NEW BORN CARE
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Initial care of the newborn
- Observe or assist with initiation of respirations
- Assess APGAR score
- Note characteristics of cry
- Monitor abnormal respiration like nasal flaring, grunting, and retractions
- Obtain vital signs
- Observe for hypothermia or hyperthermia
- Assess for any gross anomalies
- Suction mouth, then nares with bulb syringe
- Maintain temperature, warp newborn in Warm blankets, and a cap for the head
- Dry the newborn and stimulate crying by rubbing
- Keep the newborn with mother to promote bonding
- Place the newborn at mother’s breast if breast feed is planned, or place on mother’s abdomen
- Place newborn in warmer
- Ensure newborn’s proper identification like foot print of the newborn and finger print of the mother should be made.
- Place identification bracelets on mother and newborn hand.
- Perform at one minute and after 5 minute
- If the score is less than 7 at 5 minutes the apgar score should be performed at 10 minutes
- A score of 7 to 10 indicate healthy new born
- A score of 3 to 6 is considered moderately depressed
- A score of 0 to 2 is severely depressed
|INDICATOR||POINT 0||POINT 1||POINT 2|
|Heart rate||Absent||Less than 100||More than 100|
|Respiratory rate||Absent||Slow irregular weak cry||Good vigorous cry|
|Muscle tone||Flaccid limp||Some flexion of extremity||Good flexion, active motion|
|Reflex irritability||No response||Weak cry and grimace||Vigorous cry, cough, sneeze|
|Skin color||Blue||Body skin color normal, Extremities blue||Body and extremity skin color normal|
- 7 to 10
- Rarely needs resuscitation
- 3 to 6
- Requires resuscitation, suction, dry quickly, maintain warmth
- Ventilate 30 to 50 times / minute until HR is above 100, color is pink, and spontaneous respiration begins.
- Provide oxygen
- 0 to 2
- Require intensive resuscitation
- Clean airway
- Insert ET tube , and use AMBU bag if necessary
- Ventilate with 100% oxygen at 40 to 60 birth / minute
- Initiate full CPR as needed
- Maintain body temperature
- Support parents
INITIAL PHYSICAL EXAMINATION
- Keep newborn warm during the examination
- Begin with general observation then perform assessment
- Initiate nursing intervention for abnormal findings
- Document all abnormal finding
- HR 100 to 160 b/m (apical) assess for full one minute
- Respiration 30 to 80 Br/m check for full one minute
- Axillary temperature 96.8 to 99F
- Blood pressure 73/55 mm of hg
- Length 45 to 55 cm (18 to 22 inch)
- Weight 2500 to 4300gm (5.5 to 9.5 pound)
- Head circumference 33 to 35 cm (13 to 14 inch)
- Chest circumference 30 to 33cm (12 to 13 inches)
- Bones of the skull are not fused
- Anterior fontanel is soft, flat, diamond shaped 3 to 4 cm wide by 2 to 3 cm long, close between 12 to 18 months of age
- Posterior fontanels is triangular in shape 0.5 to 1 cm wide closed between 2 to 3 months of age
- Umbilical cord contains two arteries and one vein
- If fewer than three vessels are noted to physician
- Assess for intact cord and ensure that clamp is secured
- Cord should be clamped for at least the first 24 hours. It can be removed when the cord is dried and occluded
- Note any bleeding or drainage from cord
- Triple dye is use to applied in the cord to prevent growth of microorganism and promote drying. It paint the cord at one time and 1 inch surrounding skin
- Application of 70% isopropyl alcohol to the cord with each diaper change and at least 2 to 3 times a day to minimize microorganism and promote drying
- Monitor for symptoms of infection such as moistness, oozing, discharge, and reddened base occur.
- If so antibiotic treatment should be start
Management of cord
- Umbilical clamp can be removed after 24 hours
- Teach the mother how to perform cord care
- Keep the cord wiping with alcohol swab with each diaper change
- Keep the diaper below the cord
- Assess cord for odor, swelling, or discharge.
