clinical application for child health nursing nur 327 newborn assessment lecture 1-b +lecture 2

Clinical Application for Child Health Nursing

NUR 327

Newborn Assessment

Lecture 1-B +Lecture 2

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Definitions

Lab 3

Definitions Health a state of complete physical, mental and

social wellbeing and not merely absence of disease. (WHO)

12:05 ص Newborn Assessment 3

Definitions

Mortality :Rate of occurrence death.

Morbidity: a specific illness in the population


Mortality of infancy:

-Low birth weight <2500mg

(Lower birth weight = Higher mortality)

-Short or long gestational.



Essential Newborn Care Interventions Clean the baby’s nose & mouth Suctioning the baby’s nose & mouth The baby’s breathing Tying the umbilical cord Thermal protection

Prevent and manage newborn hypo/hyperthermia Early and exclusive breastfeeding

Started within 1 hour after childbirth

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APGAR APGAR SCORESCORE

Lab 3


APGAR EXPANSION

A for Appearance (Color)

P for Pulse Rate (Heart rate)

G for Grimace (Reflex irritability)

A for Activity (Muscle tone)

R for Respiration


The time for judging the five objective signs were sixty seconds after the complete birth of the baby

APGAR Score


Apgar Scoring system

Meaning of an Apgar score

APGAR Score


The newborn with special needs Weight-related gestational conditions

1- Small for gestational age infant (SGA)

2-Large for gestational age infant (LGA)

Age-related gestational condition

1-Premature infant

2-Postmature infant



Characteristics: Thin & wasted infant Little s/c fat The head looks really big



The following conditions occur more frequently in SGA

Asphyxia Hypoglycemia Hypothermia Congenital anomalies


2-Large for gestational age infant (LGA)

The following conditions occur more frequently in LGA

Hypoglycemia Hypocalcemia Hyperbilirubinemia Respiratory distress syndrome Congenital anomalies

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Vital Signs

Lab 3


Vital Signs Temperature

Heart rate

Respiration

Blood pressure

Oxygen Saturation


Temperature - range 36.5 to 37 C axillary -range 35.6 to 37.5 C Rectally

Common variations

-Crying may elevate temperature

-Stabilizes in 8 to 10 hours after delivery

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Temperature

Position for takingaxillary temperature.

Ear (Tympanic) Temperature

Can also be affected by: Impacted ear wax & ear

infections

Should NOT be used if child had ear surgery

Ear (Tympanic) Temperature

What Patients Think About Ear Temperatures

Parents like them! Fast, easy, clean, and safe

Children react better! Faster measurement

No holding or restraining No positioning

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Temperature

Oral temperature for children over 5 to 6 years.

Rectal temperatures are contraindicated if the child has had anal surgery, diarrhea, or rectal irritation.


•Heart rate - range 120 to 180 beats per minute Common variations -Heart rate range to 120 when sleeping to 180 when

crying-Color pink with acrocyanosis-Heart rate may be irregular with crying

Signs of potential distress or deviations from expected findings

-All murmurs should be followed-up and referred for medical evaluation

-Deviation from range-Faint sound

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Pulse

Apical pulse for infants and toddlers under 2 years

Count for 1 full minute

Will be increased with: crying, anxiety, fever, and pain

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Pulse rates

Neonate: 100 – 180

1-year: 100 – 160

3 years: 80- 110

14 years 60 - 100

Pulse - Brachial

Used for infants and small childrenPlace fingertips of first 2 or middle 3 fingers over the brachial pulse area

Inside of the elbowLightly press your fingertips on the pulse area

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Heart Sounds


•Respiration - range 30 to 60 breaths per minute

Common variations Bilateral bronchial breath sounds


-Asymmetrical chest movements-Apnea >15 seconds-Diminished breath sounds-Nasal flaring-Tachypnea

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Respiratory

Count for one full minute May want to do before you wake the infant up

Rate will be elevated with crying / fever Newborn: 30 – 60 Toddler: 25- 40 School-age: 18 - 30 Adolescent: 16- 20


Blood pressure –systolic: 60 to 80 mmHg -diastolic: 40 to 50 mmHg

Factors to consider-Appropriate cuff size important for accurate

reading-Average newborn: 75/42 mmHg in both upper

and lower extremities

Oxygen Saturation

Oxygen Saturation provide important information about cardio-pulmonary dysfunction and is considered by many to be a fifth vital sign.

For those suffering from either acute or chronic cardio-pulmonary disorders, Oxygen Saturation can help quantify the degree of impairment.

Oxygen Saturation

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Growth Measurements

Lab 3

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1. Weight

2. Height / length

3. Head circumferences

4. Chest circumferences

Physical growth parameter:

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Weight

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Needs to be recorded on a growth chart Newborn may lose up to 10% of birth weight in 3-4 days. Too much or too little weight gain needs to be further

investigated. Double birth weigh by 5-6 months Triple birth weight by 1 year Nutritional counseling The normal birth weight is 2500- 4000g .

Weight

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Weight

Weight-for-age percentiles, boys 0 to 24 months, WHO

growth standards

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Infants head is against end point and legs fully extended.

