final copy of newborn care
TRANSCRIPT
Presented By
GROUP 2Leader Rizalyn Joy C Gadugdug
Helen Grace G VillacinJelanie B MangombayaAminoden B CamarudinRafsanjani UmpaNewsryn DucayGenila Marie O Bait-itMa Lorelyn PendangGwendolyn T MabaquiaoSheena Claire D GentallanSheena Marie Aguilar
Outline
Objectives Introduction Definition of Terms Assesment
-Initial Assessment-Transitional Assessment-Gestational Assessment-Physical Assessment
- General Measurement Head to toe-Vital Signs- General Appearance
-Skin-Head-Eyes-Ears-Nose-Mouth-Neck-Chest-Lungs-Heart-Abdomen-Female Genitalia-Male Genitalia-Back and Rectum-Extremities-Neuromuscular System
Anatomy and Physiology-Thermoregulation-Circulatory-Hemopoetic System -Fluid and Electrolytes-Gastrointestinal System
-Renal System-Integumentary System-Skeletal System-Respiratory System-Endocrine-Neurology-Sensory-Immune System
Nursing Principles-Maintaining Patent Airway-Maintaining Stable Temperature-Identification-Protection from infection and injury
-Medical Management-Bathing-Cord Care-Circumcision-Providing Optimum Nutrition-Promoting Parent infant bonding
NCP HEP Discharge Plan Prognosis Presentation of Concept Map
OBJECTIVES
At the end of this case study students will be able to
1 Describe the normal characteristics of a term newborn2 Describe the state of a newborn3 Perform newborn assessments such as the APGAR Ballard and Silverman Test4 Implement nursing care to a normal newborn such as administering a first bath or instructing parents on how to care for their newborn5 Describe the nursing management of the newborn respirations maintenance of temperature prevention of infection and optimal nutrition6 Discuss initial identification registration and screening procedure for the newborn7 Relate the importance of the bonding process to the newborn babyrsquos and parentrsquos adjustment to each other8 Develop a teaching plan for parents of a newborn specific to home care9 Discuss the importance of breastfeeding to the mother and family10Apply correct nursing intervention necessary for newborn care
I INTRODUCTION
NEWBORN ndash the first hour of life
The primary focus at this time is the transition from intrauterine to extrauterine life with an introduction to family members as the neonatersquos condition warrants
The first 24 hours of life constitute a highly vulnerable time during which the infant must make several adjustments to uterine life During this period of transition 6 overlapping stages have been identified
Stage 1 Receives stimulation from the pressure of the uterine contractions during labor and from changes in pressure when the membranes rupture In this stage there is the transition from the intrauterine to extrauterine life The fetus takes part in this process from the flexion until the expulsion of oneself Nurses should take into consideration the risk factors that may be involved in such delivery putting in mind the safety of the newborn
Stage 2 Encounters a variety of foreign stimuli ndash light cold gravity and sound In this stage the newborn is introduced to the extrauterine life Certain factors such as these would stimulate the basic instinct of survival These factors classified as the thermal and chemical factors enables the infant to take in the first breath of life Nurses should consider these factors and should provide adequate temperature to regulate the change from the intrauterine temperature to the extrauterine temperature change protecting the newborn from these factors would help the newborn gradually adjust to such dramatic change
Stage 3 Initiates breathing In this stage the first breath is taken in after the umbilical cord is cut This stimulates the first inspiration Nursersquo consideration they should provide patent airway to prevent aspiration from fluids accumulated This would facilitate the beginning process of respiration and circulation
Stage 4 Changes from fetal to neonatal circulation Circulation begins right after the first breath has been taken in The circulation of oxygen throughout the newborn allows the start of the metabolic processes within the body Nurse should take into consideration the importance of circulation right after the first seconds of transition from intrauterine to extrauterine life
Stage 5 Undergoes alteration in metabolic processes with activation of liver renal and gastrointestinal tracts for passage of meconium With the exchange of gas and the circulation of oxygen within the body each organ begins their process of adjustment in the extrauterine life Such metabolic process activates these major organs to promote vitality of life of the newborn Nurse should take into consideration by assessing such changes whether it is successful and able to adjust with such dramatic change
Stage 6 Achieves a steady level of equilibrium in metabolic processes Taking into consideration the production of enzymes increased blood oxygen saturation decrease in acidosis associated with birth and recovery of the neurologic tissues from the trauma of labor and delivery It is in this stage the newborn takes into the final adjustment period of ones life independently This stage is crucial hence the nurse should give importance of making sure such level of equilibrium be maintained at such time the newborn will be finally discharged together with hisher family
DEFINITION OF TERMS
Habituation - the gradual adaptation to a stimulus or to the environment with a decreasing response
Orientation - awareness of ones environment with reference to time place and people
Reflexes - a reflected action or movement the sum total of any particular automatic response mediated by the nervous system
Posture - a reflected action or movement the sum total of any particular automatic response mediated by the nervous system
Square window - an angle of the wrist between the hypothenar prominence and forearm It is used as a reference point for estimating the gestational age of a newborn
Motor Performance ndash quality of movement and tone
Range of state ndash measure of general arousal level or arousability of infant
Regulation of state ndash how infant responds when aroused
Autonomic stability ndash signs of stress related to homeostatic adjustment of the nervous system
Normothermic - a normal state of temperature
Bradycardia - a slow heart rate Bradycardia is one of the two types of arrhythmia
Tachycardia - abnormally rapid heart rate
Apnea - Temporary absence or cessation of breathing
Tachypnea - abnormally rapid rate of breathing such as that associated with high fever
Vitamin K - any of a group of structurally similar fat-soluble compounds that promote blood clotting
Hepa B vaccine - a viral hepatitis caused by the hepatitis B virus (HBV) a hepa and virus The virus is transmitted by transfusion of contaminated blood or blood products by sexual contact with an infected person by the use of contaminated needles and instruments or in utero
Prognosis - a prediction of the probable outcome of a disease based on the condition of the person and the usual course of the disease as observed in similar situations
BCG vaccination - has been used in the control of tuberculosis in cattle but has many disadvantages especially interference with tuberculin testing and is not recommended for use unless the prevalence of the disease is very high
Pallor - an unnatural paleness or absence of color in the skin
Plethora - An excess of blood in the circulatory system or in one organ or area
Scelerema - a severe sometimes fatal disorder of adipose tissue occurring chiefly in preterm sick debilitated infants manifested by induration of the involved tissue causing the skin to become cold yellowish white mottled boardlike and inflexible
Milia - a tiny spheroidal epithelial cyst lying superficially within the skin usually of the face containing lamellated keratin and often associated with vellus hair follicles
Miliaria - a cutaneous condition with retention of sweat which is extravasated at different levels in the skin
Mongolian spot - a smooth brown to grayish blue nevus consisting of an excess of melanocytes typically found at birth in the sacral region in Asians and dark-skinned races it usually disappears during childhood
Acrocyanosis - s a decrease in the amount of oxygen delivered to the extremities The hands and feet turn blue because of the lack of oxygen Decreased blood supply to the affected areas is caused by constriction or spasm of small blood vessels
Craniotabes - eduction in mineralization of the skull with abnormal softness of the bone usually affecting the occipital and parietal bones along the lambdoidal sutures
Nystagmus - Rhythmic oscillating motions of the eyes are called nystagmus The to-and-fro motion is generally involuntary Vertical nystagmus occurs much less frequently than horizontal nystagmus and is often but not necessarily a sign of serious brain damage Nystagmus can be a normal physiological response or a result of a pathologic problem
Strabismus - occurs in 2-5 of all children About half are born with the condition which causes one or both eyes to turn
Hypotelorism - abnormally decreased distance between two organs or parts
Torticollis - is a type of movement disorder in which the muscles controlling the neck cause sustained twisting or frequent jerking
Frenulum - a small fold of integument or mucous membrane that limits the movements of an organ or part
Xiphoid process - he pointed process of cartilage supported by a core of bone connected with the posterior end of the body of the sternum
Candidiasis - is an infection caused by a species of the yeast Candida usually Candida albicans
Cardiomegaly - abnormal enlargement of the heart
Diastasis recti - is a disorder defined as a separation of the rectus abdominis muscle into right and left halves
Whartonrsquos Jelly - is a gelatinous substance within the umbilical cord composed of cells that originate in the original egg and sperm of conception It is largely made up of mucopolysaccharides
Ascites - s an accumulation of fluid in the peritoneal cavity Although most commonly due to cirrhosis and severe liver disease its presence can portend other significant medical problems Diagnosis of the cause is usually with blood tests an ultrasound scan of the abdomen and direct removal of the fluid by needle or paracentesis
Gastroschisis - is a type of abdominal wall defect in which the intestines and sometimes other organs develop outside the fetal abdomen through an opening in the abdominal wall This defect is the result of obstruction of the omphalomesenteric vessels during development
Pseudomenstruation - bleeding from the uterus that resembles menstruation but is not associated with the usual changes in endometrial tissues
Epispadias - ongenital absence of the upper wall of the urethra occurring in both sexes but more often in the male with the urethral opening somewhere on the dorsum of the penis
Chordee - downward bowing of the penis due to a congenital anomaly or to urethral infection
Hydrocele - circumscribed collection of fluid especially in the tunica vaginalis of the testis or along the spermatic cord
Polydactyly - the presence of supernumerary digits on the hands or feet
Syndactyly - persistence of webbing between adjacent digits of the hand or foot so that they are more or less completely fused together
Phocomelia - congenital absence of the proximal portion of a limb or limbs the hands or feet being attached to the trunk by a small irregularly shaped bone
Hemimelia - a developmental anomaly characterized by absence of all or part of the distal half of a limb
Quivering - To shake with a slight rapid tremulous movement
Hypotonia - the state of being hypotonic
Hypertonia - the state of being hypertonic
Tremors - A relatively minor seismic shaking or vibrating movement Tremors often precede larger earthquakes or volcanic eruptions
Pupillary - Of or affecting the pupil of the eye
Glabellar - The smooth area between the eyebrows just above the nose
Extrusion - The act or process of pushing or thrusting out
Startle - To cause to make a quick involuntary movement or start
Pseudomonas - any of a genus of rodlike Gram-negative bacteria that live in soil and decomposing organic matter many species are pathogenic to plants and a few are pathogenic to man
Prophylaxis - Prevention of or protective treatment for disease
Cirrhosis - A chronic disease of the liver characterized by the replacement of normal tissue with fibrous tissue and the loss of functional liver cells It can result from alcohol abuse nutritional deprivation or infection especially by the hepatitis virus
Dehiscence - he spontaneous opening at maturity of a plant structure such as a fruit anther or sporangium to release its contents
Meatitis - inflammation of the urinary meatus
Urethral fistula - due to trauma occurs in bulls in which the urethra lies superficially near its end A fistula may affect the discharge of semen from the normal meatus sufficiently to cause infertility
DTP - diphtheria and tetanus toxoids and pertussis vaccine
Conduction ndash is the transfer of body heat to a cooler solid object in contact with a baby
Convection ndash is the flow of heat from the newborns body surface to cooler surrounding air
Radiation ndash is the transfer of body heat to a cooler solid object not in contact with the baby
Evaporation ndash is loss of heat through conversion of a liquid to vapor
Attachement ndash is the mode of contact between babyrsquos mouth and the motherrsquos breast during the act of breastfeeding
Kangaroo Mother Care - A universally available and biologically sound method of care for all newborns but in particular for premature babies with t three components skin-to-skin contact exclusive breastfeeding and support to the mother infant dyad
Newborn Resuscitation ndash a series of action taken to establish normal breathing in a newborn with depressed vital signs
Neonate - is a baby who is 4 weeks old or younger
Neonatal Period - the first 4 weeks of a childs life represents a time when changes are very rapid and many critical events can occur
Positive Pressure Ventilaiton (PPV) - refers to the process of forcing air into the lungs of a (usually apneic or dyspneic) patient usually using a baby valve mask or mechanical ventilator
ASSESSMENT
The new born requires thorough skilled observation to ensure a satisfactory to extra-uterine life 4 phases of physical assessment after delivery
The initial assessment The transitional assessment The assessment of gestational age The comprehensive and systematic physical examination
INITIAL ASSESSMENT includes APGAR scoring
APGAR SCORING METHOD - is the most frequent in assessing the newbornrsquos immediate adjustment to extra uterine life (Papile 2001)
SIGNS 0 1 2Heart rate Absent Slow lt 100 beats min Beats min
Respiratory effort Absent Irregular slow weak cry Good strong cryMuscle Tone Limp Some flexion of extremities Well flexed
Reflex Irritability No response Grimace Cry sneezeColor Blue Pale Body pink extremities blue Completely pink
SCORES0 - 3 Severe Distress4 ndash 6 Moderate Difficulty7 ndash 10 Absent in Difficulty
TRANSITIONAL ASSESSMENT
Newborn exhibits behavioral and physiological characteristics that can at first appear to be signs of stress
During newbornrsquos initial 24 hours changes in heart rate respiration motor activity color mucus production and bowel activity occur in an orderly predictable sequence which is normal and indicate lack of stress
- During the first 30 min the infant is alert cries vigorously may suck his or her fingers or fist and appears interested in the environment
For 6 to 8 hours after birth the newborn is in the first period of reactivity - the neonates eyes are usually open- has vigorous suck reflex- grasp the nipple quickly This is important to remember because after this initial highly active state the infant may be sleepy and uninterested in sucking
Physiologically the respiratory rate can be- As high as 80 breaths min- Crackles may be heard- Heart rate may reach 180 breaths min - Bowel sounds are active- Mucus secretion are increased- Temperature may decreased slightly
After this initial stage of alertness and activity the infant enters the second stage of the first reactive period - darr heart and respiratory rate- darr temperature- darr mucus production- Urine and stool usually not pass The infant is in a state of sleep and relative calm and avoid undressing or bathing the infant during this time
The second period of reactivity begins with the infant wakes from the deep sleep it last about the 2-5 hours- Infant is alert and responsive- uarr heart and respiratory rate- Gag reflex is active
- uarr gastric and respiratory secretions- Passage of meconium occurs- After this stage is a period of stabilization of physiologic system and vacillating patterns of sleep and activity
GESTATIONAL ASSESSMENT includes Ballard Scale
The Ballard Maturational Assessment Ballard Score or Ballard Scale is a commonly used technique of gestational age assessment It assigns a score to various criteria the sum of all of which is then extrapolated to the gestational age of the baby These criteria are divided into Physical and Neurological criteria This scoring allows for the estimation of age in the range of 26 weeks-44 weeks The New Ballard Score is an extension of the above to include extremely pre-term babies
Posture - with infant quiet and in a supine position observe degree of flexion in arms and legs Muscle tone and degree of flexion increase with maturity Score full flexion of the arms and legs = 4
Square window - with thumb supporting back of arm below wrist apply gently pressure with index and third fingers on dorsum of hand without rotating infantrsquos wrist Measure angle between base of thumb and forearm Score Full flexion (hand lies flat on ventral surface of forearm) = 4
Arm recoil - with infant supine fully flex both forearms on upper arms hold for 5 seconds pull down on hands to fully extend and
rapidly release arms Observe rapidity and intensity of recoil to state of flexion
Popliteal angle - With infants supine and pelvis flat on a firm surface flex lower leg on thigh and then flex thigh on abdomen While holding knee with numb and
and index finger extend lower legs with index finger of other hand Measure degree of angle behind knee (popliteal angle) Score an angle of less than 90 degree = 5
Scarf sign - with infant supine support head in midline with one hand use other hand to pull infantrsquos arm across the shoulder so that infantrsquos hand touches shoulder Determine location of elbow in relation to midline Score elbow does not reach midline = 4
Heel to ear - with infant supine and pelvis flat on a firm surface pull foot as far as possible up toward ear on same side measure distance of foot from ear and degree of knee flexion (same as popliteal angle) Score knees flexed with a popliteal angle of less than 10 degrees
SUMMARY OF PHYSICAL ASSESSMENT OF NEWBORN
USUAL FINDINGS COMMON VARIATIONS POTENTIAL SIGNS OF DISTRESSMINOR ABNORMALITIES MAJOR ABNORMALITIES
GENERAL MEASUREMENTSHead circumstance 33-35 cm (13-14 in) 1in Molding after birth altering head circumference Head Circumference lt10th orgt 90th percentileAbout 2-3cm (1 in) larger than chest circumference Head and chest circumference equal for first 1-2days after birth
Chest circumference 305-33cm (12-13 in)Crown-to-rump length 31-35cm (125-14in)Approximately equal to head circumferenceHead-to-heel length 48-53cm (19-21in)
Birth Weight 2700-4000g (6-9 lb) Loss of 10 of birth weight in first week regained in 10-14days Birth weight lt10th orgt 90th percentileDepending on feeding method
VITAL SIGNSTemperature axillary 365deg-37degC (979deg-98degF) Crying increasing body temperature slightly Hypothermia
Radiant warmer falsely increasing axillary temperature Hypothermia
Heart rate apical120-140 beatsmin Crying increasing heart rate sleep decreasing heart rate Bradycardia Resting reate below 80-100 BpmDuring 1st period of reactivity (6-8hr) rate up to 190 Bpm Tachycardia Rate above 160-180 Bpm
Irregular rhythm
Respiration 30-60 Bpm Crying increasing respiratory rate sleep decreasing respiratory Tachypnea Rate gt60 Bpmrate Apnea 20 sec or moreDuring 1st period of reactivity (6-8hr) rate up to 80 Bpm
Blood pressure (BP) oscillometric 6541 mmHg in Crying and activity increasing BP Oscillometric systolic pressure in calf 6-9 mmHg less thanArm and calf Placing cuff on thigh agitates ionfant in upper extremity (sign of coarctation aorta)
Thigh BP higher then arm or calf BP by 4-8mmHg
GENERAL APPEARANCEPosture Flexion of head and extremities which rest Frank breech Extended legs abducted and fully Limp posture Extension of ExtremitiesOn chest and abdomen rotated thighs Flattened occiput extended neck
SKINAt birth bright red puffy smooth Neonatal jaundice after first 24hr Progressive jaundice especially in first 24hr2nd-3rd day pink flasky dry Ecchymoses or petechiae caused by birth trauma Generalized cyanosisVernix caseosa Milia Distended sebaceous glands that appear PallorLanugo as tiny white papules on cheeks chin and nose MottlingEdema around eyes face legs dorsa of hands feet GraynessAnd scrotum or labia Milaria or sudamina Distended sweat (eccrine) PlethoraAcrocyanosis Cyanosis of hands and feet glands that appear as minute vesicles especially on face Hemorrhage ecchymoses or petechiae that persistCutis marmorata Transient mottling when infant is Erythema toxicum Ping popular rash with vesicles Sclereme Hard and stiff skinExposed to decreased temperature superimposed on thorax back buttocks and abdomenl Poor skin turgor
May appear in 24-48 hr and resolve after several days Rashes pustules or blistersErythema toxicum pink popular rash with vesicles cafeacute au lait spot light brown spotssuperimposed on thorax back buttocks and abdomen nevus flammeus port-wine stainmay appear in 24-48 hrs and resolve after several daysHarlequin Color change clearly outlined color changeas infant lies on the side lower half of body becomespink and upper half is paleMongolian spots irregular areas of deep blue pigmentationusually in sacral and gluteal regions seen predominantly in newborn of African native American asian or Hispanic descentTalengiectatic nevi (stork bite) flat deep pink localizedareas usually seen on back of neck
HEADAnterior fontanels Diamond shape size varies form molding after vaginal delivery fused suturesbarely palpable to 4-5 cm third sagital (parietal) fontanel bulging or depressed fontanels when quietPosterior fontanels triangular 05-1cm bulging fontanel because of crying or coughing widened sutures and fontanelsFontanels flat soft and firm caput succedaneum edema of soft scalp tissue craniotabes snapping sensation along lambdoidWidest part of fontanel measured from bone to bone cephalhematoma hematoma between periosteum and skull bone sutures that resembles indentation of ping-pong ballnot suture to suture
EYES
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Objectives Introduction Definition of Terms Assesment
-Initial Assessment-Transitional Assessment-Gestational Assessment-Physical Assessment
- General Measurement Head to toe-Vital Signs- General Appearance
-Skin-Head-Eyes-Ears-Nose-Mouth-Neck-Chest-Lungs-Heart-Abdomen-Female Genitalia-Male Genitalia-Back and Rectum-Extremities-Neuromuscular System
Anatomy and Physiology-Thermoregulation-Circulatory-Hemopoetic System -Fluid and Electrolytes-Gastrointestinal System
-Renal System-Integumentary System-Skeletal System-Respiratory System-Endocrine-Neurology-Sensory-Immune System
Nursing Principles-Maintaining Patent Airway-Maintaining Stable Temperature-Identification-Protection from infection and injury
-Medical Management-Bathing-Cord Care-Circumcision-Providing Optimum Nutrition-Promoting Parent infant bonding
NCP HEP Discharge Plan Prognosis Presentation of Concept Map
OBJECTIVES
At the end of this case study students will be able to
1 Describe the normal characteristics of a term newborn2 Describe the state of a newborn3 Perform newborn assessments such as the APGAR Ballard and Silverman Test4 Implement nursing care to a normal newborn such as administering a first bath or instructing parents on how to care for their newborn5 Describe the nursing management of the newborn respirations maintenance of temperature prevention of infection and optimal nutrition6 Discuss initial identification registration and screening procedure for the newborn7 Relate the importance of the bonding process to the newborn babyrsquos and parentrsquos adjustment to each other8 Develop a teaching plan for parents of a newborn specific to home care9 Discuss the importance of breastfeeding to the mother and family10Apply correct nursing intervention necessary for newborn care
I INTRODUCTION
NEWBORN ndash the first hour of life
The primary focus at this time is the transition from intrauterine to extrauterine life with an introduction to family members as the neonatersquos condition warrants
The first 24 hours of life constitute a highly vulnerable time during which the infant must make several adjustments to uterine life During this period of transition 6 overlapping stages have been identified
Stage 1 Receives stimulation from the pressure of the uterine contractions during labor and from changes in pressure when the membranes rupture In this stage there is the transition from the intrauterine to extrauterine life The fetus takes part in this process from the flexion until the expulsion of oneself Nurses should take into consideration the risk factors that may be involved in such delivery putting in mind the safety of the newborn
Stage 2 Encounters a variety of foreign stimuli ndash light cold gravity and sound In this stage the newborn is introduced to the extrauterine life Certain factors such as these would stimulate the basic instinct of survival These factors classified as the thermal and chemical factors enables the infant to take in the first breath of life Nurses should consider these factors and should provide adequate temperature to regulate the change from the intrauterine temperature to the extrauterine temperature change protecting the newborn from these factors would help the newborn gradually adjust to such dramatic change
Stage 3 Initiates breathing In this stage the first breath is taken in after the umbilical cord is cut This stimulates the first inspiration Nursersquo consideration they should provide patent airway to prevent aspiration from fluids accumulated This would facilitate the beginning process of respiration and circulation
Stage 4 Changes from fetal to neonatal circulation Circulation begins right after the first breath has been taken in The circulation of oxygen throughout the newborn allows the start of the metabolic processes within the body Nurse should take into consideration the importance of circulation right after the first seconds of transition from intrauterine to extrauterine life
Stage 5 Undergoes alteration in metabolic processes with activation of liver renal and gastrointestinal tracts for passage of meconium With the exchange of gas and the circulation of oxygen within the body each organ begins their process of adjustment in the extrauterine life Such metabolic process activates these major organs to promote vitality of life of the newborn Nurse should take into consideration by assessing such changes whether it is successful and able to adjust with such dramatic change
Stage 6 Achieves a steady level of equilibrium in metabolic processes Taking into consideration the production of enzymes increased blood oxygen saturation decrease in acidosis associated with birth and recovery of the neurologic tissues from the trauma of labor and delivery It is in this stage the newborn takes into the final adjustment period of ones life independently This stage is crucial hence the nurse should give importance of making sure such level of equilibrium be maintained at such time the newborn will be finally discharged together with hisher family
DEFINITION OF TERMS
Habituation - the gradual adaptation to a stimulus or to the environment with a decreasing response
Orientation - awareness of ones environment with reference to time place and people
Reflexes - a reflected action or movement the sum total of any particular automatic response mediated by the nervous system
Posture - a reflected action or movement the sum total of any particular automatic response mediated by the nervous system
Square window - an angle of the wrist between the hypothenar prominence and forearm It is used as a reference point for estimating the gestational age of a newborn
Motor Performance ndash quality of movement and tone
Range of state ndash measure of general arousal level or arousability of infant
Regulation of state ndash how infant responds when aroused
Autonomic stability ndash signs of stress related to homeostatic adjustment of the nervous system
Normothermic - a normal state of temperature
Bradycardia - a slow heart rate Bradycardia is one of the two types of arrhythmia
Tachycardia - abnormally rapid heart rate
Apnea - Temporary absence or cessation of breathing
Tachypnea - abnormally rapid rate of breathing such as that associated with high fever
Vitamin K - any of a group of structurally similar fat-soluble compounds that promote blood clotting
Hepa B vaccine - a viral hepatitis caused by the hepatitis B virus (HBV) a hepa and virus The virus is transmitted by transfusion of contaminated blood or blood products by sexual contact with an infected person by the use of contaminated needles and instruments or in utero
Prognosis - a prediction of the probable outcome of a disease based on the condition of the person and the usual course of the disease as observed in similar situations
BCG vaccination - has been used in the control of tuberculosis in cattle but has many disadvantages especially interference with tuberculin testing and is not recommended for use unless the prevalence of the disease is very high
Pallor - an unnatural paleness or absence of color in the skin
Plethora - An excess of blood in the circulatory system or in one organ or area
Scelerema - a severe sometimes fatal disorder of adipose tissue occurring chiefly in preterm sick debilitated infants manifested by induration of the involved tissue causing the skin to become cold yellowish white mottled boardlike and inflexible
Milia - a tiny spheroidal epithelial cyst lying superficially within the skin usually of the face containing lamellated keratin and often associated with vellus hair follicles
Miliaria - a cutaneous condition with retention of sweat which is extravasated at different levels in the skin
Mongolian spot - a smooth brown to grayish blue nevus consisting of an excess of melanocytes typically found at birth in the sacral region in Asians and dark-skinned races it usually disappears during childhood
Acrocyanosis - s a decrease in the amount of oxygen delivered to the extremities The hands and feet turn blue because of the lack of oxygen Decreased blood supply to the affected areas is caused by constriction or spasm of small blood vessels
Craniotabes - eduction in mineralization of the skull with abnormal softness of the bone usually affecting the occipital and parietal bones along the lambdoidal sutures
Nystagmus - Rhythmic oscillating motions of the eyes are called nystagmus The to-and-fro motion is generally involuntary Vertical nystagmus occurs much less frequently than horizontal nystagmus and is often but not necessarily a sign of serious brain damage Nystagmus can be a normal physiological response or a result of a pathologic problem
Strabismus - occurs in 2-5 of all children About half are born with the condition which causes one or both eyes to turn
Hypotelorism - abnormally decreased distance between two organs or parts
Torticollis - is a type of movement disorder in which the muscles controlling the neck cause sustained twisting or frequent jerking
Frenulum - a small fold of integument or mucous membrane that limits the movements of an organ or part
Xiphoid process - he pointed process of cartilage supported by a core of bone connected with the posterior end of the body of the sternum
Candidiasis - is an infection caused by a species of the yeast Candida usually Candida albicans
Cardiomegaly - abnormal enlargement of the heart
Diastasis recti - is a disorder defined as a separation of the rectus abdominis muscle into right and left halves
Whartonrsquos Jelly - is a gelatinous substance within the umbilical cord composed of cells that originate in the original egg and sperm of conception It is largely made up of mucopolysaccharides
Ascites - s an accumulation of fluid in the peritoneal cavity Although most commonly due to cirrhosis and severe liver disease its presence can portend other significant medical problems Diagnosis of the cause is usually with blood tests an ultrasound scan of the abdomen and direct removal of the fluid by needle or paracentesis
Gastroschisis - is a type of abdominal wall defect in which the intestines and sometimes other organs develop outside the fetal abdomen through an opening in the abdominal wall This defect is the result of obstruction of the omphalomesenteric vessels during development
Pseudomenstruation - bleeding from the uterus that resembles menstruation but is not associated with the usual changes in endometrial tissues
Epispadias - ongenital absence of the upper wall of the urethra occurring in both sexes but more often in the male with the urethral opening somewhere on the dorsum of the penis
Chordee - downward bowing of the penis due to a congenital anomaly or to urethral infection
Hydrocele - circumscribed collection of fluid especially in the tunica vaginalis of the testis or along the spermatic cord