- Sponge bath the newborn until the cord fall off
BODY SYSTEM ASSESSMENT
- Take apical heart rate for 1 full minutes
- Listen for murmurs
- Assess for cyanosis
- Observe for cardiac distress when newborn is feeding
- Suction if necessary, use a bulb syringe for suction
- Position newborn on side
- Observe for respiratory distress, hypoxemia, nasal flaring, severe retractions, grunting, cyanosis, and bradycardia
- Administer oxygen via hood if necessary.
- Normal or physiological jaundice appear after the first 24 hours in full term neonates and after first 48 hours in premature neonates
- Jaundice occurring before 24 hours known as pathological jaundice may indicate hemolysis of red blood cells and it must be reported
- Monitor S. bilirubin levels
- Feed early to stimulate intestinal activity and to keep the bilirubin level low
- If bilirubin level exceed 15 to 20 mg/dl temporarily discontinue breastfeeding
- Liver stores iron passed from the mother for 5 to 6 months
- Neonate is at risk of hemorrhagic disorder so administer vitamin K
- The immature kidneys are unable to concentrate urine
- A weight loss of 5% to 15%occur in the first week of life due to increase output and limited intake
- Weigh newborn daily
- Monitor I/O, weigh diaper if necessary
- Assess for the signs of dehydration ex: dry mucous membrane, sunken eyeballs, poor skin turgor, Sunken fontanels.
- Passive immunity via the placenta (IgG)
- Passive immunity via breast milk (IgA)
- Use of aseptic technique when caring for the newborn
- Ensure meticulous hand washing.
- Wear gowns when caring for newborn.
- Monitor newborn’s temperature.
- Administer eye medication with in 1 hour after birth to prevent ophthalmia neonatorum.
- Apply petroleum gauze jelly to penis
- Remove petroleum gauze jelly after first voiding following circumcision.
- Observe for swelling, infection, or bleeding from the circumcision site.
- Clean the penis after each voiding by warm water
- A milky covering over the gland penis is normal and should not be disrupted.
- Monitor for urinary retention.
- Newborns are able to digest simple carbohydrates but are unable to digest fat because of lack of lipase
- Newborns have a small stomach capacity about 90 ml.
- Breast feed can start immediately after birth.
- For bottle feed baby initially start with few milliliters of sterile water or 5% dextrose 1 to 4 hours after birth to feed with formula.
- Monitor for reflexes such as rooting, sucking, and swallowing.
- Burp newborn during and after feeding
- Assess for regurgitation or vomiting.
- Observe for the passage of meconium stool.
- Soft, yellow stool are noted in breast feeding child.
- Seedy, yellow stool are noted in formula feed child
Thermal regulatory system
- Newborns do not shiver to produce heat.
- Newborns have brown fat deposits, which produce heat.
- Prevent heat loss through evaporation by keeping newborn dry and well wrapped with a Blanket.
- Prevent heat loss through radiation by keeping newborn away from cold objects and outside walls.
- Prevent heat loss resulting from conduction by performing all treatment on a warm padded surface.
- Keep temperature in room warm.
- Take temperature every hour for first 4 hours then every 4 hours remaining 24 hours by axillary.
Sucking and rooting
- Touch the newborn’s lip, cheek, or corner of the mouth with a nipple.
- Newborn turns head towards the nipple, open the mouth, takes hold of the nipple and suck.
- Usually disappear after 3 to 4 months but may persist for up to 1 year.
- Occurs spontaneously after sucking and obtaining fluids.
- Newborn swallows in coordination with sucking without gagging, coughing, or vomiting.
Tonic neck or fencing
- While the newborn is falling asleep or sleeping, gently and quickly turn the head to one side.
- When the head turn to left side, the left arm and leg extend outward, while the right arm and leg flex.
- When the head is turned to right side the right arm and leg extend outward while the left arm and leg flex.
- Usually disappears with in 3 to 4 months.
Palmar- plantar grasp
- Place a finger in the palm of the newborn’s hand, then place a finger at the base of the toes.
- The newborn’s fingers curl around the examiner fingers, and newborns toes curl downward
- Palmar response lessens within 3 to 4 months
- Hold the newborn in a semi sitting position; then allow the head and trunk to fall backward to at least a 30 degree angle.
- The newborn symmetrically abducts and extends the arms.
- It may present at birth complete response may occur up to 8 weeks.