Height / length Measurement

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Length-for-age percentiles, boys birth to 24 months, WHO growth standards


Length range - 48 to 53 cm

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Child is measured whilestanding in stocking orbare feet with the heelsback and shoulders touching the wall.


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Stature-for-age percentiles, boys, 2 to 20 years, CDC growth charts: United States


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Head Circumference - 33 to 35 cm

Head circumference is measured by wrapping the paper tape over the eyebrows and the around the occipital prominence.

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Head circumference-for-age percentiles, boys 0 to 24 months, WHO growth standards

Head Circumference

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Head circumference is measured in children from birth to 3 years of age because this is the period of rapid brain growth.

Head circumference also should be measured in older children with abnormal growth because it may be helpful in determining the etiology.

Head Circumference

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Head, chest, and abdominal circumference.


. Chest circumference - 30.5 to 33 cm Head should be 2 to 3 cm larger than the

chest Head and chest circumference may be

equal for the first 24 to 48 hours of life

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Physical Assessment

Lab 3

General appearanceGeneral appearance and behavior of new born.

Flexion position

Head flexed, chin resting on the upper chest, arm flexed with hand clenched and the feet dorsiflexed.

Tiers easily with feeding or activity.

Fever

Sleep pattern



•Skin

Expected findings Skin reddish in color, smooth and puffy at birth At 24 - 36 hours of age, skin flaky, dry and pink in color Edema around eyes, feet, and genitals Turgor good with quick recoil Nipples present and in expected locations Cord with one vein and two arteries


Vernix caseosa The white, cheesy substance covering the

newborn's body. Often present only in the skin folds.


•Lanugo

Fine downy body hair usually distributed over shoulders, sacral area, and back of newborns. Usually disappears before birth or shortly after birth


Common variations

Acrocyanosis - result of sluggish peripheral circulation


•Mongolian Spots:

Patch of purple-black or blue-black color distributed over coccygeal and sacral regions of infants of African-American

or Asian descent. Not malignant. Resolves in time.


•Mottling: Generalized red and white discoloration of skin of chilled

infants with fair complexion


Jaundice Physiologic Jaundice: Hyperbilirubinemia not associated with

hemolytic disease or other pathology in the newborn. Jaundice that appears in full term newborns 24 hours after birth and peaks at 72 hours.

It may caused by the inability of the infant’s immature liver to modify bilirubin


Milia:

Tiny white papules (plugged sebaceous glands) located over

nose, cheek, and chin.


Petechiae:

Pinpoint, flat hemorrhages often visualized on head, face, and chest. Associated with rapid onset of pressure followed by

immediate release of pressure during birthing process. Bruises/ Ecchymoses: Larger than petechia, hemorrhagic areas associated with

rapid delivery or breech birth.


Signs of potential distress or deviations from normal findings

Pathologic Jaundice: Jaundice occurs before the baby is 24 hours

of age It may caused by metabolic disorders


Head

Expected findings Anterior fontanel diamond shaped 2-3 - 3-4 cm Posterior fontanel triangular 0.5 - 1 cm Fontanels soft, firm and flat Sutures palpable with small separation between

each

Head

Expected findings

Check fontanels: Anterior: 12 to 18 months Posterior: closes by 2-3 months

head control usually establish by 6 month



Common variations

Caput succedaneum: Swelling of the soft tissue of the scalp caused by

pressure of the fetal head on a cervix that is not fully dilated. Swelling crosses suture line and decreases rapidly in a few days after birth.

Molding of head may result in a lower head circumference measurement

refers to the process by which the neonates head is shaped during labor as it passes through the birth canal. The head may become elongated due to the overlapping of the cranial bones at the suture lines.


Common variations

Common variations

CEPHALHEMATOMA

Sub periosteal extravasation of blood due rupture of vessels. Swelling increases in size on second and third day after delivery.

Often associated with delivery by forceps. Swelling does not cross suture line and may take several weeks after birth. Jaundice may occur as blood cells are broken down as the swelling resolves.



Eyes Expected findings Slate gray or blue eye color No tears Fixation at times - with ability to follow objects to midline Distinct eyebrows Cornea bright and shiny Pupils equal and reactive to light


•Common variations

Edematous eyelids


Uncoordinated movements


•Signs of potential distress or deviations from expected findings

Discharges Conjunctivitis


. Doll's Eyes Reflex:

When the head is moved slowly to the right or left, the eyes do not follow nor adjust immediately to the position of the head.


. Reflexes absent Subconjunctival hemorrhage


•Ears

Expected findings

Pinna top on horizontal line with outer canthus of eye

Loud noise elicits Startle Reflex

Flexible pinna with cartilage present

.

pulled down and back to straighten ear canal in children under 3 years

Ear Exam


Common variations

Skin tags on or around ears



-Ear placement low

-Clefts present

-Malformations


Nose

Expected findings

-Nostrils patent bilaterally

-Obligate nose breathers

-No nasal discharge

Common variations

-Sneezes to clear nostrils

-Bridge appears absent

-Thin white nasal mucus discharge



-Other discharge

-Malformation

-Nasal flaring beyond first few moments after birth


Mouth and Throat Expected findings Mucosa moist. Shortly after birth may visualize sucking

calluses on central portions of lips.


