THE NEWBORN

1
Nursing Care of the Normal Newborn
2
THE NEWBORN
I had heard about the negatives---the fatigue,
the loneliness, loss of self. But nobody
told me about the wonderful parts holding
my baby close to me, seeing his first smile,
watching him grow and become more
responsive day by day.....For the first time I
cared about somebody else more than
myself, and I would do anything to
nurture and protect him.
3
Transition to Extrauterine Life
4
Newborns undergo profound physiologic changes at
the moment of birth. Within minutes after
birth, a newborn has to initiate respirations,
and adapt a circulatory system to extrauterine
oxygenation. Within 24 hours, neurologic, renal,
endocrine, and gastrointestinal functions must
be operating competently for life to be
sustained.
5
Respiratory Adaptation
6
Surfactant

• What is the function of surfactant?
• When is it produced?
• When it is sufficient to support extrauterine
  life?

7
Respiratory Changes
What part do each of these factors play in
initiation of respirations in the neonate?
Mechanical
Initiation of Breathing
Chemical
Sensory/ Thermal
8
Chemical Events

• 1. With cutting of the cord, remove oxygen
  supply
• 2. Asphyxia occurs
• 3. CO2 and O2 and pH
  ACIDOSIS
• 4. Acidotic state-- stimulates
  the
• respiratory center in the
  medulla and
• the chemoreceptors in
  carotid artery to
• initiate breathing

9
Mechanical Events

• As the chest passes
• through the birth canal
• the lungs are compressed

• Subsequent recoil of the chest wall produces
  passive inspiration of air into the lungs

Fluid expelled
Air Enters
10
Mechanical Events

• About 60-110 ml. of fluid is squeezed out of the
  lungs as the chest is compressed
• The remaining fluid evaporates or is reabsorbed
  by the blood vessels and lymphatics surrounding
  the lungs.
• When a baby is delivered in a presentation
  other than vertex, it takes longer for the lungs
  to rid themselves of the fluid

11
Sensory / Thermal Events

• Thermal--the decrease in
• environmental temperature
  after
• delivery is a major stimulus
  of breathing
• 
  
  
• Tactile--nerve endings in the skin
• are stimulated
• Visual--change from a dark world to
• one of light
• Auditory--sound in the extrauterine
• environment
  stimulates the infant

12
Answer this !
Answer This!

• When a baby is born by cesarean delivery, which
  of the mechanisms to initiate breathing does it
  lack?

13
Cardiovascular Changes
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Fetal CirculationWhat is the flow of blood
through the fetal heart?

1. ____________
2. ____________
3. ____________
4. ____________

LA
RA
LV
RV
15
Fetal Circulation
Why does blood flow In this route?
16
Fetal Circulation

• What is the stimulus for the change in
  circulation?
• What are the changes in circulation from
• Intrauterine to
• Extrauterine?

17
Intrauterine to Extrauterine
1. Infant takes first breath and the
lungs inflate ______________
pulmonary vascular resistance
Increased ______________ blood flow
pulmonary
artery pressure _________.
2. Increase pressure in ____ atrium, ____
pressure in right atrium
_________ of foramen ovale
3. The ______ arteriosus and ductus venosus close
related to pressure changes and ? ______
levels.
18
Cardiovascular Changes
3. Ductus Arteriosus begins to constrict
2. Blood flows to the lungs
4. Pressure in the LA increases RT Flow
of blood from the lungs
1. Pressure in RA decreases
5. Increase pressure in the LA forces the foramen
ovale to close
19
True / False

• An infants first breath results in reduced
  pulmonary vascular resistance, decreased left
  atrium pressure, and increased right atrium
  pressure
• Increase CO2 , decreased O2, and increased pH
  help trigger initial breathing

20
Temperature Regulation
21
Temperature Regulation

• Why is the newborn at a DISADVANTAGE in
  maintaining a normal temperature ?

