Newborn Assessment (2)

8/3/2019 Newborn Assessment (2)

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PHYSIOLOGICEXTRAUTERINEADAPTATION

NORMAL NEWBORN


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RESPIRATION

Theories of Respiration 1. Chest recoil after pressure passing

through birth canal

2. Chemical increased pCO2,decreased pH & pO2

3. Thermal decreased temperature

4.Sensory over stimulation

5. Increased BP after cord is clamped

First breath normally within seconds ofbirth

Newborns are obligatory nose breathers


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Cardio-Pulmonary

CIRCULATION:Increased

aortic pressure & decreased

venous pressure cord results when cordis cut

less blood return to vena cava, (noplacental circulation)

Increased systemic pressure &

decreased pulmonary artery pressure.More pulmonary blood flow

lung expansion


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Cardio-Pulmonary CirculationIncreased blood pO2 vasodilation of

pulmonary vessels

Less pulmonary artery resistance

Less vascular pressure

vascular beds open

Foramen ovale closes (Occurs 1 to 2 hours after birth) Note: In utero, right atrial pressure is greater

After birth, left atrial pressure is greater

Some shunting may occur;permanent closure in a few mos.


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Contd:C-P CIRCULATION

Ductus arteriosus closes.

(Functionally within 15 hours after birth)

Blood flows from aorta into

pulmonary artery (Fibrotic in 3 weeks)

Ductus Venosus closes.

(Fibrosis in 3 7 days)Perfusion of liver occurs.

Note: Fetus needs more RBC for O2 transport thannewborn; Hemoglobin drops from 14 gm/dl at 4 weeksto 12 gm/dl.


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ELIMINATION - Gastrointestinal

Characteristics:

o NB digests CHO and CHON easily

o Poor fat digestion & absorption

o Meconium usually excreted within 24hours of birth

o Transitional stools passed by 3 6 d

o Yellow stools begin at about 6 dayso One to two stools QD at 2 weeks after

birth


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ELIMINATION URINARY

GFR rate is low

Acidosis & fluid imbalances canoccur rapidly

Void within 24 hours & then 5 20 times/day

Uric acid crystals may causebrick dust reddish stain ondiaper


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HEPATIC SYSTEM

Physiologic jaundice(after first 36 h) (r/tincreased load of bilirubin on liver cells &decreased bilirubin clearance from plasma.)

Non-physiologic jaundice

(r/t impaired ability to excrete conjugated bilirubin& high serum levels of conjugated bilirubin)

Breast-feeding jaundicerise in bilirubinlevels from fourth day of life

Unconjugated bilirubinfrom blood can entertissues causing yellow coloring (jaundice).

Clotting factors 2,7,9, 10 are lowbecauseVit. K not produced, making newborn susceptible

to bleeding.


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Neurology Integumentary

Neurologicsystem not fullydeveloped,

Reflexes areindicators ofnewborns

development.(APGARs scoring)

Skin pink to red,

Acrocyanosislasts 2-6 hoursafter birth,

Thin epidermis.


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TEMPERATURE REGULATION

1. Large surface area in proportion tomass

2. Less fats =Greater potential for heatloss than adult

3. Heat transfer by: a.Evaporationnewborn wet with amniotic

fluid loses heat.

b.Radiationnewborns heat is transferred to

cooler objects in envi; heat loss to air, objects. c.Convectionpassage of cool air againstskin.

d.Conductionthermal conductivity toobjects, which are cooler.


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HEAT PRODUCTION

Nonshivering thermogenesismetabolizes brown fat

Increased muscular activity

Flexed posture decreases amount ofskin surface exposed to cold

Vasomotor controlretains heat bycontrolling blood flow to the skin.

IMMUNITYa. Capable of combating some infections

b. IgG crosses placenta, fetussynthesizes IgM, IgA is not found at

birth, but it is in the breast milk.


