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Ms . Amal Alqudah
Respiratory Adaptations
Chemical Stimulation Mechanical Stimulation Sensory Stimulation Pulmonary Blood Flow
Chemical Stimulation
Catecholamine surge prior to labor corresponds to rapid drop in level of fluid in lung field Catecholamine's increase the release of surfactant
Chemical Stimulation
Decrease O2 & Increase CO2 concentration along with decrease pH stimulates aortic & carotid chemoreceptors triggering the medulla to initiation of respirations
Respiratory Adaptations
Surfactant promotes lung expansion by preventing the complete collapsing of the alveoli with each expiration. Increases the lungs ability to fill with air
Mechanical Stimulation
Compression of the chest during vaginal birth forces 1/3 of the fluid out of the lung fields Once the chest is delivered the reexpansion draws air into the lungs Crying creates positive intrathoracic pressure keeping alveoli open
Sensory Stimulation
Tactile Visual Auditory
Respiratory Adaptations
Established within 1 minute of birth Respirations should be quiet Diaphragmatic and abdominal muscles used Nose breathers 30-60/minute
Respiratory Adaptations
Acrocyanosis and circumoral cyanosis 1-2hrs Respiratory distress nasal flaring, grunting, costal retractions and a rate less than 30 & greater than 60
Cardiovascular Adaptations
Fetal to neonatal circulation occurs simultaneously with the respiratory adaptation Cessation of blood through the umbilical vessels and placenta causes the change from fetal to neonatal circulation
Cardiovascular Adaptation
Closure of the ductus venosus, foramen ovale and the ductus arteriousus Shift to pulmonary circulation
Neonatal Circulation
Apical pulse counted for a full minute PMI is at the 4th intercostal space to the left of the midclavicular line Heart rate at birth 120-160 Tachycardia greater than 160 Bradycardia less than 100
Neonatal Circulation
Capillary refill less than 3 sec. Femoral/Bracial pulses palpated for symmetry, strength and rate will provide information about the change to adult circulation pattern Average systolic 60-80, diastolic 4050
Neonatal Circulation
Average blood Volume 300ml Late clamping of the cord can lead to polycythemia Hemoglobin 14-24g/dl Hematocrit 44%-64%
Neonatal Circulation
RBC 4.8-7.1/mm WBC 9,000-30,00 per mm Platelets 200,000-300,00 Factors II, VII, IX, and X are low due to the lack of Vit. K
Thermogenic Adaptation
Balance between heat loss and production Newborns ability to maintain its temperature is controlled by external environmental factors and internal physiologic process
Renal System
40 ml of urine at birth 2-6 voids/day for the first 2 days 5-25 voids/day after 48 hours 15-60 ml. of urine per/kg/day Urine odorless straw color Uric crystals cause pink staining in diapers One year to fully mature
Gastrointestinal System
Audible bowel sounds within 1 hour Stomach capacity 30-90 ml. Uncoordinated peristaltic activity in the esophagus for a few days Immature cardiac sphincter Enzymes able to digest CHO, protein & fats 1 st meconium passed 12-24 hrs Transitional stool passed for 1-2 days
Hepatic Adaptation
In utero iron is stored for use in hemoglobin production after birth. If adequate will last till 5th month without needing supplement. Glucose is stored as glycogen for neonatal metabolic demands Due to the rapid depletion of glycogen during the first 24 hours the glucose level will be between 50 to 60 mg/ml Feedings will help stabilize the glucose levels, which after day 3 will be between 60-70 mg/ml
Initial Assessment
Apgar score determined Assess for gross abnormalities Apply cord clamp Obtain foot prints Apply identification bands Administer Vit. K & eye prophylaxis Promote bonding
Newborn Assessment
Length-19 to 21 inches Weight- average 7lb 8oz (10th to 90th %) SGA less than 5lb 8 oz (Less than the 10th %) LGA greater than 9 lb ( greater than the 90th %) Newborns can loose up to 10% of birth weight Head circumference- 33-38 cm Chest circumference-31-36 cm
Newborn Assessment
