Chapter 17 and 18
Care of the Newborn
Transition period
à 6-8 hours after being born.All systems have different requirements.
First:
Order in which assessment is done:
Respiratory.
May have tachypnea = fast resps. Should go away after a couple of hours. May have apnea, greater than 15-20 should be reported.
S&S of Respiratory problems:
Auscultate breath sounds. If you hear rales, sometimes right after birth, baby may still have amniotic fluid. If not symptomatic then not a problem.
Cardiovascular.
Fetal circulation - page 294.
When cord is clamped, mom no longer supplies oxygen. As baby takes it in, lungs fill and pulmonary artery pressure decreases then the lungs expand and oxygen goes to the baby.
Blood volume of left side of heart is what causes foremen ovale to close. Ductus arteriosis also closes at 15-24 hours after birth.
Ductus venosis stops functioning when umbilical cord is clamped, then baby’s liver starts to function. Will close completely in 2 weeks.
Check heart rate. Should be 120-160. Count for 1 full minute. When crying, it can go up. When sleeping, it should go down. It should never go up when sleeping.
Check BP in all 4 extremities. Will be around 70/40. Discrepancy may indicate cardiac anomalies.
Nervous system.
Most neurons have been completely formed. Should get a strong cry.
Muscle tone should be good.
Growth is from head-to-toe.
GI system.
Stomach will only hold 40-60cc (1-1 ½ oz).
Cannot digest fat yet completely.
Gastric emptying is 2-4 hours after they eat.
Cardiac sphincter is immature. (spits up).
Sucking and swallowing should be well developed.
First stool is meconium for first 24 hours.
Rectal temp to see if anus is patent.
Intestines are sterile.
Formula helps normal flora to come into stomach which produces vitamin K.
Vitamin K has to be injected when first born.
Hepatic System.
Liver is immature. Its functions are to store iron, CHO metabolism, and blood coagulation.
Skin.
Assess color. There could be mottling or jaundice (1st day = biliary obstruction).
Assess for breaks in the skin, bruising (because of delivery) and vernix.
About Jaundice: It progresses head-to-toe. Can press on forehead and if blanch is yellow = jaundice. If a baby is jaundice within 1st 24 hours = pathological jaundice. Most common cause is ABO incompatibility. Usually mom is O and baby is A or B. If jaundice appears at about 2-3 days after birth it is physiological jaundice. Caused by an immature liver. Also called icterus neonatorum. When baby is born, it has a high erythrocyte count. When lungs become functional, some if the RBC's are not needed so they break down (they have a shorter life span than an adult anyway) into bilirubin. Bilirubin goes to the liver. Bilirubin loves to deposit in fatty tissue. If it builds to a dangerous level = kernicterus and causes brain damage. In an adult, bilirubin changes from being fat solable to being water soluble and leaves the body thru urine. In an infant, the liver is immature and is unable to change to water-soluble form and bilirubin levels sometimes go up. Do not get jaundice until level gets to be 5mg. Physiological jaundice usually resolves itself in 7 to 10 days. Get rid of it by increasing urine output by increasing fluids. At 14mg, will treat jaundice with phototherapy. Purpose = the rays help change the bilirubin to a water soluble form to be excreted in urine.
Precautions:
Only wear a diaper.
Protect eyes.
Change position frequently.
Document how far ray is away and how much.
Check temp.
Urine should look darker (tea color).
Adequate fluid intake.
Levels >20mg/dl = kernicterus.
Home treatment: lie near window close to sun.
Breast fed babies bilirubin may go up and should be monitored closely because of a substance in breast milk that breaks down bilirubin to a fat soluble form.
Full term baby skin:
Dry, peeling of hands and feet.
Check skin turgor over abdomen.
Vernix in creases.
Lanugo in patches.
Harlequin sign: normal variation where one side of baby's body is red and is due to vasomotor instability.
Musculoskeletal.
Assess muscle tone.
Should have arms and legs flexed.
Sometimes tremors or extremities shaking.
Flacid, frog-legged, or extended extremities need to be investigated.
Lethargic: needs stimulation for activity.
Listless: just lying there.
Immune system.
Antiobodies IgG from placenta used for about 2 months and while breast feeding.
Give immunity to polio, tetanus, chicken pox, pertussis and diptheria.
Urinary system.
Excreting CO2 thru the placenta and kidneys are not mature.
Have difficulty concentrating urine and retaining electrolytes, and excreting medications.
Should void within 24-48 hours and be sure to document.
Thermoregulation.
Very important.
Loses heat when crying.
4 mechanisms of heat loss:
Cold Stress
Will use up calories and oxygen.
S&S:
Cold stress is the metabolic demands placed on the neonate to maintain adequate body heat. When the neonate gets cold, receptors sends a message to the hypothalamus (responsible for coordinating heat loss and heat production) which sends a message to the sympathetic nervous system to activate heat production thru a process called thermogenesis. This is a non-shivering process. This method is produced by brown fat (unique to neonates). It is specialized tissue that is highly vascular and produces heat in the newborn. Located in adipose tissue of axillary, above kidney, sternum, across shoulders, and nape of neck.
If under cold stress, baby uses more oxygen and glucose and may become hypoxic. Respiratory distress and metabolic acidosis will occur. Acidosis of cold stress results in decreased production of surfactant.
Respiratory distress symptoms:
Preventing neonate heat loss:
Baby will assume the fetal position to decrease body surface area and conserve heat.
Neonatal Behavior
Apgar Scoring
Heart rate
Respiratory rate
Muscle tone
Reflexes
Color
Each category has a score of 2. 10 is highest although no baby usually is a 10. During this also check for obvious deformities.
Vital signs abdomen should rise and fall
Respirations:
Heart rate:
Temperature:
Weight:
Length: 45-55cm or 17.75-21.5 inches.
Preterm = <37 weeks
Term = 38-42 weeks
Post term = >42 weeks
Senses:
Vision - can see a foot from their face. They like black on white.
Hearing - will turn head to sound. Startles easily. Heart rate goes up. Likes being talked to.
Acute smelling.
Taste - likes sweet fluids vs. salty fluids. Sensitive to touch. Soothed by rocking and body contact. Like to be stroked and rubbed. Responds to pain.
