Kim Martin RN, MSN
Nursing Instructor
HACC, Pennsylvania’s Community College
Nursing 101; Summer 2012

• Begins immediately after birth
• Continues throughout hospital stay
• APGAR score at one minute and 5 minutes
• Gestational age assessment within 2 hours
• Complete assessment within 24 hours
• Wear gloves until 1 st bath

• Health History
• Physical Assessment
– Hand washing and warm hands
– Sleeping newborn

• Normal
–
Axillary = 36.5 - 37.5° C
(97.7 - 99.5° F)
– Rectal = 36.5 - 37.6° C
(97.7 - 99.7° F)
– Axillary is preferred
– Rectal done first in some institutions
• Abnormal
– Decreased
– Elevated

• Normal
– Heart rate = 120 -
160 BPM
– PMI 3 rd - 4 th intercostal space
– Brachial, femoral, and pedal pulses present and equal bilaterally
• Abnormal
– Tachycardia
– Bradycardia
– PMI to right
– Murmurs and arrhythmias
– Absent or unequal pulses

• Normal
–
Rate = 30 - 60 per minute
• Abnormal
–
Tachypnea after 1 st hour
– Slow respirations
– Irregular, shallow, unlabored
– Nasal flaring, grunting, retractions
– Chest movement symmetric
– Apnea with color changes
– Breath sounds present and clear in all lobes
– Asymmetric or decreased chest expansion
– Abnormal lung sounds
– Bowel sounds in chest

• Normal
– 2,500 to 4,000 grams
(5 lbs 8 oz to 8 lbs 130z)
–
Weight loss < 10% in first 2 weeks
• Abnormal
– LGA
– SGA
– LBW
– VLBW
– ELBW
–
Weight loss > 10%

• Normal
– 45 - 55 cm
– 17.75 - 21. 5 inches
– Measure from crown to heel
• Abnormal
– Below normal
– Above normal

• Normal
– 31 to 33.8 cm
– 12.2 to 15 inches
– Measured over prominent part of occiput and just above eyebrows
• Abnormal
– Small
– Large

CHARACTERISTICS OF THE
NEWBORN

Acrocyanosis
Lanugo

Mottling Harlequin Sign

ABNORMAL SKIN VARIATIONS

Excessive Vernix
Cyanosis
Jaundice

Forceps Marks
Petechiae

Nevus flammeus
Cafe’ au lait spots Nevus vascularis

HEAD AND FACE

Caput and Molding

Think “Ears and Kidneys”

Mouth – Normal
Precocious teeth
Epstein’s pearls

CHEST AND ABDOMEN

• Asymmetrical
• Supernumerary nipples

EXTREMITIES

• Diminished movement of arm with extension and pronation of forearm
– (Erb-Duchenne paralysis)

•Ortolani and Barlow signs positive
•unequal leg length
•Malposition of feet = position in uterus, talipes equinovarus

NEWBORN REFLEXES

Rooting Reflex
Sucking Reflex
Swallowing Reflex

ROUTINE PROCEDURES AND
CARE

• Hand washing
• Standard Precautions
– Gloves must be worn
• Until first bath
• Heel stick
• Diaper changes
• Breastmilk
• Regurgitation
• Suctioning

Prevent Hemorrhagic Disease
• AquaMephyton (Vit K) 1 mg IM in vastus lateralis

• HepB vaccine
– O.5 ml IM Hepatitis B vaccine prior to hospital discharge
– Then at 1-2 months and 6 – 18 months of age
– Moms with + HbsAG:
• baby also gets Hep B immune globulin (HBIG)

• Cord blood
– Blood type and Rh
– Coombs’ prn
• State law mandates screening for inborn errors of metabolism
– PKU
– Hypothyroidism
• Some states include
– Sickle cell, galactosemia, and MSUD

• Bilirubin (total and direct)
• Microglucose, if at risk
– Perinatal stress
– SGA
– LGA
– Maternal DM
– Post term (> 41 wks.)
– Pre term (< 37 wks.)
– NORMAL = > 40 mg/dl

• Surgical removal of foreskin of penis
– Controversial
– Nursing Care
• Assess for bleeding
• Assess for signs of infection
• Voiding

• General Hygiene
– Complete bath 2 – 3 times/week
– Mild soap and water; no powder
– Wash hair with bath, brush while washing to prevent cradle cap (seborrheic dermatitis)
– Cut nails straight across while infant is asleep
– Diapering and diaper rash
– Suctioning prn

• Never leave infant alone
• Hold during feedings
• Prevent heat loss
• Support head at all times
• Always use seatbelt in carriers, swings, strollers, etc.
• DO NOT leave alone with young siblings
• Clothing

BACK TO SLEEP

Car Seat necessary for all infants
Federally approved
Must have seat to leave hospital
Law in all 50 states
Rear-facing until one year AND
20 lbs.

