1
Q
Back and Buttocks
A
- Straight Spine
- Spina Bifida Occulta-dimple or tuft of hair
- Meningocel (sac with fluid only)
- Meningomyelocele (sac with fluid and spinal cord)
(FOLIC ACID DEFICIT)
2
Q
Neuroligic S x S- 1 A
A
Reflexes which can dissapear at certain intervals.
- Balinsky
- Plantar/Palmars grasp
- Moro-
- Rooting
- sucking
- reflexes disappear at certain intervals
- Galant reflex-back stroke move hips toward the side
- Tonic Neck Reflex
- Stepping reflex
3
Q
Neurologic Sx S 2 A
A
- Sensory
- Do eyes track?
- Does infant respond to sound?
- Habituation
- Seizures
- Difficult to recognize because of many extraneous movements
- Maybe caused by acute or chronic conditions (hemorrhage, trauma, infection, brain malformation…)
4
Q
Gestational Exam
A
EDD is not alway correct only accurate 75-85% of the time.
-Performing a genstation exam helps the nurse evaluate for potential age-related problems. Should be done in the first 4 hours of life.
-Gestation age tools have 2 components:phhysical maturity and neuromuscular maturity.
Most common tool is the New Ballard Score
5
Q
Lab Assessments
A
- Blood Gluclose->40 mg/dl is normal
- Bilirubin Level-< 12 is normal, Peeks on 3rd day of life
- Newborn Screening Test (NBS)- State required test:
- Phneylketonuri (PKU)
- Hypothyoidism
- Galactosemia
- Hemoglobinopathies
6
Q
Medications
A
-immediatly after birth;
-Vitamin K injections
-Erythromycin ophthalmic ointment
-Hepatitis B
-CDC recommendations
+All newborns be immunized forHepatitis B
+Neonates who have been exposed to Hep B during birthing should also recive HBIG.
7
Q
Initiation and Maintenance of Respirations
A
- Lung Development-as a fetus nears birth, fluid begins to move to interstitial space.
- Production of surfactant by 34-36 weeks.
- It’s a mixture of lipoproteins
- It reduces surface tension in the alveoli, which promotes lung expansion after birth.
- It keeps alveoli of lungs from collapsing when exhalation occurs.
8
Q
Factors that initiate Respiration
Chemical Factors
A
DROP in O2 and RISE in CO2 causes impulses to stimulate the respiratory center in the medulla of the brain.
9
Q
Factors that initiate Respiration
Thermal Factors
A
Abrupt temperature change sends impulses impulses fromskin recepotors to the brain’s respiratory center.
10
Q
Factors that initiate Repiration
A
Mechanical Factors: Fetal chest is compressed during birth, forcing fluid out. Plus, suctioning, holding, sounds, and lights.
11
Q
Factors that maintain respirations
A
surfactant & functional residual capacity (both the thorax and lung are very complaint, so that the FRC is very small)
12
Q
Cardiovascular Adaption
FETAL CIRCULATION
A
A combination of structures/vessels that are present only during the fetal period, helps shunt the the highest oxygenated blood to the liver, brain, and heart.
13
Q
ICLICKER
42 WEEKS of gestational age
A
AT RISK FOR INJURY DURING BIRTH
14
Q
THREE MAIN STRUCTURS of Cardio
A
- Ductus Arteriosus (Pulmonary Atery to Aorta)
- Foramen Oval (Right Atrium to Left Atrium)
- Ductus VEnosus (Umbilical Vein to interior Vena Cava)
15
Q
Cardiovascular Adaption 2 A
A
At birth, after the first few breaks, the following cardiovascular changes occur:
16
Q
Cardio
Ductus Arteriosus
A
Closes in response to INCREAS o2 and DECREASE to resistance in the LUNGS (PDA Murmurs)
17
Q
Pulmonary blood vessels -Cardio
A
Dilate in response to demand in lungs
18
Q
Foramen Ovale- Cardio
A
Is forced to close because of increased pressure in the left side of the heart.
19
Q
Ductus Venosis- Cardio
A
Constricts when umbilical cord is clamped
-Reversal of blood flow:from aorta to pulmonary artery (in the fetus, blood flow: from aorta to pulmonary artery (in the fetus, blood is shunted from the pulmonary artery to the aorta through the patent ductus arteriosus)
20
Q
Apgar Scoring
A
- Dr. Virtginia Apgar (1909-1974) develop the first scoring system of the Newborn
- The Apgar score description the condition of the newborn infant immediatly after birth.
- scoring is done at 1 minute and 5 minutes of age.
- The Apgar is affected by gestational age, maternal medications, resuscitation, and cardiorespiratory and neurologic conditions.