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REACTIVITYIST PERIOD OF REACTIVITY(immed. after birth)

1. rapid RRup to 80 per minute 2. transient nasal flaring

3. grunting may occur

4. HR= up to 180 BPM

FIRST SLEEP

1. Occurs within 2 hours after birth 2. Lasts up to several hours

SECOND PERIOD OF REACTIVITY

1. Hyper-response to stimuli 2. skin color slightly cyanotic

3. rapid heart rate

4. oral mucus may cause choking


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l. NUTRITION

i. Weight loss of 5-10%

in first 3-4 days

ii. Should regain birth

weight by two weeks

iii.Stomach capacity 30-

60ml

m. WEIGHT

i. Average-3405 gm

(7 lb, 8 oz)

ii. Range-2500-400gm

(5 lb, 8 oz to 8 lb, 13

oz)

iii. Lose 10% or less of

birth weight


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n. MEASUREMENT

i. Length

1. top of the head to soles of feet

2. average- 50 cm (20 inches)

3. range- 45-55 cm (18-22 inches)

ii. head circumference- measurement of occipitofrontal diameter,

average 33-35 cm (13-14 inches)

iii. chest circumference

1. measurement at nipple line

2. equal to or less than head circumferene


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o. VITAL SIGNS

i. Temperature

1. rectal-measures core temperature. Normal range- 36.6-37.2oC

(97.8-99oF)

2. axilliary-reflects body temperature. Normal range 36.5-37oC

(97.7-98.6oF)

ii. pulse

1. normal range-120-160 BPM

2. low normal-90-120 BPM

3. high normal- 160-180 BPMiii. respiration-abdominal-range 30-60 per minute


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III. PHYSICAL CHARACTERISTICS (normal and varation)

A. INTEGUMENT


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A. INTIGUMENT

a. Acrocyanosis-normal-lasts2-6 hours after birth

b. Circumoral cyanosis-abnormal-bluish around mouth

c. Jaundice-seen first on head, physiological peaks about 5-7 days

d. HARLEQUIN SIGN

i. Color discrepancy between 2 longitudinal halves

ii. Dependent half dark pink

iii. Upper half pale

iv. Occurs 48-96 hours

e. ecchymosis-birth trauma


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f. PETECHIAE

i. Increased vascular pressure causing rapture capillaries during delivery

ii. On upper trunk and face

iii. Remain 24-48 hours

g. ERYTHEMA TOXICUM

i. Pink papular rash

ii. May have pustules

iii. Occur 24-48 hours after birth

iv. Occur in 30-70% of newborns

h. MILIA i. Distended sebaceous glands

ii. Tiny white papules on face

iii. Disappear in few weeks

i. VERNIX CASEOSA

i. Whitish cheese-like substance ii. Protects skin in utero

iii. Covers body up to 38 weeks gestation

iv In the creases up to 42 weeks


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j. lanugo- fine downy hair over back and shoulders disappear about 38

weeks gestation

k. MONGOLIAN SPOTS

i. Bluish-black areas of pigmentation over the back and buttocks of

dark-skinned infants ii. Fade in the first or second year

l. TELANGIECTIC NEVI

i. Stork bites

ii. Flat, deep pink localized area of capillaries dilation

iii. Blanch with pressure iv. On back of neck, occiput eyelids, nose

v. Disappear by two years

vi. May reappear if child cries


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d. NEVUS FLAMMEUS- port-wine stain; capillary angioma.

i. Red-to-purple dense area of capillaries

ii. Vary in size

iii. Flat

iv. Commonly on the face

v. Do not blanch with pressure

vi. Does not disappear

e. NEVUS VASCULOSUS- strawberry mark

i. Raised. Sharply outlined, rough ii. Dark red

iii. Capillary hemingioma

iv. Consists of newly formed and enlarged capillaries in dermaland subdermal layers

v. Most in head areas

vi. Grow until 8 months

vii. Disappear by 7 years


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B. HEAD

a. Molding

i. Overriding of skull bones

ii. Resolves in 2-3 days

b. fontanel

i. anterior- diamond shape, closes about 18 months ii. posterior- triangle shape, closes by 2-3 months