Temperature Normal axillary temperature 97F 99.5F Cardiovascular system Normal heart rate 110160 bpm Observe color, pulse, murmurs
Newborn Assessment
Respiratory system Normal rate is 3060/minute Nose-breather Observe for flaring, grunting, retracting Auscultate for rales
Head
Measure circumference Anterior fontanel diamond shaped closes in 18 months Posterior fontanel triangle shaped closes in 812 weeks Fontanels need to be open and soft Depressed fontanel indicates dehydration Bulging fontanel may indicate increased intracranial pressure
Head
Molding result of fetal position in utero and pressure from passage through birth canal ( resolves in 24-48hrs) Cephalhematoma result from trauma (resolves in few weeks) Caput succedaneum pressure from delivery ( resolves in 1-2 weeks)
Head
Inspect face for symmetry of eyes, nose, lips, mouth and ears Eyes usually blue or gray, permanent color established in 3-12 months Red reflex present cornea intact Can see up to 2 feet clearest vision is 8 to 12 inched Subconjunctive hemorrhages may be present due to the pressure from delivery
Head
Nose midline with patent nares Ears aligned with outer canthus of eyes; pinna well formed, open auditory canal ( low set ears associated with chromosomal abnormalities) Mouth mucosa pink and moist; tongue mobile, strong suck, hard/soft palate intact( Epsteins pearls may be noted on the gums or hard palate)
Neck
Shape typically short with deep folds of skin Webbing associated with Down Syndrome Assess for full range of motion Palpate for abnormal masses Note the position of the trachea
Chest
Shape should be cylindrical (bell shaped could be a sign of underdeveloped lungs) Palpate clavicle bones and ribs Assess nipples for size, placement and number Evaluate respiratory effort and movement Auscultate the lung fields and heart sounds Unequal breath sounds could be a pneumothorax
Abdomen
Umbilical cord, 2 arteries 1 vein Cylindrical with some protrusion Flat abdomen indicates diaphragmatic hernia Auscultate for bowel sounds Suprapubic area palpated for bladder distention Femoral pulses palpated, if unable to locate could signify coarctation of the aorta
Rugae present on the scrotum Scrotal edema may be present due to maternal hormones Testes descended Check for placement of the meatus Dorsal surface- epispadias Ventral surface-hypospadias Anus should be patent
Extremities
Assess for full range of motion, symmetry and signs of trauma Spontaneous motion of all extremities should be present Assess muscle tone Hyperflexibility of joints associated with Down Syndrome Hips assessed for dislocation
Extremities
Nail beds pink- persistent cyanosis associated with hypoxia Palms should have normal creases Simian crease (transverse palmer) suggests Down syndrome Count digits on extremities (more than five digits polydactyl-Digits fused together syndactyl
Spine
Straight Flat Shoulders, scapulae and iliac crests line up in same plane Evaluate for dimpling or fissures Dimpling associated with spina bifida
Skin
Assess color Check for birth marks, trauma, rashes or bruises Presence of lanugo Palpate texture ( ranges from smooth to peeling) Turgor ( elasticity)
Skin Assessment
Common variations Milia Mongolian spots Birthmarks Common problems Petechiae Blisters, lesions Abnormal hair distribution Port wine stains
Neurological System
Infant alert, responsive, strong lusty cry in a flexed position Reflexes provides information on the system and maturity Reflexive behaviors are necessary for survival and safety Absence, weakness or asymmetry indicates abnormalities
Neurological Reflexes
Sucking Rooting Grasping Extrusion Tonic neck Moro Stepping Crawling Babinski Truncal incurvation Blinking
Neurologic System
Common problems Brachial plexus injury (Erbs palsy) Spina bifida Anencephaly Absent or abnormal reflexes Seizure activity
Behavioral Assessment
Sleep-wake cycles Activity Social interactions Response to stimuli
Pain Assessment
Most common sign crying Changes in heart rate Intracranial pressure Respiratory rate and oxygen saturation
Pain Management
