioral Responses
Orientation:
-Response of newborns to stimuli
-Validated by movement of eyes, head
-Prefer human face & shiny objects
Habituation
-Ability to process & respond to visual/auditory stimuli
-Block out external stimuli
-Improves within 24 hours
-Reflected by sleep patterns
Neurobehavioral Responses
Motor Maturity:
-Evaluation of posture, tone, coordination & movements
-Varies with age
Self-Quieting:
-Ability to quiet & comfort self
-Consolability
Social:
-Ability to cuddle/snuggle when held
-Important for parents to gauge ability to be caregivers
Gestational Age Assessment
Determines newborn's stage of maturity
-Includes assessment of:
-physical & neuromuscular maturity
-Points given for each assessment parameter
-Scores from each section are added together & correspond to gestational age in weeks
Newborns classified as
-Preterm/premature: before 37 weeks
-Term- born between 38-42 weeks
-Postterm/postdate- born after 42 weeks
-Postmature- born after 42 weeks & displays signs of placental aging
APGAR Scoring
Evaluates newborn 1 & 5 minutes after birth
Assess:
A- Appearance
P- Pulse
G-Grimace (reflex irritability)
A- Activity (muscle tone)
R- Respiratory (effort)
0= absent or poor
2= normal response
Totals:
8-10= normal newborn score
4-7= moderate difficulty; need intervention
0-3= severe difficulty adjusting; need intervention
Length & Weight
Taken soon after birth
Length: head of newborn to heel, unclothed
Place supine & extend leg fully
Normal 19-21 inches
Weight:
Use digital scale
Normal 6-9 lbs
Typically lose 10% weight by day 4 & regained by day 10
Normal Newborn Ranges
Temp: 97.9-99.7°F (36.5-37.5°C)
HR: 120-160 bpm (up to 180 with crying)
Listen for apical (4th intercostal space; full minute)
RR: 30-60 at rest (will increase with crying)
Assess for full minute (may be slightly irregular; diaphragmatic)
BP: 50-75 systolic/ 30-45 diastolic
Usually Taken:
-On admission to nursery
-q 30 minutes until newborn has been stable for 2 hours
-Then, once q 4-8 hours
Maintaining a Patent Airway
Immediately after birth:
-Newborn suctioned to remove fluids from mouth & nose
-Mouth first
-Reduces risk of aspiration
-Always keep bulb syringe at the bedside in case of sudden choking/blockage in the nose
Nasal/Oral Suctioning
-Obligatory nose breathers
- Position head to side
-Compress bulb syringe first & insert between cheek & gum
-Do not insert into back of throat
-Remove syringe & expel contents into an emesis basin
Vitamin K
-Promotes blood clothing
-Vitamin K supply not sufficient until 1 week
-Single IM dose
-Research currently looking for oral forms
Eye Prophylaxis
-Erythromycin or Tetracycline
-US mandates all receive within 1-2 hrs after birth
-Prevents Ophthalmia Neonatorum
-Conjunctivitis that can cause blindness within
1- 10 days
Anthropometric Measurements
-Length
-Weight
-Head circumference
-32-38cm (13-15in)
-Measure at head's widest diameter
-Chest circumference
-30-36cm (12-14in)
-2-3 cm less than the head
-Place tape around chest at nipple line (unclothed)
Skin
-Check turgor (chest/abdomen)
-Lanugo may be present
-Fine hair
-Should be warm, dry & intact
-Acrocyanosis?
-Mottled blue color/ persistent cyanosis
-Normal & intermittent
Harlequin Sign
-Color change
-Dilated blood vessels on ONE side of body
-Immature autoregulation of blood flow
-Common in low birth weight newborns
Head
Should be symmetric & round
Fontanels:
-Anterior
-Diamond shape; closes at 18-24 mos
-Posterior
-Triangular; closes 6-12 weeks
Palpate both
-Should be soft, flat, open
-Palpate skull, should feel smooth
Caput Succedaneum
A localized soft tissue edema of the scalp.
