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39 Cards in this Set
- Front
- Back
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Initiation of breathing |
1) Establishment of respiratory gas exchange - lung expansion: surfactant production at 35 wks - Respiratory musculature: lung volume and growth - Removal of fetal lung fluid to gas filled organ 2) Establishment of pulmonary perfusion initiates circulatory changed in fetal heart rate: pressure changed fundamental to newborn circulation |
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Adaptation Initiation of Breathing: 4 Key physiological processes |
1. Mechanical a) 80-100 mls of fluid in fetal lungs of fetus at term b) Squeezing of chest in labour-intrathoracic pressure, recoil creates passive inspiration= "thoracic squeeze" c) Functional residual capacity established d) Lymphatic systems help clear fluid
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Initiation of Breathing: 4 processes cont'd |
2) Chemical a) Asphyxia-triggers onset of breathing- triggered by elevated CO2, decrease in pH and O2 b) Cord clamping c) Chemical sensors trigger the breathing center |
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Initiation of Breathing: 4 processes cont'd |
3. Sensory a) Tactile, auditory, visual stimuli and gravity. Gentle physical contact create respiratory stimulation
4. Thermal a) Chilling of moist baby, stimulate breathing |
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Assessment of Newborn |
1) Be organized 2) Prevent Heat Loss 3) Be aware that babies cry 4) Involve parents |
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Nursing Assessment and Care at Birth |
1) Dry the baby 2) Skin to skin; breastfeeding 3) Apgar score 4) Vital signs 5) Identify baby 6) Wt, length, head circum 7) Head to toe exam 8) Vitamin K and eye prohylaxis |
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Apgar Score |
Taken at 1 min, 5 min and score should be between 7-10 Rated on 0-2, 2 being strong and 0 being absent Tests: Heart rate, resp rate, muscle tone, reflex irritability, colour |
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Gestational Age |
1) Preterm: infant born before completion of the 36 week (sometime up to 37 weeks) 2) Term: Infant born between 37 weeks and 41 weeks 3) Post term: infant born after 42 weeks |
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Relationship between weight and gestational age: key terms |
1) Small for gestational age (SGA)- infants weight fall under the 10th percentile for gestational age 2) Appropriate for gestational age (AGA)-infants weight falls between the 10th and 90th percentiles for gestational age 3) Large for gestational age (LGA)-infants weight falls above 90th percentile for gestational age |
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Head to Toe Assessment |
Daily Assessment: TPR (hospital policy), Color, respiratory effort, tone, sleep-wake patterns, feeding, elimination, behaviour, parental interactions and learning needs |
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Key Priorities during Transition (Birth- 72 hours) |
Think pink, think warm, and think sweet |
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Think Pink: Respiration |
Respiratory rate, apnea, chest appearance, chest-abdominal movement, retractions, grunting, nasal flaring, breath sounds, chest circumference |
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Hypoxia / Asyphyxia |
Symptoms: cyanosis, limp posture, heart rate < 100, gasping, lacking respiratory effort
Causes: placental insufficiency, cord compression, blood loss, immature organ systems, difficult birth
Treatment: establish airway suctioning if necessary, oxygen, cardiac massage |
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Think Warm |
Normal range: 36.5-(37.2 to 37.5) Sources of Heat Loss: - evaporation, conduction, convection, radiation If baby gets cold: -increased O2 need, respiratory distress, decreased surfactant production, hypoglycemia, metabolic acidosis, jaundice Increases in metabolic rate can cause to inreased need for O2 and chances of respiratory distress
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Hypothermia |
Symptoms: feels cold, feeds poorly, pallor, cyanosis, increased activity, weak cry and tone, irritability Causes: decreased body fat, glycogen and brown fat, large body surface to weight, decreased vasomotor response, wetness, in drafts, on cold surface Treatment: (neutral thermal environment): Dry baby with towels, put on a hat, use warm blankets, moms skin to skin contact, incubators or radiant warmers, monitorthe axillary temp. |
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Think Sweet |
- Adequate nourishment, support breastfeeding - Maternal glucose stores for 24 hrs - Monitor weight-normal loss is 5-10% during first few days |
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Hypoglycemia |
Symptoms: tremors, jitteriness, irritability, apnea, limpness, cyanosis, hypothermia, poor feeding
Causes: decreased glycogen, increased insulin, cold stress, delayed food, infection
Treatment: Assess blood sugar if >2.6mmol/L, observe, give early feeding (1hr) and frequent feeds, keep warm, monitor Q1-2 hrs, if persistent low blood sugar then additional interventions needed
Support parents with teaching re: rationales |
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Dehydration |
- Less than 4 wet diapers/24 hrs after 4-5 days - concentrated dark urine - poor skin turgor, fine cracking over skin surface, fever, shrunken fontanel (late sign) - Acetone on breath (late) - poor muscle tone, weak cry, lethargy |
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Poor Weight Gain |
- loses more than 10% body weight - failure to regain birth weight by 3 weeks - gains less than 15-30 grams / day - stools are hard, dry and less than 1/day - wet diapers fewer than 6-8 day, 3-4 paper diapers
Nursing approach: complete early telephone assessment and home visit, weigh baby, observe feeding, complete assessment, ask mom to top baby up with EBM or formula, contact physician if >10% weight loss or weight loss has worsened |