Polydactyly - the presence of supernumerary digits on the hands or feet
Syndactyly - persistence of webbing between adjacent digits of the hand or foot so that they are more or less completely fused together
Phocomelia - congenital absence of the proximal portion of a limb or limbs the hands or feet being attached to the trunk by a small irregularly shaped bone
Hemimelia - a developmental anomaly characterized by absence of all or part of the distal half of a limb
Quivering - To shake with a slight rapid tremulous movement
Hypotonia - the state of being hypotonic
Hypertonia - the state of being hypertonic
Tremors - A relatively minor seismic shaking or vibrating movement Tremors often precede larger earthquakes or volcanic eruptions
Pupillary - Of or affecting the pupil of the eye
Glabellar - The smooth area between the eyebrows just above the nose
Extrusion - The act or process of pushing or thrusting out
Startle - To cause to make a quick involuntary movement or start
Pseudomonas - any of a genus of rodlike Gram-negative bacteria that live in soil and decomposing organic matter many species are pathogenic to plants and a few are pathogenic to man
Prophylaxis - Prevention of or protective treatment for disease
Cirrhosis - A chronic disease of the liver characterized by the replacement of normal tissue with fibrous tissue and the loss of functional liver cells It can result from alcohol abuse nutritional deprivation or infection especially by the hepatitis virus
Dehiscence - he spontaneous opening at maturity of a plant structure such as a fruit anther or sporangium to release its contents
Meatitis - inflammation of the urinary meatus
Urethral fistula - due to trauma occurs in bulls in which the urethra lies superficially near its end A fistula may affect the discharge of semen from the normal meatus sufficiently to cause infertility
DTP - diphtheria and tetanus toxoids and pertussis vaccine
Conduction ndash is the transfer of body heat to a cooler solid object in contact with a baby
Convection ndash is the flow of heat from the newborns body surface to cooler surrounding air
Radiation ndash is the transfer of body heat to a cooler solid object not in contact with the baby
Evaporation ndash is loss of heat through conversion of a liquid to vapor
Attachement ndash is the mode of contact between babyrsquos mouth and the motherrsquos breast during the act of breastfeeding
Kangaroo Mother Care - A universally available and biologically sound method of care for all newborns but in particular for premature babies with t three components skin-to-skin contact exclusive breastfeeding and support to the mother infant dyad
Newborn Resuscitation ndash a series of action taken to establish normal breathing in a newborn with depressed vital signs
Neonate - is a baby who is 4 weeks old or younger
Neonatal Period - the first 4 weeks of a childs life represents a time when changes are very rapid and many critical events can occur
Positive Pressure Ventilaiton (PPV) - refers to the process of forcing air into the lungs of a (usually apneic or dyspneic) patient usually using a baby valve mask or mechanical ventilator
ASSESSMENT
The new born requires thorough skilled observation to ensure a satisfactory to extra-uterine life 4 phases of physical assessment after delivery
The initial assessment The transitional assessment The assessment of gestational age The comprehensive and systematic physical examination
INITIAL ASSESSMENT includes APGAR scoring
APGAR SCORING METHOD - is the most frequent in assessing the newbornrsquos immediate adjustment to extra uterine life (Papile 2001)
SIGNS 0 1 2Heart rate Absent Slow lt 100 beats min Beats min
Respiratory effort Absent Irregular slow weak cry Good strong cryMuscle Tone Limp Some flexion of extremities Well flexed
Reflex Irritability No response Grimace Cry sneezeColor Blue Pale Body pink extremities blue Completely pink
SCORES0 - 3 Severe Distress4 ndash 6 Moderate Difficulty7 ndash 10 Absent in Difficulty
TRANSITIONAL ASSESSMENT
Newborn exhibits behavioral and physiological characteristics that can at first appear to be signs of stress
During newbornrsquos initial 24 hours changes in heart rate respiration motor activity color mucus production and bowel activity occur in an orderly predictable sequence which is normal and indicate lack of stress
- During the first 30 min the infant is alert cries vigorously may suck his or her fingers or fist and appears interested in the environment
For 6 to 8 hours after birth the newborn is in the first period of reactivity - the neonates eyes are usually open- has vigorous suck reflex- grasp the nipple quickly This is important to remember because after this initial highly active state the infant may be sleepy and uninterested in sucking
Physiologically the respiratory rate can be- As high as 80 breaths min- Crackles may be heard- Heart rate may reach 180 breaths min - Bowel sounds are active- Mucus secretion are increased- Temperature may decreased slightly
After this initial stage of alertness and activity the infant enters the second stage of the first reactive period - darr heart and respiratory rate- darr temperature- darr mucus production- Urine and stool usually not pass The infant is in a state of sleep and relative calm and avoid undressing or bathing the infant during this time
The second period of reactivity begins with the infant wakes from the deep sleep it last about the 2-5 hours- Infant is alert and responsive- uarr heart and respiratory rate- Gag reflex is active
- uarr gastric and respiratory secretions- Passage of meconium occurs- After this stage is a period of stabilization of physiologic system and vacillating patterns of sleep and activity
GESTATIONAL ASSESSMENT includes Ballard Scale
The Ballard Maturational Assessment Ballard Score or Ballard Scale is a commonly used technique of gestational age assessment It assigns a score to various criteria the sum of all of which is then extrapolated to the gestational age of the baby These criteria are divided into Physical and Neurological criteria This scoring allows for the estimation of age in the range of 26 weeks-44 weeks The New Ballard Score is an extension of the above to include extremely pre-term babies
Posture - with infant quiet and in a supine position observe degree of flexion in arms and legs Muscle tone and degree of flexion increase with maturity Score full flexion of the arms and legs = 4
Square window - with thumb supporting back of arm below wrist apply gently pressure with index and third fingers on dorsum of hand without rotating infantrsquos wrist Measure angle between base of thumb and forearm Score Full flexion (hand lies flat on ventral surface of forearm) = 4
Arm recoil - with infant supine fully flex both forearms on upper arms hold for 5 seconds pull down on hands to fully extend and
rapidly release arms Observe rapidity and intensity of recoil to state of flexion
Popliteal angle - With infants supine and pelvis flat on a firm surface flex lower leg on thigh and then flex thigh on abdomen While holding knee with numb and
and index finger extend lower legs with index finger of other hand Measure degree of angle behind knee (popliteal angle) Score an angle of less than 90 degree = 5
Scarf sign - with infant supine support head in midline with one hand use other hand to pull infantrsquos arm across the shoulder so that infantrsquos hand touches shoulder Determine location of elbow in relation to midline Score elbow does not reach midline = 4
Heel to ear - with infant supine and pelvis flat on a firm surface pull foot as far as possible up toward ear on same side measure distance of foot from ear and degree of knee flexion (same as popliteal angle) Score knees flexed with a popliteal angle of less than 10 degrees
SUMMARY OF PHYSICAL ASSESSMENT OF NEWBORN
USUAL FINDINGS COMMON VARIATIONS POTENTIAL SIGNS OF DISTRESSMINOR ABNORMALITIES MAJOR ABNORMALITIES
GENERAL MEASUREMENTSHead circumstance 33-35 cm (13-14 in) 1in Molding after birth altering head circumference Head Circumference lt10th orgt 90th percentileAbout 2-3cm (1 in) larger than chest circumference Head and chest circumference equal for first 1-2days after birth
Chest circumference 305-33cm (12-13 in)Crown-to-rump length 31-35cm (125-14in)Approximately equal to head circumferenceHead-to-heel length 48-53cm (19-21in)
Birth Weight 2700-4000g (6-9 lb) Loss of 10 of birth weight in first week regained in 10-14days Birth weight lt10th orgt 90th percentileDepending on feeding method
VITAL SIGNSTemperature axillary 365deg-37degC (979deg-98degF) Crying increasing body temperature slightly Hypothermia
Radiant warmer falsely increasing axillary temperature Hypothermia
Heart rate apical120-140 beatsmin Crying increasing heart rate sleep decreasing heart rate Bradycardia Resting reate below 80-100 BpmDuring 1st period of reactivity (6-8hr) rate up to 190 Bpm Tachycardia Rate above 160-180 Bpm
Irregular rhythm
Respiration 30-60 Bpm Crying increasing respiratory rate sleep decreasing respiratory Tachypnea Rate gt60 Bpmrate Apnea 20 sec or moreDuring 1st period of reactivity (6-8hr) rate up to 80 Bpm
Blood pressure (BP) oscillometric 6541 mmHg in Crying and activity increasing BP Oscillometric systolic pressure in calf 6-9 mmHg less thanArm and calf Placing cuff on thigh agitates ionfant in upper extremity (sign of coarctation aorta)
Thigh BP higher then arm or calf BP by 4-8mmHg
GENERAL APPEARANCEPosture Flexion of head and extremities which rest Frank breech Extended legs abducted and fully Limp posture Extension of ExtremitiesOn chest and abdomen rotated thighs Flattened occiput extended neck
SKINAt birth bright red puffy smooth Neonatal jaundice after first 24hr Progressive jaundice especially in first 24hr2nd-3rd day pink flasky dry Ecchymoses or petechiae caused by birth trauma Generalized cyanosisVernix caseosa Milia Distended sebaceous glands that appear PallorLanugo as tiny white papules on cheeks chin and nose MottlingEdema around eyes face legs dorsa of hands feet GraynessAnd scrotum or labia Milaria or sudamina Distended sweat (eccrine) PlethoraAcrocyanosis Cyanosis of hands and feet glands that appear as minute vesicles especially on face Hemorrhage ecchymoses or petechiae that persistCutis marmorata Transient mottling when infant is Erythema toxicum Ping popular rash with vesicles Sclereme Hard and stiff skinExposed to decreased temperature superimposed on thorax back buttocks and abdomenl Poor skin turgor
May appear in 24-48 hr and resolve after several days Rashes pustules or blistersErythema toxicum pink popular rash with vesicles cafeacute au lait spot light brown spotssuperimposed on thorax back buttocks and abdomen nevus flammeus port-wine stainmay appear in 24-48 hrs and resolve after several daysHarlequin Color change clearly outlined color changeas infant lies on the side lower half of body becomespink and upper half is paleMongolian spots irregular areas of deep blue pigmentationusually in sacral and gluteal regions seen predominantly in newborn of African native American asian or Hispanic descentTalengiectatic nevi (stork bite) flat deep pink localizedareas usually seen on back of neck
HEADAnterior fontanels Diamond shape size varies form molding after vaginal delivery fused suturesbarely palpable to 4-5 cm third sagital (parietal) fontanel bulging or depressed fontanels when quietPosterior fontanels triangular 05-1cm bulging fontanel because of crying or coughing widened sutures and fontanelsFontanels flat soft and firm caput succedaneum edema of soft scalp tissue craniotabes snapping sensation along lambdoidWidest part of fontanel measured from bone to bone cephalhematoma hematoma between periosteum and skull bone sutures that resembles indentation of ping-pong ballnot suture to suture
EYES
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
-Renal System-Integumentary System-Skeletal System-Respiratory System-Endocrine-Neurology-Sensory-Immune System
Nursing Principles-Maintaining Patent Airway-Maintaining Stable Temperature-Identification-Protection from infection and injury
-Medical Management-Bathing-Cord Care-Circumcision-Providing Optimum Nutrition-Promoting Parent infant bonding
NCP HEP Discharge Plan Prognosis Presentation of Concept Map
OBJECTIVES
At the end of this case study students will be able to
1 Describe the normal characteristics of a term newborn2 Describe the state of a newborn3 Perform newborn assessments such as the APGAR Ballard and Silverman Test4 Implement nursing care to a normal newborn such as administering a first bath or instructing parents on how to care for their newborn5 Describe the nursing management of the newborn respirations maintenance of temperature prevention of infection and optimal nutrition6 Discuss initial identification registration and screening procedure for the newborn7 Relate the importance of the bonding process to the newborn babyrsquos and parentrsquos adjustment to each other8 Develop a teaching plan for parents of a newborn specific to home care9 Discuss the importance of breastfeeding to the mother and family10Apply correct nursing intervention necessary for newborn care
I INTRODUCTION
NEWBORN ndash the first hour of life
The primary focus at this time is the transition from intrauterine to extrauterine life with an introduction to family members as the neonatersquos condition warrants
The first 24 hours of life constitute a highly vulnerable time during which the infant must make several adjustments to uterine life During this period of transition 6 overlapping stages have been identified
Stage 1 Receives stimulation from the pressure of the uterine contractions during labor and from changes in pressure when the membranes rupture In this stage there is the transition from the intrauterine to extrauterine life The fetus takes part in this process from the flexion until the expulsion of oneself Nurses should take into consideration the risk factors that may be involved in such delivery putting in mind the safety of the newborn
Stage 2 Encounters a variety of foreign stimuli ndash light cold gravity and sound In this stage the newborn is introduced to the extrauterine life Certain factors such as these would stimulate the basic instinct of survival These factors classified as the thermal and chemical factors enables the infant to take in the first breath of life Nurses should consider these factors and should provide adequate temperature to regulate the change from the intrauterine temperature to the extrauterine temperature change protecting the newborn from these factors would help the newborn gradually adjust to such dramatic change
Stage 3 Initiates breathing In this stage the first breath is taken in after the umbilical cord is cut This stimulates the first inspiration Nursersquo consideration they should provide patent airway to prevent aspiration from fluids accumulated This would facilitate the beginning process of respiration and circulation
Stage 4 Changes from fetal to neonatal circulation Circulation begins right after the first breath has been taken in The circulation of oxygen throughout the newborn allows the start of the metabolic processes within the body Nurse should take into consideration the importance of circulation right after the first seconds of transition from intrauterine to extrauterine life
Stage 5 Undergoes alteration in metabolic processes with activation of liver renal and gastrointestinal tracts for passage of meconium With the exchange of gas and the circulation of oxygen within the body each organ begins their process of adjustment in the extrauterine life Such metabolic process activates these major organs to promote vitality of life of the newborn Nurse should take into consideration by assessing such changes whether it is successful and able to adjust with such dramatic change
Stage 6 Achieves a steady level of equilibrium in metabolic processes Taking into consideration the production of enzymes increased blood oxygen saturation decrease in acidosis associated with birth and recovery of the neurologic tissues from the trauma of labor and delivery It is in this stage the newborn takes into the final adjustment period of ones life independently This stage is crucial hence the nurse should give importance of making sure such level of equilibrium be maintained at such time the newborn will be finally discharged together with hisher family
DEFINITION OF TERMS
Habituation - the gradual adaptation to a stimulus or to the environment with a decreasing response
Orientation - awareness of ones environment with reference to time place and people
Reflexes - a reflected action or movement the sum total of any particular automatic response mediated by the nervous system
Posture - a reflected action or movement the sum total of any particular automatic response mediated by the nervous system
Square window - an angle of the wrist between the hypothenar prominence and forearm It is used as a reference point for estimating the gestational age of a newborn
Motor Performance ndash quality of movement and tone
Range of state ndash measure of general arousal level or arousability of infant
Regulation of state ndash how infant responds when aroused
Autonomic stability ndash signs of stress related to homeostatic adjustment of the nervous system
Normothermic - a normal state of temperature
Bradycardia - a slow heart rate Bradycardia is one of the two types of arrhythmia
Tachycardia - abnormally rapid heart rate
Apnea - Temporary absence or cessation of breathing
Tachypnea - abnormally rapid rate of breathing such as that associated with high fever
Vitamin K - any of a group of structurally similar fat-soluble compounds that promote blood clotting
Hepa B vaccine - a viral hepatitis caused by the hepatitis B virus (HBV) a hepa and virus The virus is transmitted by transfusion of contaminated blood or blood products by sexual contact with an infected person by the use of contaminated needles and instruments or in utero
Prognosis - a prediction of the probable outcome of a disease based on the condition of the person and the usual course of the disease as observed in similar situations
BCG vaccination - has been used in the control of tuberculosis in cattle but has many disadvantages especially interference with tuberculin testing and is not recommended for use unless the prevalence of the disease is very high
Pallor - an unnatural paleness or absence of color in the skin
Plethora - An excess of blood in the circulatory system or in one organ or area
Scelerema - a severe sometimes fatal disorder of adipose tissue occurring chiefly in preterm sick debilitated infants manifested by induration of the involved tissue causing the skin to become cold yellowish white mottled boardlike and inflexible
Milia - a tiny spheroidal epithelial cyst lying superficially within the skin usually of the face containing lamellated keratin and often associated with vellus hair follicles
Miliaria - a cutaneous condition with retention of sweat which is extravasated at different levels in the skin
Mongolian spot - a smooth brown to grayish blue nevus consisting of an excess of melanocytes typically found at birth in the sacral region in Asians and dark-skinned races it usually disappears during childhood
Acrocyanosis - s a decrease in the amount of oxygen delivered to the extremities The hands and feet turn blue because of the lack of oxygen Decreased blood supply to the affected areas is caused by constriction or spasm of small blood vessels
Craniotabes - eduction in mineralization of the skull with abnormal softness of the bone usually affecting the occipital and parietal bones along the lambdoidal sutures
Nystagmus - Rhythmic oscillating motions of the eyes are called nystagmus The to-and-fro motion is generally involuntary Vertical nystagmus occurs much less frequently than horizontal nystagmus and is often but not necessarily a sign of serious brain damage Nystagmus can be a normal physiological response or a result of a pathologic problem
Strabismus - occurs in 2-5 of all children About half are born with the condition which causes one or both eyes to turn
Hypotelorism - abnormally decreased distance between two organs or parts
Torticollis - is a type of movement disorder in which the muscles controlling the neck cause sustained twisting or frequent jerking
Frenulum - a small fold of integument or mucous membrane that limits the movements of an organ or part
Xiphoid process - he pointed process of cartilage supported by a core of bone connected with the posterior end of the body of the sternum
Candidiasis - is an infection caused by a species of the yeast Candida usually Candida albicans
Cardiomegaly - abnormal enlargement of the heart
Diastasis recti - is a disorder defined as a separation of the rectus abdominis muscle into right and left halves
Whartonrsquos Jelly - is a gelatinous substance within the umbilical cord composed of cells that originate in the original egg and sperm of conception It is largely made up of mucopolysaccharides
Ascites - s an accumulation of fluid in the peritoneal cavity Although most commonly due to cirrhosis and severe liver disease its presence can portend other significant medical problems Diagnosis of the cause is usually with blood tests an ultrasound scan of the abdomen and direct removal of the fluid by needle or paracentesis
Gastroschisis - is a type of abdominal wall defect in which the intestines and sometimes other organs develop outside the fetal abdomen through an opening in the abdominal wall This defect is the result of obstruction of the omphalomesenteric vessels during development
Pseudomenstruation - bleeding from the uterus that resembles menstruation but is not associated with the usual changes in endometrial tissues
Epispadias - ongenital absence of the upper wall of the urethra occurring in both sexes but more often in the male with the urethral opening somewhere on the dorsum of the penis
Chordee - downward bowing of the penis due to a congenital anomaly or to urethral infection
Hydrocele - circumscribed collection of fluid especially in the tunica vaginalis of the testis or along the spermatic cord
Polydactyly - the presence of supernumerary digits on the hands or feet
Syndactyly - persistence of webbing between adjacent digits of the hand or foot so that they are more or less completely fused together
Phocomelia - congenital absence of the proximal portion of a limb or limbs the hands or feet being attached to the trunk by a small irregularly shaped bone
Hemimelia - a developmental anomaly characterized by absence of all or part of the distal half of a limb
Quivering - To shake with a slight rapid tremulous movement
Hypotonia - the state of being hypotonic
Hypertonia - the state of being hypertonic
Tremors - A relatively minor seismic shaking or vibrating movement Tremors often precede larger earthquakes or volcanic eruptions
Pupillary - Of or affecting the pupil of the eye
Glabellar - The smooth area between the eyebrows just above the nose
Extrusion - The act or process of pushing or thrusting out
Startle - To cause to make a quick involuntary movement or start
Pseudomonas - any of a genus of rodlike Gram-negative bacteria that live in soil and decomposing organic matter many species are pathogenic to plants and a few are pathogenic to man
Prophylaxis - Prevention of or protective treatment for disease
Cirrhosis - A chronic disease of the liver characterized by the replacement of normal tissue with fibrous tissue and the loss of functional liver cells It can result from alcohol abuse nutritional deprivation or infection especially by the hepatitis virus
Dehiscence - he spontaneous opening at maturity of a plant structure such as a fruit anther or sporangium to release its contents
Meatitis - inflammation of the urinary meatus
Urethral fistula - due to trauma occurs in bulls in which the urethra lies superficially near its end A fistula may affect the discharge of semen from the normal meatus sufficiently to cause infertility
DTP - diphtheria and tetanus toxoids and pertussis vaccine
Conduction ndash is the transfer of body heat to a cooler solid object in contact with a baby
Convection ndash is the flow of heat from the newborns body surface to cooler surrounding air
Radiation ndash is the transfer of body heat to a cooler solid object not in contact with the baby
Evaporation ndash is loss of heat through conversion of a liquid to vapor
Attachement ndash is the mode of contact between babyrsquos mouth and the motherrsquos breast during the act of breastfeeding
Kangaroo Mother Care - A universally available and biologically sound method of care for all newborns but in particular for premature babies with t three components skin-to-skin contact exclusive breastfeeding and support to the mother infant dyad
Newborn Resuscitation ndash a series of action taken to establish normal breathing in a newborn with depressed vital signs
Neonate - is a baby who is 4 weeks old or younger
Neonatal Period - the first 4 weeks of a childs life represents a time when changes are very rapid and many critical events can occur
Positive Pressure Ventilaiton (PPV) - refers to the process of forcing air into the lungs of a (usually apneic or dyspneic) patient usually using a baby valve mask or mechanical ventilator
ASSESSMENT
The new born requires thorough skilled observation to ensure a satisfactory to extra-uterine life 4 phases of physical assessment after delivery
The initial assessment The transitional assessment The assessment of gestational age The comprehensive and systematic physical examination
INITIAL ASSESSMENT includes APGAR scoring
APGAR SCORING METHOD - is the most frequent in assessing the newbornrsquos immediate adjustment to extra uterine life (Papile 2001)
SIGNS 0 1 2Heart rate Absent Slow lt 100 beats min Beats min
Respiratory effort Absent Irregular slow weak cry Good strong cryMuscle Tone Limp Some flexion of extremities Well flexed
Reflex Irritability No response Grimace Cry sneezeColor Blue Pale Body pink extremities blue Completely pink
SCORES0 - 3 Severe Distress4 ndash 6 Moderate Difficulty7 ndash 10 Absent in Difficulty
TRANSITIONAL ASSESSMENT
Newborn exhibits behavioral and physiological characteristics that can at first appear to be signs of stress
During newbornrsquos initial 24 hours changes in heart rate respiration motor activity color mucus production and bowel activity occur in an orderly predictable sequence which is normal and indicate lack of stress
- During the first 30 min the infant is alert cries vigorously may suck his or her fingers or fist and appears interested in the environment
For 6 to 8 hours after birth the newborn is in the first period of reactivity - the neonates eyes are usually open- has vigorous suck reflex- grasp the nipple quickly This is important to remember because after this initial highly active state the infant may be sleepy and uninterested in sucking
Physiologically the respiratory rate can be- As high as 80 breaths min- Crackles may be heard- Heart rate may reach 180 breaths min - Bowel sounds are active- Mucus secretion are increased- Temperature may decreased slightly
After this initial stage of alertness and activity the infant enters the second stage of the first reactive period - darr heart and respiratory rate- darr temperature- darr mucus production- Urine and stool usually not pass The infant is in a state of sleep and relative calm and avoid undressing or bathing the infant during this time
The second period of reactivity begins with the infant wakes from the deep sleep it last about the 2-5 hours- Infant is alert and responsive- uarr heart and respiratory rate- Gag reflex is active
- uarr gastric and respiratory secretions- Passage of meconium occurs- After this stage is a period of stabilization of physiologic system and vacillating patterns of sleep and activity
GESTATIONAL ASSESSMENT includes Ballard Scale
The Ballard Maturational Assessment Ballard Score or Ballard Scale is a commonly used technique of gestational age assessment It assigns a score to various criteria the sum of all of which is then extrapolated to the gestational age of the baby These criteria are divided into Physical and Neurological criteria This scoring allows for the estimation of age in the range of 26 weeks-44 weeks The New Ballard Score is an extension of the above to include extremely pre-term babies
Posture - with infant quiet and in a supine position observe degree of flexion in arms and legs Muscle tone and degree of flexion increase with maturity Score full flexion of the arms and legs = 4
Square window - with thumb supporting back of arm below wrist apply gently pressure with index and third fingers on dorsum of hand without rotating infantrsquos wrist Measure angle between base of thumb and forearm Score Full flexion (hand lies flat on ventral surface of forearm) = 4
Arm recoil - with infant supine fully flex both forearms on upper arms hold for 5 seconds pull down on hands to fully extend and
rapidly release arms Observe rapidity and intensity of recoil to state of flexion
Popliteal angle - With infants supine and pelvis flat on a firm surface flex lower leg on thigh and then flex thigh on abdomen While holding knee with numb and
and index finger extend lower legs with index finger of other hand Measure degree of angle behind knee (popliteal angle) Score an angle of less than 90 degree = 5
Scarf sign - with infant supine support head in midline with one hand use other hand to pull infantrsquos arm across the shoulder so that infantrsquos hand touches shoulder Determine location of elbow in relation to midline Score elbow does not reach midline = 4
Heel to ear - with infant supine and pelvis flat on a firm surface pull foot as far as possible up toward ear on same side measure distance of foot from ear and degree of knee flexion (same as popliteal angle) Score knees flexed with a popliteal angle of less than 10 degrees
SUMMARY OF PHYSICAL ASSESSMENT OF NEWBORN
USUAL FINDINGS COMMON VARIATIONS POTENTIAL SIGNS OF DISTRESSMINOR ABNORMALITIES MAJOR ABNORMALITIES
GENERAL MEASUREMENTSHead circumstance 33-35 cm (13-14 in) 1in Molding after birth altering head circumference Head Circumference lt10th orgt 90th percentileAbout 2-3cm (1 in) larger than chest circumference Head and chest circumference equal for first 1-2days after birth
Chest circumference 305-33cm (12-13 in)Crown-to-rump length 31-35cm (125-14in)Approximately equal to head circumferenceHead-to-heel length 48-53cm (19-21in)
Birth Weight 2700-4000g (6-9 lb) Loss of 10 of birth weight in first week regained in 10-14days Birth weight lt10th orgt 90th percentileDepending on feeding method
VITAL SIGNSTemperature axillary 365deg-37degC (979deg-98degF) Crying increasing body temperature slightly Hypothermia
Radiant warmer falsely increasing axillary temperature Hypothermia
Heart rate apical120-140 beatsmin Crying increasing heart rate sleep decreasing heart rate Bradycardia Resting reate below 80-100 BpmDuring 1st period of reactivity (6-8hr) rate up to 190 Bpm Tachycardia Rate above 160-180 Bpm
Irregular rhythm
Respiration 30-60 Bpm Crying increasing respiratory rate sleep decreasing respiratory Tachypnea Rate gt60 Bpmrate Apnea 20 sec or moreDuring 1st period of reactivity (6-8hr) rate up to 80 Bpm
Blood pressure (BP) oscillometric 6541 mmHg in Crying and activity increasing BP Oscillometric systolic pressure in calf 6-9 mmHg less thanArm and calf Placing cuff on thigh agitates ionfant in upper extremity (sign of coarctation aorta)
Thigh BP higher then arm or calf BP by 4-8mmHg
GENERAL APPEARANCEPosture Flexion of head and extremities which rest Frank breech Extended legs abducted and fully Limp posture Extension of ExtremitiesOn chest and abdomen rotated thighs Flattened occiput extended neck
SKINAt birth bright red puffy smooth Neonatal jaundice after first 24hr Progressive jaundice especially in first 24hr2nd-3rd day pink flasky dry Ecchymoses or petechiae caused by birth trauma Generalized cyanosisVernix caseosa Milia Distended sebaceous glands that appear PallorLanugo as tiny white papules on cheeks chin and nose MottlingEdema around eyes face legs dorsa of hands feet GraynessAnd scrotum or labia Milaria or sudamina Distended sweat (eccrine) PlethoraAcrocyanosis Cyanosis of hands and feet glands that appear as minute vesicles especially on face Hemorrhage ecchymoses or petechiae that persistCutis marmorata Transient mottling when infant is Erythema toxicum Ping popular rash with vesicles Sclereme Hard and stiff skinExposed to decreased temperature superimposed on thorax back buttocks and abdomenl Poor skin turgor
May appear in 24-48 hr and resolve after several days Rashes pustules or blistersErythema toxicum pink popular rash with vesicles cafeacute au lait spot light brown spotssuperimposed on thorax back buttocks and abdomen nevus flammeus port-wine stainmay appear in 24-48 hrs and resolve after several daysHarlequin Color change clearly outlined color changeas infant lies on the side lower half of body becomespink and upper half is paleMongolian spots irregular areas of deep blue pigmentationusually in sacral and gluteal regions seen predominantly in newborn of African native American asian or Hispanic descentTalengiectatic nevi (stork bite) flat deep pink localizedareas usually seen on back of neck