• Increased frustration
• Smoking
• Domestic Violence
• Sexual Abuse
• CPR

• Signs of Illness
– Change in skin color
– Difficulty breathing or absence of breathing
– Axillary temp. > 37.8
°
C (100
°
F)
– Projectile vomiting
– Refuses 2 consecutive feedings
– Excessive crying, fussiness, lethargy, or difficulty waking infant
– Stool or urine changes
– S&S of infection from cord or circ site
– Appears or act ill

NEWBORN NUTRITION

• Many factors influence mother’s preference to breast or bottle feed
• Breastfeeding is almost
ALWAYS BEST for infant, but may not be best choice for mother

• Assess latch
• Listen for suck/swallow
• Observe infant and mother for comfort level
• Count wet and soiled diapers

• Supplements maybe recommended for breastfed infants
– Vitamin D
– Vitamin K
– Iron
– Fluoride
• Mother should continue prenatal vitamins
• Mother needs proper diet

• Closely resembles human breastmilk
• Provides essential vitamins
• Should be Iron enriched
• WIC (Women, Infant,
Children) = state/federal supplemental food program

•
Types :
– Cow milk based
– Soy based
– Predigested
•
Forms :
– Ready to feed
– Liquid concentrate
– Powdered
•
Teach parents importance of following directions

•
Positioning
– Held in semi-upright position
– Lying down predisposes to:
• Middle ear infections
• Aspiration
– Nipple filled with formula to avoid air
– Burp every ½ oz.

• After feedings, position on back
• Give feedings at room temperature
• Warm cold formula or breastmilk in pan of warm water
•
DO NOT MICROMAVE formula or breastmilk
• Clean bottles with soap/water or dishwasher
• If well water, boil water 5 – 10 minutes

HIGH-RISK NEWBORN

• “Winkled old man”
– Lacks subcutaneous fat
– Skin delicate, thin, transparent
• Covered with lanugo
• Prominent fontanels/suture lines
• Weak cry
• Abundant vernix
• Few creases on soles of feet

• Abdomen protrudes
• Short nails
• Genitals small
– Testicles high in scrotum
– No rugae until after 36 weeks
– Clitoris exposed
– Labia majora opened
– Ears lack shape/cartilage

• Problems
– Decreased brown and subcutaneous fat
– Large body surface area in relation to weight
– Poor muscle tone
– Thin skin
– Blood vessels close to surface
• Warmer or isolete
– Monitor skin temperature with sensor

COMPLICATIONS OF
PREMATURITY

• Functionally and structurally immature
– Insufficient surfactant
– Chest muscles not fully developed
– Abdomen distended = pressure on diaphragm
– Respiratory centers in brain immature
• Irregular pattern; apnea
• Predisposed to respiratory distress and infection

RESPIRATORY
COMPLICATIONS

• Hyaline Membrane Disease
– Membrane forms around alveoli and prevents exchange of O2 and CO2
– Lack of surfactant
– Synthetic or natural surfactant introduced into neonate’s endotracheal tube

Bronchopulmonary Dysplasia
(BPD)
• Supplemental O2 for extended period of time causes:
– Thickening of alveolar sacs
– Atelectasis and scaring
• Results in long term dependence on oxygen
• Prevention
– Monitor O2 concentrations closely
– Maintain lower O2 saturations

• Also Called Retrolental Fibroplasia
– Prolonged high concentrations of O2 cause proliferation and rupture of retinal blood vessels
– Blindness
• Prevention
– Monitor O2 carefully
– Decrease lighting in NICU
– Reduce stress to infant

CIRCULATORY SYSTEM

•
S&S = systolic murmur, active precordium, bounding peripheral pulses
•
Medical Management
– indomethacin (Indocin) inhibits prostaglandin synthesis
– diuretics
– surgical ligation
•
Nursing Care
– Accurate I&O,
– O2 sats,
– ABG’s