c. caput succedaneum

i. edematous swelling of scalp from pressure of delivery

ii. may cross suture lines

iii. present at birth

iv. disappears in few days

d. cephalohematoma

i. bleeding between cranial bone and periosteal membrane

ii. does not cross suture lines

iii. may not appear for hours

iv. may take months to disappear


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C. FACE & D. EYES

C. FACE

a. Symmetrical

b. Sucking pads in cheeks

D. EYES

a. Permanent color by 312 months

b. Equal pupils

c. Pupils react to light

d. Blink present

e. Red reflex present

f. Pseudostrabismus

i. Poor neuromuscular control

ii. Regresses in 234 months

g. Sub-conjunctival hemorrhage

i. Caused by changes in vascular tension at birth

ii. Lasts a few weeks


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E. MOUTH & F. EARS

E. MOUTH

a. Epsteins pearls small white epithelial cysts on gums, disappear in

weeks

b. Teethrare

c. Cleft lip or palateabnormal

F. EARS

a. Top should be at level of inner canthus of eye

b. Pinna is curved & cartilage stands upright

c. Maybe filled with vernix d. Hearing improves at first cry


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G.NECK, H.CHEST &

I.ABDOMEN G. NECK

Cannot support head weight, short with many folds

H. CHEST

a. Retractions abnormal

b. Extra nipples maybe present

c. Breast buds raised

d. Engorgement (from maternal hormones) may last up to 2 weeks

e. Heart murmur90% subside in days

I. ABDOMEN

a. Umbilical cord falls off in 710 days

b. Bowel sounds heard 1 hour after birth

c. Protrudes


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J.BLADDER & K.GENETALIA

J. BLADDER

a. Nonpalpable, voiding within 24 hours

K. GENITALIA

a. Female i. Pseudomenstruation (from maternal hormones) disappears in 24 weeks

ii. Labiaedematous

iii. Hymenal tag disappears in weeks

b. Male

i. Foreskin not easily retracted

ii. Testes descend at 3638 weeks of gestation iii. Epispadiasurinary meatus on dorsal surface of penis

iv. Hypospadiasurinary meatus on ventral surface of penis


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L.BACK, M.ANUS &

N.EXTREMITIES L. BACK

a. Straight spine

b. Nevus pilosus (hairy dimple at bese of spine) associated with spina bifida

M. ANUSstooling in 2448 hours

N. EXTREMITIES

a. Equal movement b. Sole creases

i. 2/3 at 3638 weeks gestation

ii. 3/3 at 3842 weeks gestation

c. Polydactylyextra digits

d. Syndactylywebbing of digits

e. Phocomeliaabsence of portion of limb f. CHD

i. Hip click

ii. Unequal leg length

iii. Unequal gluteal folds

g. Club Foottalipes equinovaruswill not return to midline


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IV. NEUROLOGICAL

ASSESSMENT


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A. Neuromuscular maturity

a. Arm recoilpull arm straight & release

b. Scarf signbring elbow to midline

c. Heel to earbring heel to ear

d. Popliteal angle

i. Press thigh on

abdomen & try to straighten leg

ii. Measure angle at

back of knee

Square windowpress hand against forearm


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B. Neurological Status

a. Moro reflex (startle)

i. Suddenly lower head a few centimeters

ii. Should abduct & extend arms symmetrically

iii. Fingers fan out

iv. Thumb & forefinger form C

v. Arms adduct, legs extend

b. Pupillary reflexpupil constrict in bright light

c. Blinking reflexeyelids close in bright light d. Rooting reflexturns head in response to light touch on cheek

e. Sucking reflexsucks on nipple or finger


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f. Grasp reflexfingers close around finger or object placed in hand

g. Babinski reflex

i. Upward stroking on lateral surface of foot

ii. Hyper extends toes & dorsiflexes great toe

h. Plantar reflextoes curl downward when finger is pressed againstbase of toes

i. Tonic-neck reflex (fencing)

i. Quickly turn head to one side while lying on back

ii. Extremities on side turned to extend while others flex

j. Trunk incurvation (Galants)

i. Place in prone position & stroke back about 2 inches from spine ii. Curves body to side of stimulus

k. Stepping reflex

i. Hold infant upright & allow one foot to touch aflat surface

Alternately moves feet in stepping motion


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NEWBORN ASSESSMENT

A. GENERAL

a. Wear gloves

b. Assess under radiant warmer or in skin to skin contact with mother

B. NORMAL FINDINGS

a. Respirations

i. Rate3060/min

ii. Irregular

iii. No retractions

iv. No grunting

b. Apical pulserate 120160 BPM, irregular

c. Temperatureskin 36.5 degrees C (97.8 degrees F)d. Skin colorbody pink, bluish extremities

