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NEWBORN TRANSITIONASSESSMENT
Mary L. Dunlap MSN, APRNFall 10
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Newborn Care Period
Physical Adaptations
Newborn Assessment
Nutrition Discharge Assessment
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Neonatal Physiologic Adaptations
Respiratory
Breathing noted asearly as 11 weeksgestation
Fetal lung fluidnecessary fordevelopment and
decreases withgestational age
Functioning lungsoccurs after 26weeks gestation
Surfactant found insufficient quantityaround 35 weeks
gestation
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Respiratory Adaptations
Chemical Stimulation
Mechanical Stimulation
Sensory Stimulation Pulmonary Blood Flow
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Chemical Stimulation
Catecholamine surge prior to laborcorresponds to rapid drop in level offluid in lung field
Catecholamines increase the release ofsurfactant
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Chemical Stimulation
Decrease O2 & Increase CO2concentration along with decrease pHstimulates aortic & carotidchemoreceptors triggering themedulla to initiation of respirations
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Respiratory Adaptations
Surfactant promotes lung expansion
by preventing the complete collapsing
of the alveoli with each expiration. Increases the lungs ability to fill with
air
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Mechanical Stimulation
Compression of the chest duringvaginal birth forces 1/3 of the fluid outof the lung fields
Once the chest is delivered the re-expansion draws air into the lungs
Crying creates positive intrathoracicpressure keeping alveoli open
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Sensory Stimulation
Tactile
Visual
Auditory
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Pulmonary Blood Flow
Pulmonary vasodilatation occurs as
O2 enters the lungs
The decrease in PVR allows foradequate gas exchange andtransition
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Respiratory Adaptations
Established within 1 minute of birth
Respirations should be quiet
Diaphragmatic and abdominalmuscles used
Nose breathers
30-60/minute
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Respiratory Adaptations
Acrocyanosis and circumoral
cyanosis 1-2hrs
Respiratory distress nasal flaring,grunting, costal retractions and a rateless than 30 & greater than 60
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Cardiovascular Adaptations
Fetal to neonatal circulation occurssimultaneously with the respiratory
adaptation Cessation of blood through the umbilical
vessels and placenta causes the
change from fetal to neonatal circulation
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Cardiovascular Adaptation
Closure of the ductus venosus,
foramen ovale and the ductus
arteriousus Shift to pulmonary circulation
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Fetal to Neonatal Circulation
Clamping the umbilical cord increases theSVR
Closure of the ductus venosus allows bloodflow through the portal/hepatic system
Increase pressure in the left atrium from thepulmonary venous return closes the foramenovale
Rising O2 concentration in the blood anddecreased prostaglandin levels closes theductus arteriousus
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Neonatal Circulation
Apical pulse counted for a full minute
PMI is at the 4th intercostal space to
the left of the midclavicular line Heart rate at birth 120-160
Tachycardia greater than 160
Bradycardia less than 100
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Neonatal Circulation
Capillary refill less than 3 sec.
Femoral/Bracial pulses palpated for
symmetry, strength and rate willprovide information about the changeto adult circulation pattern
Average systolic 60-80, diastolic 40-50
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Neonatal Circulation
Average blood Volume 300ml
Late clamping of the cord can lead to
polycythemia Hemoglobin 14-24g/dl
Hematocrit 44%-64%
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Neonatal Circulation
RBC 4.8-7.1/mm
WBC 9,000-30,00 per mm
Platelets 200,000-300,00 Factors II, VII, IX, and X are low due
to the lack of Vit. K
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Thermogenic Adaptation
Balance between heat loss and
production
Newborns ability to maintain itstemperature is controlled by externalenvironmental factors and internal
physiologic process
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Thermogenic Adaptation
Environmental Evaporation: Heat loss as water
evaporates from the skin
Convection: transfer of body heat tosurrounding air ( cold del. Room)
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Thermogenic Adaptation
Environmental Conduction: transfer of heat tosurface the newborn is lying on
Radiation: loss of heat through the airto a cooler surface ( not in directcontact with the neonate)
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Thermogenic Adaptation
Internal Newborns have limited ability to
shiver to generate heat
Heat is produced by the metabolismof brown fat
Voluntary muscle activity: flexion of
extremities, restlessness, and crying
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Thermogenic Adaptation
Effects of cold stress Increase O2 consumption can lead to
metabolic acidosis
Increase glucose utilizes leads tohypoglycemia
Production of surfactant is decreased
and respiratory distress can occur
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Signs of Cold
Stress/Hypothermia Skin cool to touch Mottling of the skin
Central cyanosis
Decreased responsiveness
Jittery Tachypnea
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Renal System
40 ml of urine at birth 2-6 voids/day for the first 2 days
5-25 voids/day after 48 hours
15-60 ml. of urine per/kg/day Urine odorless straw color
Uric crystals cause pink staining indiapers
One year to fully mature
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Gastrointestinal System
Audible bowel sounds within 1 hour
Stomach capacity 30-90 ml.