HEADAnterior fontanels Diamond shape size varies form molding after vaginal delivery fused suturesbarely palpable to 4-5 cm third sagital (parietal) fontanel bulging or depressed fontanels when quietPosterior fontanels triangular 05-1cm bulging fontanel because of crying or coughing widened sutures and fontanelsFontanels flat soft and firm caput succedaneum edema of soft scalp tissue craniotabes snapping sensation along lambdoidWidest part of fontanel measured from bone to bone cephalhematoma hematoma between periosteum and skull bone sutures that resembles indentation of ping-pong ballnot suture to suture
EYES
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
OBJECTIVES
At the end of this case study students will be able to
1 Describe the normal characteristics of a term newborn2 Describe the state of a newborn3 Perform newborn assessments such as the APGAR Ballard and Silverman Test4 Implement nursing care to a normal newborn such as administering a first bath or instructing parents on how to care for their newborn5 Describe the nursing management of the newborn respirations maintenance of temperature prevention of infection and optimal nutrition6 Discuss initial identification registration and screening procedure for the newborn7 Relate the importance of the bonding process to the newborn babyrsquos and parentrsquos adjustment to each other8 Develop a teaching plan for parents of a newborn specific to home care9 Discuss the importance of breastfeeding to the mother and family10Apply correct nursing intervention necessary for newborn care
I INTRODUCTION
NEWBORN ndash the first hour of life
The primary focus at this time is the transition from intrauterine to extrauterine life with an introduction to family members as the neonatersquos condition warrants
The first 24 hours of life constitute a highly vulnerable time during which the infant must make several adjustments to uterine life During this period of transition 6 overlapping stages have been identified
Stage 1 Receives stimulation from the pressure of the uterine contractions during labor and from changes in pressure when the membranes rupture In this stage there is the transition from the intrauterine to extrauterine life The fetus takes part in this process from the flexion until the expulsion of oneself Nurses should take into consideration the risk factors that may be involved in such delivery putting in mind the safety of the newborn
Stage 2 Encounters a variety of foreign stimuli ndash light cold gravity and sound In this stage the newborn is introduced to the extrauterine life Certain factors such as these would stimulate the basic instinct of survival These factors classified as the thermal and chemical factors enables the infant to take in the first breath of life Nurses should consider these factors and should provide adequate temperature to regulate the change from the intrauterine temperature to the extrauterine temperature change protecting the newborn from these factors would help the newborn gradually adjust to such dramatic change
Stage 3 Initiates breathing In this stage the first breath is taken in after the umbilical cord is cut This stimulates the first inspiration Nursersquo consideration they should provide patent airway to prevent aspiration from fluids accumulated This would facilitate the beginning process of respiration and circulation
Stage 4 Changes from fetal to neonatal circulation Circulation begins right after the first breath has been taken in The circulation of oxygen throughout the newborn allows the start of the metabolic processes within the body Nurse should take into consideration the importance of circulation right after the first seconds of transition from intrauterine to extrauterine life
Stage 5 Undergoes alteration in metabolic processes with activation of liver renal and gastrointestinal tracts for passage of meconium With the exchange of gas and the circulation of oxygen within the body each organ begins their process of adjustment in the extrauterine life Such metabolic process activates these major organs to promote vitality of life of the newborn Nurse should take into consideration by assessing such changes whether it is successful and able to adjust with such dramatic change
Stage 6 Achieves a steady level of equilibrium in metabolic processes Taking into consideration the production of enzymes increased blood oxygen saturation decrease in acidosis associated with birth and recovery of the neurologic tissues from the trauma of labor and delivery It is in this stage the newborn takes into the final adjustment period of ones life independently This stage is crucial hence the nurse should give importance of making sure such level of equilibrium be maintained at such time the newborn will be finally discharged together with hisher family
DEFINITION OF TERMS
Habituation - the gradual adaptation to a stimulus or to the environment with a decreasing response
Orientation - awareness of ones environment with reference to time place and people
Reflexes - a reflected action or movement the sum total of any particular automatic response mediated by the nervous system
Posture - a reflected action or movement the sum total of any particular automatic response mediated by the nervous system
Square window - an angle of the wrist between the hypothenar prominence and forearm It is used as a reference point for estimating the gestational age of a newborn
Motor Performance ndash quality of movement and tone
Range of state ndash measure of general arousal level or arousability of infant
Regulation of state ndash how infant responds when aroused
Autonomic stability ndash signs of stress related to homeostatic adjustment of the nervous system
Normothermic - a normal state of temperature
Bradycardia - a slow heart rate Bradycardia is one of the two types of arrhythmia
Tachycardia - abnormally rapid heart rate
Apnea - Temporary absence or cessation of breathing
Tachypnea - abnormally rapid rate of breathing such as that associated with high fever
Vitamin K - any of a group of structurally similar fat-soluble compounds that promote blood clotting
Hepa B vaccine - a viral hepatitis caused by the hepatitis B virus (HBV) a hepa and virus The virus is transmitted by transfusion of contaminated blood or blood products by sexual contact with an infected person by the use of contaminated needles and instruments or in utero
Prognosis - a prediction of the probable outcome of a disease based on the condition of the person and the usual course of the disease as observed in similar situations
BCG vaccination - has been used in the control of tuberculosis in cattle but has many disadvantages especially interference with tuberculin testing and is not recommended for use unless the prevalence of the disease is very high
Pallor - an unnatural paleness or absence of color in the skin
Plethora - An excess of blood in the circulatory system or in one organ or area
Scelerema - a severe sometimes fatal disorder of adipose tissue occurring chiefly in preterm sick debilitated infants manifested by induration of the involved tissue causing the skin to become cold yellowish white mottled boardlike and inflexible
Milia - a tiny spheroidal epithelial cyst lying superficially within the skin usually of the face containing lamellated keratin and often associated with vellus hair follicles
Miliaria - a cutaneous condition with retention of sweat which is extravasated at different levels in the skin
Mongolian spot - a smooth brown to grayish blue nevus consisting of an excess of melanocytes typically found at birth in the sacral region in Asians and dark-skinned races it usually disappears during childhood
Acrocyanosis - s a decrease in the amount of oxygen delivered to the extremities The hands and feet turn blue because of the lack of oxygen Decreased blood supply to the affected areas is caused by constriction or spasm of small blood vessels
Craniotabes - eduction in mineralization of the skull with abnormal softness of the bone usually affecting the occipital and parietal bones along the lambdoidal sutures
Nystagmus - Rhythmic oscillating motions of the eyes are called nystagmus The to-and-fro motion is generally involuntary Vertical nystagmus occurs much less frequently than horizontal nystagmus and is often but not necessarily a sign of serious brain damage Nystagmus can be a normal physiological response or a result of a pathologic problem
Strabismus - occurs in 2-5 of all children About half are born with the condition which causes one or both eyes to turn
Hypotelorism - abnormally decreased distance between two organs or parts
Torticollis - is a type of movement disorder in which the muscles controlling the neck cause sustained twisting or frequent jerking
Frenulum - a small fold of integument or mucous membrane that limits the movements of an organ or part
Xiphoid process - he pointed process of cartilage supported by a core of bone connected with the posterior end of the body of the sternum
Candidiasis - is an infection caused by a species of the yeast Candida usually Candida albicans
Cardiomegaly - abnormal enlargement of the heart
Diastasis recti - is a disorder defined as a separation of the rectus abdominis muscle into right and left halves
Whartonrsquos Jelly - is a gelatinous substance within the umbilical cord composed of cells that originate in the original egg and sperm of conception It is largely made up of mucopolysaccharides
Ascites - s an accumulation of fluid in the peritoneal cavity Although most commonly due to cirrhosis and severe liver disease its presence can portend other significant medical problems Diagnosis of the cause is usually with blood tests an ultrasound scan of the abdomen and direct removal of the fluid by needle or paracentesis
Gastroschisis - is a type of abdominal wall defect in which the intestines and sometimes other organs develop outside the fetal abdomen through an opening in the abdominal wall This defect is the result of obstruction of the omphalomesenteric vessels during development
Pseudomenstruation - bleeding from the uterus that resembles menstruation but is not associated with the usual changes in endometrial tissues
Epispadias - ongenital absence of the upper wall of the urethra occurring in both sexes but more often in the male with the urethral opening somewhere on the dorsum of the penis
Chordee - downward bowing of the penis due to a congenital anomaly or to urethral infection
Hydrocele - circumscribed collection of fluid especially in the tunica vaginalis of the testis or along the spermatic cord
Polydactyly - the presence of supernumerary digits on the hands or feet
Syndactyly - persistence of webbing between adjacent digits of the hand or foot so that they are more or less completely fused together
Phocomelia - congenital absence of the proximal portion of a limb or limbs the hands or feet being attached to the trunk by a small irregularly shaped bone
Hemimelia - a developmental anomaly characterized by absence of all or part of the distal half of a limb
Quivering - To shake with a slight rapid tremulous movement
Hypotonia - the state of being hypotonic
Hypertonia - the state of being hypertonic
Tremors - A relatively minor seismic shaking or vibrating movement Tremors often precede larger earthquakes or volcanic eruptions
Pupillary - Of or affecting the pupil of the eye
Glabellar - The smooth area between the eyebrows just above the nose
Extrusion - The act or process of pushing or thrusting out
Startle - To cause to make a quick involuntary movement or start
Pseudomonas - any of a genus of rodlike Gram-negative bacteria that live in soil and decomposing organic matter many species are pathogenic to plants and a few are pathogenic to man
Prophylaxis - Prevention of or protective treatment for disease
Cirrhosis - A chronic disease of the liver characterized by the replacement of normal tissue with fibrous tissue and the loss of functional liver cells It can result from alcohol abuse nutritional deprivation or infection especially by the hepatitis virus
Dehiscence - he spontaneous opening at maturity of a plant structure such as a fruit anther or sporangium to release its contents
Meatitis - inflammation of the urinary meatus
Urethral fistula - due to trauma occurs in bulls in which the urethra lies superficially near its end A fistula may affect the discharge of semen from the normal meatus sufficiently to cause infertility
DTP - diphtheria and tetanus toxoids and pertussis vaccine
Conduction ndash is the transfer of body heat to a cooler solid object in contact with a baby
Convection ndash is the flow of heat from the newborns body surface to cooler surrounding air
Radiation ndash is the transfer of body heat to a cooler solid object not in contact with the baby
Evaporation ndash is loss of heat through conversion of a liquid to vapor
Attachement ndash is the mode of contact between babyrsquos mouth and the motherrsquos breast during the act of breastfeeding
Kangaroo Mother Care - A universally available and biologically sound method of care for all newborns but in particular for premature babies with t three components skin-to-skin contact exclusive breastfeeding and support to the mother infant dyad
Newborn Resuscitation ndash a series of action taken to establish normal breathing in a newborn with depressed vital signs
Neonate - is a baby who is 4 weeks old or younger
Neonatal Period - the first 4 weeks of a childs life represents a time when changes are very rapid and many critical events can occur
Positive Pressure Ventilaiton (PPV) - refers to the process of forcing air into the lungs of a (usually apneic or dyspneic) patient usually using a baby valve mask or mechanical ventilator
ASSESSMENT
The new born requires thorough skilled observation to ensure a satisfactory to extra-uterine life 4 phases of physical assessment after delivery
The initial assessment The transitional assessment The assessment of gestational age The comprehensive and systematic physical examination
INITIAL ASSESSMENT includes APGAR scoring
APGAR SCORING METHOD - is the most frequent in assessing the newbornrsquos immediate adjustment to extra uterine life (Papile 2001)
SIGNS 0 1 2Heart rate Absent Slow lt 100 beats min Beats min
Respiratory effort Absent Irregular slow weak cry Good strong cryMuscle Tone Limp Some flexion of extremities Well flexed
Reflex Irritability No response Grimace Cry sneezeColor Blue Pale Body pink extremities blue Completely pink
SCORES0 - 3 Severe Distress4 ndash 6 Moderate Difficulty7 ndash 10 Absent in Difficulty
TRANSITIONAL ASSESSMENT
Newborn exhibits behavioral and physiological characteristics that can at first appear to be signs of stress
During newbornrsquos initial 24 hours changes in heart rate respiration motor activity color mucus production and bowel activity occur in an orderly predictable sequence which is normal and indicate lack of stress
- During the first 30 min the infant is alert cries vigorously may suck his or her fingers or fist and appears interested in the environment
For 6 to 8 hours after birth the newborn is in the first period of reactivity - the neonates eyes are usually open- has vigorous suck reflex- grasp the nipple quickly This is important to remember because after this initial highly active state the infant may be sleepy and uninterested in sucking
Physiologically the respiratory rate can be- As high as 80 breaths min- Crackles may be heard- Heart rate may reach 180 breaths min - Bowel sounds are active- Mucus secretion are increased- Temperature may decreased slightly
After this initial stage of alertness and activity the infant enters the second stage of the first reactive period - darr heart and respiratory rate- darr temperature- darr mucus production- Urine and stool usually not pass The infant is in a state of sleep and relative calm and avoid undressing or bathing the infant during this time
The second period of reactivity begins with the infant wakes from the deep sleep it last about the 2-5 hours- Infant is alert and responsive- uarr heart and respiratory rate- Gag reflex is active
- uarr gastric and respiratory secretions- Passage of meconium occurs- After this stage is a period of stabilization of physiologic system and vacillating patterns of sleep and activity
GESTATIONAL ASSESSMENT includes Ballard Scale
The Ballard Maturational Assessment Ballard Score or Ballard Scale is a commonly used technique of gestational age assessment It assigns a score to various criteria the sum of all of which is then extrapolated to the gestational age of the baby These criteria are divided into Physical and Neurological criteria This scoring allows for the estimation of age in the range of 26 weeks-44 weeks The New Ballard Score is an extension of the above to include extremely pre-term babies
Posture - with infant quiet and in a supine position observe degree of flexion in arms and legs Muscle tone and degree of flexion increase with maturity Score full flexion of the arms and legs = 4
Square window - with thumb supporting back of arm below wrist apply gently pressure with index and third fingers on dorsum of hand without rotating infantrsquos wrist Measure angle between base of thumb and forearm Score Full flexion (hand lies flat on ventral surface of forearm) = 4
Arm recoil - with infant supine fully flex both forearms on upper arms hold for 5 seconds pull down on hands to fully extend and
rapidly release arms Observe rapidity and intensity of recoil to state of flexion
Popliteal angle - With infants supine and pelvis flat on a firm surface flex lower leg on thigh and then flex thigh on abdomen While holding knee with numb and
and index finger extend lower legs with index finger of other hand Measure degree of angle behind knee (popliteal angle) Score an angle of less than 90 degree = 5
Scarf sign - with infant supine support head in midline with one hand use other hand to pull infantrsquos arm across the shoulder so that infantrsquos hand touches shoulder Determine location of elbow in relation to midline Score elbow does not reach midline = 4
Heel to ear - with infant supine and pelvis flat on a firm surface pull foot as far as possible up toward ear on same side measure distance of foot from ear and degree of knee flexion (same as popliteal angle) Score knees flexed with a popliteal angle of less than 10 degrees
SUMMARY OF PHYSICAL ASSESSMENT OF NEWBORN
USUAL FINDINGS COMMON VARIATIONS POTENTIAL SIGNS OF DISTRESSMINOR ABNORMALITIES MAJOR ABNORMALITIES
GENERAL MEASUREMENTSHead circumstance 33-35 cm (13-14 in) 1in Molding after birth altering head circumference Head Circumference lt10th orgt 90th percentileAbout 2-3cm (1 in) larger than chest circumference Head and chest circumference equal for first 1-2days after birth
Chest circumference 305-33cm (12-13 in)Crown-to-rump length 31-35cm (125-14in)Approximately equal to head circumferenceHead-to-heel length 48-53cm (19-21in)
Birth Weight 2700-4000g (6-9 lb) Loss of 10 of birth weight in first week regained in 10-14days Birth weight lt10th orgt 90th percentileDepending on feeding method
VITAL SIGNSTemperature axillary 365deg-37degC (979deg-98degF) Crying increasing body temperature slightly Hypothermia
Radiant warmer falsely increasing axillary temperature Hypothermia
Heart rate apical120-140 beatsmin Crying increasing heart rate sleep decreasing heart rate Bradycardia Resting reate below 80-100 BpmDuring 1st period of reactivity (6-8hr) rate up to 190 Bpm Tachycardia Rate above 160-180 Bpm
Irregular rhythm
Respiration 30-60 Bpm Crying increasing respiratory rate sleep decreasing respiratory Tachypnea Rate gt60 Bpmrate Apnea 20 sec or moreDuring 1st period of reactivity (6-8hr) rate up to 80 Bpm
Blood pressure (BP) oscillometric 6541 mmHg in Crying and activity increasing BP Oscillometric systolic pressure in calf 6-9 mmHg less thanArm and calf Placing cuff on thigh agitates ionfant in upper extremity (sign of coarctation aorta)
Thigh BP higher then arm or calf BP by 4-8mmHg
GENERAL APPEARANCEPosture Flexion of head and extremities which rest Frank breech Extended legs abducted and fully Limp posture Extension of ExtremitiesOn chest and abdomen rotated thighs Flattened occiput extended neck
SKINAt birth bright red puffy smooth Neonatal jaundice after first 24hr Progressive jaundice especially in first 24hr2nd-3rd day pink flasky dry Ecchymoses or petechiae caused by birth trauma Generalized cyanosisVernix caseosa Milia Distended sebaceous glands that appear PallorLanugo as tiny white papules on cheeks chin and nose MottlingEdema around eyes face legs dorsa of hands feet GraynessAnd scrotum or labia Milaria or sudamina Distended sweat (eccrine) PlethoraAcrocyanosis Cyanosis of hands and feet glands that appear as minute vesicles especially on face Hemorrhage ecchymoses or petechiae that persistCutis marmorata Transient mottling when infant is Erythema toxicum Ping popular rash with vesicles Sclereme Hard and stiff skinExposed to decreased temperature superimposed on thorax back buttocks and abdomenl Poor skin turgor
May appear in 24-48 hr and resolve after several days Rashes pustules or blistersErythema toxicum pink popular rash with vesicles cafeacute au lait spot light brown spotssuperimposed on thorax back buttocks and abdomen nevus flammeus port-wine stainmay appear in 24-48 hrs and resolve after several daysHarlequin Color change clearly outlined color changeas infant lies on the side lower half of body becomespink and upper half is paleMongolian spots irregular areas of deep blue pigmentationusually in sacral and gluteal regions seen predominantly in newborn of African native American asian or Hispanic descentTalengiectatic nevi (stork bite) flat deep pink localizedareas usually seen on back of neck
HEADAnterior fontanels Diamond shape size varies form molding after vaginal delivery fused suturesbarely palpable to 4-5 cm third sagital (parietal) fontanel bulging or depressed fontanels when quietPosterior fontanels triangular 05-1cm bulging fontanel because of crying or coughing widened sutures and fontanelsFontanels flat soft and firm caput succedaneum edema of soft scalp tissue craniotabes snapping sensation along lambdoidWidest part of fontanel measured from bone to bone cephalhematoma hematoma between periosteum and skull bone sutures that resembles indentation of ping-pong ballnot suture to suture
EYES
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Stage 3 Initiates breathing In this stage the first breath is taken in after the umbilical cord is cut This stimulates the first inspiration Nursersquo consideration they should provide patent airway to prevent aspiration from fluids accumulated This would facilitate the beginning process of respiration and circulation
Stage 4 Changes from fetal to neonatal circulation Circulation begins right after the first breath has been taken in The circulation of oxygen throughout the newborn allows the start of the metabolic processes within the body Nurse should take into consideration the importance of circulation right after the first seconds of transition from intrauterine to extrauterine life
Stage 5 Undergoes alteration in metabolic processes with activation of liver renal and gastrointestinal tracts for passage of meconium With the exchange of gas and the circulation of oxygen within the body each organ begins their process of adjustment in the extrauterine life Such metabolic process activates these major organs to promote vitality of life of the newborn Nurse should take into consideration by assessing such changes whether it is successful and able to adjust with such dramatic change
Stage 6 Achieves a steady level of equilibrium in metabolic processes Taking into consideration the production of enzymes increased blood oxygen saturation decrease in acidosis associated with birth and recovery of the neurologic tissues from the trauma of labor and delivery It is in this stage the newborn takes into the final adjustment period of ones life independently This stage is crucial hence the nurse should give importance of making sure such level of equilibrium be maintained at such time the newborn will be finally discharged together with hisher family
DEFINITION OF TERMS
Habituation - the gradual adaptation to a stimulus or to the environment with a decreasing response
Orientation - awareness of ones environment with reference to time place and people
Reflexes - a reflected action or movement the sum total of any particular automatic response mediated by the nervous system
Posture - a reflected action or movement the sum total of any particular automatic response mediated by the nervous system
Square window - an angle of the wrist between the hypothenar prominence and forearm It is used as a reference point for estimating the gestational age of a newborn
Motor Performance ndash quality of movement and tone
Range of state ndash measure of general arousal level or arousability of infant
Regulation of state ndash how infant responds when aroused
Autonomic stability ndash signs of stress related to homeostatic adjustment of the nervous system
Normothermic - a normal state of temperature
Bradycardia - a slow heart rate Bradycardia is one of the two types of arrhythmia
Tachycardia - abnormally rapid heart rate
Apnea - Temporary absence or cessation of breathing
Tachypnea - abnormally rapid rate of breathing such as that associated with high fever
Vitamin K - any of a group of structurally similar fat-soluble compounds that promote blood clotting
Hepa B vaccine - a viral hepatitis caused by the hepatitis B virus (HBV) a hepa and virus The virus is transmitted by transfusion of contaminated blood or blood products by sexual contact with an infected person by the use of contaminated needles and instruments or in utero
Prognosis - a prediction of the probable outcome of a disease based on the condition of the person and the usual course of the disease as observed in similar situations
BCG vaccination - has been used in the control of tuberculosis in cattle but has many disadvantages especially interference with tuberculin testing and is not recommended for use unless the prevalence of the disease is very high
Pallor - an unnatural paleness or absence of color in the skin
Plethora - An excess of blood in the circulatory system or in one organ or area
Scelerema - a severe sometimes fatal disorder of adipose tissue occurring chiefly in preterm sick debilitated infants manifested by induration of the involved tissue causing the skin to become cold yellowish white mottled boardlike and inflexible
Milia - a tiny spheroidal epithelial cyst lying superficially within the skin usually of the face containing lamellated keratin and often associated with vellus hair follicles
Miliaria - a cutaneous condition with retention of sweat which is extravasated at different levels in the skin
Mongolian spot - a smooth brown to grayish blue nevus consisting of an excess of melanocytes typically found at birth in the sacral region in Asians and dark-skinned races it usually disappears during childhood
Acrocyanosis - s a decrease in the amount of oxygen delivered to the extremities The hands and feet turn blue because of the lack of oxygen Decreased blood supply to the affected areas is caused by constriction or spasm of small blood vessels
Craniotabes - eduction in mineralization of the skull with abnormal softness of the bone usually affecting the occipital and parietal bones along the lambdoidal sutures
Nystagmus - Rhythmic oscillating motions of the eyes are called nystagmus The to-and-fro motion is generally involuntary Vertical nystagmus occurs much less frequently than horizontal nystagmus and is often but not necessarily a sign of serious brain damage Nystagmus can be a normal physiological response or a result of a pathologic problem
Strabismus - occurs in 2-5 of all children About half are born with the condition which causes one or both eyes to turn
Hypotelorism - abnormally decreased distance between two organs or parts
Torticollis - is a type of movement disorder in which the muscles controlling the neck cause sustained twisting or frequent jerking
Frenulum - a small fold of integument or mucous membrane that limits the movements of an organ or part
Xiphoid process - he pointed process of cartilage supported by a core of bone connected with the posterior end of the body of the sternum
Candidiasis - is an infection caused by a species of the yeast Candida usually Candida albicans
Cardiomegaly - abnormal enlargement of the heart
Diastasis recti - is a disorder defined as a separation of the rectus abdominis muscle into right and left halves
Whartonrsquos Jelly - is a gelatinous substance within the umbilical cord composed of cells that originate in the original egg and sperm of conception It is largely made up of mucopolysaccharides
Ascites - s an accumulation of fluid in the peritoneal cavity Although most commonly due to cirrhosis and severe liver disease its presence can portend other significant medical problems Diagnosis of the cause is usually with blood tests an ultrasound scan of the abdomen and direct removal of the fluid by needle or paracentesis
Gastroschisis - is a type of abdominal wall defect in which the intestines and sometimes other organs develop outside the fetal abdomen through an opening in the abdominal wall This defect is the result of obstruction of the omphalomesenteric vessels during development
Pseudomenstruation - bleeding from the uterus that resembles menstruation but is not associated with the usual changes in endometrial tissues
Epispadias - ongenital absence of the upper wall of the urethra occurring in both sexes but more often in the male with the urethral opening somewhere on the dorsum of the penis
Chordee - downward bowing of the penis due to a congenital anomaly or to urethral infection
Hydrocele - circumscribed collection of fluid especially in the tunica vaginalis of the testis or along the spermatic cord
Polydactyly - the presence of supernumerary digits on the hands or feet
Syndactyly - persistence of webbing between adjacent digits of the hand or foot so that they are more or less completely fused together
Phocomelia - congenital absence of the proximal portion of a limb or limbs the hands or feet being attached to the trunk by a small irregularly shaped bone
Hemimelia - a developmental anomaly characterized by absence of all or part of the distal half of a limb
Quivering - To shake with a slight rapid tremulous movement
Hypotonia - the state of being hypotonic
Hypertonia - the state of being hypertonic
Tremors - A relatively minor seismic shaking or vibrating movement Tremors often precede larger earthquakes or volcanic eruptions
Pupillary - Of or affecting the pupil of the eye
Glabellar - The smooth area between the eyebrows just above the nose
Extrusion - The act or process of pushing or thrusting out
Startle - To cause to make a quick involuntary movement or start
Pseudomonas - any of a genus of rodlike Gram-negative bacteria that live in soil and decomposing organic matter many species are pathogenic to plants and a few are pathogenic to man
Prophylaxis - Prevention of or protective treatment for disease
Cirrhosis - A chronic disease of the liver characterized by the replacement of normal tissue with fibrous tissue and the loss of functional liver cells It can result from alcohol abuse nutritional deprivation or infection especially by the hepatitis virus
Dehiscence - he spontaneous opening at maturity of a plant structure such as a fruit anther or sporangium to release its contents
Meatitis - inflammation of the urinary meatus
Urethral fistula - due to trauma occurs in bulls in which the urethra lies superficially near its end A fistula may affect the discharge of semen from the normal meatus sufficiently to cause infertility
DTP - diphtheria and tetanus toxoids and pertussis vaccine
Conduction ndash is the transfer of body heat to a cooler solid object in contact with a baby
Convection ndash is the flow of heat from the newborns body surface to cooler surrounding air
Radiation ndash is the transfer of body heat to a cooler solid object not in contact with the baby
Evaporation ndash is loss of heat through conversion of a liquid to vapor
Attachement ndash is the mode of contact between babyrsquos mouth and the motherrsquos breast during the act of breastfeeding
Kangaroo Mother Care - A universally available and biologically sound method of care for all newborns but in particular for premature babies with t three components skin-to-skin contact exclusive breastfeeding and support to the mother infant dyad
Newborn Resuscitation ndash a series of action taken to establish normal breathing in a newborn with depressed vital signs
Neonate - is a baby who is 4 weeks old or younger
Neonatal Period - the first 4 weeks of a childs life represents a time when changes are very rapid and many critical events can occur
Positive Pressure Ventilaiton (PPV) - refers to the process of forcing air into the lungs of a (usually apneic or dyspneic) patient usually using a baby valve mask or mechanical ventilator
ASSESSMENT
The new born requires thorough skilled observation to ensure a satisfactory to extra-uterine life 4 phases of physical assessment after delivery
The initial assessment The transitional assessment The assessment of gestational age The comprehensive and systematic physical examination
INITIAL ASSESSMENT includes APGAR scoring
APGAR SCORING METHOD - is the most frequent in assessing the newbornrsquos immediate adjustment to extra uterine life (Papile 2001)
SIGNS 0 1 2Heart rate Absent Slow lt 100 beats min Beats min
Respiratory effort Absent Irregular slow weak cry Good strong cryMuscle Tone Limp Some flexion of extremities Well flexed
Reflex Irritability No response Grimace Cry sneezeColor Blue Pale Body pink extremities blue Completely pink
SCORES0 - 3 Severe Distress4 ndash 6 Moderate Difficulty7 ndash 10 Absent in Difficulty
TRANSITIONAL ASSESSMENT