e. Umbilical cord2 arteries, one vein, clamp present

f. Gestational agebasic neuromuscular & physical maturity assessment


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g. Apgar s

i. Heart rate

1. 0absent

2. 1- 100

ii. Respiratory effort 1. 0absent

2. 1slowirregular

3. 2good crying

iii. Muscle tone

1. 0flaccid

2. 1some flexion of extremities 3. 2active motion


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iv. Iv. Reflex irritability

1. 0none

2. 1grimace

3. 2vigorous cry

v. Color

1. 0pale blue

2. 1body pink, extremities blue

3. 2completely pink

h. Birth defects & anomalies


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II. ASSESSMENT DURING

FIRST HOURS A. General

a. Head to toe

b. Wear gloves

c. Keep infant warm

B. Posture a. Extremities in moderate flexion

b. Spontaneous movement

C. Weightbalance scale or use electronic scale, use scale paper cover

D. Measurements

a. Length

b. HC

c. Chest circumference

d. Abdominal Circumferenceif abdominal distention suspected

e. Use soft tape measure


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E. VS

a. Temperature

i. Skin

1. Axillary- leave glass thermometer in place for 3 minutes or useelectronic thermometer

2. Ear- use electronic thermometer

3. Continuous skin probe

ii. Core

b. Apical Pulsecount one full minute, auscultate for murmurs

c. Respirationscount 1 full minute, observe rise & fall of abdomen

F. Cry G. Integumentcolor, turgor, texture, temperature, markings

H. Headshape, fontanels, sutures

I. Faceeyes, ears, nose, mouth

J. Neck


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K. Chestappearance, retractions, HR & sounds, lung sounds, RR

L. Abdomenappearance, umbilical cord (color & number of

vessels), intestines (bowel sounds, rectum stools)

M. Genitalia- appearance & sex

N. Bladderif palpable, voiding

O. Skeletal structureclavicles, extremities, spine

L. Gestational age

a. Neuromuscular maturity

b. Physical maturityskin, lanugo, plantar creases, breasts, earsgenitals


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NEWBORN CARE

I. IMMEDIATE CARE

A. Maintain Respirations

a. Suction mouth & nose with buld syringe or Dee Lee mucus trap asneeded

b. Place in trendelenburg position if necessary (can be done on mothersabdomen)

c. Suction mouth first then nose. If nose is suctioned while mucus is inairway, infant may make an inspiratory gasp & aspirate mucus

B. Maintain warmth

a. Dry immediately

b. Place under warm blankets in skin to skin contact with mothersabdomen

c. Place under radiant warmer uncovered


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C. Apgar Scoreat 1 & 5 minutes

D. Care for Umbilical cord

a. Apply cord clamp 0.51 inch from abdomen

b. Maintain asep0sis when shortening cord

c. Count vessels in cord & record

E. Evaluate newbornfor deviations from normal

F. Identify Newborn

a. Apply arm & leg bracelet on newborn

b. Apply matching bracelet on mother

c. Footprint newborn & fingerprint mother if hospital policy indicates


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G. Promote attachment

a. Allow parents to hold & touch infant

b. Assist with breast feeding if desired

c. Help establish eye- to eye contact

H. Perform procedures

a. Weighif hospital policy at this time

b. Administer eye prophylaxisif hospital policy at this time


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II. CARE DURING THE FIRST

FEW HOURS A. Admission a. Maintain clear airway by suctioning as

necessary

b. Place under radiant heater or wrapped securelyin blankets

c. Lie- on- sideprop with blanket

d. Assess V/S hourly for first few hors

e. Weigh & measure

f. Perform physical assessment


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g. Prevention of Infection

i. Perform scrub prior to entering nursery or rooming-in unit

ii. Wash hands between infants

iii. Wear gloves until after bath & when handling

blood & body fluidiv. Clean stethoscope between infants or use

separate stethoscope for each infant

v. Apply drying agent to cord after bath

vi. Administer prophylactic eye treatment to

prevent opthalmia neonatorum (Neisseria G. & Chlamydiatrachomatis)