Uncoordinated peristaltic activity in the
esophagus for a few days Immature cardiac sphincter
Enzymes able to digest CHO, protein & fats
1 st meconium passed 12-24 hrs Transitional stool passed for 1-2 days
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Hepatic Adaptation
In utero iron is stored for use in hemoglobinproduction after birth. If adequate will last till 5thmonth without needing supplement.
Glucose is stored as glycogen for neonatal
metabolic demands Due to the rapid depletion of glycogen during the
first 24 hours the glucose level will be between 50to 60 mg/ml
Feedings will help stabilize the glucose levels,which after day 3 will be between 60-70 mg/ml
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Immune System Adaptation
Neonate depends on threeimmunoglobins: IgA, IgG, and IgM
IgG crosses the placenta and is found inthe fetus by the 3rd trimester. It protectsthe newborn against bacterial and viral
infections the mother has developedantibodies for ( tetanus, measles,
mumps)
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Immune System Adaptation
IgM is found in the blood and lymph and isthe first immunoglobulin to respond toinfection. Production starts at birth. If
elevated at birth may indicate exposure tointrauterine infection
IgA is found in colostrum and can
contribute to passive immunity. It limitsbacterial growth in the GI tract and isproduced gradually.
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Normal Newborn Assessment
Evaluate the newborns adjustment
to Extrauterine.
Assess for possible birth trauma The assessment should progress
from head to toe.
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Initial Assessment
Apgar score determined Assess for gross abnormalities
Apply cord clamp
Obtain foot prints
Apply identification bands
Administer Vit. K & eye prophylaxis Promote bonding
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Transition to Extrauterine LifeFirst period of Reactivity
Birth to 30 minutes
Heart rate160 to 180 beats/min
Returns to 110-160 after 30 min Resp. rate 60-80/crackles may be present
Reactive to stimuli
After this period newborn could sleep up to60-100 min.
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Transition Second Period
4-8 hours after birth
10 min to several duration
Brief periods of Tachycardia andTachypnea
Increase muscle tone and color
changes
Meconium may be passed
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Newborn Assessment
Length-19 to 21 inches Weight- average 7lb 8oz (10th to 90th %)
SGA less than 5lb 8 oz (Less thanthe 10th %)
LGA greater than 9 lb ( greaterthan the 90th %)
Newborns can loose up to 10% of birth weight
Head circumference- 33-38 cm Chest circumference-31-36 cm
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Newborn Assessment
Temperature
Normal axillary temperature 97F
99.5F Cardiovascular system
Normal heart rate 110160 bpm
Observe color, pulse, murmurs
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Newborn Assessment
Respiratory system
Normal rate is 3060/minute
Nose-breatherObserve for flaring, grunting,
retracting
Auscultate for rales
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Head
Measure circumference Anterior fontanel diamond shaped closes in 18months
Posterior fontanel triangle shaped closes in 8-12 weeks
Fontanels need to be open and soft
Depressed fontanel indicates dehydration
Bulging fontanel may indicate increasedintracranial pressure
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Head
Molding result of fetal position in utero andpressure from passage through birth canal( resolves in 24-48hrs)
Cephalhematoma result from trauma(resolves in few weeks)
Caput succedaneum pressure from
delivery ( resolves in 1-2 weeks)
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Head
Inspect face for symmetry of eyes, nose, lips,mouth and ears
Eyes usually blue or gray, permanent colorestablished in 3-12 months
Red reflex present cornea intact
Can see up to 2 feet clearest vision is 8 to12 inched
Subconjunctive hemorrhages may bepresent due to the pressure from delivery
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Head
Nose midline with patent nares Ears aligned with outer canthus of eyes;
pinna well formed, open auditory canal ( low
set ears associated with chromosomalabnormalities)
Mouth mucosa pink and moist; tongue
mobile, strong suck, hard/soft palate intact(Epsteins pearls may be noted on the gumsor hard palate)
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Neck
Shape typically short with deep folds of skin
Webbing associated with Down Syndrome
Assess for full range of motion
Palpate for abnormal masses
Note the position of the trachea
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Chest
Shape should be cylindrical (bell shaped could be asign of underdeveloped lungs)
Palpate clavicle bones and ribs
Assess nipples for size, placement and number
Evaluate respiratory effort and movement
