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21 Cards in this Set
- Front
- Back
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Assessing and reducing risk in the Normal Newborn
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•Fetal Circulation
•APGARS •Gestational Age assessment •Supporting normal respiratory function •Supporting thermoregulation •Fluid balance •Minimizing risk of infection •Behavioral assessment •Preventing hypoglycemia •Managing Hyperbilirubinemia •Clinical Pathway-pgs 550-3 and NCP pgs.559-60 |
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APGARS (table 17-3)
•When is this assessment done? |
1 minute
5 minutes |
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APGARS
Factors assessed |
–Heart rate: abscent, <100, 100 or greater
–Resp effort –Muscle tone (activity) –Reflex response (irritability or grimace) –Color (appearance) |
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Apgars
•Interventions 0-3: |
Resuscitate
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Apgars
4-7 : |
Stimulation, O2,
Narcan |
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APGARS
8-10 |
observe
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Signs of NB respiratory distress
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-noisy breathing
-retractions -Inc RR -flaring nostrils -cyanosis |
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Respiratory Interventions
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Bulb Syringe
(McKinney 2005, pg 555) •Suction-(procedure 23-1) •Positioning •Teaching •Assessment |
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Supporting thermoregulation
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•Temperature-axillary 97.7-99.5
•Heat loss occurs through convection, conduction, evaporation, radiation •Positioning to conserve heat •Nonshivering thermogenesis •Relationship of “cold stress” to glucose levels (fig 22-4) •Decreased temperature related to… •Increased temperature related to… •Environmental factors |
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•Interventions to prevent heat loss:
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heat
wrapping pre warmed warmer skin to skin avoid drafts |
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Increased temp d/t
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-infection
-environment -metabolic acidosis d/t metabolism of brown fat -increase fatty acid -jaundiced |
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Kidney development/function
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- kedneys develop at 12 weeks gestation
-1-2 years of age they are fully developed |
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Assesment of NB kedney function
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-first void within 24 hours
-brick red in color -2-6 voids in the first 48 hours -6-8 wet diaperd at home per day |
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Hyperbilirubinemia
•Physiologic jaundice |
–Hemolysis of erythrocytes
–Uncongugated bilirubin –Role of the immature liver –Impact of delivery trauma –Impact of cold stress –Timing of symptoms –Lab-bilirubin 5-6 mg/dl |
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Hyperbilirubinemia
–Defined |
after 48 hours
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–Uncongugated bilirubin
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not water soluble
increased levels cuse brain damage |
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Physiologic jaundice
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•Risk factors for physiologic jaundice (p. 529)
–Hemolysis of rbc’s –Trauma –Fatty acids = byproduct of brown fat metabolism –Preterm –Cephalohematoma |
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Assessment of jaundice
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•Observation
–Cephalocaudal •Lab-normal 5-6 mg/dl at 2-4 days of age. •Factors considered –Age in hours –Screening –Heel stick screen –Serum levels –Preterm •Preventing complications |
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Nursing care to promote health in the Newborn
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•Prophylactic Medications
–Vitamin K (Aquamephyton)-drug guide 554 –Erythromycin Opthalmic Ointment-drug guide 555, vs. gonorrhea and chlamydia •Newborn Screening Tests –Inborn errors of metabolism. Examples-phenylketonuria (PKU), hypothyroidism and sickle cell anemia. –Hearing Screen |
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Health Promotion
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•Immunizations-Hepatitis B Vaccine or Hepatitis Immunoglobulin (HBIG)
•Safety –Preventing abductions –box 23-1 –Car seats –Cribs-maximum 2 3/8 inch between slats –Parent resources –Sudden infant death syndrome (SIDS) –Accident prevention –Shaken Baby syndrome |
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Expected Outcomes
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•Sleeps between feedings
•Lost less than 10% birth weight •Good skin turgor •Voids 6-8 times/day •2-3 BM’s/day •Maintains VS within Normal range |