22
Minimizing Heat Loss in the Newborn
is IMPERATIVE
23
Four Avenues of Heat Loss

• Conduction --Loss of heat to a cooler surface by
  direct skin contact
• Convection--Loss of heat to cooler air currents
• Radiation--loss of heat to cooler surfaces and
  objects not directly in contact with the skin
• Evaporation-- loss of heat when water is
  converted to a vapor.
• What are nursing interventions to decrease each
  of these?

24
Heat Production

• 1. Increase in Muscular activity--shown by crying
  and restlessness increases BMR
• 2. Non-Shivering Thermogenesis - unique to
  newborns. Uses the infants stores of brown fat.
• Brown fat is found in the midscapular area,
  around the neck, in the axillas, and around the
  trachea, kidneys, and adrenal glands

25
Non Shivering Thermogenesis

• 1. Skin receptors perceive a drop in
  environmental temperataure
• 2. Transmit impulses to the central nervous
  system
• 3. Which stimulates the sympathetic nervous
  system
• 4. Norepinephrine is released at local nerve
  endings in the brown
• 5. Metabolism of brown fat
• 6. Release of fatty acids
• 7. Release of HEAT!

26
Peripheral Vasoconstriction
Subcutaneous Fat
Heat Maintenance
Curl up in fetal position
27
Hematologic Adaptation
28
Blood Changes

• At birth, an infant has more RBCs and higher
  hemoglobin and hematocrit levels than an adult
• Once proper oxygenation is established, the need
  for the high RBCs diminishes

29
Lab values for Newborn

• hemoglobin 14-20 g/dl
• hematoctrit 43-63
• WBC 10,000-30,000/mm3
• glucose 45-96 mg/dl

30
Gastrointestinal Adaptation
31
Gastrointestinal Changes

• By 36-38 weeks of fetal life, the GI system is
  fully mature and ready to digest simple
  carbohydrates, fats, and protein.
• What is the capacity of the newborns stomach?
• What is meconium? Why is it important for the
  newborn to pass this?

32
Hepatic Adaptation
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Hepatic and LiverFunctions

• iron storage and RBC production
• carbohydrate metabolism
• conjugation of bilirubin
•  

34

• Coagulation--coagulation factors are under the
  influence of vit. K. The absence of normal flora
  needed to synthesize vit. K results in low levels
  of vitamin K and creates a transient blood
  coagulation alteration between the second and
  fifth day after birth.
• Vitamin K is given prophylactically to combat
  potential clinical bleeding problems

35
Physiological Jaundice

• What is Physiological Jaundice?
• What is the main cause?

36
Conjugation of Bilirubin

• Where do we get bilirubin?
• What is the difference in Unconjugated bilirubin
  and conjugated bilirubin?
• Why does it need to be conjugated?

37
Conjugation of Bilirubin is a conversion of
Fat Soluble
Water Soluble
to
Unconjugated
Conjugated
by ___________________________________?
38
Physiological Jaundice

• About 50 of all infants exhibit signs in 2 - 3
  days after birth
• Bilirubin levels at birth are about 3 mg./dl
  and should not exceed 12 mg. Peak bilirubin
  levels are reached between days 3 5 in the term
  infant. Toxic levels are approximately 20mg/dl.
•  Nursing Care
• Keep well hydrated
• Promote elimination
• early feedings tend to keep bilirubin levels down
  by stimulating intestinal activity thus removing
  the contents and not allowing reabsorption

39
Renal / Kidney Changes

• Intrauterine
• Urine if formed in utero and some excreted into
  the amniotic fluid
• Excretion of wastes is the function of the
  placenta

• Extrauterine
• GFR is low --decrease ability to excrete drugs
• Limited ability to reabsorb Sodium
• Decreased ability to concentrate urine
• Bladder capacity is
• 6 - 44 ml
• Void within the first 24 hrs. and should void 6 -
  10 times per day

40
Immunologic Adaptation

• Active acquired immunity
• Pregnant woman forms antibodies herself
• Passive acquired immunity
• Mom passes antibodies to the fetus
• Lasts from 4-8 months
• Newborn begins to produce own immunity about 4
  weeks of age