- There is a need for professional to be consistent in assigning an Apgar score during a resuscitation.”
21
Q
Neurologic Adaptation:Thermoregulation
A
-The maintenance of body temperature is a major task for the NB infant (normal temperatur is 97.7-99.1)
22
Q
Neurologic Adaptation: 1A
A
Their skin is thin and blood vessels areclose to the surface.
- They have little SQ fat to serve as a barrier to heat loss.
- Their surface area in proportionto body mass is 3x that of adults
- Preterm infnats are especially susceptible to heat loss because their tone is poor and they have even less fat and thinner skin than full term babies.
- Signs of inadequate thermorgulation p 694
- There are 4 ways of Heat loss…
23
Q
Effects of COLD STRESS
Non-Shivering Thermogensis
A
Initial response, metabolism of Brown fat. This leads to increased production of free fatty acids, which can lead to metabolic acidosis and jaundice.
24
Q
Cold Stress
INCREASE METABLOIC RATE
A
Leads to INCREASE use of glucose and decrease production of Surfactant. This can lead to hypoglycemia and respiratory distress.
25
Cold Stress
| Vasoconstriction
Leads to pale, mottled skin and shut down of pulmonary vessels, which may lead to repiratory distress (fetal ciruclatory patterns)
26
Nuetral Thermal Envirc (NTE)
- NTE helps to prevent heat loss in newborns
- Maintains stable temp without an increase in oxygen or metabolic rate.
- In health unclothed NB's an environmental temp of 89.6 to 92.3 (32'-33.5'C) provides a thermoneutral zone; 24'-27'C if infants is dressed.
27
Hematologic Adaptation
| BLOOD VALUES
RBC's NEWBORNS have a higher # of RBC's than adults, and their RBC's than adults, and their RBC's are larger in order to recive adequate O2 to cells.
-Fetal hemoglobin carries 20% - 50% more O2 than adult hemoglobin.
28
POLYCYTHEMIS
.65% is a higher RBC count. It increases risk for jaundice and brain infarct
29
Hematocrit
-Higher than in the adult: 48% -69% is normal when by a heel stick and 65% in venous blood.
30
Hermatologic Adaptation Cont. 1A
WBC- ave is 15,000 mm3 (9,000-30,000/mm3) at birth
- Elevation is normal, because the stress of birth increases production.
- Infection can cause abnormal WBC with large # of immature WBC's (bands)
31
Risk of Clotting deficiencies
- the NB are at risk because they lack Vitamin K, which activities several clotting factors in the body-factors 2,7,9 and 10.
- To decrease this risk, NB's are given an injection of Vitamin K at birth.
32
Gastrointestinal System Adaptation
- Stomach campcity is low at birth, but expands to about 90ml within a few days. The cardiac sphincter is feleaxed, which causes a tendency to reguriate.
- Intestines- sterile at birth, once the infant takes in food, bacteria enters the GI tract.
- Digestive enzymes-deficient in amylase (to digest complex carbohydrates) and lipase (fat absorption) until 3-6 months of age. Breast milk has these two enzymes.
- Stools-1st stool is meconium, which has accumulated in the intestines throughout gestation. usually the 1st meconiun is passed within first 24 hrs of life. Passage during labor is of fetal stress.
33
Hepatic System Adaptation
-Blood Glucose
-Maintenance-gluclose is stored in the liver during the last 4-8 weeks of pregnancy. This is used for the energy of birth, heat production, and stores untill the first feedings are taken.
-Normal blood glucose for infants is:
-Infants at rsik for hyoglycemia.
+Preterm baby
+Cold stress
+Diebetic monitor.
34
Conjugation of Bilirubin
- Billirubin is a byproduct of the breakdown of RBC's.
- It is released in the unconjugated form.
- Unconjugated billrubin is fat-soluable, toxic to tissue, and is absorbed by the SQ fat, causing a yellowish discoloration of the skin, called jaundice.
- The liver must conjugate the billrubin (change it into a water-soluable form) in order for the body to excrete it through the urine (small ammount) and the tool (mostly).
35
Hyperbillrubinemia
- Definition: excessive levels of billrubin in the blood > 12 mg/dl
- The most common neonatal problem.
- Extemely high levels (varies with different infants) can lead to brain damage because the brain tissues are stained
- Namogram.
36
TYPES of JUNDICE:
| Physiologic Jaundice
-Occurs in 60-80% of NB's
- Etiology: Caused by breakdown of excessive RBC's after birth, the immature liver can't handle them.