• Immature
• Suck, gag, and swallow reflexes uncoordinated or absent before 34 to
35 weeks gestation
• Intraventricular Hemorrhage

• Weak sucking and swallowing
• Delayed stomach emptying
• Reduced intestinal motility
• Small capacity
• Poor fat absorption
• Stomach sphincter immature – vomiting
• Tire easily – feeding uses a lot of energy
• Usually tube fed or IV nutrition only

• Ischemia of bowel
• Cells stop secreting protective mucus
• Intestinal cell damage and death
• Intestinal wall becomes invaded by bacteria
• Untreated, it can be fatal

Necrotizing Enterocolitis
TREATMENT: NG with suction to decompress bowel
IV antibiotics
Parenteral nutrition = TPN to rest gut

• Kidneys are immature
• At risk for fluid retention and/or over hydration

• Preterm at high risk for infection
– Invasive procedures
– Fragile skin
– Decreased immunity acquired from mom
• Meticulous hand washing and good aseptic technique

• Hypoglycemia due to inadequate brown fat and glycogen stores
• Increased glucose needs for growth and needs of heart and brain
• Microglucose done

• Family may need to grieve loss of
“perfect” baby
• May initially be afraid to become attached
• Encourage visits and involvement in care ASAP
• Allow verbalization

Cuddling Twins
Eat better
Sleep better
THIVE

• Born after 42 weeks gestation
• Placenta does not function well after 40 weeks
– Decreased O2
• In labor, O2 reserve is limited
• Higher risk of fetal distress and meconium aspiration
– Decreased nutrients
• Increased risk of hypoglycemia
• Look thin with loose skin
– Decreased vernix
• Skin dry and cracked

NEONATAL COMPLICATIONS

Hypoglycemia
• Plasma glucose levels < 40 mg/dL
– At risk
• Preterm
• LGA
• Infants born to mothers with DM

Hypoglycemia
• Common signs
• Lethargy
• Hypotonia
• Jitteriness
• Sweating
• Low temperature
– Treat immediately
Poor feeding
Tachypnea
Apnea
Shrill cry
Seizures

N
• Generalized bacterial infection in blood stream
• Caused by
– Staph aureus
– Staph epidermidis
– E-coli
– Haemophilus influenzea
– Group B strep

•
S igns of sepsis
• Lethargy
• Hypothermia
• Respiratory distress
• Cyanosis, pallor
• Jaundice
• Poor sucking and feeding
• Vomiting
• Diarrhea
•
Treatment
• Prevention
• Antibiotic therapy
• O2 therapy
• Careful regulation of fluids and electrolytes

Hyperbilirubinemia
• Excessive level of bilirubin in blood
• Characterized by jaundice
• Common in newborn
• Destroyed or dead RBC’s release bilirubin as they breakdown

Hyperbilirubinemia
•
Physiological Jaundice
– Common
– Self-limiting
– Peaks 3 – 4 th day of life
– Screening tool: Cutaneous bilimeter
– Blood test: Direct Bili

Hyperbilirubinemia
•
Pathologic Jaundice
– Occurs within 24 hours of birth
– Total serum Bili 12 mg/dl or > in term infant
• Formula fed < 12 mg/dl
• Breast fed < 14 mg/dl
– Total serum Bili of 16 mg/dl or > in preterm infant
– Primary cause is Rh and ABO incompatibilities

Rh and ABO Incompatibility
First Pregnancy
Next Pregnancy
Rhogam = Prevention

Hyperbilirubinemia
• Bilirubin encephalopathy
– CNS damage from deposits of unconjugated bilirubin
– High levels of bilirubin may cause
• Decreased activity
• Poor feeding
• Lethargy
Long-term effects
• Mental retardation
• Behavior disorders
• Motor dysfunction

Hyperbilirubinemia
Diagnostic Tests
• Total serum bili :
– Measures conjugated (direct) and unconjugated (indirect) bili
•
Direct Coombs :
– Measures antibody coated Rh +
RBC’s in infant’s blood
– Performed to ID hemolysis
• Indirect Coombs :
– Measures Rh + antibodies in mother’s blood

Phototherapy
Protect eyes and skin; maintain temp and fluid balance