Cephalohematoma
is a collection of blood between the periosteum and the skull bone that it covers. It does not cross the suture line.
Head
...
Microcephaly
-Circumference is less than 10% of normal parameters
-Associated with poor brain development or genetic disorders
Macrocephaly
-Circumference is more than 90% of normal
-Usually r/t hydrocephalus
Face & Nose
Observe for fullness & symmetry
Forceps in delivery:
-May cause facial nerve paralysis
-Observe nose for size, symmetry & lesions
Should be:
-Midline
-Patent nares
-Obligate nose breathers
Mouth
-Lips should be intact & midline with no lesions
-Lips should encircle around finger; vacuum
-Inspect inside of mouth:
-Intact gag swallow & sucking reflex
-Uvula midline
-Pink, moist with minimal saliva
Abnormalities:
-Epstein's pearls
-Erupted teeth
-Thrush
-Candida albicans
Eyes
-Clear & symmetrically placed
-Blink reflex
-Bring object close to eye & should blink
-Pupillary reflex
-+PEARL
May be some edema d/t birth process
Abnormalities
Transient Strabismus
-Searching Nystagmus- involuntary repetitive eye movement
-Chemical conjunctivitis
-Lid edema & discharge from both eyes 24 hrs post eye prophylaxis placement
Neck
-Creases should be noted
-Almost appears non-existent
-Capable of holding head midline
-Clavicles should be straight & intact
Chest
-Should be 2-3 cm smaller than head diameter
-Xiphoid process may be prominent at birth
-Nipples may be engorged & secrete white substance
-Goes away in a few weeks, d/t excess maternal estrogen
Auscultate:
-Heart & lung sounds
-Murmur 12 hours after birth should be reported
Supernumerary Nipple
extra nipple along the the embryonic "milk line" on the thorax or abdomen; a congenital finding
Abdomen & Umbilical Cord
-Inspect for shape & movement
-Note abdominal breathing
-Auscultate bowel sounds
-Palpate for tenderness/masses
Inspect umbilical cord
-Two arteries & one vein
Note any bleeding
-abnormal
Should fall off within 2 weeks
Genitalia- Male
Inspect penis/scrotum
Scrotum usually large
Should be no bulging, edema, discoloration
Palpate testes
Firm & equal size
Hypospadias
Epispadias
Inspect anus for patency
Passage of meconium would indicate this
Hypospadias
A congenital condition in the male where the urethra ends on the ventral side of the glans penis, anywhere along the penile shaft, on the corona, or on the perineum
Epispadias
Abnormal opening of the penile urethra on the superior/dorsal side of the penis due to faulty positioning of the genital tubercle
Genitalia- Female
Inspect external surfaces only
Will be engorged with labia edematous
d/t maternal hormones
Pseudomenstruation
white/ & bloody d/c
normal in first few weeks; no treatment
Abnormalities
...
Ambiguous genitals
xx female exposed to very high levels of androgens
Rectovaginal fistula with feces
abnormal opening between the vagina and rectum
Imperforate hymen
a hymen that completely closes the introitus
Extremities
Inspect upper & lower extremities
Note:
Number of digits
Polydactyl
Syndactyly
Palmar creases
Simian line
ROM
Erb's Palsy
Affected arms hangs & adducted
Recovery in 3-6 months
Polydactyl
Extra digits
Syndactyl
Fusion of digits
Single Transverse Palmar Crease
simian crease
Erb's Palsy
Paralysis of the upper plexus incl. 5th and 6th cervical nerves; C7 may be invol. in some case
Ortolani Maneuvers
Grasp inner aspect of thighs & abduct while applying upward pressure
Clicking or clucking is abnormal
Suggests hip dysplasia
Barlow Maneuvers
Grasp inner aspect of thighs & adduct while applying outward & downward pressure
Feel for femoral head slipping out of acetabulum [Show Less]