-Timing:Occurs after 24 hrs, peaks on 3 rd day of life
-Timing: Occurs after 24 hrs, peaks 3rd day of life/
-Incidence; buidup of unconjugated billrubins occurs and skin becomes yellow (bc of immature liver)
+Brusing, cephalohemoatoma, polycythemia or poor feeding (dehydration) worsens this normal occurrence
-Important: Billrubin is a powerful antioxidant (helps w/adjusting to environmental 02)
-Breastfeeding jaundice: sleey infants who have a poor suck do not recive enough colustrum)
-Breast milk:late onset billrubin rise (after the first week), may last several weeks, related to milk composition.
37
Nursing Care and Treatment-Jandice Therapy.
| +Phototherapy
Lights are started-high intenisty fourescent lights that convert the billruibin under the skin so that it can be excreted in the stool.
- The eyes and the genitals of the infant must be portected.
- Feedings are increased to promote stooling and urination (with breastfeeding jaundice-formula supplementation is given 24-48 hours); early and frequent feeds.
- IV fludis may be needed if infant not feeding well.
38
Pathologic jaundice
Timing: Usually occurs in the first 24 hours of life; some infants born jaundiced. Level reaches 12 mg/dl by 24 hrs.
- Etiology: anything that causes an excessive destruction of RBC's
- Infection
- Metabolic Disorders
- Incompatibilities between maternal and fetal blood: Rh and ABO incompatibility.
39
Rh Incompatibility
+Pathophysiology
- People who are Rh+ have antigen on their RBC's. People who are Rh- do not.
- If blood that is Rh+ enters the body of a person who Rh-, the body reacts as it would to any foreign substance, and develops antibodies that destroy the invading antigen ("sensitization")
40
Fetal and Neonatal Implications
- Theoretically, there is no mixing of fetal and maternal blood during pregnancy.
- However, small placental accidents can occur (usually at the time birth) that allow a drop or two of fetal blood to enter the maternal circulation.
- This can also occur during a spontaneous or elective abortion, or during antepartal procedures, such as amniocentesis, or with placental problems, such as abruptio placenta
- Matarnal antibodies cross the placental barrier and may cause massive destruction of the future fetus RBC's.
- To destroy the Rh antigen (which exists as part of the RBC), the antibody must destroy the entire RBC.
41
Fetal and Neonatal Implicataion
-Pathophysiology
+Once the mother is sensitized and has developed antibodies, the current fetus (if occurs early in pregnancy) and any subsequent Rh+ fetus will devlop a condition called "Erythroblasts Fetalis" (Hemolytic Disease of the Newborn)
42
S x S Fetal and Neonatal
- Infant born severely anemic and jaundiced
- Infant has generalized edema because of the profound anemia "Hydrops Fetalis"
- Congestive heart failure
- High risk for death.
43
Maternal Implicatons-During Pregnancy.
- All pregnants women tested for Blood type and Rh
- Any Rh- women also tested with "Coomb's Test" (determines presence of Rh antibodies in maternal blood)
- If unsentsitized:A Rh immunioglobulin (RhoGAM) is given at 28 weeks
- If sensitized: Coomb's test is repeated throughout pregnancy to determine if the titer is rising. Any increase means this infants is Rh+ and is in jepardy. Amnicentesis is done to determine fetus' Rh factor. Fetal diagnostic tests are done weekly to determine fetus' well being. Intraterine transfusion and/or early delivery may be needed.
44
Maternal Implications 1 A
| Postpartum Management
- Infant is tested from cord blood to determine blood type and Rh factor.
- If infant is Rh+, the mother must recieve another dose of RhoGAm within 72 hrs of birth to prevent antibody formation.
- If infant is Rh-, no treatment is needed.
45
ABO Incompatibility
- Occurs when the mother is type o blood and the infant is A, B, AB
- Not as severe as Rh incompatibility, but can lead to jaundice in the NB
- Pathophysiology: Type A, B, or AB blood has an antigen that is not present in type O blood. People with type 0 develop ant-A or anti-B antibodies naturally as a result of exposure to antgens in foods, or to infections by gram negative bacteria. IgG or IgM antibodies are formed. The IgG antibodies cross the placenta and cause hemolysis in the fetus.
46
ABO Incompatibility Cont.
- The first fetus can be affected
- IgG are the only antidodies that can cross the placental barrier, and usually most of the antiboides formed are IgM, so this condition is usually much milder than Rh incompatiability
- At birth, the coomb's test will detect whether antibodies are present. If so, serial billrubin level checks are done, and the infant is watched closely for jaundice.
47
Other Liver Functions
| IRON STORAGE
Is stored from the mother in the last weeks of pregnancy. If the infant is full term, enough iron should be present to last 4-6 months. By then the infant should be started on foods that have iron, such as infant cereal.
48
Other Liver Functions
| METABOLISM of Drugs
NB's metabolize drugs slower than older children because their liver is immature. Any drug taken in labor may take a while to get out of the baby's system. Also, breastfeeding women need to be cautous what they take.
