The Normal Newborn: Assessment, Care, Feeding Presented by, Joy Haskin, RN, MS Joke for the day…. Should children witness childbirth? TERMS: Neonatal Period: Birth --> 28 days of life Term Infant: 38 - 42 weeks of gestation Transition Period: Phases of instability during the first 6-8 hours after birth Viability Capacity to live outside of the uterus about 22 to 24 weeks since the last menstrual period, or fetal weight greater than 500 g. In the past was 28 weeks - with technology and advancements this is becoming shorter and shorter…... Physiologic Changes of the NB to adjust to extrauterine life: What happens during birth to the neonate? Circulatory: Transitional Circulation = acrocyanosis Peripheral circulation = sluggish High: RBC 4.8-7.1; Hgb 14-24; Hct 44-64 WBC 18,000 @ birth; 23-24,000 @ 1 day Coagulation: Vit K dependent clotting factors are decreased. Platelet counts ok (150,000-350,000) Respiratory Before birth O2 needs met by placenta L/S ratio should be > 2:1 After delivery need mature lungs that are vascularized, have surfactant and sacules - usually adequate by 32-35 weeksat term the lungs hold approx. 20 ml of fluid/kg What initiates respiration? Periodic Breathing -vsApnea Apnea: no breathing for periods of greater than 15 seconds should be evaluated. Periodic Breathing: Notify MD if resp < 30 or > 60 Gastrointestinal System Immature at birth, reaches maturity at 23 years of age place food at back of tongue sucking becomes coordinated @32 wks little saliva until 3 months of age bowel sounds after 1 hour of birth Gastrointestinal (continued) NB have difficulty digesting complex starches and fat Abdomen becomes easily distended after eating Initial fecal material = meconium No normal flora at birth in GI system to synthesize Vit. K Immune System Limited specific and Non-specific immunity at birth passive immunity(from mom- IgG) for the first 3 months of life ~ this will be reduced if baby is born premature breastfeeding = ^ passive immunity (IgA) Temperature Regulation Non-Shivering thermogenesis: brown fat is the primary source of heat production. Brown fat is broken down into glycerol & fatty acids producing heat. Brown fat is found @ the nape of the neck, axillae, around the kidneys and in the mediastinum. Slightly warmer to touch than nml skin. Cold Stress An increase in the metabolic rate associated with non-shivering thermogenesis --> increased O2 demands and caloric consumption It’s important to provide a neutral thermal environment to prevent metabolic acidosis and prevent depleted brown fat. Kidneys and Urination 92% of all healthy infants void in the first 24 hrs of birth initial urine:cloudy, scant amounts, uric acid crystals-> reddish stain on diaper Kidneys not fully functional until child is 2 years of age. Hepatic Function Liver produces substances essential for clotting of blood. Stores needed iron for the first few months. Preterm & small infants have lower iron stores than full term and heavier infants. (full term infants stores last 4-6 mo) NB at risk for Physiologic Jaundice after 24 hours of age, d/t increased breakdown of RBC’s and immature liver functioning. Increased Bilirubin Levels Jaundice in the 1st day is NOT normal Bilirubin level greater than 12 at any time needs further attention Maternal causes of increased bilirubin levels in the NB: epidural use, oxytocin induced labor, infection, hepatitis Ethnic Influences: Asian infants levels may be double other ethnic groups. Kernicterus Complication of neonatal hyperbilirubinemia --> encephalopathy basal ganglia and other areas of the brain and spinal card are infiltrated w/ bilirubin (produced by the breakdown of hemoglobin -> levels of 20 - 25 or more). Poor prognosis if untreated. Neurologic All neurons are present, but many are immature: uncoordinated movements poor muscle control startle easily tremors in extremities Weight Loss It is normal for the newborn infant to loose 5-10% of weight in the first 4 to 5 days of life. Infants at Risk “RED FLAGS” after birth include: gagging --> turning blue (esp. after fdg) generalized cyanosis weak cry grunting or respiratory distress decreased or absent movements excessive twitching or trembling OTHERS>>>>> Nursing Diagnosis: Ineffective Airway Clearance R/T excessive oropharyngeal mucus Ineffective Thermoregulation R/T newborn transition to extrauterine life High Risk for infection R/T maturational factors, immature immune system PC: Hypoxemia PC: Hyperbilirubinemia (W) Beginning Integration of NB into Family Unit Nursing Care to Meet NB Needs Prevent infection: handwashing, stay away from large groups or ill individuals, prophlactic agents (EES, cord care, bathing) Vernix Breastfeeding Warmth Bath after temperature is stable warmer/isolette/bundle hat keep out of drafts skin to skin Position of sleep/prevent SIDS Back to sleep feet to foot of bed no stuffed animals or excessive blankets in bed don’t cover head in stroller don’t keep house too warm No smoking around infant Cleanliness No tub baths until cord off and healed clean around organs of elimination and mouth after soiling to prevent skin break down daily head to toe bath not necessary OK to clean and touch the “soft spot” fold diapers away from umbilicus NEVER leave child alone in tub!! Research and Cord Care 1,811 NB’s- 2 groups - one receiving cord care with alcohol and one group not: * equal # infections in infants who received and did not receive cord care *cord separation ~ alcohol use: 9.8 days –no alcohol used: 8.16 days Carseats “AS a condition for licensure, public and private hospitals, birth centers, and clinics must have a written policy on the dissemination of child passenger restraint system information to parents or the person to whom the child is released” (SB503 REQ) Genital Care Male Infant: if penis is uncircumcised DO NOT RETRACT THE FORESKIN--“leave it alone” Female Infant: wipe front to back. If “smegma” has accumulated in the labial folds it can be carefully removed Infant Feeding Why may a mother decide to Breast Feed? Discussion Formula feeding Why may a mother decide to formula feed her infant? Discussion Frequency of Feedings Breastfeeding: successful latch-on and feeding should occur every 1.5 to 3 hours daily. Formula Feeding: 3-4 oz every 3-4 hours for full-term babies. Baby should have 6-10 wet diapers/day calculate amnt of formula mult. baby’s wt in lbs by 2 then 3, this is oz per day. (EX: 8lb. Baby~ 8 X2 = 16; 8 x3 = 24 therefore 16-24oz of formula per day is needed for adequate nutrition) Nursing Diagnosis Effective Breastfeeding Risk for Altered Nutrition (more or less than body requirements) R/T (insufficient caloric intake or excessive caloric intake) Circumcision Elective Procedure Not pd for by medi-cal Decision made based on tradition, religion, culture, or personal factors VALUE OPPOSITION Procedure Usually delayed 12 to 24 hours until NB is stabilized Do not feed 1 hr prior to procedure Consent required from one parent Methods: Gomco or Plastibell Restraint required Anesthetic is physician dependent After Care Comfort measures keep wound clean and dry (warm water) ck urination w/in 12 hrs after procedure monitor for bleeding s/s of infection will not occur immediately after procedure Periods of Reactivity REVIEW 1st period of reactivity:after birth of baby, bursts of rapid movements. Quiet times during this period are ideal for breastfdg & interacting Deep Sleep - lasts 60-100 minutes 2nd period of reactivity: occurs 4-8 hrs after birth lasts 10 min to several hours. Periods of tachycardia & tachypnea. Increased muscle tone, skin color, mucus production, pass meconium The end….