1. Erythromycin, Tetracycline, Penicillin

2. Silver Nitrate sol 1% (not effective against chlamydia)

3. Instill into lower conjunctival sac both eyes


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h. Prevent hemorrhage

i. Administer Vit K IM vastus lateralis muscles

ii. Provide Vit K until gut can begin synthesizing it

i. Assess glucose level if indicated or is hospital policy

i. Drop of blood from heel on glucose strip ii. Should be >45 mg/dl

j. Bathe infant with warm water & mild soap when temperature isstable

k. Provide nutrition

i. First feeding per hospital policybreast milk, glucose water,sterile water

ii. Glucose water can damage lung tissue if aspirated

iii. Do not overfeed

l. Facilitate attachmentif infant is separated from mother, return

infant to mother as soon as policy permits


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III. ROUTINE CARE

A. Assess Vital Signsfollow hospital policy

a. Temperature

b. Apical pulse

c. Respirations

B. Maintain Airway

a. Position on sideprop with blankets

b. Keep bulb syringe within reach

C. Maintain Warmth

a. Dress in shirt & diaper

b. Wrap in blankets

c. Stockinette cap if needed for warmth


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D. Promotion of Nutrition

A. Breastfeeding

i. Put to breast as soon as possible

ii. Feed on demand every 1.53 hours

iii. Position the i8nfant so that the body facesmothers body

iv. Elicit rooting reflex to entice infant to turningtoward breast

v. Put as much on areola in mouth as possible

vi. Direct nipple straight into mouth

vii. Hold breast cupped in hand with thumb on top so that nippleprotrudes, make sure nose is not blocked by mothers breast

viii. Make sure infant has latched on & is suckingproperly

ix. Do not use a nipple shield


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x. Allow infant to suck on one breast as long as it is sucking

correctly & breast has not been emptied

xi. Do not set time limits

xii. Breast suction by inserting finger into infants mouth next to

nipple xiii. Alternate use breast

xiv. Burp infant between breasts

xv. Burp well at end of feeding

xvi. Rotate positions used to hold infant to decrease nipple trauma


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b. Bottle Feeding

i. Feed on demandusually every 35 hours

ii. Cradle infant close to body

iii. Elevate head to prevent development of otitis media

iv. Never prop bottlev. Check flow of formula from nippleto ensure

flow in drops, not a stream

vi. Place nipple on top of tongue, pointed toward back of mouth

vii. Tilt bottle so that nipple remains full of formula

viii. Burp every to 1 ounce ix. Burp before feeding if infant has been crying

x. Do not force the infant to drink once it seems disinterested


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E. Provide cleanliness

i. Change diapers & clean diaper area as needed

ii. Bathe as needed

F. Prevent Complications

i. Weigh daily & compare to previous weights ii. Apply alcohol to cord with diaper changes

iii. Assess for signs of infection

iv. Do not cut nails

v. Provide circumcision care

1. Assess for swelling or infection 2. Observe & record for fir4st voiding

3. Apply Vaseline, A&D or other ointment to area with diaperchangeswith all types except Plastibell

vi. PKU screening test done on second or third day


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H. Document Care Provided

I. Provide parent Education

i. Suctioningdepress buld before inserting

ii. Positioning=- right side is optimal

iii. Wrapping & Swaddling iv. Dressingdo not overdress

v. Diaperingwash & dry area with each diaper change

vi. Holdingcradle, upright

vii. Umbilical Cord carealcohol after diaper changes

viii. Temperature Takingaxillary ix. Bathing

1. Sponge bathe until cord falls off

2. Tub bath every other day after cord falls off

x. FeedingBreast or Bottle feeding


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xi. Burping

1. Upright on shoulder

2. Sitting on lap

3. Lying face down across lap

xii. Formula Preparation

xiii. Nail caretrim after 2 weeks with infant scissors

xiv. Traveluse car seat

xv. Call Physician

1. Axillary temp >101 degrees F

2. Watery stool persists

3. Vomiting

4. Less than 6 wet diapers per day 5. Refuses 2 feedings in a row

6. Lethargic

vi. Return appointment date on time

1. For routine follow-up

2. For PKU testing


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GESTATION RELATED

CONDITIONS


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I.PRETERM NEWBORN

a. DEFINITION-infant born before 38 weeks gestation

b. ETIOLOGY AND PATHOPHYSIOLOGY

i. Many contributing factors

ii. Exhibit immaturity in all body systems

c. ASSESSMENT DATA

i. Respiratory distress syndrome- tachypnea, retractions,nasal flaring, expiratory grunt, pallor, cyanosis