41
Behavorial / Sleep - Awake States

• Sleep States
• Deep or quiet sleep
• Active rapid eye movement/ light sleep
• Alert States
• Drowsy
• Wide awake/quiet alert
• Active awake/ active alert
• Crying

42
Which state is optimal for parent-infant
interaction?

• Quiet Alert

43
Sensory

• Visual
• Can follow and fixate on visual stimuli for short
  period of time
• Hearing
• Alert to and searches for auditory stimulus
• Olfactory
• Able to select people by smell
• Taste
• Able to respond to different tastes
• Tactile
• Sensitive to touch, cuddling, and being held

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Nursing Assessment of the Newborn
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Immediate Care of the Newborn

• Ensure a Patent Airway
• Position on side
• Suction mouth then nares
• supply warmed oxygen is necessary
• Always have bulb suction in view !

46
Clamping of the Cord

• Cord should be clamped off about 1 from base of
  cord.
• Inspect the cord for
• 2 arteries and 1 vein.

47
Maintain Body Temperature

• Dry off
• Place in warmer
• Skin to skin contact

48
Apgar Score

• Scoring system to appraise the newborn
• Done at 1, 5, and 10 minutes after birth

49
Apgar Score
0 1 2
Heart Rate is the most important !
50
Apgar Score

• Score of 7 - 10 Good Condition
• Score of 4 - 6 Fair Condition
• Score of 0 - 3 Poor Condition

51
Score This !

• Baby girl Doe has a heart rate of 102, with slow,
  irregular respirations. She grimaces when
  stimulated. She has some flexion in her
  extremities and her skin color is pale.
• What is her Apgar Score?

52
Identification of the Newborn

• Mother and infant should have
• matching identibands.
• Bands should be placed on infant prior to leaving
  the delivery room
• Footprint of infant and fingerprint of the mother

53
Eye Care

• Legal requirement that all newborns have
  treatment to prevent Ophthalmia neonatorium which
  can lead to newborn blindness.
• Treated with antibiotic eye medication either
  ointment or drops
• (Tetracycline or Erythromycin )

54
Hemorrhage Prophylaxis

• Administration of Vitamin K (AquaMEPHYTON)
• This promotes liver formation of clotting factors
• The newborn does not have bacteria in the GI
  tract to synthesize vit. K.
• By 5 - 8 days after birth, it is formed.

55
Transfer to the Nursery

• Identification checks
• Full report must be given to the nursery nurse by
  the L D nurse
• Condition of the neonate
• Labor and Birth record
• Antepartal history
• Parent-newborn interaction

56
Nursing Assessments of the Newborn
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Physical Assessment

• Temperature - 97.6 - 98.6
• Heart Rate - 120 - 160 BPM. Regular rate. PMI
  
• on the left side
  of the chest
• Respirations- 30 - 60 breaths / min.
  Diaphragmatic with a shallow, irregular rate and
  rhythm. Chest and abdominal movements should
  synchronize. Periodic Breathing is normal. They
  are nose breathers. Tachypnea is abnormal
• Blood Pressure - 80-60 / 45-35.

58
Measurements and Weights

• Length 18 - 22 inches
• Head and Chest Circumference Head is 13
  Chest is 12. Head is larger than the chest by
  one inch or 2 cm.
• Weight - 6 - 9 lbs average. Newborns lose 5 -
  10 of birth weight the first few days after
  birth.

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Reflexes

• Moro
• Tonic Neck
• Palmar and Plantar grasp
• Babinski
• Feeding--Rooting, Sucking, Swallowing, Gag
• Protective -- Sneezing, Blinking, Gag

60
Daily Nursing Care

• Need for warmth and dry
• Need for protection from infection
• Need for food
• Need for attachment and loving
• Need for bathing and cord care

61
Nutritional Needs

• The newborns diet must supply nutrients to meet
  the rapid rate of physical growth and development
• Daily caloric intake should be 110 - 120 calories
  / kg. / day

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Circumcision

• It is not medically necessary. It is a personal
  decision of the parents.
• What is the priority nursing assessment following
  a circumcision? Explain?
• What is important to teach parents about care?