Nonpharmacologic management: containment (swaddling), nonnutritive sucking and distraction: visual, oral, auditory, tactile Pharmacologic management: local and topical anesthesia, Nonopioid analgesia and opioids
Infant Nutrition
American Academy of Pediatrics (AAP) recommends infants be breastfed exclusively for first 6 months of life Breastfeeding should continue for at least 12 months If infants are weaned before 12 months, they should receive iron-fortified infant formula
Infant nutrition
Human milk designed specifically for human infants; nutritionally superior to any alternative Breast milk considered living tissue because it contains almost as many live cells as blood Bacteriologically safe and always fresh Nutrients in breast milk more easily absorbed than those in formula
Contraindications of Breastfeeding
Maternal cancer therapy/ radioactive isotopes
Active tuberculosis HIV
Cytomegalovirus (CMV)
Maternal substance abuse
Lactation
Female breast composed of 15 to 20 segments (lobes) embedded in fat and connective tissues, well supplied with blood vessels, lymphatic vessels, and nerves Within each lobe are alveoli, the milkproducing cells, surrounded by myoepithelial cells that contract to send the milk forward into the ductules
Lactation
Ductules enlarge into lactiferous ducts and sinuses, where milk collects behind nipple Each nipple has 15 to 20 pores through which milk is transferred to the suckling infant After birth, precipitate decrease in estrogen and progesterone levels triggers release of prolactin from anterior pituitary gland
Lactation
Prolactin highest first 10 days Gradually decline, but remain above baseline levels for duration of lactation Prolactin produced by infant suckling and emptying of the breasts Breasts never completely empty Milk production supply/demand
Lactation
Oxytocin: other hormone essential to lactation As nipple is stimulated by suckling infant, posterior pituitary prompted by hypothalamus produces oxytocin Responsible for milk-ejection reflex (MER), or let-down reflex Nipple-erection reflex is integral to lactation
Lactation
Colostrum, a clear yellowish fluid birth to 48hrs. More concentrated than mature milk Extremely rich in immunoglobulins Higher concentration of protein and minerals Less fat than mature milk Coates and protects the stomach and intestines from invading organisms
Lactation
Transition milk 48-72hrs High levels of fat, lactose and water soluble vitamins Higher calorie content Larger volume
Lactation
Mature milk produce by 10th to 15th day Two types of milk: foremilk and hind milk Hind milk higher in fat which is needed for growth 90% water which maintains newborns fluid balance Remaining 10% contains carbohydrates, proteins and fats
Lactation Frequency/Duration
A newborns stomach is the size of a small marble and can hold 5-7 ccs. This is matches the amount of colostrum produced From 7-10 days it increases to the size of a golf ball and can hold 1.5 to 2 oz
Lactation Frequency/Duration
Newborns nurse on average 8-12 times/24hrs Feed by cue signs about every 1-3 hours Should have no more than one 4 hr period
Lactation Education
Positioning Latch-on Let-down Frequency of feedings Pumping Milk storage Duration of feedings Supplements, bottles, and pacifiers Diet Breast care
Breastfeeding
Engorgement noted when milk comes in and is bilateral (increase feedings to q2hrs) Sore nipples usually result of poor latch on Plugged milk ducts result of inadequate emptying or underwire bra/apply warm compresses prior to nursing Mastitis infection characterized by sudden flu like symptoms usually effects only one breast
Formula-Feeding
Personal preference Influence by significant family members Lack of familiarity with breastfeeding Contraindications present
Formulas
Ready to feed Concentrated Powdered Cows milkbased Soy-based Casein/ whey Amino acid
Formula-Feeding Education
Types of formula Formula Preparation Feeding patterns Feeding techniques Bottles preparation
Discharge Assessment
Determine knowledge deficits Educate on car safety Importance of Immunizations Follow care Newborn hearing screen Collect blood for PKU