Newborn exhibits behavioral and physiological characteristics that can at first appear to be signs of stress
During newbornrsquos initial 24 hours changes in heart rate respiration motor activity color mucus production and bowel activity occur in an orderly predictable sequence which is normal and indicate lack of stress
- During the first 30 min the infant is alert cries vigorously may suck his or her fingers or fist and appears interested in the environment
For 6 to 8 hours after birth the newborn is in the first period of reactivity - the neonates eyes are usually open- has vigorous suck reflex- grasp the nipple quickly This is important to remember because after this initial highly active state the infant may be sleepy and uninterested in sucking
Physiologically the respiratory rate can be- As high as 80 breaths min- Crackles may be heard- Heart rate may reach 180 breaths min - Bowel sounds are active- Mucus secretion are increased- Temperature may decreased slightly
After this initial stage of alertness and activity the infant enters the second stage of the first reactive period - darr heart and respiratory rate- darr temperature- darr mucus production- Urine and stool usually not pass The infant is in a state of sleep and relative calm and avoid undressing or bathing the infant during this time
The second period of reactivity begins with the infant wakes from the deep sleep it last about the 2-5 hours- Infant is alert and responsive- uarr heart and respiratory rate- Gag reflex is active
- uarr gastric and respiratory secretions- Passage of meconium occurs- After this stage is a period of stabilization of physiologic system and vacillating patterns of sleep and activity
GESTATIONAL ASSESSMENT includes Ballard Scale
The Ballard Maturational Assessment Ballard Score or Ballard Scale is a commonly used technique of gestational age assessment It assigns a score to various criteria the sum of all of which is then extrapolated to the gestational age of the baby These criteria are divided into Physical and Neurological criteria This scoring allows for the estimation of age in the range of 26 weeks-44 weeks The New Ballard Score is an extension of the above to include extremely pre-term babies
Posture - with infant quiet and in a supine position observe degree of flexion in arms and legs Muscle tone and degree of flexion increase with maturity Score full flexion of the arms and legs = 4
Square window - with thumb supporting back of arm below wrist apply gently pressure with index and third fingers on dorsum of hand without rotating infantrsquos wrist Measure angle between base of thumb and forearm Score Full flexion (hand lies flat on ventral surface of forearm) = 4
Arm recoil - with infant supine fully flex both forearms on upper arms hold for 5 seconds pull down on hands to fully extend and
rapidly release arms Observe rapidity and intensity of recoil to state of flexion
Popliteal angle - With infants supine and pelvis flat on a firm surface flex lower leg on thigh and then flex thigh on abdomen While holding knee with numb and
and index finger extend lower legs with index finger of other hand Measure degree of angle behind knee (popliteal angle) Score an angle of less than 90 degree = 5
Scarf sign - with infant supine support head in midline with one hand use other hand to pull infantrsquos arm across the shoulder so that infantrsquos hand touches shoulder Determine location of elbow in relation to midline Score elbow does not reach midline = 4
Heel to ear - with infant supine and pelvis flat on a firm surface pull foot as far as possible up toward ear on same side measure distance of foot from ear and degree of knee flexion (same as popliteal angle) Score knees flexed with a popliteal angle of less than 10 degrees
SUMMARY OF PHYSICAL ASSESSMENT OF NEWBORN
USUAL FINDINGS COMMON VARIATIONS POTENTIAL SIGNS OF DISTRESSMINOR ABNORMALITIES MAJOR ABNORMALITIES
GENERAL MEASUREMENTSHead circumstance 33-35 cm (13-14 in) 1in Molding after birth altering head circumference Head Circumference lt10th orgt 90th percentileAbout 2-3cm (1 in) larger than chest circumference Head and chest circumference equal for first 1-2days after birth
Chest circumference 305-33cm (12-13 in)Crown-to-rump length 31-35cm (125-14in)Approximately equal to head circumferenceHead-to-heel length 48-53cm (19-21in)
Birth Weight 2700-4000g (6-9 lb) Loss of 10 of birth weight in first week regained in 10-14days Birth weight lt10th orgt 90th percentileDepending on feeding method
VITAL SIGNSTemperature axillary 365deg-37degC (979deg-98degF) Crying increasing body temperature slightly Hypothermia
Radiant warmer falsely increasing axillary temperature Hypothermia
Heart rate apical120-140 beatsmin Crying increasing heart rate sleep decreasing heart rate Bradycardia Resting reate below 80-100 BpmDuring 1st period of reactivity (6-8hr) rate up to 190 Bpm Tachycardia Rate above 160-180 Bpm
Irregular rhythm
Respiration 30-60 Bpm Crying increasing respiratory rate sleep decreasing respiratory Tachypnea Rate gt60 Bpmrate Apnea 20 sec or moreDuring 1st period of reactivity (6-8hr) rate up to 80 Bpm
Blood pressure (BP) oscillometric 6541 mmHg in Crying and activity increasing BP Oscillometric systolic pressure in calf 6-9 mmHg less thanArm and calf Placing cuff on thigh agitates ionfant in upper extremity (sign of coarctation aorta)
Thigh BP higher then arm or calf BP by 4-8mmHg
GENERAL APPEARANCEPosture Flexion of head and extremities which rest Frank breech Extended legs abducted and fully Limp posture Extension of ExtremitiesOn chest and abdomen rotated thighs Flattened occiput extended neck
SKINAt birth bright red puffy smooth Neonatal jaundice after first 24hr Progressive jaundice especially in first 24hr2nd-3rd day pink flasky dry Ecchymoses or petechiae caused by birth trauma Generalized cyanosisVernix caseosa Milia Distended sebaceous glands that appear PallorLanugo as tiny white papules on cheeks chin and nose MottlingEdema around eyes face legs dorsa of hands feet GraynessAnd scrotum or labia Milaria or sudamina Distended sweat (eccrine) PlethoraAcrocyanosis Cyanosis of hands and feet glands that appear as minute vesicles especially on face Hemorrhage ecchymoses or petechiae that persistCutis marmorata Transient mottling when infant is Erythema toxicum Ping popular rash with vesicles Sclereme Hard and stiff skinExposed to decreased temperature superimposed on thorax back buttocks and abdomenl Poor skin turgor
May appear in 24-48 hr and resolve after several days Rashes pustules or blistersErythema toxicum pink popular rash with vesicles cafeacute au lait spot light brown spotssuperimposed on thorax back buttocks and abdomen nevus flammeus port-wine stainmay appear in 24-48 hrs and resolve after several daysHarlequin Color change clearly outlined color changeas infant lies on the side lower half of body becomespink and upper half is paleMongolian spots irregular areas of deep blue pigmentationusually in sacral and gluteal regions seen predominantly in newborn of African native American asian or Hispanic descentTalengiectatic nevi (stork bite) flat deep pink localizedareas usually seen on back of neck
HEADAnterior fontanels Diamond shape size varies form molding after vaginal delivery fused suturesbarely palpable to 4-5 cm third sagital (parietal) fontanel bulging or depressed fontanels when quietPosterior fontanels triangular 05-1cm bulging fontanel because of crying or coughing widened sutures and fontanelsFontanels flat soft and firm caput succedaneum edema of soft scalp tissue craniotabes snapping sensation along lambdoidWidest part of fontanel measured from bone to bone cephalhematoma hematoma between periosteum and skull bone sutures that resembles indentation of ping-pong ballnot suture to suture
EYES
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
DEFINITION OF TERMS
Habituation - the gradual adaptation to a stimulus or to the environment with a decreasing response
Orientation - awareness of ones environment with reference to time place and people
Reflexes - a reflected action or movement the sum total of any particular automatic response mediated by the nervous system
Posture - a reflected action or movement the sum total of any particular automatic response mediated by the nervous system
Square window - an angle of the wrist between the hypothenar prominence and forearm It is used as a reference point for estimating the gestational age of a newborn
Motor Performance ndash quality of movement and tone
Range of state ndash measure of general arousal level or arousability of infant
Regulation of state ndash how infant responds when aroused
Autonomic stability ndash signs of stress related to homeostatic adjustment of the nervous system
Normothermic - a normal state of temperature
Bradycardia - a slow heart rate Bradycardia is one of the two types of arrhythmia
Tachycardia - abnormally rapid heart rate
Apnea - Temporary absence or cessation of breathing
Tachypnea - abnormally rapid rate of breathing such as that associated with high fever
Vitamin K - any of a group of structurally similar fat-soluble compounds that promote blood clotting
Hepa B vaccine - a viral hepatitis caused by the hepatitis B virus (HBV) a hepa and virus The virus is transmitted by transfusion of contaminated blood or blood products by sexual contact with an infected person by the use of contaminated needles and instruments or in utero
Prognosis - a prediction of the probable outcome of a disease based on the condition of the person and the usual course of the disease as observed in similar situations
BCG vaccination - has been used in the control of tuberculosis in cattle but has many disadvantages especially interference with tuberculin testing and is not recommended for use unless the prevalence of the disease is very high
Pallor - an unnatural paleness or absence of color in the skin
Plethora - An excess of blood in the circulatory system or in one organ or area
Scelerema - a severe sometimes fatal disorder of adipose tissue occurring chiefly in preterm sick debilitated infants manifested by induration of the involved tissue causing the skin to become cold yellowish white mottled boardlike and inflexible
Milia - a tiny spheroidal epithelial cyst lying superficially within the skin usually of the face containing lamellated keratin and often associated with vellus hair follicles
Miliaria - a cutaneous condition with retention of sweat which is extravasated at different levels in the skin
Mongolian spot - a smooth brown to grayish blue nevus consisting of an excess of melanocytes typically found at birth in the sacral region in Asians and dark-skinned races it usually disappears during childhood
Acrocyanosis - s a decrease in the amount of oxygen delivered to the extremities The hands and feet turn blue because of the lack of oxygen Decreased blood supply to the affected areas is caused by constriction or spasm of small blood vessels
Craniotabes - eduction in mineralization of the skull with abnormal softness of the bone usually affecting the occipital and parietal bones along the lambdoidal sutures
Nystagmus - Rhythmic oscillating motions of the eyes are called nystagmus The to-and-fro motion is generally involuntary Vertical nystagmus occurs much less frequently than horizontal nystagmus and is often but not necessarily a sign of serious brain damage Nystagmus can be a normal physiological response or a result of a pathologic problem
Strabismus - occurs in 2-5 of all children About half are born with the condition which causes one or both eyes to turn
Hypotelorism - abnormally decreased distance between two organs or parts
Torticollis - is a type of movement disorder in which the muscles controlling the neck cause sustained twisting or frequent jerking
Frenulum - a small fold of integument or mucous membrane that limits the movements of an organ or part
Xiphoid process - he pointed process of cartilage supported by a core of bone connected with the posterior end of the body of the sternum
Candidiasis - is an infection caused by a species of the yeast Candida usually Candida albicans
Cardiomegaly - abnormal enlargement of the heart
Diastasis recti - is a disorder defined as a separation of the rectus abdominis muscle into right and left halves
Whartonrsquos Jelly - is a gelatinous substance within the umbilical cord composed of cells that originate in the original egg and sperm of conception It is largely made up of mucopolysaccharides
Ascites - s an accumulation of fluid in the peritoneal cavity Although most commonly due to cirrhosis and severe liver disease its presence can portend other significant medical problems Diagnosis of the cause is usually with blood tests an ultrasound scan of the abdomen and direct removal of the fluid by needle or paracentesis
Gastroschisis - is a type of abdominal wall defect in which the intestines and sometimes other organs develop outside the fetal abdomen through an opening in the abdominal wall This defect is the result of obstruction of the omphalomesenteric vessels during development
Pseudomenstruation - bleeding from the uterus that resembles menstruation but is not associated with the usual changes in endometrial tissues
Epispadias - ongenital absence of the upper wall of the urethra occurring in both sexes but more often in the male with the urethral opening somewhere on the dorsum of the penis
Chordee - downward bowing of the penis due to a congenital anomaly or to urethral infection
Hydrocele - circumscribed collection of fluid especially in the tunica vaginalis of the testis or along the spermatic cord
Polydactyly - the presence of supernumerary digits on the hands or feet
Syndactyly - persistence of webbing between adjacent digits of the hand or foot so that they are more or less completely fused together
Phocomelia - congenital absence of the proximal portion of a limb or limbs the hands or feet being attached to the trunk by a small irregularly shaped bone
Hemimelia - a developmental anomaly characterized by absence of all or part of the distal half of a limb
Quivering - To shake with a slight rapid tremulous movement
Hypotonia - the state of being hypotonic
Hypertonia - the state of being hypertonic
Tremors - A relatively minor seismic shaking or vibrating movement Tremors often precede larger earthquakes or volcanic eruptions
Pupillary - Of or affecting the pupil of the eye
Glabellar - The smooth area between the eyebrows just above the nose
Extrusion - The act or process of pushing or thrusting out
Startle - To cause to make a quick involuntary movement or start
Pseudomonas - any of a genus of rodlike Gram-negative bacteria that live in soil and decomposing organic matter many species are pathogenic to plants and a few are pathogenic to man
Prophylaxis - Prevention of or protective treatment for disease
Cirrhosis - A chronic disease of the liver characterized by the replacement of normal tissue with fibrous tissue and the loss of functional liver cells It can result from alcohol abuse nutritional deprivation or infection especially by the hepatitis virus
Dehiscence - he spontaneous opening at maturity of a plant structure such as a fruit anther or sporangium to release its contents
Meatitis - inflammation of the urinary meatus
Urethral fistula - due to trauma occurs in bulls in which the urethra lies superficially near its end A fistula may affect the discharge of semen from the normal meatus sufficiently to cause infertility
DTP - diphtheria and tetanus toxoids and pertussis vaccine
Conduction ndash is the transfer of body heat to a cooler solid object in contact with a baby
Convection ndash is the flow of heat from the newborns body surface to cooler surrounding air
Radiation ndash is the transfer of body heat to a cooler solid object not in contact with the baby
Evaporation ndash is loss of heat through conversion of a liquid to vapor
Attachement ndash is the mode of contact between babyrsquos mouth and the motherrsquos breast during the act of breastfeeding
Kangaroo Mother Care - A universally available and biologically sound method of care for all newborns but in particular for premature babies with t three components skin-to-skin contact exclusive breastfeeding and support to the mother infant dyad
Newborn Resuscitation ndash a series of action taken to establish normal breathing in a newborn with depressed vital signs
Neonate - is a baby who is 4 weeks old or younger
Neonatal Period - the first 4 weeks of a childs life represents a time when changes are very rapid and many critical events can occur
Positive Pressure Ventilaiton (PPV) - refers to the process of forcing air into the lungs of a (usually apneic or dyspneic) patient usually using a baby valve mask or mechanical ventilator
ASSESSMENT
The new born requires thorough skilled observation to ensure a satisfactory to extra-uterine life 4 phases of physical assessment after delivery
The initial assessment The transitional assessment The assessment of gestational age The comprehensive and systematic physical examination
INITIAL ASSESSMENT includes APGAR scoring
APGAR SCORING METHOD - is the most frequent in assessing the newbornrsquos immediate adjustment to extra uterine life (Papile 2001)
SIGNS 0 1 2Heart rate Absent Slow lt 100 beats min Beats min
Respiratory effort Absent Irregular slow weak cry Good strong cryMuscle Tone Limp Some flexion of extremities Well flexed
Reflex Irritability No response Grimace Cry sneezeColor Blue Pale Body pink extremities blue Completely pink
SCORES0 - 3 Severe Distress4 ndash 6 Moderate Difficulty7 ndash 10 Absent in Difficulty
TRANSITIONAL ASSESSMENT
Newborn exhibits behavioral and physiological characteristics that can at first appear to be signs of stress
During newbornrsquos initial 24 hours changes in heart rate respiration motor activity color mucus production and bowel activity occur in an orderly predictable sequence which is normal and indicate lack of stress
- During the first 30 min the infant is alert cries vigorously may suck his or her fingers or fist and appears interested in the environment
For 6 to 8 hours after birth the newborn is in the first period of reactivity - the neonates eyes are usually open- has vigorous suck reflex- grasp the nipple quickly This is important to remember because after this initial highly active state the infant may be sleepy and uninterested in sucking
Physiologically the respiratory rate can be- As high as 80 breaths min- Crackles may be heard- Heart rate may reach 180 breaths min - Bowel sounds are active- Mucus secretion are increased- Temperature may decreased slightly
After this initial stage of alertness and activity the infant enters the second stage of the first reactive period - darr heart and respiratory rate- darr temperature- darr mucus production- Urine and stool usually not pass The infant is in a state of sleep and relative calm and avoid undressing or bathing the infant during this time
The second period of reactivity begins with the infant wakes from the deep sleep it last about the 2-5 hours- Infant is alert and responsive- uarr heart and respiratory rate- Gag reflex is active
- uarr gastric and respiratory secretions- Passage of meconium occurs- After this stage is a period of stabilization of physiologic system and vacillating patterns of sleep and activity
GESTATIONAL ASSESSMENT includes Ballard Scale
The Ballard Maturational Assessment Ballard Score or Ballard Scale is a commonly used technique of gestational age assessment It assigns a score to various criteria the sum of all of which is then extrapolated to the gestational age of the baby These criteria are divided into Physical and Neurological criteria This scoring allows for the estimation of age in the range of 26 weeks-44 weeks The New Ballard Score is an extension of the above to include extremely pre-term babies
Posture - with infant quiet and in a supine position observe degree of flexion in arms and legs Muscle tone and degree of flexion increase with maturity Score full flexion of the arms and legs = 4
Square window - with thumb supporting back of arm below wrist apply gently pressure with index and third fingers on dorsum of hand without rotating infantrsquos wrist Measure angle between base of thumb and forearm Score Full flexion (hand lies flat on ventral surface of forearm) = 4
Arm recoil - with infant supine fully flex both forearms on upper arms hold for 5 seconds pull down on hands to fully extend and
rapidly release arms Observe rapidity and intensity of recoil to state of flexion
Popliteal angle - With infants supine and pelvis flat on a firm surface flex lower leg on thigh and then flex thigh on abdomen While holding knee with numb and
and index finger extend lower legs with index finger of other hand Measure degree of angle behind knee (popliteal angle) Score an angle of less than 90 degree = 5
Scarf sign - with infant supine support head in midline with one hand use other hand to pull infantrsquos arm across the shoulder so that infantrsquos hand touches shoulder Determine location of elbow in relation to midline Score elbow does not reach midline = 4
Heel to ear - with infant supine and pelvis flat on a firm surface pull foot as far as possible up toward ear on same side measure distance of foot from ear and degree of knee flexion (same as popliteal angle) Score knees flexed with a popliteal angle of less than 10 degrees
SUMMARY OF PHYSICAL ASSESSMENT OF NEWBORN
USUAL FINDINGS COMMON VARIATIONS POTENTIAL SIGNS OF DISTRESSMINOR ABNORMALITIES MAJOR ABNORMALITIES
GENERAL MEASUREMENTSHead circumstance 33-35 cm (13-14 in) 1in Molding after birth altering head circumference Head Circumference lt10th orgt 90th percentileAbout 2-3cm (1 in) larger than chest circumference Head and chest circumference equal for first 1-2days after birth
Chest circumference 305-33cm (12-13 in)Crown-to-rump length 31-35cm (125-14in)Approximately equal to head circumferenceHead-to-heel length 48-53cm (19-21in)
Birth Weight 2700-4000g (6-9 lb) Loss of 10 of birth weight in first week regained in 10-14days Birth weight lt10th orgt 90th percentileDepending on feeding method
VITAL SIGNSTemperature axillary 365deg-37degC (979deg-98degF) Crying increasing body temperature slightly Hypothermia
Radiant warmer falsely increasing axillary temperature Hypothermia
Heart rate apical120-140 beatsmin Crying increasing heart rate sleep decreasing heart rate Bradycardia Resting reate below 80-100 BpmDuring 1st period of reactivity (6-8hr) rate up to 190 Bpm Tachycardia Rate above 160-180 Bpm
Irregular rhythm
Respiration 30-60 Bpm Crying increasing respiratory rate sleep decreasing respiratory Tachypnea Rate gt60 Bpmrate Apnea 20 sec or moreDuring 1st period of reactivity (6-8hr) rate up to 80 Bpm
Blood pressure (BP) oscillometric 6541 mmHg in Crying and activity increasing BP Oscillometric systolic pressure in calf 6-9 mmHg less thanArm and calf Placing cuff on thigh agitates ionfant in upper extremity (sign of coarctation aorta)
Thigh BP higher then arm or calf BP by 4-8mmHg
GENERAL APPEARANCEPosture Flexion of head and extremities which rest Frank breech Extended legs abducted and fully Limp posture Extension of ExtremitiesOn chest and abdomen rotated thighs Flattened occiput extended neck
SKINAt birth bright red puffy smooth Neonatal jaundice after first 24hr Progressive jaundice especially in first 24hr2nd-3rd day pink flasky dry Ecchymoses or petechiae caused by birth trauma Generalized cyanosisVernix caseosa Milia Distended sebaceous glands that appear PallorLanugo as tiny white papules on cheeks chin and nose MottlingEdema around eyes face legs dorsa of hands feet GraynessAnd scrotum or labia Milaria or sudamina Distended sweat (eccrine) PlethoraAcrocyanosis Cyanosis of hands and feet glands that appear as minute vesicles especially on face Hemorrhage ecchymoses or petechiae that persistCutis marmorata Transient mottling when infant is Erythema toxicum Ping popular rash with vesicles Sclereme Hard and stiff skinExposed to decreased temperature superimposed on thorax back buttocks and abdomenl Poor skin turgor
May appear in 24-48 hr and resolve after several days Rashes pustules or blistersErythema toxicum pink popular rash with vesicles cafeacute au lait spot light brown spotssuperimposed on thorax back buttocks and abdomen nevus flammeus port-wine stainmay appear in 24-48 hrs and resolve after several daysHarlequin Color change clearly outlined color changeas infant lies on the side lower half of body becomespink and upper half is paleMongolian spots irregular areas of deep blue pigmentationusually in sacral and gluteal regions seen predominantly in newborn of African native American asian or Hispanic descentTalengiectatic nevi (stork bite) flat deep pink localizedareas usually seen on back of neck
HEADAnterior fontanels Diamond shape size varies form molding after vaginal delivery fused suturesbarely palpable to 4-5 cm third sagital (parietal) fontanel bulging or depressed fontanels when quietPosterior fontanels triangular 05-1cm bulging fontanel because of crying or coughing widened sutures and fontanelsFontanels flat soft and firm caput succedaneum edema of soft scalp tissue craniotabes snapping sensation along lambdoidWidest part of fontanel measured from bone to bone cephalhematoma hematoma between periosteum and skull bone sutures that resembles indentation of ping-pong ballnot suture to suture
EYES
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Hepa B vaccine - a viral hepatitis caused by the hepatitis B virus (HBV) a hepa and virus The virus is transmitted by transfusion of contaminated blood or blood products by sexual contact with an infected person by the use of contaminated needles and instruments or in utero
Prognosis - a prediction of the probable outcome of a disease based on the condition of the person and the usual course of the disease as observed in similar situations
BCG vaccination - has been used in the control of tuberculosis in cattle but has many disadvantages especially interference with tuberculin testing and is not recommended for use unless the prevalence of the disease is very high
Pallor - an unnatural paleness or absence of color in the skin
Plethora - An excess of blood in the circulatory system or in one organ or area
Scelerema - a severe sometimes fatal disorder of adipose tissue occurring chiefly in preterm sick debilitated infants manifested by induration of the involved tissue causing the skin to become cold yellowish white mottled boardlike and inflexible
Milia - a tiny spheroidal epithelial cyst lying superficially within the skin usually of the face containing lamellated keratin and often associated with vellus hair follicles
Miliaria - a cutaneous condition with retention of sweat which is extravasated at different levels in the skin
Mongolian spot - a smooth brown to grayish blue nevus consisting of an excess of melanocytes typically found at birth in the sacral region in Asians and dark-skinned races it usually disappears during childhood
Acrocyanosis - s a decrease in the amount of oxygen delivered to the extremities The hands and feet turn blue because of the lack of oxygen Decreased blood supply to the affected areas is caused by constriction or spasm of small blood vessels
Craniotabes - eduction in mineralization of the skull with abnormal softness of the bone usually affecting the occipital and parietal bones along the lambdoidal sutures
Nystagmus - Rhythmic oscillating motions of the eyes are called nystagmus The to-and-fro motion is generally involuntary Vertical nystagmus occurs much less frequently than horizontal nystagmus and is often but not necessarily a sign of serious brain damage Nystagmus can be a normal physiological response or a result of a pathologic problem
Strabismus - occurs in 2-5 of all children About half are born with the condition which causes one or both eyes to turn
Hypotelorism - abnormally decreased distance between two organs or parts
Torticollis - is a type of movement disorder in which the muscles controlling the neck cause sustained twisting or frequent jerking
Frenulum - a small fold of integument or mucous membrane that limits the movements of an organ or part
Xiphoid process - he pointed process of cartilage supported by a core of bone connected with the posterior end of the body of the sternum
Candidiasis - is an infection caused by a species of the yeast Candida usually Candida albicans
Cardiomegaly - abnormal enlargement of the heart
Diastasis recti - is a disorder defined as a separation of the rectus abdominis muscle into right and left halves
Whartonrsquos Jelly - is a gelatinous substance within the umbilical cord composed of cells that originate in the original egg and sperm of conception It is largely made up of mucopolysaccharides
Ascites - s an accumulation of fluid in the peritoneal cavity Although most commonly due to cirrhosis and severe liver disease its presence can portend other significant medical problems Diagnosis of the cause is usually with blood tests an ultrasound scan of the abdomen and direct removal of the fluid by needle or paracentesis
Gastroschisis - is a type of abdominal wall defect in which the intestines and sometimes other organs develop outside the fetal abdomen through an opening in the abdominal wall This defect is the result of obstruction of the omphalomesenteric vessels during development
Pseudomenstruation - bleeding from the uterus that resembles menstruation but is not associated with the usual changes in endometrial tissues
Epispadias - ongenital absence of the upper wall of the urethra occurring in both sexes but more often in the male with the urethral opening somewhere on the dorsum of the penis
Chordee - downward bowing of the penis due to a congenital anomaly or to urethral infection
Hydrocele - circumscribed collection of fluid especially in the tunica vaginalis of the testis or along the spermatic cord
Polydactyly - the presence of supernumerary digits on the hands or feet
Syndactyly - persistence of webbing between adjacent digits of the hand or foot so that they are more or less completely fused together
Phocomelia - congenital absence of the proximal portion of a limb or limbs the hands or feet being attached to the trunk by a small irregularly shaped bone
Hemimelia - a developmental anomaly characterized by absence of all or part of the distal half of a limb
Quivering - To shake with a slight rapid tremulous movement
Hypotonia - the state of being hypotonic
Hypertonia - the state of being hypertonic
Tremors - A relatively minor seismic shaking or vibrating movement Tremors often precede larger earthquakes or volcanic eruptions
Pupillary - Of or affecting the pupil of the eye
Glabellar - The smooth area between the eyebrows just above the nose
Extrusion - The act or process of pushing or thrusting out
Startle - To cause to make a quick involuntary movement or start
Pseudomonas - any of a genus of rodlike Gram-negative bacteria that live in soil and decomposing organic matter many species are pathogenic to plants and a few are pathogenic to man
Prophylaxis - Prevention of or protective treatment for disease
Cirrhosis - A chronic disease of the liver characterized by the replacement of normal tissue with fibrous tissue and the loss of functional liver cells It can result from alcohol abuse nutritional deprivation or infection especially by the hepatitis virus
Dehiscence - he spontaneous opening at maturity of a plant structure such as a fruit anther or sporangium to release its contents
Meatitis - inflammation of the urinary meatus
Urethral fistula - due to trauma occurs in bulls in which the urethra lies superficially near its end A fistula may affect the discharge of semen from the normal meatus sufficiently to cause infertility
DTP - diphtheria and tetanus toxoids and pertussis vaccine
Conduction ndash is the transfer of body heat to a cooler solid object in contact with a baby
Convection ndash is the flow of heat from the newborns body surface to cooler surrounding air
Radiation ndash is the transfer of body heat to a cooler solid object not in contact with the baby
Evaporation ndash is loss of heat through conversion of a liquid to vapor
Attachement ndash is the mode of contact between babyrsquos mouth and the motherrsquos breast during the act of breastfeeding
Kangaroo Mother Care - A universally available and biologically sound method of care for all newborns but in particular for premature babies with t three components skin-to-skin contact exclusive breastfeeding and support to the mother infant dyad
Newborn Resuscitation ndash a series of action taken to establish normal breathing in a newborn with depressed vital signs
Neonate - is a baby who is 4 weeks old or younger
Neonatal Period - the first 4 weeks of a childs life represents a time when changes are very rapid and many critical events can occur
Positive Pressure Ventilaiton (PPV) - refers to the process of forcing air into the lungs of a (usually apneic or dyspneic) patient usually using a baby valve mask or mechanical ventilator
ASSESSMENT
The new born requires thorough skilled observation to ensure a satisfactory to extra-uterine life 4 phases of physical assessment after delivery
The initial assessment The transitional assessment The assessment of gestational age The comprehensive and systematic physical examination
INITIAL ASSESSMENT includes APGAR scoring
APGAR SCORING METHOD - is the most frequent in assessing the newbornrsquos immediate adjustment to extra uterine life (Papile 2001)
SIGNS 0 1 2Heart rate Absent Slow lt 100 beats min Beats min
Respiratory effort Absent Irregular slow weak cry Good strong cryMuscle Tone Limp Some flexion of extremities Well flexed