ii. Bronchopulmonary displaisa

iii. Retinopathy

iv. Patent ductus arteriosus- continuous murmur, boundingperipheral pulses, wide pulse pressure, persistent respiratorydistress, hypoxia

v. Intracranial hemorrhage- beginning at 16 hours of life,apnea, dropping hematocrit, bulging fontanel, change in activity


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vi. Inadequate temperature regulation- lethargy, fatigue, poor

feeding, bradycardia, unstable blood pressure, depressed respiration

vii. Immature feeding reflexes

viii. Necrotizing enterocolitis (NEC)- abdominal

distention, decrease in peristalsis of bowels, occult blood in stool,peritoneal gas, unstable pressure, apnea, bradycadia, sepsis

ix. Low hetmatocrit

x. Impaired conjugation of bilirubin

xi. Infection


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d. TREATMENT

i. For RDS- supplemental humidified oxygen via hood,intubation if breathing difficulties, nasotracheal or orotrachealtube, continuous positive airway pressure(CPAP), musclerelaxants if needed, chest percussion, postural drainage, diluretics,

temperature controlled environment.

ii. Nutrition- IV fluids, nasograstic or ososgrastic feeding,total prenatal nutrition (TPN) if indicated, daily weight

iii. For bronchopulmonary dysplasia- broncho dilators,suction

iv. For periodic breathing- pneumogram tracing,cardiorespiratory monitoring, theophylline of caffeine

v. For retinopathy- ophthalmologic examination


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vi. For patent ductus arteriosus- indomethacin, intake

and output, surgical repair

vii. For intracranial hermorhage- ultrasound

of head, medication for seizures, if needed, serial lumbarpunctures

viii. For NEC- nasograstic tube, measure

abdominal girth, test stools and nasograstic drainage for

occult blood, withhold feedings, IV antibiotics, surgical

intervention if necessary


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e. NURSING INTERVENTION

i. Frequent vital signs

ii. Auscultate breath sounds

iii. Suction endotracheal tube

iv. Give oxygen before suctioning, if needed, and forrespiratory distress

v. Monitor blood glucose levels

vi. Maintain skin temperature at 36.1-36.7oC

vii. Minimize heat loss

viii. Monitor signs of cold stress ix. Monitor signs of hypoglycemia

x. Provide nutrition per physician order


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xi. Record intake and output

xii. Weigh diapers

xiii. Monitor IV site and rate hourly

xiv. Begin bottle or breast feeding slowly

xv. Monitor weight daily xvi. Monitor hematocrit level

xvii. Monitor bilirubin levels

xviii. Report signs of complications

xix. Include parents in planning care

xx. Encourage parental visiting and participationxxi. Provide sensory stimulation

xxii. Provide emotional support for parents

xxiii. Provide discharge instructions


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II. POSTMATURE NEWBORN

a. DEFINITION- newborn born after 42 weeks gestation


a. Placenta is unable to nourish fetus inadequately

b. Placenta loses its ability for gas and nutrient exchange

c. Newborn loses subcutaneous fat and muscle mass

c. ASSESSMENT DATA

a. Loss of subcutaneous fat and muscle mass

b. Peeling skin

c. Long fingernails

d. Wide-eyed gaze

e. Loigohydramnios

f. Asphyxia- cyanosis, limp, weak, unresponsive to simulation,seizures, poor suck

g. Meconium staining

h. Meconium aspiration syndrome- tachypnea, cyanosis, grunting,

nasal flaring, acidosis, retractions, hypoxia, hypercarbia


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d. TREATMENT

a. Resuscitation if necessary

b. Thorough suctioning of mouth and nose after head is born c. Tracheal suctioning before first breath, if possible

d. Laryngoscopic examination of airway to visualize vocal

cords (to determine if meconium reached that level)