Auscultate the lung fields and heart sounds
Unequal breath sounds could be a pneumothorax
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Abdomen
Umbilical cord, 2 arteries 1 vein
Cylindrical with some protrusion
Flat abdomen indicates diaphragmatic hernia
Auscultate for bowel sounds Suprapubic area palpated for bladder
distention
Femoral pulses palpated, if unable to locatecould signify coarctation of the aorta
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Female Genital and AnalAssessment
Term newborn labia majora covers
labia minora and clitoris
Mucoid vaginal discharge due tomaternal hormones
Hymental tag may be present
Annus patent
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Male Genital and AnalAssessment
Rugae present on the scrotum
Scrotal edema may be present due tomaternal hormones
Testes descended Check for placement of the meatus
Dorsal surface- epispadias
Ventral surface-hypospadias Anus should be patent
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Extremities
Assess for full range of motion, symmetry andsigns of trauma
Spontaneous motion of all extremities should
be present Assess muscle tone
Hyperflexibility of joints associated with Down
Syndrome Hips assessed for dislocation
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Extremities
Nail beds pink- persistent cyanosis associatedwith hypoxia
Palms should have normal creases
Simian crease (transverse palmer) suggestsDown syndrome
Count digits on extremities (more than fivedigits polydactyl-Digits fused togethersyndactyl
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Spine
Straight
Flat
Shoulders, scapulae and iliac crestsline up in same plane
Evaluate for dimpling or fissures
Dimpling associated with spina bifida
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Skin
Assess color
Check for birth marks, trauma, rashes orbruises
Presence of lanugo
Palpate texture ( ranges from smooth to
peeling) Turgor ( elasticity)
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Skin Assessment
Common variations
Milia
Mongolian spots
Birthmarks
Common problems
Petechiae
Blisters, lesions
Abnormal hair distribution
Port wine stains
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Neurological System
Infant alert, responsive, strong lusty cry ina flexed position
Reflexes provides information on the
system and maturity Reflexive behaviors are necessary for
survival and safety
Absence, weakness or asymmetryindicates abnormalities
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Neurological Reflexes
Sucking
Rooting
Grasping
Extrusion
Tonic neck
Moro
Stepping
Crawling
Babinski
Truncal incurvation
Blinking
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Neurologic System
Common problems
Brachial plexus injury (Erbs palsy)
Spina bifida
Anencephaly
Absent or abnormal reflexes
Seizure activity
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Behavioral Assessment
Sleep-wake cycles
Activity
Social interactions
Response to stimuli
P i A
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Pain Assessment
Most common sign crying
Changes in heart rate
Intracranial pressure
Respiratory rate and oxygen saturation
P i M
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Pain Management
Nonpharmacologic management:containment (swaddling),nonnutritive sucking and
distraction: visual, oral, auditory,tactile
Pharmacologic management:
local and topical anesthesia,Nonopioid analgesia and opioids
G i l A A
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Gestational Age AssessmentBallard Score
Neuromuscularmaturity
Posture
Square window
Arm recoil
Popliteal angle
Scarf sign
Heel-to-ear
Physical maturity
Skin
Lanugo
Plantar surface
Breasts
Eye and ear
Genitalia
I f t N t iti
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Infant Nutrition
American Academy of Pediatrics (AAP)recommends infants be breastfedexclusively for first 6 months of life
Breastfeeding should continue for at least 12months
If infants are weaned before 12 months, they
should receive iron-fortified infant formula
I f t t iti
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Infant nutrition
Human milk designed specifically for humaninfants; nutritionally superior to any alternative
Breast milk considered living tissue because it
contains almost as many live cells as blood Bacteriologically safe and always fresh
Nutrients in breast milk more easily absorbed
than those in formula
Contraindications of
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Contraindications ofBreastfeeding
Maternal cancer therapy/ radioactive isotopes
Active tuberculosis
HIV Maternal herpes simplex lesion
Galactosemia in infant
Cytomegalovirus (CMV)
Maternal substance abuse
Ch i F di M th d
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Choosing a Feeding Method
Nurse must provide information toparents in nonjudgmental mannerand respect their decision