Reflex Irritability No response Grimace Cry sneezeColor Blue Pale Body pink extremities blue Completely pink
SCORES0 - 3 Severe Distress4 ndash 6 Moderate Difficulty7 ndash 10 Absent in Difficulty
TRANSITIONAL ASSESSMENT
Newborn exhibits behavioral and physiological characteristics that can at first appear to be signs of stress
During newbornrsquos initial 24 hours changes in heart rate respiration motor activity color mucus production and bowel activity occur in an orderly predictable sequence which is normal and indicate lack of stress
- During the first 30 min the infant is alert cries vigorously may suck his or her fingers or fist and appears interested in the environment
For 6 to 8 hours after birth the newborn is in the first period of reactivity - the neonates eyes are usually open- has vigorous suck reflex- grasp the nipple quickly This is important to remember because after this initial highly active state the infant may be sleepy and uninterested in sucking
Physiologically the respiratory rate can be- As high as 80 breaths min- Crackles may be heard- Heart rate may reach 180 breaths min - Bowel sounds are active- Mucus secretion are increased- Temperature may decreased slightly
After this initial stage of alertness and activity the infant enters the second stage of the first reactive period - darr heart and respiratory rate- darr temperature- darr mucus production- Urine and stool usually not pass The infant is in a state of sleep and relative calm and avoid undressing or bathing the infant during this time
The second period of reactivity begins with the infant wakes from the deep sleep it last about the 2-5 hours- Infant is alert and responsive- uarr heart and respiratory rate- Gag reflex is active
- uarr gastric and respiratory secretions- Passage of meconium occurs- After this stage is a period of stabilization of physiologic system and vacillating patterns of sleep and activity
GESTATIONAL ASSESSMENT includes Ballard Scale
The Ballard Maturational Assessment Ballard Score or Ballard Scale is a commonly used technique of gestational age assessment It assigns a score to various criteria the sum of all of which is then extrapolated to the gestational age of the baby These criteria are divided into Physical and Neurological criteria This scoring allows for the estimation of age in the range of 26 weeks-44 weeks The New Ballard Score is an extension of the above to include extremely pre-term babies
Posture - with infant quiet and in a supine position observe degree of flexion in arms and legs Muscle tone and degree of flexion increase with maturity Score full flexion of the arms and legs = 4
Square window - with thumb supporting back of arm below wrist apply gently pressure with index and third fingers on dorsum of hand without rotating infantrsquos wrist Measure angle between base of thumb and forearm Score Full flexion (hand lies flat on ventral surface of forearm) = 4
Arm recoil - with infant supine fully flex both forearms on upper arms hold for 5 seconds pull down on hands to fully extend and
rapidly release arms Observe rapidity and intensity of recoil to state of flexion
Popliteal angle - With infants supine and pelvis flat on a firm surface flex lower leg on thigh and then flex thigh on abdomen While holding knee with numb and
and index finger extend lower legs with index finger of other hand Measure degree of angle behind knee (popliteal angle) Score an angle of less than 90 degree = 5
Scarf sign - with infant supine support head in midline with one hand use other hand to pull infantrsquos arm across the shoulder so that infantrsquos hand touches shoulder Determine location of elbow in relation to midline Score elbow does not reach midline = 4
Heel to ear - with infant supine and pelvis flat on a firm surface pull foot as far as possible up toward ear on same side measure distance of foot from ear and degree of knee flexion (same as popliteal angle) Score knees flexed with a popliteal angle of less than 10 degrees
SUMMARY OF PHYSICAL ASSESSMENT OF NEWBORN
USUAL FINDINGS COMMON VARIATIONS POTENTIAL SIGNS OF DISTRESSMINOR ABNORMALITIES MAJOR ABNORMALITIES
GENERAL MEASUREMENTSHead circumstance 33-35 cm (13-14 in) 1in Molding after birth altering head circumference Head Circumference lt10th orgt 90th percentileAbout 2-3cm (1 in) larger than chest circumference Head and chest circumference equal for first 1-2days after birth
Chest circumference 305-33cm (12-13 in)Crown-to-rump length 31-35cm (125-14in)Approximately equal to head circumferenceHead-to-heel length 48-53cm (19-21in)
Birth Weight 2700-4000g (6-9 lb) Loss of 10 of birth weight in first week regained in 10-14days Birth weight lt10th orgt 90th percentileDepending on feeding method
VITAL SIGNSTemperature axillary 365deg-37degC (979deg-98degF) Crying increasing body temperature slightly Hypothermia
Radiant warmer falsely increasing axillary temperature Hypothermia
Heart rate apical120-140 beatsmin Crying increasing heart rate sleep decreasing heart rate Bradycardia Resting reate below 80-100 BpmDuring 1st period of reactivity (6-8hr) rate up to 190 Bpm Tachycardia Rate above 160-180 Bpm
Irregular rhythm
Respiration 30-60 Bpm Crying increasing respiratory rate sleep decreasing respiratory Tachypnea Rate gt60 Bpmrate Apnea 20 sec or moreDuring 1st period of reactivity (6-8hr) rate up to 80 Bpm
Blood pressure (BP) oscillometric 6541 mmHg in Crying and activity increasing BP Oscillometric systolic pressure in calf 6-9 mmHg less thanArm and calf Placing cuff on thigh agitates ionfant in upper extremity (sign of coarctation aorta)
Thigh BP higher then arm or calf BP by 4-8mmHg
GENERAL APPEARANCEPosture Flexion of head and extremities which rest Frank breech Extended legs abducted and fully Limp posture Extension of ExtremitiesOn chest and abdomen rotated thighs Flattened occiput extended neck
SKINAt birth bright red puffy smooth Neonatal jaundice after first 24hr Progressive jaundice especially in first 24hr2nd-3rd day pink flasky dry Ecchymoses or petechiae caused by birth trauma Generalized cyanosisVernix caseosa Milia Distended sebaceous glands that appear PallorLanugo as tiny white papules on cheeks chin and nose MottlingEdema around eyes face legs dorsa of hands feet GraynessAnd scrotum or labia Milaria or sudamina Distended sweat (eccrine) PlethoraAcrocyanosis Cyanosis of hands and feet glands that appear as minute vesicles especially on face Hemorrhage ecchymoses or petechiae that persistCutis marmorata Transient mottling when infant is Erythema toxicum Ping popular rash with vesicles Sclereme Hard and stiff skinExposed to decreased temperature superimposed on thorax back buttocks and abdomenl Poor skin turgor
May appear in 24-48 hr and resolve after several days Rashes pustules or blistersErythema toxicum pink popular rash with vesicles cafeacute au lait spot light brown spotssuperimposed on thorax back buttocks and abdomen nevus flammeus port-wine stainmay appear in 24-48 hrs and resolve after several daysHarlequin Color change clearly outlined color changeas infant lies on the side lower half of body becomespink and upper half is paleMongolian spots irregular areas of deep blue pigmentationusually in sacral and gluteal regions seen predominantly in newborn of African native American asian or Hispanic descentTalengiectatic nevi (stork bite) flat deep pink localizedareas usually seen on back of neck
HEADAnterior fontanels Diamond shape size varies form molding after vaginal delivery fused suturesbarely palpable to 4-5 cm third sagital (parietal) fontanel bulging or depressed fontanels when quietPosterior fontanels triangular 05-1cm bulging fontanel because of crying or coughing widened sutures and fontanelsFontanels flat soft and firm caput succedaneum edema of soft scalp tissue craniotabes snapping sensation along lambdoidWidest part of fontanel measured from bone to bone cephalhematoma hematoma between periosteum and skull bone sutures that resembles indentation of ping-pong ballnot suture to suture
EYES
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Strabismus - occurs in 2-5 of all children About half are born with the condition which causes one or both eyes to turn
Hypotelorism - abnormally decreased distance between two organs or parts
Torticollis - is a type of movement disorder in which the muscles controlling the neck cause sustained twisting or frequent jerking
Frenulum - a small fold of integument or mucous membrane that limits the movements of an organ or part
Xiphoid process - he pointed process of cartilage supported by a core of bone connected with the posterior end of the body of the sternum
Candidiasis - is an infection caused by a species of the yeast Candida usually Candida albicans
Cardiomegaly - abnormal enlargement of the heart
Diastasis recti - is a disorder defined as a separation of the rectus abdominis muscle into right and left halves
Whartonrsquos Jelly - is a gelatinous substance within the umbilical cord composed of cells that originate in the original egg and sperm of conception It is largely made up of mucopolysaccharides
Ascites - s an accumulation of fluid in the peritoneal cavity Although most commonly due to cirrhosis and severe liver disease its presence can portend other significant medical problems Diagnosis of the cause is usually with blood tests an ultrasound scan of the abdomen and direct removal of the fluid by needle or paracentesis
Gastroschisis - is a type of abdominal wall defect in which the intestines and sometimes other organs develop outside the fetal abdomen through an opening in the abdominal wall This defect is the result of obstruction of the omphalomesenteric vessels during development
Pseudomenstruation - bleeding from the uterus that resembles menstruation but is not associated with the usual changes in endometrial tissues
Epispadias - ongenital absence of the upper wall of the urethra occurring in both sexes but more often in the male with the urethral opening somewhere on the dorsum of the penis
Chordee - downward bowing of the penis due to a congenital anomaly or to urethral infection
Hydrocele - circumscribed collection of fluid especially in the tunica vaginalis of the testis or along the spermatic cord
Polydactyly - the presence of supernumerary digits on the hands or feet
Syndactyly - persistence of webbing between adjacent digits of the hand or foot so that they are more or less completely fused together
Phocomelia - congenital absence of the proximal portion of a limb or limbs the hands or feet being attached to the trunk by a small irregularly shaped bone
Hemimelia - a developmental anomaly characterized by absence of all or part of the distal half of a limb
Quivering - To shake with a slight rapid tremulous movement
Hypotonia - the state of being hypotonic
Hypertonia - the state of being hypertonic
Tremors - A relatively minor seismic shaking or vibrating movement Tremors often precede larger earthquakes or volcanic eruptions
Pupillary - Of or affecting the pupil of the eye
Glabellar - The smooth area between the eyebrows just above the nose
Extrusion - The act or process of pushing or thrusting out
Startle - To cause to make a quick involuntary movement or start
Pseudomonas - any of a genus of rodlike Gram-negative bacteria that live in soil and decomposing organic matter many species are pathogenic to plants and a few are pathogenic to man
Prophylaxis - Prevention of or protective treatment for disease
Cirrhosis - A chronic disease of the liver characterized by the replacement of normal tissue with fibrous tissue and the loss of functional liver cells It can result from alcohol abuse nutritional deprivation or infection especially by the hepatitis virus
Dehiscence - he spontaneous opening at maturity of a plant structure such as a fruit anther or sporangium to release its contents
Meatitis - inflammation of the urinary meatus
Urethral fistula - due to trauma occurs in bulls in which the urethra lies superficially near its end A fistula may affect the discharge of semen from the normal meatus sufficiently to cause infertility
DTP - diphtheria and tetanus toxoids and pertussis vaccine
Conduction ndash is the transfer of body heat to a cooler solid object in contact with a baby
Convection ndash is the flow of heat from the newborns body surface to cooler surrounding air
Radiation ndash is the transfer of body heat to a cooler solid object not in contact with the baby
Evaporation ndash is loss of heat through conversion of a liquid to vapor
Attachement ndash is the mode of contact between babyrsquos mouth and the motherrsquos breast during the act of breastfeeding
Kangaroo Mother Care - A universally available and biologically sound method of care for all newborns but in particular for premature babies with t three components skin-to-skin contact exclusive breastfeeding and support to the mother infant dyad
Newborn Resuscitation ndash a series of action taken to establish normal breathing in a newborn with depressed vital signs
Neonate - is a baby who is 4 weeks old or younger
Neonatal Period - the first 4 weeks of a childs life represents a time when changes are very rapid and many critical events can occur
Positive Pressure Ventilaiton (PPV) - refers to the process of forcing air into the lungs of a (usually apneic or dyspneic) patient usually using a baby valve mask or mechanical ventilator
ASSESSMENT
The new born requires thorough skilled observation to ensure a satisfactory to extra-uterine life 4 phases of physical assessment after delivery
The initial assessment The transitional assessment The assessment of gestational age The comprehensive and systematic physical examination
INITIAL ASSESSMENT includes APGAR scoring
APGAR SCORING METHOD - is the most frequent in assessing the newbornrsquos immediate adjustment to extra uterine life (Papile 2001)
SIGNS 0 1 2Heart rate Absent Slow lt 100 beats min Beats min
Respiratory effort Absent Irregular slow weak cry Good strong cryMuscle Tone Limp Some flexion of extremities Well flexed
Reflex Irritability No response Grimace Cry sneezeColor Blue Pale Body pink extremities blue Completely pink
SCORES0 - 3 Severe Distress4 ndash 6 Moderate Difficulty7 ndash 10 Absent in Difficulty
TRANSITIONAL ASSESSMENT
Newborn exhibits behavioral and physiological characteristics that can at first appear to be signs of stress
During newbornrsquos initial 24 hours changes in heart rate respiration motor activity color mucus production and bowel activity occur in an orderly predictable sequence which is normal and indicate lack of stress
- During the first 30 min the infant is alert cries vigorously may suck his or her fingers or fist and appears interested in the environment
For 6 to 8 hours after birth the newborn is in the first period of reactivity - the neonates eyes are usually open- has vigorous suck reflex- grasp the nipple quickly This is important to remember because after this initial highly active state the infant may be sleepy and uninterested in sucking
Physiologically the respiratory rate can be- As high as 80 breaths min- Crackles may be heard- Heart rate may reach 180 breaths min - Bowel sounds are active- Mucus secretion are increased- Temperature may decreased slightly
After this initial stage of alertness and activity the infant enters the second stage of the first reactive period - darr heart and respiratory rate- darr temperature- darr mucus production- Urine and stool usually not pass The infant is in a state of sleep and relative calm and avoid undressing or bathing the infant during this time
The second period of reactivity begins with the infant wakes from the deep sleep it last about the 2-5 hours- Infant is alert and responsive- uarr heart and respiratory rate- Gag reflex is active
- uarr gastric and respiratory secretions- Passage of meconium occurs- After this stage is a period of stabilization of physiologic system and vacillating patterns of sleep and activity
GESTATIONAL ASSESSMENT includes Ballard Scale
The Ballard Maturational Assessment Ballard Score or Ballard Scale is a commonly used technique of gestational age assessment It assigns a score to various criteria the sum of all of which is then extrapolated to the gestational age of the baby These criteria are divided into Physical and Neurological criteria This scoring allows for the estimation of age in the range of 26 weeks-44 weeks The New Ballard Score is an extension of the above to include extremely pre-term babies
Posture - with infant quiet and in a supine position observe degree of flexion in arms and legs Muscle tone and degree of flexion increase with maturity Score full flexion of the arms and legs = 4
Square window - with thumb supporting back of arm below wrist apply gently pressure with index and third fingers on dorsum of hand without rotating infantrsquos wrist Measure angle between base of thumb and forearm Score Full flexion (hand lies flat on ventral surface of forearm) = 4
Arm recoil - with infant supine fully flex both forearms on upper arms hold for 5 seconds pull down on hands to fully extend and
rapidly release arms Observe rapidity and intensity of recoil to state of flexion
Popliteal angle - With infants supine and pelvis flat on a firm surface flex lower leg on thigh and then flex thigh on abdomen While holding knee with numb and
and index finger extend lower legs with index finger of other hand Measure degree of angle behind knee (popliteal angle) Score an angle of less than 90 degree = 5
Scarf sign - with infant supine support head in midline with one hand use other hand to pull infantrsquos arm across the shoulder so that infantrsquos hand touches shoulder Determine location of elbow in relation to midline Score elbow does not reach midline = 4
Heel to ear - with infant supine and pelvis flat on a firm surface pull foot as far as possible up toward ear on same side measure distance of foot from ear and degree of knee flexion (same as popliteal angle) Score knees flexed with a popliteal angle of less than 10 degrees
SUMMARY OF PHYSICAL ASSESSMENT OF NEWBORN
USUAL FINDINGS COMMON VARIATIONS POTENTIAL SIGNS OF DISTRESSMINOR ABNORMALITIES MAJOR ABNORMALITIES
GENERAL MEASUREMENTSHead circumstance 33-35 cm (13-14 in) 1in Molding after birth altering head circumference Head Circumference lt10th orgt 90th percentileAbout 2-3cm (1 in) larger than chest circumference Head and chest circumference equal for first 1-2days after birth
Chest circumference 305-33cm (12-13 in)Crown-to-rump length 31-35cm (125-14in)Approximately equal to head circumferenceHead-to-heel length 48-53cm (19-21in)
Birth Weight 2700-4000g (6-9 lb) Loss of 10 of birth weight in first week regained in 10-14days Birth weight lt10th orgt 90th percentileDepending on feeding method
VITAL SIGNSTemperature axillary 365deg-37degC (979deg-98degF) Crying increasing body temperature slightly Hypothermia
Radiant warmer falsely increasing axillary temperature Hypothermia
Heart rate apical120-140 beatsmin Crying increasing heart rate sleep decreasing heart rate Bradycardia Resting reate below 80-100 BpmDuring 1st period of reactivity (6-8hr) rate up to 190 Bpm Tachycardia Rate above 160-180 Bpm
Irregular rhythm
Respiration 30-60 Bpm Crying increasing respiratory rate sleep decreasing respiratory Tachypnea Rate gt60 Bpmrate Apnea 20 sec or moreDuring 1st period of reactivity (6-8hr) rate up to 80 Bpm
Blood pressure (BP) oscillometric 6541 mmHg in Crying and activity increasing BP Oscillometric systolic pressure in calf 6-9 mmHg less thanArm and calf Placing cuff on thigh agitates ionfant in upper extremity (sign of coarctation aorta)
Thigh BP higher then arm or calf BP by 4-8mmHg
GENERAL APPEARANCEPosture Flexion of head and extremities which rest Frank breech Extended legs abducted and fully Limp posture Extension of ExtremitiesOn chest and abdomen rotated thighs Flattened occiput extended neck
SKINAt birth bright red puffy smooth Neonatal jaundice after first 24hr Progressive jaundice especially in first 24hr2nd-3rd day pink flasky dry Ecchymoses or petechiae caused by birth trauma Generalized cyanosisVernix caseosa Milia Distended sebaceous glands that appear PallorLanugo as tiny white papules on cheeks chin and nose MottlingEdema around eyes face legs dorsa of hands feet GraynessAnd scrotum or labia Milaria or sudamina Distended sweat (eccrine) PlethoraAcrocyanosis Cyanosis of hands and feet glands that appear as minute vesicles especially on face Hemorrhage ecchymoses or petechiae that persistCutis marmorata Transient mottling when infant is Erythema toxicum Ping popular rash with vesicles Sclereme Hard and stiff skinExposed to decreased temperature superimposed on thorax back buttocks and abdomenl Poor skin turgor
May appear in 24-48 hr and resolve after several days Rashes pustules or blistersErythema toxicum pink popular rash with vesicles cafeacute au lait spot light brown spotssuperimposed on thorax back buttocks and abdomen nevus flammeus port-wine stainmay appear in 24-48 hrs and resolve after several daysHarlequin Color change clearly outlined color changeas infant lies on the side lower half of body becomespink and upper half is paleMongolian spots irregular areas of deep blue pigmentationusually in sacral and gluteal regions seen predominantly in newborn of African native American asian or Hispanic descentTalengiectatic nevi (stork bite) flat deep pink localizedareas usually seen on back of neck
HEADAnterior fontanels Diamond shape size varies form molding after vaginal delivery fused suturesbarely palpable to 4-5 cm third sagital (parietal) fontanel bulging or depressed fontanels when quietPosterior fontanels triangular 05-1cm bulging fontanel because of crying or coughing widened sutures and fontanelsFontanels flat soft and firm caput succedaneum edema of soft scalp tissue craniotabes snapping sensation along lambdoidWidest part of fontanel measured from bone to bone cephalhematoma hematoma between periosteum and skull bone sutures that resembles indentation of ping-pong ballnot suture to suture
EYES
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Polydactyly - the presence of supernumerary digits on the hands or feet
Syndactyly - persistence of webbing between adjacent digits of the hand or foot so that they are more or less completely fused together
Phocomelia - congenital absence of the proximal portion of a limb or limbs the hands or feet being attached to the trunk by a small irregularly shaped bone
Hemimelia - a developmental anomaly characterized by absence of all or part of the distal half of a limb
Quivering - To shake with a slight rapid tremulous movement
Hypotonia - the state of being hypotonic
Hypertonia - the state of being hypertonic
Tremors - A relatively minor seismic shaking or vibrating movement Tremors often precede larger earthquakes or volcanic eruptions
Pupillary - Of or affecting the pupil of the eye
Glabellar - The smooth area between the eyebrows just above the nose
Extrusion - The act or process of pushing or thrusting out
Startle - To cause to make a quick involuntary movement or start
Pseudomonas - any of a genus of rodlike Gram-negative bacteria that live in soil and decomposing organic matter many species are pathogenic to plants and a few are pathogenic to man
Prophylaxis - Prevention of or protective treatment for disease
Cirrhosis - A chronic disease of the liver characterized by the replacement of normal tissue with fibrous tissue and the loss of functional liver cells It can result from alcohol abuse nutritional deprivation or infection especially by the hepatitis virus
Dehiscence - he spontaneous opening at maturity of a plant structure such as a fruit anther or sporangium to release its contents
Meatitis - inflammation of the urinary meatus
Urethral fistula - due to trauma occurs in bulls in which the urethra lies superficially near its end A fistula may affect the discharge of semen from the normal meatus sufficiently to cause infertility
DTP - diphtheria and tetanus toxoids and pertussis vaccine
Conduction ndash is the transfer of body heat to a cooler solid object in contact with a baby
Convection ndash is the flow of heat from the newborns body surface to cooler surrounding air
Radiation ndash is the transfer of body heat to a cooler solid object not in contact with the baby
Evaporation ndash is loss of heat through conversion of a liquid to vapor
Attachement ndash is the mode of contact between babyrsquos mouth and the motherrsquos breast during the act of breastfeeding
Kangaroo Mother Care - A universally available and biologically sound method of care for all newborns but in particular for premature babies with t three components skin-to-skin contact exclusive breastfeeding and support to the mother infant dyad
Newborn Resuscitation ndash a series of action taken to establish normal breathing in a newborn with depressed vital signs
Neonate - is a baby who is 4 weeks old or younger
Neonatal Period - the first 4 weeks of a childs life represents a time when changes are very rapid and many critical events can occur
Positive Pressure Ventilaiton (PPV) - refers to the process of forcing air into the lungs of a (usually apneic or dyspneic) patient usually using a baby valve mask or mechanical ventilator
ASSESSMENT
The new born requires thorough skilled observation to ensure a satisfactory to extra-uterine life 4 phases of physical assessment after delivery
The initial assessment The transitional assessment The assessment of gestational age The comprehensive and systematic physical examination
INITIAL ASSESSMENT includes APGAR scoring
APGAR SCORING METHOD - is the most frequent in assessing the newbornrsquos immediate adjustment to extra uterine life (Papile 2001)
SIGNS 0 1 2Heart rate Absent Slow lt 100 beats min Beats min
Respiratory effort Absent Irregular slow weak cry Good strong cryMuscle Tone Limp Some flexion of extremities Well flexed
Reflex Irritability No response Grimace Cry sneezeColor Blue Pale Body pink extremities blue Completely pink
SCORES0 - 3 Severe Distress4 ndash 6 Moderate Difficulty7 ndash 10 Absent in Difficulty
TRANSITIONAL ASSESSMENT
Newborn exhibits behavioral and physiological characteristics that can at first appear to be signs of stress
During newbornrsquos initial 24 hours changes in heart rate respiration motor activity color mucus production and bowel activity occur in an orderly predictable sequence which is normal and indicate lack of stress
- During the first 30 min the infant is alert cries vigorously may suck his or her fingers or fist and appears interested in the environment
For 6 to 8 hours after birth the newborn is in the first period of reactivity - the neonates eyes are usually open- has vigorous suck reflex- grasp the nipple quickly This is important to remember because after this initial highly active state the infant may be sleepy and uninterested in sucking
Physiologically the respiratory rate can be- As high as 80 breaths min- Crackles may be heard- Heart rate may reach 180 breaths min - Bowel sounds are active- Mucus secretion are increased- Temperature may decreased slightly
After this initial stage of alertness and activity the infant enters the second stage of the first reactive period - darr heart and respiratory rate- darr temperature- darr mucus production- Urine and stool usually not pass The infant is in a state of sleep and relative calm and avoid undressing or bathing the infant during this time
The second period of reactivity begins with the infant wakes from the deep sleep it last about the 2-5 hours- Infant is alert and responsive- uarr heart and respiratory rate- Gag reflex is active
- uarr gastric and respiratory secretions- Passage of meconium occurs- After this stage is a period of stabilization of physiologic system and vacillating patterns of sleep and activity
GESTATIONAL ASSESSMENT includes Ballard Scale
The Ballard Maturational Assessment Ballard Score or Ballard Scale is a commonly used technique of gestational age assessment It assigns a score to various criteria the sum of all of which is then extrapolated to the gestational age of the baby These criteria are divided into Physical and Neurological criteria This scoring allows for the estimation of age in the range of 26 weeks-44 weeks The New Ballard Score is an extension of the above to include extremely pre-term babies
Posture - with infant quiet and in a supine position observe degree of flexion in arms and legs Muscle tone and degree of flexion increase with maturity Score full flexion of the arms and legs = 4
Square window - with thumb supporting back of arm below wrist apply gently pressure with index and third fingers on dorsum of hand without rotating infantrsquos wrist Measure angle between base of thumb and forearm Score Full flexion (hand lies flat on ventral surface of forearm) = 4
Arm recoil - with infant supine fully flex both forearms on upper arms hold for 5 seconds pull down on hands to fully extend and
rapidly release arms Observe rapidity and intensity of recoil to state of flexion
Popliteal angle - With infants supine and pelvis flat on a firm surface flex lower leg on thigh and then flex thigh on abdomen While holding knee with numb and
and index finger extend lower legs with index finger of other hand Measure degree of angle behind knee (popliteal angle) Score an angle of less than 90 degree = 5
Scarf sign - with infant supine support head in midline with one hand use other hand to pull infantrsquos arm across the shoulder so that infantrsquos hand touches shoulder Determine location of elbow in relation to midline Score elbow does not reach midline = 4
Heel to ear - with infant supine and pelvis flat on a firm surface pull foot as far as possible up toward ear on same side measure distance of foot from ear and degree of knee flexion (same as popliteal angle) Score knees flexed with a popliteal angle of less than 10 degrees
SUMMARY OF PHYSICAL ASSESSMENT OF NEWBORN
USUAL FINDINGS COMMON VARIATIONS POTENTIAL SIGNS OF DISTRESSMINOR ABNORMALITIES MAJOR ABNORMALITIES
GENERAL MEASUREMENTSHead circumstance 33-35 cm (13-14 in) 1in Molding after birth altering head circumference Head Circumference lt10th orgt 90th percentileAbout 2-3cm (1 in) larger than chest circumference Head and chest circumference equal for first 1-2days after birth
Chest circumference 305-33cm (12-13 in)Crown-to-rump length 31-35cm (125-14in)Approximately equal to head circumferenceHead-to-heel length 48-53cm (19-21in)
Birth Weight 2700-4000g (6-9 lb) Loss of 10 of birth weight in first week regained in 10-14days Birth weight lt10th orgt 90th percentileDepending on feeding method
VITAL SIGNSTemperature axillary 365deg-37degC (979deg-98degF) Crying increasing body temperature slightly Hypothermia
Radiant warmer falsely increasing axillary temperature Hypothermia
Heart rate apical120-140 beatsmin Crying increasing heart rate sleep decreasing heart rate Bradycardia Resting reate below 80-100 BpmDuring 1st period of reactivity (6-8hr) rate up to 190 Bpm Tachycardia Rate above 160-180 Bpm
Irregular rhythm
Respiration 30-60 Bpm Crying increasing respiratory rate sleep decreasing respiratory Tachypnea Rate gt60 Bpmrate Apnea 20 sec or moreDuring 1st period of reactivity (6-8hr) rate up to 80 Bpm
Blood pressure (BP) oscillometric 6541 mmHg in Crying and activity increasing BP Oscillometric systolic pressure in calf 6-9 mmHg less thanArm and calf Placing cuff on thigh agitates ionfant in upper extremity (sign of coarctation aorta)
Thigh BP higher then arm or calf BP by 4-8mmHg
GENERAL APPEARANCEPosture Flexion of head and extremities which rest Frank breech Extended legs abducted and fully Limp posture Extension of ExtremitiesOn chest and abdomen rotated thighs Flattened occiput extended neck
SKINAt birth bright red puffy smooth Neonatal jaundice after first 24hr Progressive jaundice especially in first 24hr2nd-3rd day pink flasky dry Ecchymoses or petechiae caused by birth trauma Generalized cyanosisVernix caseosa Milia Distended sebaceous glands that appear PallorLanugo as tiny white papules on cheeks chin and nose MottlingEdema around eyes face legs dorsa of hands feet GraynessAnd scrotum or labia Milaria or sudamina Distended sweat (eccrine) PlethoraAcrocyanosis Cyanosis of hands and feet glands that appear as minute vesicles especially on face Hemorrhage ecchymoses or petechiae that persistCutis marmorata Transient mottling when infant is Erythema toxicum Ping popular rash with vesicles Sclereme Hard and stiff skinExposed to decreased temperature superimposed on thorax back buttocks and abdomenl Poor skin turgor
May appear in 24-48 hr and resolve after several days Rashes pustules or blistersErythema toxicum pink popular rash with vesicles cafeacute au lait spot light brown spotssuperimposed on thorax back buttocks and abdomen nevus flammeus port-wine stainmay appear in 24-48 hrs and resolve after several daysHarlequin Color change clearly outlined color changeas infant lies on the side lower half of body becomespink and upper half is paleMongolian spots irregular areas of deep blue pigmentationusually in sacral and gluteal regions seen predominantly in newborn of African native American asian or Hispanic descentTalengiectatic nevi (stork bite) flat deep pink localizedareas usually seen on back of neck
HEADAnterior fontanels Diamond shape size varies form molding after vaginal delivery fused suturesbarely palpable to 4-5 cm third sagital (parietal) fontanel bulging or depressed fontanels when quietPosterior fontanels triangular 05-1cm bulging fontanel because of crying or coughing widened sutures and fontanelsFontanels flat soft and firm caput succedaneum edema of soft scalp tissue craniotabes snapping sensation along lambdoidWidest part of fontanel measured from bone to bone cephalhematoma hematoma between periosteum and skull bone sutures that resembles indentation of ping-pong ballnot suture to suture