e. Oxygen

f. Intubation and mechanical ventilation if necessary


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e. NURSING INTERVENTIONS

a. Observe cardiopulmonary status

b. Provide warmth c. Monitor blood glucose frequently

d. Initiate early feeding (usually glucose water)

e. Institute medical management as ordered

f. Assist with resuscitation as needed g. Monitor seizures and report

h. Monitor intake and output


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i. Auscultate breath sounds

j. Monitor chest expansion for equality

k. Assist with procedures

l. Ensure chest physical therapy and postural drainagefollowed by suctioning

m. Include parents in planning care

n. Encourage parental visiting and participation

o. Provide emotional support for parents

p. Provide discharge instructions


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NEONATAL CONDITIONS

PRESENT AT BIRTH

I INFANT OF ALCOHOL


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I. INFANT OF ALCOHOL

DEPENDENT MOTHER a. DEFINITION- infant of mother who ingested alcohol during

pregnancy (5 or more drinks on occasion or at least 1.5 drinks/day)


i. Ethanol freely crosses the placenta

ii. Exactly how damage to the fetus is unknown

c. ASSESSMENT DATA

a. Identify maternal alcohol use

b. Fetal alcohol syndrome- growth retardation (prenatal and

post natal), permanent CNS damage, microcephaly, mental

retardation, cranofacial abnormalities, decreased adipose tissue,

feeding problems, hyperactivity, anomalies


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d. TREATMENT

a. Prevention by elimination of alcohol consumption inpregnancy

b. Management of CNS dysfunction and withdrawal

c. Treat seizures with Phenobarbital or diazepam e. NURSING INTERVENTION

a. Observe for withdrawal symptoms within first three days-tremors, seizures, sleeplessness, inconsolable crying, abdominalreflexes, exaggerated mouthing behaviors, abdominal distensions

b. Keep warm, avoid heat loss

c. Protect from injury

d. Monitor seizures

e. Administer medications to limit convulsions

f. Monitor IV therapy


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g. Reduce stimuli- quiet, dimly lit environment

h. Spend time with feeding

i. Observe for respiratory distress

j. Provide parental support

k. Praise positive parenting efforts

l. Provide discharge instructions

m. Refer to community resources for follow up

II INFANT OF A DIABETIC


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II.INFANT OF A DIABETIC

MOTHER a. DEFINITION- infant of mother who has diabetes mellitus


i. Alterations in glucose metabolism in diabetic mother

affect fetus and newborn

ii. Maternal hypoglycemia causes fetal hyperglycemiawhich results in fetal hyperinsulinemia

iii. Fetus at high risk for developing anomalities

iv. Birth may be difficult- preterm, macrosomic infant

v. Infants pancreas continues to produce insulin in large

quantities after birth causing hypoglycemia


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c. ASSESSMENT DATA

a. Macrosomia- plump, plethoric, puffy, exhausted (frombirth)

b. May be lethargic or jittery

c. If placental insufficiency, may be small for gestational age d. Body organs (except brain) larger

e. Respiratory distress syndrome

f. Congenital anomalities- transposition of great vessels,ventricular septal defects, patent ductus arteriosus

g. Hypoglycemia (serum glucose 12 mg/dl in term

neonate)

i. Hypocalcemia (22 gm/dl and venoushematocrit >65%)


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a. Feeding glucose as necessary

b. Administer IV therapy if ordered

c. Monitor for hypoglycemia

d. Monitor for hyperbilirubinemia

e. Assess for anomalities, birth trauma

f. Monitor for hypocalcemia

g. Monitor for respiratory distress syndrome

h. Check hematocrit level i. Check glucose strips frequently (usually hourly)

Promote nonnutritive sucking to lower activity levels

III INFANT OF DRUG


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III. INFANT OF DRUG-

DEPENDENT MOTHER

a. DEFINITON- infant of mother who abused drugsduring pregnancy


a. Most common drugs used- cocaine, opiates,

marijuana

b. Periodic episodes of cerebral anoxia fromwithdrawal causes permanent fetal brain damage

c. Infant may have behavioral and attachment

problems d. Infant may have difficulty adjusting to lights and

noise


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c. ASSESSMENT DATA

a. Identify maternal drug dependency, especially those usedbefore delivery

b. Neonatal abstinence syndrome- CNS, GI, respiratoryvasomotor

c. Irritability

d. Tremulousness

e. Respiratory distress (heroin)- meconium, aspiration,transient tachypnea

f. Jaundice (methadone)

g. Congenital anomalities

h. Behavioral abnormalities

Withdrawal (within first 72 hours)