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Newborn Behaviour |
Period of Reactivity: a) 1st period at birth, alerts, latch at breast, resp increases, Hr increases, increase mucous secretions b) Sleep- for a few hours c) 2nd period: interest in feeding, interaction Infant states: Deep sleep, light sleep (REM), drowsy, quiet alert, active alert, and crying |
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Newborn Behaviour |
Temperament: Attention to stimuli, habituation to stimuli, cuddling behaviour, consolability, self consolation |
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Newborn Physical Assessment |
Skin: Condition (intact, turgor, smooth, rashes), temperature, colour, vernix, lanugo, birth markings-petechiae, delivery marks
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Jaundice |
Physiologic jaundice: affects 50% of newborns, elevated serum bilirubin 34-250 mmol/L, starts after 24 hrs, peaks at 72-96h, d/t a high rate of bilirubin production and reabsorption, peaks faster and declines slower in asian infants
Pathologic jaundice: elevated bilirubin during first 24 hours, due to hemolytic disease, sepsis, liver disease, prematurity, asphyxia. Kernicterus unlikely over 48 hours can tolerate levels up to 350 mmol/L |
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Assessment of Jaundice |
- Undress baby and check skin in natural light - Blanching of the skin - Goes from head to toe (cephalocaudal) - Assess distribution: mild (nose and face), moderate (chest, abdomen, legs and sclera), severe (palms and soles of feet) |
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Newborn Assessment: Head and Scalp |
Appearance: hair Shape: molding, caput, cephalhematoma) Fontanelles: soft, flat, full, tense, sunken Suture lines: ridged, widely spread Condition: minor abrasions, depressed fractures |
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Newborn Assessment: Mouth |
Important for breastfeeding -Lips Palate - Movement - Tongue, frenulum - Gums - Teeth - Sucking, rooting, swallowing, gag reflexes |
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Newborn Assessment: Face |
Face: Appearance, movement Eyes: position, colour, blink responses, folds, conjunctiva, pupil size and reaction, movement Nose: Patency, mucous, shape, movement (nasal flaring) |
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Newborn Assessment: Ears, Neck, Circulation |
Ears: position, shape-cartilage, response to sound Neck: Movement, shape Circulation: Apical pulse, heart sounds, murmur, femoral pulses, skin colour, cyanosis, capillary refill
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Newborn Assessment: Abdomen, Neck |
Abdomen: Shape and intactness, texture, umbilical cord, bowel sounds, Anus patent, voiding and stooling
Genitalia: Shape, swelling, discharge, testia, labia, penis, voiding |
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Newborn Assessment: Back-spine, Extremities |
Back and spine: Shape of spinal cord, smoothness, and dimpling
Extremities: Length and use of arms and legs, muscle tone, digits, hand and sole creases, gluteal folds, pulses present |
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Newborn Assessment: Neuromuscular |
Reflexes: Rooting, sucking, swallowing, gag, dolls eyes, moro, palmar grasp, plantar grasp, Babinksis, tonic neck, stepping, prone crawl, trunk incurvation |
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Newborn Testing |
Hemoglobin, hematocrit PKU (phenylketonuria)- 1/10,000 births, deficiency of enzyme that converts ohenylalanine to tyrosine. Mental deficiencies unless diet restrictions |
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Morbidity for Full Term Infants |
Transient Tachypnea Asphyxia Hypothermia Hypoglycemia Dehydration Poor weight gain Jaundice Birth Trauma Infection Congenital Anomalies
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If Placental Insufficiency, late in pregnancy |
Hypoxia, Hypoglycemia, Meconium aspiration |
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Injury to the infant from mechanical forces during pregnancy |
Common injuries include: Petechiae, ecchymosis, caput succedaneum, cephalhematoma, fetal scalp blood sampling and electrode wounds, retinal and subconjunctival hemorrhages, clavicular fracture, brachial plexus injuries |
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Infections |
Group B Strep: a) Early onset(<7 days) includes most cases, mortality is 5-20%, sepsis and pneumonia are most common manifestations b) Late onset (>7 days) Increased incidence of meningitis c) Management: controversy for testing pregnant women, 35-37 weeks gest. or treat symptoms like fever or increased fetal heart rate d) ABx: penicillin/ampicillin in labor and post delivery monitor temp Q4h
Hepatitis: Preterm birth, acute or chronic Hep. Transmission rate about 90% with newborns when mom is seropositive. Infants treated with HBIG and Hep B vaccine |
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Early Signs of Sepsis |
General: Temp instability Respiratory System: Apnea or tachypnea, RDS Cardiovascular: Bradycardia, decreased CO, hypotension, tachycardia Gastrointestinal: Feeding intolerance, abdominal distention Integumetary: Pallor, jaundice, petechiae CNS: Temp instability, lethargy and hypotonia, irritability and seizures |
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Nursing care for infection |
Detect any signs of infection early, be meticulous to protect infant and mother via hygeine and handwashing, provide a thermoneutral environment and support infant with good nutrition and hydration, administer antibiotics and hydration, teach parents implications for any infections |
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Congenital anomalies |
2-3 % of live births Major defect leading cause of death under 1 Congenital malformation often cause abortion of fetus Most common anomalies: heart disease, neural tube defects, cleft lip or palate, clubfoot, congenital hip dysplasia |