EYES
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Dehiscence - he spontaneous opening at maturity of a plant structure such as a fruit anther or sporangium to release its contents
Meatitis - inflammation of the urinary meatus
Urethral fistula - due to trauma occurs in bulls in which the urethra lies superficially near its end A fistula may affect the discharge of semen from the normal meatus sufficiently to cause infertility
DTP - diphtheria and tetanus toxoids and pertussis vaccine
Conduction ndash is the transfer of body heat to a cooler solid object in contact with a baby
Convection ndash is the flow of heat from the newborns body surface to cooler surrounding air
Radiation ndash is the transfer of body heat to a cooler solid object not in contact with the baby
Evaporation ndash is loss of heat through conversion of a liquid to vapor
Attachement ndash is the mode of contact between babyrsquos mouth and the motherrsquos breast during the act of breastfeeding
Kangaroo Mother Care - A universally available and biologically sound method of care for all newborns but in particular for premature babies with t three components skin-to-skin contact exclusive breastfeeding and support to the mother infant dyad
Newborn Resuscitation ndash a series of action taken to establish normal breathing in a newborn with depressed vital signs
Neonate - is a baby who is 4 weeks old or younger
Neonatal Period - the first 4 weeks of a childs life represents a time when changes are very rapid and many critical events can occur
Positive Pressure Ventilaiton (PPV) - refers to the process of forcing air into the lungs of a (usually apneic or dyspneic) patient usually using a baby valve mask or mechanical ventilator
ASSESSMENT
The new born requires thorough skilled observation to ensure a satisfactory to extra-uterine life 4 phases of physical assessment after delivery
The initial assessment The transitional assessment The assessment of gestational age The comprehensive and systematic physical examination
INITIAL ASSESSMENT includes APGAR scoring
APGAR SCORING METHOD - is the most frequent in assessing the newbornrsquos immediate adjustment to extra uterine life (Papile 2001)
SIGNS 0 1 2Heart rate Absent Slow lt 100 beats min Beats min
Respiratory effort Absent Irregular slow weak cry Good strong cryMuscle Tone Limp Some flexion of extremities Well flexed
Reflex Irritability No response Grimace Cry sneezeColor Blue Pale Body pink extremities blue Completely pink
SCORES0 - 3 Severe Distress4 ndash 6 Moderate Difficulty7 ndash 10 Absent in Difficulty
TRANSITIONAL ASSESSMENT
Newborn exhibits behavioral and physiological characteristics that can at first appear to be signs of stress
During newbornrsquos initial 24 hours changes in heart rate respiration motor activity color mucus production and bowel activity occur in an orderly predictable sequence which is normal and indicate lack of stress
- During the first 30 min the infant is alert cries vigorously may suck his or her fingers or fist and appears interested in the environment
For 6 to 8 hours after birth the newborn is in the first period of reactivity - the neonates eyes are usually open- has vigorous suck reflex- grasp the nipple quickly This is important to remember because after this initial highly active state the infant may be sleepy and uninterested in sucking
Physiologically the respiratory rate can be- As high as 80 breaths min- Crackles may be heard- Heart rate may reach 180 breaths min - Bowel sounds are active- Mucus secretion are increased- Temperature may decreased slightly
After this initial stage of alertness and activity the infant enters the second stage of the first reactive period - darr heart and respiratory rate- darr temperature- darr mucus production- Urine and stool usually not pass The infant is in a state of sleep and relative calm and avoid undressing or bathing the infant during this time
The second period of reactivity begins with the infant wakes from the deep sleep it last about the 2-5 hours- Infant is alert and responsive- uarr heart and respiratory rate- Gag reflex is active
- uarr gastric and respiratory secretions- Passage of meconium occurs- After this stage is a period of stabilization of physiologic system and vacillating patterns of sleep and activity
GESTATIONAL ASSESSMENT includes Ballard Scale
The Ballard Maturational Assessment Ballard Score or Ballard Scale is a commonly used technique of gestational age assessment It assigns a score to various criteria the sum of all of which is then extrapolated to the gestational age of the baby These criteria are divided into Physical and Neurological criteria This scoring allows for the estimation of age in the range of 26 weeks-44 weeks The New Ballard Score is an extension of the above to include extremely pre-term babies
Posture - with infant quiet and in a supine position observe degree of flexion in arms and legs Muscle tone and degree of flexion increase with maturity Score full flexion of the arms and legs = 4
Square window - with thumb supporting back of arm below wrist apply gently pressure with index and third fingers on dorsum of hand without rotating infantrsquos wrist Measure angle between base of thumb and forearm Score Full flexion (hand lies flat on ventral surface of forearm) = 4
Arm recoil - with infant supine fully flex both forearms on upper arms hold for 5 seconds pull down on hands to fully extend and
rapidly release arms Observe rapidity and intensity of recoil to state of flexion
Popliteal angle - With infants supine and pelvis flat on a firm surface flex lower leg on thigh and then flex thigh on abdomen While holding knee with numb and
and index finger extend lower legs with index finger of other hand Measure degree of angle behind knee (popliteal angle) Score an angle of less than 90 degree = 5
Scarf sign - with infant supine support head in midline with one hand use other hand to pull infantrsquos arm across the shoulder so that infantrsquos hand touches shoulder Determine location of elbow in relation to midline Score elbow does not reach midline = 4
Heel to ear - with infant supine and pelvis flat on a firm surface pull foot as far as possible up toward ear on same side measure distance of foot from ear and degree of knee flexion (same as popliteal angle) Score knees flexed with a popliteal angle of less than 10 degrees
SUMMARY OF PHYSICAL ASSESSMENT OF NEWBORN
USUAL FINDINGS COMMON VARIATIONS POTENTIAL SIGNS OF DISTRESSMINOR ABNORMALITIES MAJOR ABNORMALITIES
GENERAL MEASUREMENTSHead circumstance 33-35 cm (13-14 in) 1in Molding after birth altering head circumference Head Circumference lt10th orgt 90th percentileAbout 2-3cm (1 in) larger than chest circumference Head and chest circumference equal for first 1-2days after birth
Chest circumference 305-33cm (12-13 in)Crown-to-rump length 31-35cm (125-14in)Approximately equal to head circumferenceHead-to-heel length 48-53cm (19-21in)
Birth Weight 2700-4000g (6-9 lb) Loss of 10 of birth weight in first week regained in 10-14days Birth weight lt10th orgt 90th percentileDepending on feeding method
VITAL SIGNSTemperature axillary 365deg-37degC (979deg-98degF) Crying increasing body temperature slightly Hypothermia
Radiant warmer falsely increasing axillary temperature Hypothermia
Heart rate apical120-140 beatsmin Crying increasing heart rate sleep decreasing heart rate Bradycardia Resting reate below 80-100 BpmDuring 1st period of reactivity (6-8hr) rate up to 190 Bpm Tachycardia Rate above 160-180 Bpm
Irregular rhythm
Respiration 30-60 Bpm Crying increasing respiratory rate sleep decreasing respiratory Tachypnea Rate gt60 Bpmrate Apnea 20 sec or moreDuring 1st period of reactivity (6-8hr) rate up to 80 Bpm
Blood pressure (BP) oscillometric 6541 mmHg in Crying and activity increasing BP Oscillometric systolic pressure in calf 6-9 mmHg less thanArm and calf Placing cuff on thigh agitates ionfant in upper extremity (sign of coarctation aorta)
Thigh BP higher then arm or calf BP by 4-8mmHg
GENERAL APPEARANCEPosture Flexion of head and extremities which rest Frank breech Extended legs abducted and fully Limp posture Extension of ExtremitiesOn chest and abdomen rotated thighs Flattened occiput extended neck
SKINAt birth bright red puffy smooth Neonatal jaundice after first 24hr Progressive jaundice especially in first 24hr2nd-3rd day pink flasky dry Ecchymoses or petechiae caused by birth trauma Generalized cyanosisVernix caseosa Milia Distended sebaceous glands that appear PallorLanugo as tiny white papules on cheeks chin and nose MottlingEdema around eyes face legs dorsa of hands feet GraynessAnd scrotum or labia Milaria or sudamina Distended sweat (eccrine) PlethoraAcrocyanosis Cyanosis of hands and feet glands that appear as minute vesicles especially on face Hemorrhage ecchymoses or petechiae that persistCutis marmorata Transient mottling when infant is Erythema toxicum Ping popular rash with vesicles Sclereme Hard and stiff skinExposed to decreased temperature superimposed on thorax back buttocks and abdomenl Poor skin turgor
May appear in 24-48 hr and resolve after several days Rashes pustules or blistersErythema toxicum pink popular rash with vesicles cafeacute au lait spot light brown spotssuperimposed on thorax back buttocks and abdomen nevus flammeus port-wine stainmay appear in 24-48 hrs and resolve after several daysHarlequin Color change clearly outlined color changeas infant lies on the side lower half of body becomespink and upper half is paleMongolian spots irregular areas of deep blue pigmentationusually in sacral and gluteal regions seen predominantly in newborn of African native American asian or Hispanic descentTalengiectatic nevi (stork bite) flat deep pink localizedareas usually seen on back of neck
HEADAnterior fontanels Diamond shape size varies form molding after vaginal delivery fused suturesbarely palpable to 4-5 cm third sagital (parietal) fontanel bulging or depressed fontanels when quietPosterior fontanels triangular 05-1cm bulging fontanel because of crying or coughing widened sutures and fontanelsFontanels flat soft and firm caput succedaneum edema of soft scalp tissue craniotabes snapping sensation along lambdoidWidest part of fontanel measured from bone to bone cephalhematoma hematoma between periosteum and skull bone sutures that resembles indentation of ping-pong ballnot suture to suture
EYES
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
ASSESSMENT
The new born requires thorough skilled observation to ensure a satisfactory to extra-uterine life 4 phases of physical assessment after delivery
The initial assessment The transitional assessment The assessment of gestational age The comprehensive and systematic physical examination
INITIAL ASSESSMENT includes APGAR scoring
APGAR SCORING METHOD - is the most frequent in assessing the newbornrsquos immediate adjustment to extra uterine life (Papile 2001)
SIGNS 0 1 2Heart rate Absent Slow lt 100 beats min Beats min
Respiratory effort Absent Irregular slow weak cry Good strong cryMuscle Tone Limp Some flexion of extremities Well flexed
Reflex Irritability No response Grimace Cry sneezeColor Blue Pale Body pink extremities blue Completely pink
SCORES0 - 3 Severe Distress4 ndash 6 Moderate Difficulty7 ndash 10 Absent in Difficulty
TRANSITIONAL ASSESSMENT
Newborn exhibits behavioral and physiological characteristics that can at first appear to be signs of stress
During newbornrsquos initial 24 hours changes in heart rate respiration motor activity color mucus production and bowel activity occur in an orderly predictable sequence which is normal and indicate lack of stress
- During the first 30 min the infant is alert cries vigorously may suck his or her fingers or fist and appears interested in the environment
For 6 to 8 hours after birth the newborn is in the first period of reactivity - the neonates eyes are usually open- has vigorous suck reflex- grasp the nipple quickly This is important to remember because after this initial highly active state the infant may be sleepy and uninterested in sucking
Physiologically the respiratory rate can be- As high as 80 breaths min- Crackles may be heard- Heart rate may reach 180 breaths min - Bowel sounds are active- Mucus secretion are increased- Temperature may decreased slightly
After this initial stage of alertness and activity the infant enters the second stage of the first reactive period - darr heart and respiratory rate- darr temperature- darr mucus production- Urine and stool usually not pass The infant is in a state of sleep and relative calm and avoid undressing or bathing the infant during this time
The second period of reactivity begins with the infant wakes from the deep sleep it last about the 2-5 hours- Infant is alert and responsive- uarr heart and respiratory rate- Gag reflex is active
- uarr gastric and respiratory secretions- Passage of meconium occurs- After this stage is a period of stabilization of physiologic system and vacillating patterns of sleep and activity
GESTATIONAL ASSESSMENT includes Ballard Scale
The Ballard Maturational Assessment Ballard Score or Ballard Scale is a commonly used technique of gestational age assessment It assigns a score to various criteria the sum of all of which is then extrapolated to the gestational age of the baby These criteria are divided into Physical and Neurological criteria This scoring allows for the estimation of age in the range of 26 weeks-44 weeks The New Ballard Score is an extension of the above to include extremely pre-term babies
Posture - with infant quiet and in a supine position observe degree of flexion in arms and legs Muscle tone and degree of flexion increase with maturity Score full flexion of the arms and legs = 4
Square window - with thumb supporting back of arm below wrist apply gently pressure with index and third fingers on dorsum of hand without rotating infantrsquos wrist Measure angle between base of thumb and forearm Score Full flexion (hand lies flat on ventral surface of forearm) = 4
Arm recoil - with infant supine fully flex both forearms on upper arms hold for 5 seconds pull down on hands to fully extend and
rapidly release arms Observe rapidity and intensity of recoil to state of flexion
Popliteal angle - With infants supine and pelvis flat on a firm surface flex lower leg on thigh and then flex thigh on abdomen While holding knee with numb and
and index finger extend lower legs with index finger of other hand Measure degree of angle behind knee (popliteal angle) Score an angle of less than 90 degree = 5
Scarf sign - with infant supine support head in midline with one hand use other hand to pull infantrsquos arm across the shoulder so that infantrsquos hand touches shoulder Determine location of elbow in relation to midline Score elbow does not reach midline = 4
Heel to ear - with infant supine and pelvis flat on a firm surface pull foot as far as possible up toward ear on same side measure distance of foot from ear and degree of knee flexion (same as popliteal angle) Score knees flexed with a popliteal angle of less than 10 degrees
SUMMARY OF PHYSICAL ASSESSMENT OF NEWBORN
USUAL FINDINGS COMMON VARIATIONS POTENTIAL SIGNS OF DISTRESSMINOR ABNORMALITIES MAJOR ABNORMALITIES
GENERAL MEASUREMENTSHead circumstance 33-35 cm (13-14 in) 1in Molding after birth altering head circumference Head Circumference lt10th orgt 90th percentileAbout 2-3cm (1 in) larger than chest circumference Head and chest circumference equal for first 1-2days after birth
Chest circumference 305-33cm (12-13 in)Crown-to-rump length 31-35cm (125-14in)Approximately equal to head circumferenceHead-to-heel length 48-53cm (19-21in)
Birth Weight 2700-4000g (6-9 lb) Loss of 10 of birth weight in first week regained in 10-14days Birth weight lt10th orgt 90th percentileDepending on feeding method
VITAL SIGNSTemperature axillary 365deg-37degC (979deg-98degF) Crying increasing body temperature slightly Hypothermia
Radiant warmer falsely increasing axillary temperature Hypothermia
Heart rate apical120-140 beatsmin Crying increasing heart rate sleep decreasing heart rate Bradycardia Resting reate below 80-100 BpmDuring 1st period of reactivity (6-8hr) rate up to 190 Bpm Tachycardia Rate above 160-180 Bpm
Irregular rhythm
Respiration 30-60 Bpm Crying increasing respiratory rate sleep decreasing respiratory Tachypnea Rate gt60 Bpmrate Apnea 20 sec or moreDuring 1st period of reactivity (6-8hr) rate up to 80 Bpm
Blood pressure (BP) oscillometric 6541 mmHg in Crying and activity increasing BP Oscillometric systolic pressure in calf 6-9 mmHg less thanArm and calf Placing cuff on thigh agitates ionfant in upper extremity (sign of coarctation aorta)
Thigh BP higher then arm or calf BP by 4-8mmHg
GENERAL APPEARANCEPosture Flexion of head and extremities which rest Frank breech Extended legs abducted and fully Limp posture Extension of ExtremitiesOn chest and abdomen rotated thighs Flattened occiput extended neck
SKINAt birth bright red puffy smooth Neonatal jaundice after first 24hr Progressive jaundice especially in first 24hr2nd-3rd day pink flasky dry Ecchymoses or petechiae caused by birth trauma Generalized cyanosisVernix caseosa Milia Distended sebaceous glands that appear PallorLanugo as tiny white papules on cheeks chin and nose MottlingEdema around eyes face legs dorsa of hands feet GraynessAnd scrotum or labia Milaria or sudamina Distended sweat (eccrine) PlethoraAcrocyanosis Cyanosis of hands and feet glands that appear as minute vesicles especially on face Hemorrhage ecchymoses or petechiae that persistCutis marmorata Transient mottling when infant is Erythema toxicum Ping popular rash with vesicles Sclereme Hard and stiff skinExposed to decreased temperature superimposed on thorax back buttocks and abdomenl Poor skin turgor
May appear in 24-48 hr and resolve after several days Rashes pustules or blistersErythema toxicum pink popular rash with vesicles cafeacute au lait spot light brown spotssuperimposed on thorax back buttocks and abdomen nevus flammeus port-wine stainmay appear in 24-48 hrs and resolve after several daysHarlequin Color change clearly outlined color changeas infant lies on the side lower half of body becomespink and upper half is paleMongolian spots irregular areas of deep blue pigmentationusually in sacral and gluteal regions seen predominantly in newborn of African native American asian or Hispanic descentTalengiectatic nevi (stork bite) flat deep pink localizedareas usually seen on back of neck
HEADAnterior fontanels Diamond shape size varies form molding after vaginal delivery fused suturesbarely palpable to 4-5 cm third sagital (parietal) fontanel bulging or depressed fontanels when quietPosterior fontanels triangular 05-1cm bulging fontanel because of crying or coughing widened sutures and fontanelsFontanels flat soft and firm caput succedaneum edema of soft scalp tissue craniotabes snapping sensation along lambdoidWidest part of fontanel measured from bone to bone cephalhematoma hematoma between periosteum and skull bone sutures that resembles indentation of ping-pong ballnot suture to suture
EYES
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
TRANSITIONAL ASSESSMENT
Newborn exhibits behavioral and physiological characteristics that can at first appear to be signs of stress
During newbornrsquos initial 24 hours changes in heart rate respiration motor activity color mucus production and bowel activity occur in an orderly predictable sequence which is normal and indicate lack of stress
- During the first 30 min the infant is alert cries vigorously may suck his or her fingers or fist and appears interested in the environment
For 6 to 8 hours after birth the newborn is in the first period of reactivity - the neonates eyes are usually open- has vigorous suck reflex- grasp the nipple quickly This is important to remember because after this initial highly active state the infant may be sleepy and uninterested in sucking
Physiologically the respiratory rate can be- As high as 80 breaths min- Crackles may be heard- Heart rate may reach 180 breaths min - Bowel sounds are active- Mucus secretion are increased- Temperature may decreased slightly
After this initial stage of alertness and activity the infant enters the second stage of the first reactive period - darr heart and respiratory rate- darr temperature- darr mucus production- Urine and stool usually not pass The infant is in a state of sleep and relative calm and avoid undressing or bathing the infant during this time
The second period of reactivity begins with the infant wakes from the deep sleep it last about the 2-5 hours- Infant is alert and responsive- uarr heart and respiratory rate- Gag reflex is active
- uarr gastric and respiratory secretions- Passage of meconium occurs- After this stage is a period of stabilization of physiologic system and vacillating patterns of sleep and activity
GESTATIONAL ASSESSMENT includes Ballard Scale
The Ballard Maturational Assessment Ballard Score or Ballard Scale is a commonly used technique of gestational age assessment It assigns a score to various criteria the sum of all of which is then extrapolated to the gestational age of the baby These criteria are divided into Physical and Neurological criteria This scoring allows for the estimation of age in the range of 26 weeks-44 weeks The New Ballard Score is an extension of the above to include extremely pre-term babies
Posture - with infant quiet and in a supine position observe degree of flexion in arms and legs Muscle tone and degree of flexion increase with maturity Score full flexion of the arms and legs = 4
Square window - with thumb supporting back of arm below wrist apply gently pressure with index and third fingers on dorsum of hand without rotating infantrsquos wrist Measure angle between base of thumb and forearm Score Full flexion (hand lies flat on ventral surface of forearm) = 4
Arm recoil - with infant supine fully flex both forearms on upper arms hold for 5 seconds pull down on hands to fully extend and
rapidly release arms Observe rapidity and intensity of recoil to state of flexion
Popliteal angle - With infants supine and pelvis flat on a firm surface flex lower leg on thigh and then flex thigh on abdomen While holding knee with numb and
and index finger extend lower legs with index finger of other hand Measure degree of angle behind knee (popliteal angle) Score an angle of less than 90 degree = 5
Scarf sign - with infant supine support head in midline with one hand use other hand to pull infantrsquos arm across the shoulder so that infantrsquos hand touches shoulder Determine location of elbow in relation to midline Score elbow does not reach midline = 4
Heel to ear - with infant supine and pelvis flat on a firm surface pull foot as far as possible up toward ear on same side measure distance of foot from ear and degree of knee flexion (same as popliteal angle) Score knees flexed with a popliteal angle of less than 10 degrees
SUMMARY OF PHYSICAL ASSESSMENT OF NEWBORN
USUAL FINDINGS COMMON VARIATIONS POTENTIAL SIGNS OF DISTRESSMINOR ABNORMALITIES MAJOR ABNORMALITIES
GENERAL MEASUREMENTSHead circumstance 33-35 cm (13-14 in) 1in Molding after birth altering head circumference Head Circumference lt10th orgt 90th percentileAbout 2-3cm (1 in) larger than chest circumference Head and chest circumference equal for first 1-2days after birth
Chest circumference 305-33cm (12-13 in)Crown-to-rump length 31-35cm (125-14in)Approximately equal to head circumferenceHead-to-heel length 48-53cm (19-21in)
Birth Weight 2700-4000g (6-9 lb) Loss of 10 of birth weight in first week regained in 10-14days Birth weight lt10th orgt 90th percentileDepending on feeding method
VITAL SIGNSTemperature axillary 365deg-37degC (979deg-98degF) Crying increasing body temperature slightly Hypothermia
Radiant warmer falsely increasing axillary temperature Hypothermia
Heart rate apical120-140 beatsmin Crying increasing heart rate sleep decreasing heart rate Bradycardia Resting reate below 80-100 BpmDuring 1st period of reactivity (6-8hr) rate up to 190 Bpm Tachycardia Rate above 160-180 Bpm
Irregular rhythm
Respiration 30-60 Bpm Crying increasing respiratory rate sleep decreasing respiratory Tachypnea Rate gt60 Bpmrate Apnea 20 sec or moreDuring 1st period of reactivity (6-8hr) rate up to 80 Bpm
Blood pressure (BP) oscillometric 6541 mmHg in Crying and activity increasing BP Oscillometric systolic pressure in calf 6-9 mmHg less thanArm and calf Placing cuff on thigh agitates ionfant in upper extremity (sign of coarctation aorta)
Thigh BP higher then arm or calf BP by 4-8mmHg
GENERAL APPEARANCEPosture Flexion of head and extremities which rest Frank breech Extended legs abducted and fully Limp posture Extension of ExtremitiesOn chest and abdomen rotated thighs Flattened occiput extended neck
SKINAt birth bright red puffy smooth Neonatal jaundice after first 24hr Progressive jaundice especially in first 24hr2nd-3rd day pink flasky dry Ecchymoses or petechiae caused by birth trauma Generalized cyanosisVernix caseosa Milia Distended sebaceous glands that appear PallorLanugo as tiny white papules on cheeks chin and nose MottlingEdema around eyes face legs dorsa of hands feet GraynessAnd scrotum or labia Milaria or sudamina Distended sweat (eccrine) PlethoraAcrocyanosis Cyanosis of hands and feet glands that appear as minute vesicles especially on face Hemorrhage ecchymoses or petechiae that persistCutis marmorata Transient mottling when infant is Erythema toxicum Ping popular rash with vesicles Sclereme Hard and stiff skinExposed to decreased temperature superimposed on thorax back buttocks and abdomenl Poor skin turgor
May appear in 24-48 hr and resolve after several days Rashes pustules or blistersErythema toxicum pink popular rash with vesicles cafeacute au lait spot light brown spotssuperimposed on thorax back buttocks and abdomen nevus flammeus port-wine stainmay appear in 24-48 hrs and resolve after several daysHarlequin Color change clearly outlined color changeas infant lies on the side lower half of body becomespink and upper half is paleMongolian spots irregular areas of deep blue pigmentationusually in sacral and gluteal regions seen predominantly in newborn of African native American asian or Hispanic descentTalengiectatic nevi (stork bite) flat deep pink localizedareas usually seen on back of neck
HEADAnterior fontanels Diamond shape size varies form molding after vaginal delivery fused suturesbarely palpable to 4-5 cm third sagital (parietal) fontanel bulging or depressed fontanels when quietPosterior fontanels triangular 05-1cm bulging fontanel because of crying or coughing widened sutures and fontanelsFontanels flat soft and firm caput succedaneum edema of soft scalp tissue craniotabes snapping sensation along lambdoidWidest part of fontanel measured from bone to bone cephalhematoma hematoma between periosteum and skull bone sutures that resembles indentation of ping-pong ballnot suture to suture
EYES
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
- uarr gastric and respiratory secretions- Passage of meconium occurs- After this stage is a period of stabilization of physiologic system and vacillating patterns of sleep and activity
GESTATIONAL ASSESSMENT includes Ballard Scale
The Ballard Maturational Assessment Ballard Score or Ballard Scale is a commonly used technique of gestational age assessment It assigns a score to various criteria the sum of all of which is then extrapolated to the gestational age of the baby These criteria are divided into Physical and Neurological criteria This scoring allows for the estimation of age in the range of 26 weeks-44 weeks The New Ballard Score is an extension of the above to include extremely pre-term babies
Posture - with infant quiet and in a supine position observe degree of flexion in arms and legs Muscle tone and degree of flexion increase with maturity Score full flexion of the arms and legs = 4
Square window - with thumb supporting back of arm below wrist apply gently pressure with index and third fingers on dorsum of hand without rotating infantrsquos wrist Measure angle between base of thumb and forearm Score Full flexion (hand lies flat on ventral surface of forearm) = 4
Arm recoil - with infant supine fully flex both forearms on upper arms hold for 5 seconds pull down on hands to fully extend and
rapidly release arms Observe rapidity and intensity of recoil to state of flexion
Popliteal angle - With infants supine and pelvis flat on a firm surface flex lower leg on thigh and then flex thigh on abdomen While holding knee with numb and
and index finger extend lower legs with index finger of other hand Measure degree of angle behind knee (popliteal angle) Score an angle of less than 90 degree = 5
Scarf sign - with infant supine support head in midline with one hand use other hand to pull infantrsquos arm across the shoulder so that infantrsquos hand touches shoulder Determine location of elbow in relation to midline Score elbow does not reach midline = 4
Heel to ear - with infant supine and pelvis flat on a firm surface pull foot as far as possible up toward ear on same side measure distance of foot from ear and degree of knee flexion (same as popliteal angle) Score knees flexed with a popliteal angle of less than 10 degrees
SUMMARY OF PHYSICAL ASSESSMENT OF NEWBORN
USUAL FINDINGS COMMON VARIATIONS POTENTIAL SIGNS OF DISTRESSMINOR ABNORMALITIES MAJOR ABNORMALITIES
GENERAL MEASUREMENTSHead circumstance 33-35 cm (13-14 in) 1in Molding after birth altering head circumference Head Circumference lt10th orgt 90th percentileAbout 2-3cm (1 in) larger than chest circumference Head and chest circumference equal for first 1-2days after birth
Chest circumference 305-33cm (12-13 in)Crown-to-rump length 31-35cm (125-14in)Approximately equal to head circumferenceHead-to-heel length 48-53cm (19-21in)
Birth Weight 2700-4000g (6-9 lb) Loss of 10 of birth weight in first week regained in 10-14days Birth weight lt10th orgt 90th percentileDepending on feeding method
VITAL SIGNSTemperature axillary 365deg-37degC (979deg-98degF) Crying increasing body temperature slightly Hypothermia
Radiant warmer falsely increasing axillary temperature Hypothermia
Heart rate apical120-140 beatsmin Crying increasing heart rate sleep decreasing heart rate Bradycardia Resting reate below 80-100 BpmDuring 1st period of reactivity (6-8hr) rate up to 190 Bpm Tachycardia Rate above 160-180 Bpm
Irregular rhythm
Respiration 30-60 Bpm Crying increasing respiratory rate sleep decreasing respiratory Tachypnea Rate gt60 Bpmrate Apnea 20 sec or moreDuring 1st period of reactivity (6-8hr) rate up to 80 Bpm
Blood pressure (BP) oscillometric 6541 mmHg in Crying and activity increasing BP Oscillometric systolic pressure in calf 6-9 mmHg less thanArm and calf Placing cuff on thigh agitates ionfant in upper extremity (sign of coarctation aorta)
Thigh BP higher then arm or calf BP by 4-8mmHg
GENERAL APPEARANCEPosture Flexion of head and extremities which rest Frank breech Extended legs abducted and fully Limp posture Extension of ExtremitiesOn chest and abdomen rotated thighs Flattened occiput extended neck
SKINAt birth bright red puffy smooth Neonatal jaundice after first 24hr Progressive jaundice especially in first 24hr2nd-3rd day pink flasky dry Ecchymoses or petechiae caused by birth trauma Generalized cyanosisVernix caseosa Milia Distended sebaceous glands that appear PallorLanugo as tiny white papules on cheeks chin and nose MottlingEdema around eyes face legs dorsa of hands feet GraynessAnd scrotum or labia Milaria or sudamina Distended sweat (eccrine) PlethoraAcrocyanosis Cyanosis of hands and feet glands that appear as minute vesicles especially on face Hemorrhage ecchymoses or petechiae that persistCutis marmorata Transient mottling when infant is Erythema toxicum Ping popular rash with vesicles Sclereme Hard and stiff skinExposed to decreased temperature superimposed on thorax back buttocks and abdomenl Poor skin turgor
May appear in 24-48 hr and resolve after several days Rashes pustules or blistersErythema toxicum pink popular rash with vesicles cafeacute au lait spot light brown spotssuperimposed on thorax back buttocks and abdomen nevus flammeus port-wine stainmay appear in 24-48 hrs and resolve after several daysHarlequin Color change clearly outlined color changeas infant lies on the side lower half of body becomespink and upper half is paleMongolian spots irregular areas of deep blue pigmentationusually in sacral and gluteal regions seen predominantly in newborn of African native American asian or Hispanic descentTalengiectatic nevi (stork bite) flat deep pink localizedareas usually seen on back of neck
HEADAnterior fontanels Diamond shape size varies form molding after vaginal delivery fused suturesbarely palpable to 4-5 cm third sagital (parietal) fontanel bulging or depressed fontanels when quietPosterior fontanels triangular 05-1cm bulging fontanel because of crying or coughing widened sutures and fontanelsFontanels flat soft and firm caput succedaneum edema of soft scalp tissue craniotabes snapping sensation along lambdoidWidest part of fontanel measured from bone to bone cephalhematoma hematoma between periosteum and skull bone sutures that resembles indentation of ping-pong ballnot suture to suture
EYES
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
rapidly release arms Observe rapidity and intensity of recoil to state of flexion
Popliteal angle - With infants supine and pelvis flat on a firm surface flex lower leg on thigh and then flex thigh on abdomen While holding knee with numb and