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d. TREATMENT

a. Prevention by eliminating drug dependency in pregnancy

b. Support physical needs

c. Nutritional support

d. Phenobarbital, or other drug, to control withdrawal symptoms


a. Decrease environmental stimuli

b. provide adequate rest

c. provide nutrition to meet needs on demand rather than on schedule

d. swaddle infant and support self-comforting

e. change positions frequently

f. promote parental care giving

educate parents about care

IV INFANT HEMOLYTIC


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IV. INFANT HEMOLYTIC

DISEASE a. DEFINITION- infant with a condition in which red blood cells

are destroyed as a result of an antigen-antibody reaction


a. Rh compatibility

i. Rh- mother pregnant with Rh+fetus

ii. Mother previously exposed to D antigers

iii. Fetal antigen stimulate maternal production of antibodiesagainst D antigens

iv. AntiD antibodies enter fetal circulation and destroy fetalRBCs

v. Fetus increases production of RBCs in liver, spleen and bonemarrow

vi. Fetal anemia is erythroblastosis fetalis

vii. Fetus exhausts ability to produce RBCs (hydrops fetalis) andcan have multisystem failure cardiovascular, respiratory, hepatic

viii. Rarely in first pregnancies


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b. ABO compatibility

i. Maternal blood group is incompatible with fetal

blood group

ii. Most common if mother is type O and fetus istype A or B

iii. Maternal antibodies cause agglutination of fetal

blood cells and clumping

iv. Clumps get caught in small vessels andhemolyze, producing belirubin

v. Occurs in any pregnancy


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c. ASSESSMENT DATA

a. Rh isoimmunization

i. Yellow amniotic fluid

ii. Tachycardia progressing to bradycardia

iii. Hypotension

iv. Respiratory distress

v. Jaundice beginning during first day of life

b. ABO incompatibility

vi. Jaundice in first 24 hours vii. Hyperbilirubinemia

viii. Weak to moderate direct Coombs test


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d. TREATMENT

1. Rh isoimmunization

a. prevention with administration of RhoGAM to mother is desired

b. intrauterine transfusions if severe

c. blood studies

d. photo therapy

e. exchange transfusion with Rh- whole blood

f. infusion of albumin

g. drug therapy

2. ABO incompatibility

a. may need no treatment

b. photo therapy

c. exchange transfusion, rarely


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1. Assess jaundice by blanching skin over bony prominence

2. Notify physician to evaluate hyperbilirubinemia

a. serum bilirubin level

b. birth weight

c. age in hours

3. Offer fluids between feedings

4. Avoid cold stress

5. Prevent infection

6. Provide phototherapy a. Naked infant

b. Cover eyes

c. Reposition every two hours

d. Remove eye patches for feeding


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7.. Monitor exchange transfusion for complications

following it

8. Keep umbilical cord moist

9. Encourage parents to hold; feed and talk to theinfant

10. Answer parents questions

11. provide emotional support


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c. ASSESSMENT DATA

a. Maternal history

b. CBC with differential, serum electrolytes, glucose

c. Vital signs

d. Urinalysis

e. Cultures of body fluids, drainage

f. Seizures

g. Bulging fontanels

h. Jaundice i. Chest x-ray

j. Feeding ability apnea


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d. TREATMENT

a. Identify type and source of infection

b. IV therapy with antibiotics

c. Supportive physiologic care


a. Prevent further infection

b. Administer antibiotic therapy

c. Monitor for side effects

d. Maintain neutral thermal environment

b. e. Administer oxygen if needed

c. f. Monitor vital signsd. g. Monitor caloric and fluid (PO, IV) intake

e. h. Monitor parental involvement

f. i. Teach parents about the condition

g J Monitor weight and output

Documents

Newborn Assessment (2)