49
Urinary System Adaptation
- Blood flow to the kidney increases following birth, because of decreased resistance in the renal blood vesssels.
- 1st void should occur within 24 hrs.
- Absence of urine could indicate hypovolemia, absence of kidneys, or kidney anomalies
- Usually Oligohydramnio is also present when there is a kidney dysfunction.
50
Psychosocial Adaptation
| -Behavioral States:
- Quiet sleep- deep sleep, no eye movement, resp, quiet and slower.
- Active sleep-rapid eye movements, may move extremities or stretch.
- Drowsy-transitional period, yawns, eyes glazed.
- Quit alert-infant able to focus on objects or people, tuned into environment.
- Active alert- restless, starting to fuss, faster respirations, more aware of discomfort.
- Crying-follows quickly if parent doesn't intervene during active alert state.
51
Care of the NEWBORN
- Vitamin K- 1 mg, given IM (Vastus Lateralis) to promote clotting factor formation; protect drug from light.
- Eye treatment-Antiobitic eye ointment is given to protect against organisms contracted in the birth canel.
- Gonorrhea and Chlamydia cause " Ophthalmia Neonatorum", a serious eye infection that can cause blindness if not caught early.
52
Care of the Newborn 1A
| -Blood glucose
- Check on all babies who are SGA, LGA, have low temperatures, are jittery, who had a stressful delivery or are infant's of diabetic mothers.
- If below 40 mg/dl, start feeding per P & P.
53
Care of the Newborn 2 A
| Circumcision
Pro/Cons
- Techniques p 518-523
- Pain Relief
- Nursing Responsibilities
54
Care of the Newborn 3 A
| -Bathing
- Remember about Thermoregulation
- Good time to observe for any missed abnormalities
- Sponge bath until cord falls off.
55
Care of the Newborn
| -Cord Care
- Alcohol, Betadine, Triple dye
- Teach parents how to care for cord and when to expect it to fall off (in about 10 days)
- Clean with water or per policy
- Keep it dry-roll diaper under
- watch for sings of infection.
56
Care of the Newvborn
| -Protection of Infant
- Security, ID badges, observation of any suspicious looking people
- Teaching Parents
- NB Care
- Feeding
- When to call the Doctor
- Lab tests
- Hearing Screen
57
Levels of Care
- Level 1 nurseries- Newborn care for minor problems and transitional issues (TTN, Jundice, hypothermia)
- Level 2 nurseries- care of preterm infants 32 weeks or >, conditions that will resolve rapidly (sepsis, mild RDS)
- Level 3 nuseries- care of severely preterm and infants with long term problems.
- Level 4 nurseries-"Tertiary" centers that do specialty care, such as heart surgery.
58
Infants at Risk DUE TO:
- Respiratory difficulty
- Size or getstational age: SGA, LGA, post term, preterm
- Substance abuse
- Infection
59
Infants at Risk because of Repiratatory Problems
- Transient nea of the Newborn (TTN) is the most common etiology of neonatal respiratory dxia at birth istress
- Etiology: Retained lung fluid
- Risk Factors: Cesarean Birth, asphyxia at birth, maternal analgesia, bleeding, diabetes.
60
S/S: Tachypnea
(as high as 120/min), retractions, nal falring, may or may not have grunting, mild cyanosis. Chest X-ray show streaking and presence of fluid in the lungs.
-Condition is self limiting and treatment is supportive.
61
Infants at RISK because of gestional age or size.
- Small for Gestational Age
- Large for Gestational Age
- Post term
- Preterm
62
Infants at risk becaue of gestational age or size
SGA/OIGR- an infant at < 10% normal weight for its gestational age.
- Symetric grwoth restriction indicates long-term complications because the tatal # of cells are decreased. Caused by congential anomalies, exposure to infection or drugs early in pregnacy.
- Asymmetric growth restriction (head looks big in comparison to body) Brain and heart size are normal, other organs may be small. Growth problem starts in the 3rd trimester. These babies generally "catch up".
63
Etiology of SGA/IUGR
- Materal factors (multiple-gestation pregnacy, smoking, lack of prenatal care, age extremes, low socieconomic status)
- Maternal disease (heart disease, substance abuse, sickle cell anemia, PKU, PIH, diabetes mellitus)
- Envioronmental factors (high altitude, exposure to x rays, excessive exercise, work-related exposure to toxins, hyperthermia, smoking, alcohol).
64
Etiology of SGA/IUGR 2 A
- Placental factors (small placenta, infarcted areas, abnormal cord insertions, placenta previa)
- Fetal factors (congential infections, malformations, discordant twins, chromosomal syndromes)
OB/Peds Test 1
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