and index finger extend lower legs with index finger of other hand Measure degree of angle behind knee (popliteal angle) Score an angle of less than 90 degree = 5
Scarf sign - with infant supine support head in midline with one hand use other hand to pull infantrsquos arm across the shoulder so that infantrsquos hand touches shoulder Determine location of elbow in relation to midline Score elbow does not reach midline = 4
Heel to ear - with infant supine and pelvis flat on a firm surface pull foot as far as possible up toward ear on same side measure distance of foot from ear and degree of knee flexion (same as popliteal angle) Score knees flexed with a popliteal angle of less than 10 degrees
SUMMARY OF PHYSICAL ASSESSMENT OF NEWBORN
USUAL FINDINGS COMMON VARIATIONS POTENTIAL SIGNS OF DISTRESSMINOR ABNORMALITIES MAJOR ABNORMALITIES
GENERAL MEASUREMENTSHead circumstance 33-35 cm (13-14 in) 1in Molding after birth altering head circumference Head Circumference lt10th orgt 90th percentileAbout 2-3cm (1 in) larger than chest circumference Head and chest circumference equal for first 1-2days after birth
Chest circumference 305-33cm (12-13 in)Crown-to-rump length 31-35cm (125-14in)Approximately equal to head circumferenceHead-to-heel length 48-53cm (19-21in)
Birth Weight 2700-4000g (6-9 lb) Loss of 10 of birth weight in first week regained in 10-14days Birth weight lt10th orgt 90th percentileDepending on feeding method
VITAL SIGNSTemperature axillary 365deg-37degC (979deg-98degF) Crying increasing body temperature slightly Hypothermia
Radiant warmer falsely increasing axillary temperature Hypothermia
Heart rate apical120-140 beatsmin Crying increasing heart rate sleep decreasing heart rate Bradycardia Resting reate below 80-100 BpmDuring 1st period of reactivity (6-8hr) rate up to 190 Bpm Tachycardia Rate above 160-180 Bpm
Irregular rhythm
Respiration 30-60 Bpm Crying increasing respiratory rate sleep decreasing respiratory Tachypnea Rate gt60 Bpmrate Apnea 20 sec or moreDuring 1st period of reactivity (6-8hr) rate up to 80 Bpm
Blood pressure (BP) oscillometric 6541 mmHg in Crying and activity increasing BP Oscillometric systolic pressure in calf 6-9 mmHg less thanArm and calf Placing cuff on thigh agitates ionfant in upper extremity (sign of coarctation aorta)
Thigh BP higher then arm or calf BP by 4-8mmHg
GENERAL APPEARANCEPosture Flexion of head and extremities which rest Frank breech Extended legs abducted and fully Limp posture Extension of ExtremitiesOn chest and abdomen rotated thighs Flattened occiput extended neck
SKINAt birth bright red puffy smooth Neonatal jaundice after first 24hr Progressive jaundice especially in first 24hr2nd-3rd day pink flasky dry Ecchymoses or petechiae caused by birth trauma Generalized cyanosisVernix caseosa Milia Distended sebaceous glands that appear PallorLanugo as tiny white papules on cheeks chin and nose MottlingEdema around eyes face legs dorsa of hands feet GraynessAnd scrotum or labia Milaria or sudamina Distended sweat (eccrine) PlethoraAcrocyanosis Cyanosis of hands and feet glands that appear as minute vesicles especially on face Hemorrhage ecchymoses or petechiae that persistCutis marmorata Transient mottling when infant is Erythema toxicum Ping popular rash with vesicles Sclereme Hard and stiff skinExposed to decreased temperature superimposed on thorax back buttocks and abdomenl Poor skin turgor
May appear in 24-48 hr and resolve after several days Rashes pustules or blistersErythema toxicum pink popular rash with vesicles cafeacute au lait spot light brown spotssuperimposed on thorax back buttocks and abdomen nevus flammeus port-wine stainmay appear in 24-48 hrs and resolve after several daysHarlequin Color change clearly outlined color changeas infant lies on the side lower half of body becomespink and upper half is paleMongolian spots irregular areas of deep blue pigmentationusually in sacral and gluteal regions seen predominantly in newborn of African native American asian or Hispanic descentTalengiectatic nevi (stork bite) flat deep pink localizedareas usually seen on back of neck
HEADAnterior fontanels Diamond shape size varies form molding after vaginal delivery fused suturesbarely palpable to 4-5 cm third sagital (parietal) fontanel bulging or depressed fontanels when quietPosterior fontanels triangular 05-1cm bulging fontanel because of crying or coughing widened sutures and fontanelsFontanels flat soft and firm caput succedaneum edema of soft scalp tissue craniotabes snapping sensation along lambdoidWidest part of fontanel measured from bone to bone cephalhematoma hematoma between periosteum and skull bone sutures that resembles indentation of ping-pong ballnot suture to suture
EYES
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
SUMMARY OF PHYSICAL ASSESSMENT OF NEWBORN
USUAL FINDINGS COMMON VARIATIONS POTENTIAL SIGNS OF DISTRESSMINOR ABNORMALITIES MAJOR ABNORMALITIES
GENERAL MEASUREMENTSHead circumstance 33-35 cm (13-14 in) 1in Molding after birth altering head circumference Head Circumference lt10th orgt 90th percentileAbout 2-3cm (1 in) larger than chest circumference Head and chest circumference equal for first 1-2days after birth
Chest circumference 305-33cm (12-13 in)Crown-to-rump length 31-35cm (125-14in)Approximately equal to head circumferenceHead-to-heel length 48-53cm (19-21in)
Birth Weight 2700-4000g (6-9 lb) Loss of 10 of birth weight in first week regained in 10-14days Birth weight lt10th orgt 90th percentileDepending on feeding method
VITAL SIGNSTemperature axillary 365deg-37degC (979deg-98degF) Crying increasing body temperature slightly Hypothermia
Radiant warmer falsely increasing axillary temperature Hypothermia
Heart rate apical120-140 beatsmin Crying increasing heart rate sleep decreasing heart rate Bradycardia Resting reate below 80-100 BpmDuring 1st period of reactivity (6-8hr) rate up to 190 Bpm Tachycardia Rate above 160-180 Bpm
Irregular rhythm
Respiration 30-60 Bpm Crying increasing respiratory rate sleep decreasing respiratory Tachypnea Rate gt60 Bpmrate Apnea 20 sec or moreDuring 1st period of reactivity (6-8hr) rate up to 80 Bpm
Blood pressure (BP) oscillometric 6541 mmHg in Crying and activity increasing BP Oscillometric systolic pressure in calf 6-9 mmHg less thanArm and calf Placing cuff on thigh agitates ionfant in upper extremity (sign of coarctation aorta)
Thigh BP higher then arm or calf BP by 4-8mmHg
GENERAL APPEARANCEPosture Flexion of head and extremities which rest Frank breech Extended legs abducted and fully Limp posture Extension of ExtremitiesOn chest and abdomen rotated thighs Flattened occiput extended neck
SKINAt birth bright red puffy smooth Neonatal jaundice after first 24hr Progressive jaundice especially in first 24hr2nd-3rd day pink flasky dry Ecchymoses or petechiae caused by birth trauma Generalized cyanosisVernix caseosa Milia Distended sebaceous glands that appear PallorLanugo as tiny white papules on cheeks chin and nose MottlingEdema around eyes face legs dorsa of hands feet GraynessAnd scrotum or labia Milaria or sudamina Distended sweat (eccrine) PlethoraAcrocyanosis Cyanosis of hands and feet glands that appear as minute vesicles especially on face Hemorrhage ecchymoses or petechiae that persistCutis marmorata Transient mottling when infant is Erythema toxicum Ping popular rash with vesicles Sclereme Hard and stiff skinExposed to decreased temperature superimposed on thorax back buttocks and abdomenl Poor skin turgor
May appear in 24-48 hr and resolve after several days Rashes pustules or blistersErythema toxicum pink popular rash with vesicles cafeacute au lait spot light brown spotssuperimposed on thorax back buttocks and abdomen nevus flammeus port-wine stainmay appear in 24-48 hrs and resolve after several daysHarlequin Color change clearly outlined color changeas infant lies on the side lower half of body becomespink and upper half is paleMongolian spots irregular areas of deep blue pigmentationusually in sacral and gluteal regions seen predominantly in newborn of African native American asian or Hispanic descentTalengiectatic nevi (stork bite) flat deep pink localizedareas usually seen on back of neck
HEADAnterior fontanels Diamond shape size varies form molding after vaginal delivery fused suturesbarely palpable to 4-5 cm third sagital (parietal) fontanel bulging or depressed fontanels when quietPosterior fontanels triangular 05-1cm bulging fontanel because of crying or coughing widened sutures and fontanelsFontanels flat soft and firm caput succedaneum edema of soft scalp tissue craniotabes snapping sensation along lambdoidWidest part of fontanel measured from bone to bone cephalhematoma hematoma between periosteum and skull bone sutures that resembles indentation of ping-pong ballnot suture to suture
EYES
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Thigh BP higher then arm or calf BP by 4-8mmHg
GENERAL APPEARANCEPosture Flexion of head and extremities which rest Frank breech Extended legs abducted and fully Limp posture Extension of ExtremitiesOn chest and abdomen rotated thighs Flattened occiput extended neck
SKINAt birth bright red puffy smooth Neonatal jaundice after first 24hr Progressive jaundice especially in first 24hr2nd-3rd day pink flasky dry Ecchymoses or petechiae caused by birth trauma Generalized cyanosisVernix caseosa Milia Distended sebaceous glands that appear PallorLanugo as tiny white papules on cheeks chin and nose MottlingEdema around eyes face legs dorsa of hands feet GraynessAnd scrotum or labia Milaria or sudamina Distended sweat (eccrine) PlethoraAcrocyanosis Cyanosis of hands and feet glands that appear as minute vesicles especially on face Hemorrhage ecchymoses or petechiae that persistCutis marmorata Transient mottling when infant is Erythema toxicum Ping popular rash with vesicles Sclereme Hard and stiff skinExposed to decreased temperature superimposed on thorax back buttocks and abdomenl Poor skin turgor
May appear in 24-48 hr and resolve after several days Rashes pustules or blistersErythema toxicum pink popular rash with vesicles cafeacute au lait spot light brown spotssuperimposed on thorax back buttocks and abdomen nevus flammeus port-wine stainmay appear in 24-48 hrs and resolve after several daysHarlequin Color change clearly outlined color changeas infant lies on the side lower half of body becomespink and upper half is paleMongolian spots irregular areas of deep blue pigmentationusually in sacral and gluteal regions seen predominantly in newborn of African native American asian or Hispanic descentTalengiectatic nevi (stork bite) flat deep pink localizedareas usually seen on back of neck
HEADAnterior fontanels Diamond shape size varies form molding after vaginal delivery fused suturesbarely palpable to 4-5 cm third sagital (parietal) fontanel bulging or depressed fontanels when quietPosterior fontanels triangular 05-1cm bulging fontanel because of crying or coughing widened sutures and fontanelsFontanels flat soft and firm caput succedaneum edema of soft scalp tissue craniotabes snapping sensation along lambdoidWidest part of fontanel measured from bone to bone cephalhematoma hematoma between periosteum and skull bone sutures that resembles indentation of ping-pong ballnot suture to suture
EYES
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Lids usually oedematous epicanthal folds in asian infants pink color of irisColor slate gray dark blue brown searching nystagmus or strabismus purulent dischargeAbsence of tears subconjuctival (sclera) hemorrhage ruptured capillaries upward slunt in non-asiansPresence of red reflex usually at limbus hypertelorismCorneal reflex in response to touch hypotelorismPupillary reflex in responsing to light congenital cataractsBlink reflex in response to light or touch constricted or dilated fixed pupilRudimentary fixation on objects and ability to follow to midline absence of red reflex
Absence of papillary or corneal reflexInability to follow object or bright light to midlineYellow sclera
EARSPosition top of pinna on horizontal line with outer canthus of eye inability to visualize tympanic membrane because of low placement of earsStartle reflex elicited by loud sudden noise filled aural canals absence of startle reflex in response to loud noisePinna flexible cartilage present pinna flag against head minor abnormalities possible signs of various
Irregular shape or size syndrome especially renalPits or skin tag
NOSENasal patencyNasal discharge Thin white mucus Flattened and bruised Nonpatent canalsSneezing Thick bloody nasal discharge
Flaring of nares (alae nasi)Copious nasal secretions or stuffiness (may be minor)
MOUTH AND THROATIntact high-arched palate nasal teeth teeth present at bith benign but may be cleft lipUvula in midline associated with congenital defects cleft palateFrenulum of tongue Epstein pearls Small white epithelial cysts along large protruding tongue or posterior displacement ofFrenum of upper lip midline of hard palate tongueSucking reflex strong and coordinated profuse salivation or droolingRooting reflex Candidiasis (thrush) white adherent patches onGag reflex tongue palate and buccal surfacesExtrusion reflex Inability to pass nasogastric tubeAbsent or minimum salivation Hoarse high-pitched weak absent or other abnormal cryVigorous cry
NECKShort thick usually sorounded by skin folds Torticollis (wry neck) head held to one side with chin Excessive skin foldsTonic neck reflex pointing to opposite side Resistance to flexion
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Absence of tonic neck reflexFractured clavicle crepitus
CHESTAnteroposterior and lateral diameters equal Funnel chest (pectus excavatum) Depressed sternumSlight sterna retractions evident during inspiration Pigeon chest (pectus carinatum) Marked retractions of chest and intercostals apacesXiphoid process evident Supernumerary nipples during respirationBreast enlargement secretion of milky substance from breast (witchrsquos milk) Asymmetric chest expansion
Redness and firmness around nipplesWide-spaced nipples
LUNGSRespirations chiefly abdominal Rate and depth of respirations may be irregular Inspiratory stridorCough reflex absent at birth present by 1-2 days periodic breathing Expiratory gruntBilateral equal bronchial breath sounds Crackles shortly after birth Retractions
Persistent irregular breathingPeriodic breathing with repeated apneic spellsSeesaw respirations (paradoxical)
Unequal breath soundsPersistent fine medium or coarse cracklesWheezingDiminished breath soundsPeristaltic bowel sounds on one side with diminished
Sounds on same side
HEARTApex 4th-5th intercostals spacelateral to left sterna Sinus arrhythmia Heart rate increasing with Dextrocardia Heart on right side
Border inspiration and decreasing with expiration Displacement of apex muffledS2 slightly sharper and higher in pitch than S1 Transient cyanosis on crying or straining Cardiomegaly
Abdominal shuntsMurmurThrillPersistent central cyanosisHyperactive precordium
ABDOMENCylindric in shape Umbilical hernia abdominal distentionLiver palpable 2-3 cm (08 to 18 in) below right Diastasis recti Midline gap between recti muscles Localized bulging
Costal margin Wharton jelly unusual thick umbilical cord Distended veinsSpleen Tip palpable at end of 1st week of age Absent bowel sounds
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Kidneys palpable 1-2 cm (04 to 08 in) above Enlarged liver and spleenUmbilicus Ascites
Umbilical cord Bluish white at birth with 2 arteries Visible peristaltic wavesAnd vein Scaphoid or concave abdomen
Femoral pulse equal bilaterally Moist umbilical cordPresence of only one artery in cord insertion sitePeriumbilical erythemaPalpable bladder distension after scant voidingAbsent femoral pulsesCord bleeding or hematomaOmphalocele or gastroschisisProtrusion of abdominal
contents abdominal wall defect
FEMALE GENITALIA
Labia and clitoris usually edematous Pseudomenstruation Blood-tinged or mucoid discharge Enlarged clitoris with urethral meatus at tipUrethral meatus behind clitoris Hymenal lag Fused labiaVernix caseosa between labia Absence of vaginal openingUrination within 24 hours Meconium from vaginal opening No urination within 24 hours Masses in labia Ambiguous genitalia Bladder exstrophy
MALE GENITALIA
Urethral opening at tip of glans penis Urethral opening covered by prepuce Hypospadia urethral opening on ventral surface of penisTestes palpable in each scrotum Inability to retract foreskin Epispadias urethral opening on dorsal surface of penisScrotum usually large edematous Epithelial pearls Small frim white lesions at tip of prepuce Chordee ventral curvature of penispendulous and covered with rugae usually Erection of priapism Testes not palpable in scrotum or inguinal canaldeeply pigmented in dark-skinned ethnic groups Testes palpable in inguinal canal No urination within 24 hrsSmegma Inguinal herniaUrination within 24 hours Scrotum Hypoplastic scrotum
Hydrocele Fluid in scrotum Masses in scrotum Meconium from scrotum Discoloration of testes Ambiguous genitalia Bladder exstrophy
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
BACK RECTUM
Spine intact no opening masses or prominent Green liquid stools in infant under phototherapy Anal fissures or fistulascurves Dekayed passage of meconium in very-low-birth weight Imperforate anusTrunk incurvation reflex neonates Absence of anal reflexAnal reflex No meconium within 36-48 hrsPatent anal opening Pilonidal cyst or sinusPassage of meconium within 48 hrs Tuft of hair along spine
Spina bifida (any degree)
EXTREMITIES10 fingers and toes Partial syndactyly between 2nd and 3rd toesNail beds pink with transient cyanosis immediately 2nd toe overlapping into 3rd toe After bith wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st Creases on anterior 23 of sole and 2nd toes Polydactyly extra digitsSole usually flat Asymmetric length of toes Syndactyly fused or webbed digitsSymmetry of extremities Dorsiflexion and shortness of hallux phocomelia hands or feet attached close to trunkEqual muscle tone bilaterally especially resistance to Hemimelia Absence of distal part of extremity Opposing flexion Hyperflixibility of jointsEqual bilateral brachial pulses Persistent cyanosis of nail beds
Yellowing of nail beds Sole covered with creases Fractures Decrease or absenceusually of range of motion(ROM) Unequal muscle tone or ROM
NEUROMUSCULAR SYSTEM
Extremities usually in some degrees of flexion Quevering or momentary tremors Hypotonia Floppy poor head control extremities limpExtension of extremity followed by previous position of Hypertonia Jittery arms and hands tightly flexed legsflexion stiffly extended startles easilyHead lag while sitting but momentary ability to hold head Assymmetric posturing (except tonic neck reflex)erect Opisthotonic posturing Arched back
Signs of paralysiaTremors twitches and myclonic jerksMarked head lag in all positions
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
ASSESSMENT OF REFLEXES IN THE NEWBORN
REFLEXES EXPECTED BEHAVIORIAL RESPONSESLOCALILZEDEyesBlinking or corneal reflex
Pupillary
Dollrsquos eye
Nose Sneeze
Glabellar
Mouth and ThroatSucking
Gag
Rooting
Extrusion
Yawn
Cough
Infant blinks at sudden appearance of bright light or at approach of object toward cornea persists throughout life
Pupil constricts when bright light shines toward it persists throughout life
As head is moved slowly to right or left eyes lag behind and do not immediately adjust to new position of head disappears as fixation develops if persists indicates neurologic damage
Nasal passages respond spontaneously to irritation or obstruction persists throughout life
Tapping briskly on glabella (bridge of nose) causes eyes to close tightly
Infant begins strong sucking movements of circumoral area in response to stimulation persists throughout infancy even without stimulation such as during sleep
Stimulation of posterior pharynx by food suction or passage of tube causes infant to gag persists throughout life
Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck should disappear at about age 3-4 months but may persist for up to 12 months
When tongue is touched or depresses infant responds by forcing it outward disappears by age 4 months
Infant has spontaneous response to decreased oxygen by increasing amount of inspired air persists throughout life
Irritation of mucus membranes of larynx or tracheobronchial tree causes coughing persists throughout life usually present after 1st day of birth
EXETREMITIESGrasp Touching palms or soles near base of digits causes flexion of hands and toes palmar grasp lessens after age 3 months
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Babinski
Ankle clonus
to be replaced by voluntary movement plantar grasp lessens by 8 months of age
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex disappears after age 1 year
Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements (ldquobeatsrdquo) eventually no beats should be felt
MASSMoro
Startle
Perez
Asymmetric tonic neck
Trunk incurvation (Galant) reflex
Dance or step
Crawl
Placing
Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape followed by flexion and adduction of extremities legs may weakly flex infant may cry disappears after age 3-4 months usually strongest during first 2 months
Sudden loud noise causes abduction of arms with flexion of elbows hands remained clenched disappears by age 4 months
While infant is prone on firm surface and thumb is pressed along spine from sacrum to neck infant responds by crying flexing extremities and elevating pelvis and head lordosis of spine defecation and urination may occur disappears by age 4-6 months When infantrsquos head is turned to one side arm and leg extend on that side and opposite arm and leg flex disappears by age 3-4 months to be replaced by symmetric positioning of both side of body Striking infantrsquos back alongside spine cause hips to move toward stimulated side disappears by age 4 weeks
If infant is held so that sole of foot touches hard surface there us reciprocal flexion and extension of leg stimulating walking disappears after age 3-4 weeks to be replaced by deliberate movement
When place on abdomen infant makes crawling movements with arms and legs disappears at about age 6 weeks
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object such as table leg lifts as if foot is stepping on table age of disappearance varies
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
ANATOMY AND PHYSIOLOGY
CIRCULATORY
Drying and Clamping of the Umbilical cord and stimulation of cold receptors
Increased PCO2 decreased PO2 and Increasing Acidosis
First Breath
Decreased Pulmonary Artery pressure
Closer of Foramen Ovale (pressure in the left side of hearth greater than in right
side)
Increased PO2
Closure of Ductus Arteriosus
Closure of Ductus Venosus and Umbilical arteries and Vein due to decreased flow
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
THERMOREGULATION
Is a process of maintaining balance between heat loss and heat production
1st the newbornrsquos large surface are relative to his or her weight facilitates heat loss to the environment
2nd the newbornrsquos thin layer of subcutaneous fat
3rd the newbornrsquos mechanism for producing heat
Mechanism of Heat loss a) Convection
Is the flow of the heat from the newbornrsquos body surface to cooler surrounding air
b) Conduction
Is the transfer of body heat to a cooler solid object in contact with a baby
c) Radiation
Is the transfer of body heat to a cooler solid object not in contact with a baby such as a cold window or air conditioner
d) Evaporation
Is the loss of heat through conversion of a liquid to a vapor
HEMOPOEITIC SYSTEM 80 ndash 85 mlkg blood volume of the full-term infant
300 ml after birth total blood volume
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
FLUID AND ELECTROLYTES
Changes occur in the total body water volume
Extracellular fluid volume
Intracellular fluid volume
GASTROINTESTINAL SYSTEM
The newbornrsquos ability to digest absorb and metabolize food is adequate but limited in certain functions Enzymes are available to catalyze proteins and simple carbohydrates (monosaccharides and disaccharides) but deficient production of
pancreatic amylase impairs utilization of complex carbohydrates (polysaccharides) A deficiency of pancreatic lipase limits the absorption of fats especially with ingestion of foods that have high saturated fatty acid content
such as cowrsquos milk Human milk despite itrsquos high fat content is easily digested and absorbed because it contains enzymes such as lipase which assist in
digestion The liver is the most immature of the gastrointestinal organs The activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin with glucuronic acid which contributes
to physiologic jaundice of the newborn The liver is also deficient in forming plasma proteins which likely plays a role in the edema usually seen at birth Prothrombin and other coagulation factors are also law The liver stores less glycogen at birth glycemia which may be prevented by early and effective feeding especially breast-feeding Salivary glands are functioning at birth but the majority do not begin to secrete saliva until about 2 to 3 months when drooling is common The stomach capacity is limited to about 90 ml I in an average-sized full-term infant(75 pounds [34 kg]) thus the infant requires frequent
small feedings Newborns who breast-feed usually have more frequent feedings and more frequent stools than infants who receive formula
CHANGE IN STOOLING PATTERNS OF NEWBORNS
MECONIUM
o This is the infantrsquos first stool composed of amniotic fluid and itrsquos constituents intestinal secretions shed mucosal cells and possibly blood
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
o Passage of meconium should occur within the first 24 to 48 hours although it may be delayed up to 10 days in very-low-birth-weight infants
TRANSITIONAL STOOLS
o These usually appear by the third day after initiation of feeding they are greenish brown to yellowish brown thin and less sticky than meconuim and may contain some milk curds
MILK STOOLS
o These usually appear by fourth dayo In breast-fed infants stools are yellow to golden are pasty in consistency and have an odor similar to that of sour milko In formula-fed infants stools are pale yellow to light brown are firmer in consistency and have a more offensive odor
RENAL SYSTEM
All structural components are present in the renal system but the kidney has a functional deficiency in itrsquos ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute load
Total volume of urinary output per 24 hours is about 200 to 300 ml by the end of the first week The bladder involuntarily empties when stretched by a volume of 15 ml resulting in as many as 20 voidings per day The first voiding
should occur within 24 hours The urine is colorless and odorless and has a specific gravity of approximately 1020
INTEGUMENTARY SYSTEM
At birth all structures within the skin are present but many of the functions of the integument are immature The two layers of the skin the epidermis and dermis are loosely bound to each other and are very thin Rete pegs which later in life anchor the epidermis to the dermis are not developed Slight friction across the epidermis such as from rapid removal of tape can cause separation of these layers and blister formation or loss
of the epidermis In full-term infants the transitional zone between the cornified and living layers of epidermis is effective in preventing fluid from reaching
the skin surface
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
The sebaceous glands are active late in fetal life and in early infancy because of high levels of maternal androgens They are most densely located on the scalp face and the genitalia and produced the grayish white greasy vernix caseosa that covers the infant at birth
The eccrine glands which produce sweat in response to heat or emotional stimuli are functional at birth and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults Observing palmar sweating is helpful in assessing pain
The eccrine glands produce sweat in response to higher temperatures than those required in adults and the retention of sweat may result in milia
The apocrine glands sweat glands that develop as attachments to hair follicles remain small and non-functional until puberty The growth phases of hair follicles usually occur simultaneously at birth During the first few months the synchrony between hair loss and re-growth is disrupted and there may be over-growth of hair or
temporary alopecia The amount of melanin is low at birth newborns are lighter skinned than they will be as children Consequently infants are more susceptible to the harmful effects of ultraviolet light such as the sun
MUSCULOSKELETAL SYSTEM
At birth the skeletal system contains larger amounts of cartilage than ossified bone although the process of ossification is fairly rapid during the first year The nose for example is predominantly cartilage at birth and is frequently by the force of delivery The six skull bones are relatively soft and not yet joined The sinuses are incompletely formed as well Unlike the skeletal system the muscular system is almost completely formed at birth Growth in the size of muscular tissue is caused by hypertrophy rather than hyperplasia of cells
ENDOCRINE SYSTEM
Ordinarily the newbornrsquos endocrine system is adequately developed but its functions are immature For example the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone or vasopressin which inhibits dieresis This renders the newborn highly susceptible to dehydration The effect of maternal sex hormones is particularly evident in the newborn The labia are hypertrophied and the breasts in both sexes may be engorged and secrete milk (witchrsquos milk) during the first few days of life to as long as 2 months of age Female newborns may have pseudo menstruation (more often seen as a milky secretion rather than actual blood) from a sudden drop in progesterone and estrogen levels
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
RESPIRATORY SYSTEM
The most critical and immediate physiologic change required of the newborn is the onset of breathing The stimuli that help initiate respiration are primarily chemical and thermal Chemical factors
1 Low oxygen
2 High carbon dioxide
3 Low pH
The primary thermal stimulus is the sudden chilling if the infant who leaves a warm environment and enters a relatively cooler atmosphere This abrupt change in the temperature excites sensory impulses in the skin that are transmitted to the respiratory center Tactile stimulation may assist in initiating respiration Descent through the birth canal and normal handling during delivery such as drying the skin help stimulate respiration in uncompromised infants Acceptable methods of tactile stimulation include slapping or flicking the soles of the feet or gently rubbing the newbornrsquos back trunk or extremities Slapping the newbornrsquos buttocks or back is a harmful technique and should not be done The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli Some fetal lung fluid is removed during the normal forces of labor and delivery As the chest emerges from the birth canal fluid is squeezed from the lungs through the nose and mouth After complete emergence of the neonatersquos chest brisk recoil of the thorax occurs Air enters the upper airway to replace the lost fluid In the alveoli the fluidrsquos surface tension is reduced by surfactant a substance produced by the alveolar epithelium that coats the alveolar surface
NEUROLOGIC SYSTEM
At birth nervous system is immature and incomplete integrated but there is a sufficient development to sustain extrauterine life Most neurologic functions are primitive reflexes The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid-base balance and partially regulates temperature control
Myelination of the nervous system follows the cephalocaudal-proximodistala (head-to-toe-center-to-periphery) laws of development and is closely related to the observed mastery of fine and gross motor skills Myelin is necessary for rapid and efficient transmission of some but not all nerve impulses along the neural pathway Tracts that develop myelin earliest are the sensory cerebellar and extrapyramidal This accounts for the acute senses of taste smell and hearing as well as the perception of pain in the newborn All cranial nerves are myelinated except the optic and olfactory nerves
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
SENSORY FUNCTIONS
The newbornrsquos sensory functions are remarkably well developed and have a significant effect on groth and development including attachment process
VisionAt birth the eye is structurally incomplete The fovea centralis is not yet completely differentiated from the macula The ciliary muscles are also immature limiting the eyesrsquo ability to accommodate and fixate on an object for any length of time The pupils react to light the blink reflex is responsive to minimum stimulus and the corneal reflex is activated by a light touch Tear glands usually do not begin to function until 2-4 weeks of ageThe newborn has the ability to momentarily fixate on a bright moving object that is within 20 cm (8 inches) and in the midline of the visual field In fact the infantrsquos ability to fixate or coordinate movement is greater during the first hour of life than during the succeeding several days Visual acuity is reported to be between 20100 and 20400 depending on the vision measurement techniquesThe infant also demonstrates visual preferences medium colors over dim or bright colors black-and-white contrasting patterns especially geometric shapes and checkerboards large objects with medium complexity rather than small complex objects and reflecting objects over dull ones