- No response may be noted by 6 months as neurological system matured.
- The examiner makes a loud noise or claps hand to elicit the response.
- The newborn’s arms abduct while the elbows flex, the hand stay clenched.
Babinski sign – plantar
- Gently stroke the heel of the foot upward along the lateral aspects of the sole, then the examiner moves the finger along the ball of the foot.
- The newborn’s toes hyperextend while the big toe dorsiflexes.
- Absence of this reflex indicates the need for a neurological examination.
- Reflex disappears after one year old.
Stepping or walking
- Hold the newborn in a vertical position allowing one foot to touch a table surface.
- The newborn stimulate walking alternately flexing and extending the feet.
- This reflex usually 3 to 4 months.
- Place the newborn on the abdomen.
- The newborn begins making crawling movements with the arms and legs.
- The reflex disappears after about 6 weeks.
- Take purified water for making formula.
- Do not heat the bottle of formula in microwave oven.
- Inform the mother that formula is sufficient diet for the first 4 to 6 months.
- Assess the mother’s ability to burp the newborn.
- Bath the new born before feeding.
- Keep the room warm.
- Have all the equipment for bathing is available.
- Use a mild soap.
- Start the bathing from the cleanest area to the dirtiest.
- Clean eyes from the inner canthus to outward.
- Special care should be given under the folds of the neck, underarms, groin, and genitals.
- Make bath time enjoyable for both the newborn and the mother.
Care of a uncircumcised new born
- Inform the mother that the foreskin and glands are two similar layers of the cells that separate from each other, that will occur between 3 to 5 year.
- So instruct the mother not to pull back the foreskin but allow for the natural separation to occur.
- Jaundice during first 24 hr indicates a pathological process caused by haemolysis of blood.
- Evaluation indicated when serum levels are over 12 mg/dl in the term newborn.
- Elevated serum bilirubin levels
- Enlarged liver
- Poor muscle tone
- Poor sucking reflex
- Monitor the presence of jaundice.
- Examine baby skin color in natural light.
- Press the finger or nose to press out capillary blood from the tissues.
- Note that jaundice start from the head first, spreads to the chest, then the abdomen then the arm and legs followed by the hands and feet.
- Keep the newborn in well hydrated.
- Facilitate early, frequent feeding, to eliminate meconium and encourage excretion of bilirubin.
- Report to the physician if jaundice appear within 24 hours.
- Prepare for phototherapy.
- Use of intense fluorescent lights to reduce serum bilirubin levels in the new born.
- Eye damage.
- Sensory deprivation can occur.
- Expose as much as of the newborns’ skin as possible.
- Cover the genital area and monitor genital area for skin breakdown.
- Cover the eyes with eye shields or patches, make sure that eye lids are closed.
- Remove it one per shift and inspect for infection or irritation.
- Measure the quantity of light and every 8 hours.
- Monitor skin temperature.
- Increase fluid intake to compensate water loss
- Expect loose green stools and green urine
- Monitor the skin on normal light every 4 to 8 hour
- Reposition newborn every 2 hours.
- Destruction of R.B.Cs the result from an antigen antibody reaction.
- It is characterised by hemolytic anemia or hyperbilirubinemia.
- Jaundice develops rapidly after birth and before 24 hours.
- Administer Rh D immuneglobuline to the mother during first 72 hours after delivery. if the Rh negative mother deliver Rh positive fetus.
- Assist with exchange transfusion after birth.
- The baby’s blood is replaced with Rh negative blood to stop the destruction of baby’s Red blood cells; the Rh negative blood is replaced with the baby’s on blood gradually.
NEW BORN OF DIABETIC MOTHER:
- High incidents of congenital anomalies, hypoglycemia, respiratory distress, hypocalcemia, and hyperbilirubinemia.
- Excessive size and weight
- Edema or puffiness in the face and cheeks.
- Signs of hypoglycemia
- Signs of respiratory distress.
- Monitor for signs of respiratory distress
- Monitor bilirubin and blood glucose level
- Monitor weight
- Feed early with 10% of glucose in water, breast milk, formula as prescribed
- Administer I.V glucose to prevent hypoglycemia
- Monitor tremors , seizure, apnea and acidosis