Provide Factual information about nutritionaland immunologic needs met by human milk
Potential benefits to infant and mother
Inherent risks with infant formulas
Ch i F di M th d
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Choosing a Feeding Method
Cultural beliefs and practices are asignificant influences
Immigrants from poorer countries often
choose to formula feed because theybelieve it a better, modern method
Others formula feed because they want to
adapt to American culture and perceive itthe custom to bottle feed
L t ti
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Lactation
Female breast composed of 15 to 20segments (lobes) embedded in fat andconnective tissues, well supplied with bloodvessels, lymphatic vessels, and nerves
Within each lobe are alveoli, the milk-producing cells, surrounded by myoepithelialcells that contract to send the milk forward into
the ductules
L t ti
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Lactation
Ductules enlarge into lactiferous ducts andsinuses, where milk collects behind nipple
Each nipple has 15 to 20 pores through which
milk is transferred to the suckling infant After birth, precipitate decrease in estrogen
and progesterone levels triggers release of
prolactin from anterior pituitary gland
L t ti
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Lactation
Prolactin highest first 10 days Gradually decline, but remain above
baseline levels for duration of lactation
Prolactin produced by infant suckling andemptying of the breasts
Breasts never completely empty
Milk production supply/demand
Lactation
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Lactation
Oxytocin: other hormone essential tolactation
As nipple is stimulated by suckling infant,
posterior pituitary prompted byhypothalamus produces oxytocin
Responsible for milk-ejection reflex
(MER), or let-down reflex Nipple-erection reflex is integral to
lactation
Lactation
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Lactation
Colostrum, a clear yellowish fluid birth to48hrs.
More concentrated than mature milk
Extremely rich in immunoglobulins
Higher concentration of protein andminerals
Less fat than mature milk
Coates and protects the stomach andintestines from invading organisms
Lactation
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Lactation
Transition milk 48-72hrs
High levels of fat, lactose and water
soluble vitamins Higher calorie content
Larger volume
Lactation
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Lactation Mature milk produce by 10th to 15th day
Two types of milk: foremilk and hind milk
Hind milk higher in fat which is needed forgrowth
90% water which maintains newborns fluidbalance
Remaining 10% contains carbohydrates,
proteins and fats
Lactation Frequency/Duration
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Lactation Frequency/Duration
A newborns stomach is the size of a
small marble and can hold 5-7 ccs.
This is matches the amount ofcolostrum produced
From 7-10 days it increases to the
size of a golf ball and can hold 1.5 to2 oz
Lactation Frequency/Duration
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Lactation Frequency/Duration
Newborns nurse on average 8-12
times/24hrs
Feed by cue signs about every 1-3hours
Should have no more than one 4 hr
period
Lactation Education
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Lactation Education
Positioning
Latch-on
Let-down
Frequency offeedings
Pumping
Milk storage
Duration offeedings
Supplements,
bottles, andpacifiers
Diet
Breast care
Breast feeding Special
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Breast feeding SpecialConsiderations
Sleepy baby- use gentle stimulate to
bring to alert state
Fussy baby- use calming techniques
Slow weight gain- evaluate
breastfeeding
Breastfeeding
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Breastfeeding
Engorgement noted when milk comes in andis bilateral (increase feedings to q2hrs)
Sore nipples usually result of poor
latch on Plugged milk ducts result of inadequate
emptying or underwire bra/apply warm
compresses prior to nursing Mastitis infection characterized by sudden
flu like symptoms usually effects only onebreast
Formula Feeding
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Formula-Feeding
Personal preference
Influence by significant family
members Lack of familiarity with breastfeeding
Contraindications present
Formulas
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Formulas
Ready to feed Concentrated
Powdered
Cows milkbased Soy-based
Casein/ whey
Amino acid
Formula Feeding Education
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Formula-Feeding Education
Types of formula
Formula Preparation
Feeding patterns Feeding techniques
Bottles preparation
Discharge Assessment
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Discharge Assessment
Determine knowledge deficits Educate on car safety
Importance of Immunizations
Follow care
Newborn hearing screen
Collect blood for PKU