HearingOnce the amniotic fluid has drained from the ears the infant probably has auditory acuity similar to that of an adult The newborn is able to detect a loud sound of about 90 dB and reacts with a startle reflex The newbornrsquos response to sounds of low frequency and high frequency differs the former such as heartbeat metronome or lullaby tends to decrease an infantrsquos motor activity and crying whereas the latter elicits an alerting reaction
SmellNewborns react to strong odors such as alcohol or vinegar by turning their heads away Breast-fed infants are able to smell breast milk and will cry for their mothers when the breasts are leaking Infants are also able to differentiate their motherrsquos breast milk from that of other women by smell Maternal odors are belived to influence the attachment process and successful breast-feeding Unnecessary routine washing of the breasts may interfere with establishment of early breast-feeding
TasteThe newborn can distinguish between tastes and various types of solutions elicit differing facial reflexes A tasteless solution elicits no facial expression a sweet solution elicits an eager suck and a look of satisfaction a sour solution causes the usual puckering of the lipsl and a bitter liquid produces an angry upset expression Newborns prefer the sweet taste of glucose and water to sterile water
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
TouchThe newborn perceives tactile sensation in any part of the body although the face hands and soles of the feet seem to be most sensitive Sufficient evidence now shows that touch and motion are essential components in the attachment process and in normal growth and development Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from the infant However painful stimuli such as pinprick elicit an upset response
IMMUNE SYSTEM
At the time of birth babies still have the high amount of IgG in their bloodstream yet their overall immunity to germs is still not completely developed Now the newborns must receive further immune system help via the breast milk However the first thing secreted from the breasts is actually the colostrum It is a thick carbohydrate-rich substance that is easier for a baby to digest Additionally the colostrum is packed with antibodies to give the newborn a first package of other adaptive immunoglobulin types
Once the regular breast milk starts to flow it also contains necessary immune system components By drinking breast milk babies receive doses of immunoglobulins A E M D and more IgG This is called passive immunity However this does not mean that the immunoglobulin doesnt fight germs-it just means that the mother has transferred active immunity to her child (passed it on)
Over time the mother gives less and less immunity to the baby via the breast milk In fact the newborns germ-fighting system begins making its own antibodies when the child is 2-3 months old The production of antibodies does not reach a normal adult rate until the baby is about six months of age
When a child is newly born its immunity is not yet strong enough to protect it from harm Thus doctors and hospitals should be very careful with allowing newborns to come into contact with things that can cause possible birth infections
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
NURSING PRINCIPLES
MAINTAIN A PATENT AIRWAY
Establishing a patent airway is the primary objective in the delivery room When the newborn is supine a neutral neck position (avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway After feeding position the infant to facilitate drainage of secretions
Suctioning if needed may be done with a bulb syringe Used bulb syringe should be replaced every 24 hours in the hospital and boiled for 10 minutes after use in the home to prevent bacterial contamination Use of the proper ndashsized catheter and correct suctioning technique is essential to prevent mucosal damage and edema Gentle suctioning is necessary to prevent laryngospasm reflex bradycardia and other cardiac arrythmias from vagal stimulation
If nasal suctioning is necessary it must be done after oral suctioning to minimize the possibility of aspiration of oropharyngeal contents The stomach may be emptied to remove amniotic fluid passing a catheter to the stomach may also rule out esophageal atresia Vital signs are
closely monitored and any indication of respiratory distress is immediately reported
MAINTAIN A STABLE BODY TEMPERATURE
Conserving the newbornrsquos body heat is an essential nursing goal At birth a major cause of heat loss is evaporation the loss of heat through moisture The amniotic fluid that bathes the infantrsquos skin favors evaporation especially when combined with the cool atmosphere of the delivery room Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in a heated environment
Another source of heat loss is radiation the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant Loss of heat through radiation increases as these solid objects become colder and closer to the infant The temperature of ambient air in the incubator essentially has no effect on loss of heat through radiation This is a critical point to remember when attempting to maintain a constant temperature for the infant because even when the temperature of the ambient air is optimum the infant can become hypothermic
An example of radiant heat loss is the placement of the incubator close to a close window or air conditioning unit The cold from either source will cool the incubator walls and subsequently the neonatersquos body To prevent this the incubator is placed as far as away as possible from walls windows or ventilating units
Heat loss can also occur through conduction ad convection Conduction involves loss of body heat from direct skin contact with a cooler solid object it is minimized by placing the infant on a padded covered surface rather than directly on a cool hard table and by providing insulation with
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
clothes and blankets Placing the newborn nested close to the mother such as in her arms or on her abdomen immediately after delivery in skin-to-skin contact(kangaroo care) is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breast-feeding
Convection is similar to conduction except that heat loss is aided by surrounding air currents For example placing the infant in the direct flow of air from a fan or air conditioning vent causes rapid heat loss through convention Transporting the neonate in a crib with solid sides reduces airflow around the infant
Protect from Infection and Injury The most important practice fro preventing cross-infection is thorough hand washing by al individuals involved in the infantrsquos care Other
procedures to prevent infection include eye care umbilical care bathing and care of the circumcision
IDENTIFICATION
Proper identification of the newborn is essential The nurse must verify that identifying bands are securely fastened on the newborn and verify the information (name sex motherrsquos admission number date and time of birth) against the birth records and the childrsquos actual gender
PROTECTION FROM INFECTION AND INJURY
EYE CARE (CREDErsquoS PROPHYLAXIS)
Prophylactic eye treatment against opthalmia neonatorum infectious conjunctivitis of the newborn includes the use of (1) silver nitrate (1) solution (2) erythromycin (05) ophthalmic ointment or drops or (3) tetracydine (1) ophthalmic ointment or drops (preferably in single-dose ampules or tubes)
VITAMIN K ADMINISTRATIONShortly after birth vitamin k is administered as a single intramuscular dose of 05 to 1 mg to prevent hemorrhagic disease of the newborn Normally vitamin K is synthesized by the intestinal flora However because the infantrsquos intestine is presumably sterile at birth and because breast milk contains low levels of vitamin K the supply is inadequate for at least the first 3 days to 4 days The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver which is needed for blood clotting The vastus lateralis muscle is the traditionally recommended injection site
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
HEPATITIS B VACCINATIONTo decrease the incidence of hepatitis B virus (HBV) in children and its serious consequences cirrhosis ad liver cancer in adulthood the first 3 doses of HBV vaccine is recommended between birth and 2 months of age for all newborns born to hepatitis B surface antigen (HBsAg)- negative mothers The injection is given in the vastus lateralis muscle since this site is associated with a better immune response
DRUG STUDY
Brand nameor
Generic name
General action
Indication Mechanism of action
Side effects amp Adverse effects
Drug interaction Route Frequency
dosageAquamephat
onor
Phytonadione
Vitamin K is used for
the prophylaxi
s and treatment
of hemorrha
gic disease of
the newborn
It is a necessary component for the
production of
certain coagulation factors (II VII IX and X)
Hypoprothrombinemia cause by Vitamin K malabsorption drug therapy or excessive
Vitamin A dosage
Hypoprothrobinemia caused by effects of oral coagulant
To prevent hemorrhagic disease of the newborn
To prevent hypoprothrombinemia related
to Vitamin K deficiency in long term parenteral
nutrition
To prevent hypoprothrombinemia in infants receiving less less than 01 mgL Vitamin K in
breast milk or milk substitutes
An anti-hemorrhagic factor that
promotes hepatic
formation of active
coagulation factor
CNS dizziness
CV flushing transient
hypotension after IV
administration rapid and weak
pulse
Skin diaphoresis erythema
Other anaphylaxis or anaphylactoid
reactions usually after excessively
rapid IV administration pain swelling
and hematoma in injection site
Anticoagulant may cause temporary
resistance to prothrombin-depressing coagulants
especially when large doses of
phytonadione are used Monitor
patient closely
Cholestyramine mineral oil or list at may inhibit GI
absorption of oral Vitamin K
separate doses if possible If
unavailable use together
cautiously
Prophylaxis- 05 to 10 mg IM one time immediately after
birth treatment
for hemorrha
gic disease
1 to 2 mg intramusc
ular or subcutan
eous daily
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
produced by
microorganism in
the intestinal
tractNursing considerations
Check brand name labels for administration route and restriction
For IM administration on adults and other children give in upper outer quadrant of buttocks for infants give in anterolateral aspect of thigh and deltoid region SC route is preferred to avoid hematoma transition
Allergic reactions may also occur after IM or SC use
Anticipate order for wkly addition of 5 to 10 mg of phytonadione to total parenteral nutrition solution
Monitor patient or INR to determine dosage effectiveness
If severe bleeding occurs donrsquot delay after measures such as administration of fresh frozen plasma of whole blood
Vitamin K doesnrsquot reverse the anticoagulant effects of heparin
Watch for flushing weakness tachycardia and hypotension condition may progress to shock
Phytonadione therapy for hemorrhagic disease in infantsrsquo causes fever adverse reactions than other Vitamin K analogues
Brand name or Generic
name
General action Indication Mechanism of action
Side effects amp Adverse reactions
Drug interactio
n
Route Frequency dosage
Ilotycin or Erythromycin an Acute and chronic Inhibit protein EENT slowed None 05-1 cm in
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Erythromycin(ophthalmic ointment)
antibiotic is effective against gonorrhea and
Chlamydia microorganisms
making it the drug of choice for eye
prophylaxis at birth
conjunctivitis other eye infection
Chlamydial ophthalmic infection
To prevent opthalmia
neonatorum caused by Nesseiria gonorrhea
synthesis usually bacteriostatic but
may be bactericidal in high
concentrations or against highly
susceptible microorganisms
corneal wound healing blurred
vision itching and burning eyes
Skin urticaria dermatitis
Other overgrowth of non-susceptible microorganisms
with long term use
significant each eye
Nursing considerations
To prevent opthalmia neonatorum apply ointment not later than 1 hour after birth Drug is used in neonates born either vaginally or by Caesarian section Gently massage eyelids for 1 minute to spread ointment
Use drug only when sensitivities studies show itrsquos effective against infecting microorganisms donrsquot use in infection of unknown cause
Store drug at room temperature in tightly closed light resistant container
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
For the BabyVaccine Minimum age at 1st of Doses Minimum interval Route Dosage Storage temp Typeform of
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
dose between doses Site vaccineBCG Birth or anytime
after birth1 ID 005 ml right
arm2-8 degree celcius in body of ref
Freeze dried live attenuated bacteria
DPT 6 weeks 3 4 weeks IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
D- weakened toxinP- killed bacteriaT- toxin
OPV 6 weeks 3 4 weeks Oral 2 drops Mouth
-15 to -25 degree celcius (freezer)
Live attenuated virus
Hepa B At birth 3 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd to 3rd dose
IM 05 ml Thigh (vastus lateralis)
2-8 degree celcius in body of ref
RNA recombinant
NEWBORN SCREENING FOR DISEASEa What is newborn screening -Is the process of testing newborn babies for treatable genetic endocrinologic metabolic and hematologic diseases b Why is it important to have newborn screening - Most babies with metabolic disorders look normal at birth One will never know that the baby has the disorder until the onset of signs and symptoms and more often ill effects are already irreversible c When is newborn screening done - Newborn screening is ideally done on the 48th hour or at least 24 hours from birth Some disorders are not detected if the test is done earlier than 24 hours The baby must be screened again after 2 weeks for more accurate results d How is new born screening done - Newborn screening is a simple procedure Using the heel prick method a few drops of blood are taken from the babys heel and blotted on a special absorbent filter card The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab) e How much is the fee for newborn screening -P550 The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample f When are newborn screening results available -Newborn screening results are available within seven working days to three weeks after the NBS Lab receives and tests the samples sent by the institutions Results are released by NBS Lab to the institutions and are released to your attending birth attendants or physicians Parents
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
may seek the results from the institutions where samples are collected A negative screen mean that the result of the test is normal and the baby is not suffering from any of the disorders being screened In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator of the institution where the sample was collected for recall of patients for confirmatory testing g Who will collect the sample for newborn screening -Newborn screening can be done by a physician a nurse a midwife or medical technologist h Where is newborn screening available - Newborn screening is available in participating health institutions (hospitals lying-ins Rural Health Units and Health Centers) If babies are delivered at home babies may be brought to the nearest institution offering newborn screening i What are the disorders included in the newborn screening package Define each - 1 Congenital Hypothyroidism (CH) CH results from lack or absence of thyroid hormone which is essential to growth of the brain and the body If the disorder is not detected and hormone replacement is not initiated within (4) weeks the babys physical growth will be stunted and shehe may suffer from mental retardation 2 Congenital Adrenal Hyperplasia (CAH) CAH is an endocrine disorder that causes severe salt lose dehydration and abnormally high levels of male sex hormones in both boys and girls If not detected and treated early babies may die within 7-14 days 3 Galactosemia (GAL)GAL is a condition in which the body is unable to process galactose the sugar present in milk Accumulation of excessive galactose in the body can cause many problems including liver damage brain damage and cataracts 4 Phenylketonuria (PKU)PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called phenylalanine Excessive accumulation of phenylalanine in the body causes brain damage 5 Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)G6PD deficiency is a condition where the body lacks the enzyme called G6PD Babies with this deficiency may have hemolytic anemia resulting from exposure to certain drugs foods and chemicals j What should be done when a baby is tested a positive NBS result -Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory testing and further management Should there be no specialist in the area the NBS secretariat office will assist its attending physician
BATHING
Bath time is an opportunity for the nurse to accomplish much more than general hygiene It is an excellent time for observing the infants behavior state of arousal alertness and muscular activity Bathing is usually performed after the vital signs have stabilized especially the temperature
Because of the possibility of blood and body fluid contagions as part of Standard Precautions nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing
The bath time provides an opportunity for the nurse to involve the parents in the care of their child to teach correct hygiene procedures and to help them learn about their infantrsquos individual characteristics
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Cleansing should proceed in the cephalocaudal direction Vigorous rubbing to remove vernix is unnecessary and may cause more harm than good A diaper is applied after bath and the infant is clothed appropriately to prevent heal loss
CARE OF THE UMBILICUS
Because the umbilical stump is an excellent medium for bacterial growth various methods of cord care practiced to prevent infection Common methods include the use of an antimicrobial agent such as bacitracin or triple dye although some experts advocate the use of alcohol alone soap and water sterile water povidone-iodine or no treatment (natural healing)
The diaper is placed below the cord to avoid irritation and wetness on the site Parents are instructed regarding stump deterioration and proper umbilical care The stump deteriorates through the process of dry gangrene Cord separation time is influenced by a number of factors including type of cord care type of delivery and other perinatal events The average cord separation time is 10 to 14 days It takes a few more weeks for the cord base to heal completely after cord separation During this time care consists of keeping the base clean and dry and observing for any signs of infection
CIRCUMSICION
Risks and Benefits of Neonatal CircumcisionRISKS (COMPLICATIONS)Hemorrhage Infection Dehiscence (separation of approximated edges of skin) Meatitis (from loss of protective foreskin) Adhesions Concealed penis Urethral fistula Meatal stenosis Pain in unanesthesized infants It should not be performed immediately after delivery because of the neonatersquos unstable physiologic status and increased susceptibility to stress
BENEFITS Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased of incidence of balanitis (inflammation of glans) and possibly UTI in infants as some STDs in later life
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Prevention of complications associated with later circumsicion Preservation of malersquos body image that is consistent with peers
PROVIDE OPTIMUM NUTRITION
Only 16 of mothers in the Philippines breastfeed their babies despite the health benefits of doing so
The World Health Organization of the United Nations makes it clear that the healthiest option for babies is for them to be exclusively breastfed for the first six months and for breastfeeding to be supplemented with solid foods until the age of two Infant milk powder (lsquoformularsquo) should be used when medical practitioners recommend it based on the health of the mother
ADVANTAGES OF BREASTFEEDING
1 Due to the anti-infective properties of breastmilk breastfed babies tend to have less incidence of or less pronounced symptoms of ear infections respiratory illness allergies diarrhea and vomiting 2 Due to the digestibility of breastmilk breastfed babies are rarely constipated 3 The stools of breastfed babies are mild-smelling 4 SIDS (Sudden Infant Death Syndrome) is less common in breastfed babies 5 Breast milk is constantly changing in its composition to meet the changing needs of the baby It has the exact combination of protein fats vitamins minerals enzymes and sugars needed for the human infant at various stages of his growth6 Breastfed babies are constantly exposed to a variety of tastes through their mothers milk7 Breastfed children are at less risk for chrohns disease (also known as granulomatous and colitis is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus) and juvenile diabetes8 Children who were breastfed are less likely to need orthodontic work such as braces due to the unique sucking action required with breastfeeding They also seem to have better overall dental health than formula-fed children Children who were breastfed need speech therapy less often than those who were bottle-fed9 IQ levels are an average of 8 points higher in children who were breastfed10 Adult daughters who were breastfed are at less risk for breast cancer11 Adults who were breastfed have a lower risk for high cholesterol and asthma12 The bond between mother and child seems to be enhanced with breastfeeding
Ten Steps to Successful BreastfeedingEvery facility providing maternity services and care for newborn infants should
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
1 Have a written breastfeeding policy that is routinely communicated to all health care staff 2 Train all health care staff in skills necessary to implement this policy 3 Inform all pregnant women about the benefits and management of breastfeeding 4 Help mothers initiate breastfeeding within half an hour of birth 5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants 6 Give newborn infants no food or drink other than breast milk unless medically indicated 7 Practice rooming-in - that is allow mothers and infants to remain together - 24 hours a day 8 Encourage breastfeeding on demand 9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants 10 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicFor biblio Protecting Promoting and Supporting Breastfeeding The Special Role of Maternity Services a joint WHOUNICEF statement published by the World Health Organization
PROMOTE INFANT-PARENT BONDING (ATTACHEMENT)
An infant comes into the world with certain abilities which will encourage his attachment to his parents An infants softness and appearance is appealing to parents In The Nature of the Childs Tie to His Mother John Bowlby writes It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothersrdquo From the first touch parents and children begin to create a bond
In their book The Earliest Relationship Drs T Berry Brazelton and Bertrand G Cramer explore fully the role of body language in attaching parents and infants
When a mother holds her newborn in a comfortable cuddled position the infant molds into her body On her shoulder the infant lifts his or her head to scan the room then settles a soft fuzzy scalp into the crook of her neck As she automatically pulls the infant to her a newborn will burrow harder into her neck molding his or her body against hers legs adjusting to fit her body All of these responses say to her You are doing the right thing If she leans down to speak in one ear the baby turns to her voice and looks for her face Finding it the newborns face brightens as if to say There you are A newborn will choose a female voice over a male as if to say I know you already and you are important to me
Nurses can positively influence the attachment of parent and child The first step is recognizing individual differences and explaining to parents that such characteristics are normal
Discharge Planning for Newborn
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Preparation for home care Instruction is given concerning infant bathing and care preparation of formula and infant feeding Written formula with instructions for preparation is provided to parents Instruction for infant care is a combined responsibility of the medical and nursing staffs
Provide ample opportunity for parent contact Early attachment results in improved parent-child relationship
Parent teaching A teach the parent infant feeding technique
1 allow the infant to feed on demand 2 hold and talk to the infant while feeding3 formula should be at room temperature for feeding4 do not prop the bottle leaking of milk into infants ear can results in infection5 bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding6 place infant on right side or abdomen following feeding- safer position should be regurgitate
B teach the parent infant bathing technique 1 never leave the infant alone 2 prevent and due exposure- room temperature 24deg-31degC (75deg-88degF) bath water 366deg-377degC (98deg-100degF)3 use cotton balls or soft disposable wash cloths to wipe eyes face and outer ear Eyes are wiped from inside corner outward4 use a mild soap 5 wash the infants head using the gentle circular motion wash trunk and extremities quickly to avoid chilling the infant 6 inspect umbilical cord Checked area for bleeding or foul odor A drying agent such as 70 alcohol is applied several times daily
Dressings are not usually used7 cleanse genital area of male infant
a retract foreskin gently for cleansing b circumcision care- keep area clean Place sterile petrolatum gauze over area for 1st 24 hours change after voiding Observe for
bleeding Position the infant and diaper to avoid friction8 cleanse genital area of female
a use wet cotton ball b separate labiac wipe from front to back and discard cotton ball
C discuss with the parents the infantrsquos behavioural responses
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
1 sleeping pattern2 response to environmental stimuli3 response to soothing attempts 4 ways in which environmental changes tone of voice and approaches to soothing may enhance the infants responses
D teach the parents to the infantrsquos temperaturetake axillary temperature by placing thermometer in axilla and pressing the infants arm gently but firmly against it for 3 minutes
E teach the parents to recognize reportable signs and symptoms 1 pallor or cyanosis2 anorexia vomiting Diarrhea3 abnormal respiration4 irritability lethargy fever or hypothermia
Early Newborn Discharge Checklist
Feeding- Adequate latch-on demonstrated for breast-feeding newborn successfully feeding at least 1 to 2 ounces of formula every 3 to 4 hours with minimal spitting or absence of vomiting
Elimination- Voiding every 4 to 6 hours or more often stool- one stool passed in first 24 to 48 hours
Circumcision- Evidence of voiding no bleeding circumcision (does not require pressure)
Color- Pink centrally and buccal mucosa moist no evidence of jaundice in first 24 hours
Cord- Cleansingantibacterial agent applied per unit protocol
Vital signs- stable heart rate respiratory rate and temperature for at least 8 to 12 hours no apnea
Activity- Wakeful periods before feedings moves all extremities
Home visitprimary practitioner visit- Appointment made within 2 to 3 days after discharge
Newborn Home Care After Early Discharge
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Wet diapers- 6 to 10 per day
Breast-feeding- Successful latch-on and feeding every 15 to 3 hours daily
Formula feeding- Successfully voiding as above taking at least 1 to 2 ounces every 3 to 4 hours
Circumcision- Wash with warm water only yellow exudate forming nonbleeding Plastibell intact 48 hours
Stools- At least one every 48-72 hours(bottle-feeding) or two to three per day (breast-feeding)
Color- Pink to ruddy when cry8ing pink centrally when at rest or asleep
Activity- has four to five wakefull period per day and alerts to environmental sounds and voices
Jaundice- physiologic jaundice (not appearing in 1st 24 hours) feeding voiding and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hours of birth ABORh problem suspected) decreased activity poor feeding dark orange skin color persisiting 5th day in light-skinned newborn
Cord- kept above diaper line drying no drainage periumbilical area nonerythematous
Vital signs- heart rate 120-140 beatsminute at rest respiratory rate 30-55 at rest without evidence of sternal retractions granting or nasal flurring temperature 363 to 37 degrees Celsius axillary
Position of sleep- back
HEALTH EDUCATION PLAN (HEP)
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Objectives1 To provide basic knowledge regarding the importance of newborn care2 To promote sense of independence to the mother regarding in fulfilling the needs for her baby3 To provide information to the mother regarding the specific nutritional diet necessary for the infantMaterials needed Visual aids
General Health Teachings Specific Health Teachings
Hygiene
Rest
Diet
Follow-up Check-ups
Teach the mother that bathing should proceed from the cleanest to the most soiled areasTeach the mother to wash the infantrsquos hair daily with the bath Use soap and water with the baby lying in the bassinet
Stress to parents that a newborn should be positioned on the back for sleep to prevent Sudden infant death syndrome
Encourage the mother to breastfeed the infant to promote mother and child bondingStress also the benefits of breastfeeding Instruct the mother not to give food or drink other than breast milkInstruct the mother not to give pacifiers to breast-feeding infants
Stress to parents the importance of Newborn ScreeningEncourage mother that the infant must have a complete immunizations as prevention
Reference Maternal and Child Health Nursing Care of the Childbearing and Childbearing Family by Pillitteri
PROGNOSIS
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
First the good news infant and child mortality rates have decreased dramatically over the past two decades As a result there is a high probability of meeting the goal of reducing infant and child mortality to 19 and 267 respectively by 2015 according to the Philippines Midterm Progress Report on the Millennium Development Goals (MDGs) The DOH has also recently launched the Essential Newborn Care (ENC) Protocol which aims to reduce neonatal deaths or deaths of infants within the first 28 days of life The protocol will guide health workers and medical practitioners in providing evidence-based essential newborn care DOH data has shown that 50 percent of neonatal deaths occur during the first two days of life The top three causes include birth asphyxia (31) complications of prematurity (30) and severe infection (19) The protocol classifies procedures as time bound non-time bound or unnecessary Time-bound interventions which should be routinely performed first include immediate drying skin-to-skin contact followed by cord clamping no separation of newborn from mother and breastfeeding initiation Non-time bound interventions include immunizations eye care and vitamin K administration weighing and washing Unnecessary procedures include routine suctioning routine separation of newborns for observation administration of glucose water or formula and foot printing
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
BIBLIOGRAPHY
Books
Doenges M et al (2008) Nursersquos Pocket Guide 11th ed Taiwan iGroup Press Co Ltd
HockenberryWilson (2007) Wongrsquos Nursing Care of Infants and Children 8th ed Vol 1 Philippines Elsevier
Integrated management of Childhood Illness
Karch A (2009) Nursing Drug Guide Philippines Lippincott Williams and Williams
Pillitteri A (2007) Maternal and Child Health Nursing 5th ed Vol 1 Philippines Lippincott Williams and Williams
Reyala J et al (2000) Community Health Nursing Services in the Philippines 9th ed Philippines Community Health Nursing Section
Scott S (2007) Essentials of Maternity Newborn and Womenrsquos Health Nursing Philippines Lippincott Williams and Williams
Electronic sources
Department of Health Number of newborn deaths to drop soon --- DOH Press Release December 7 2009 Available httpportaldohgovph
National Statistical Coordination Board MDGWatch Statistics at a glance of the Philippinesrsquo Progress based on the MDG indicators (as of October 2009) Available httpwww nscbgovphstatsmdgmdg_watchasp
NEDA-UNDP Philippines Midterm Progress Report on the Millenium Development Goals (2007) Available httpwwwnedagovpheconreports_dbsMDGsmidterm01-9620UNDP_finalpdf
Orbeta AC (2005) Poverty Vulnerability and Family Size Evidence from the Philippines PIDS Discussion Paper SERIES NO 2005-19
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members
Philippine Information Agency (2009) DOH global partners move to reduce maternal neonataldeaths in RP Available httpwwwpiagovphm=12ampr=ampy=ampmo=ampfi=p090918htmampno=59
United Nations Population Fund (2009) Philippines Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs Available httpwwwunfpaorgpublicNewspid2452
World Health Organization Statistical Information System- Detailed database search Accessed on January 16 2010 Philippines AvailablehttpappswhointwhosisdataSearchjspcountries=[Location]Members