•.

•Palate high arched


. Uvula midline Minimal or absent salivation Tongue moves freely and does not protrude Sucking reflex Gag reflex



Epstein's pearls on ridges of gums



-Cleft lip or cleft palate

-Lip movement asymmetrical

-Reflexes absent or incomplete

-Protruding tongue

-Diminished tongue movement

-Candida Albicans


•Neck

Expected findings

-Short and thick

-Turns easily side to side

-Clavicles intact

-Some head control



-Torticollis -stiff neck drawing head to one side

-Resistance to flexion

-Large fat pad on back of neck

-Movement with palpation of clavicle


•Chest

Expected findings

-Evident xiphoid process

-Equal anteroposterior and lateral diameter

-Bilateral synchronous chest movement

-Symmetrical nipples


Common variations

-Enlarged breasts

-Accessory nipples



-Asymmetrical chest movements

-Sternum depressed

-Marked retractions

-Absent breast tissue

-Flattened chest

-Supernumerary nipples-

-Nipples widely spaced

-Bowel sounds auscultated


Abdomen

Expected findings Dome-shaped abdomen

Abdominal respirationsSoft to palpationWell formed umbilical cordThree vessels in cordCord dry at baseLiver palpable 2 - 3 cm below right costal marginBilaterally equal femoral pulsesBowel sounds auscultated within two hours of birthVoiding within 24 hours of birthMeconium within 24 - 48 hours of birth



Small umbilical hernia



-Bowel sounds absent

-Abdominal distention

-Palpable masses

-Base of cord with redness or drainage

-Cord with two vessels


Female Genitalia

Expected findings

-Edematous labia and clitoris

-Labia majora are larger and surrounding labia minora

-Vernix between labia

Common variationsPseudomenstruationIncreased pigmentationEcchymosis and edema after breech birth



Labia fused Fecal discharge from vaginal openingAmbiguous genitaliaWidely separated labia


•Male Genitalia Expected findings -Urinary meatus at tip of glans penis-Palpable testes in scrotum-Large, edematous, pendulous scrotum.-Stream adequate on voiding

Common variations-Prepuce covering urinary meatus -Erections-Increased pigmentation-Edema and ecchymosis after breech delivery



Non palpable testes Scrotum smooth Ambiguous genitalia


•Back and Rectum

Expected findings Intact spine without masses or openings Patent anal opening



Limitation of movement Fusion of vertebrae Imperforate anus Anal fissures


•Extremities

Expected findings

-Maintains posture of flexion

-Equal and bilateral movement and tone

-Full range of motion all joints

-Ten fingers and ten toes

-Legs appear bowed

-Feet appear flat


Palmar creases present


Sole creases present



-Asymmetrical movement of extremities

-Polydactyly


.

Unequal leg lengthAsymmetrical skin creases posterior thigh


.

-Dislocation of hip

-Persistent cyanosis of nail beds

-Marked metatarsus varus


•Neuromuscular System Expected findings

-Maintains position of flexion-When prone, turns head side to side-Holds head and back in horizontal plane when held prone-Ability to hold head momentarily erect



-Quivering

-Limp extremities or straightening of extremities

-Clonic jerking

-Paralysis

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Nutritional needs of the Neonate

Lab 3

Feeding the Infant

Good nutrition is essential for the growth and development that occurs during an infant’s first year of life. When developing infants are fed, the appropriate types and amounts of foods, their health is promoted.

Early nutrition affects later development, and early feedings establish eating habits that influence nutrition throughout life.

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111

SFCC: Figure 14.14

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Why Is Breast Milk So Good for Babies?

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Why Is Breast Milk So Good for Babies?

• Breastfeeding is a natural extension of pregnancy – the mother’s body continues to nourish the infant.

• The American Dietetic Association (ADA) and American Association of Pediatrics recognize exclusive breastfeeding for 6 months, and breastfeeding with complementary foods for at least 12 months, as an optimal feeding pattern for infants.

Breast milk is more easily and completely digested than infant formula, so breastfed infants usually need to eat more frequently than formula-fed infants do.

During the first few weeks, the newborn will need approximately 8 to 12 feedings a day, on demand.

As the infant gets older, there are longer intervals between feedings.

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During the first two or three days of lactation, the breasts produce colostrum, a premilk substance containing antibodies and white cells from the mother’s blood.

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Immune Factors in Breast Milk

Breastfed infants may have: Less allergies

Lower blood cholesterol

Less ear and respiratory infections

May protect against obesity in childhood and later years.

May have a positive effect on later intelligence.


Infant formulas are designed to resemble breast milk.

Special formulas are available for premature infants, allergic infants, and others.

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Formula Feeding

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Complementary feeding practices

Different reasons to start complementary food can be highlighted:

Breast milk is not enough in quantity: this is the main reason for the huge majority of the mothers.

Breast milk is not sufficient to cover the infant’s nutritional needs for growing.

The mother has to go to work, so the child must be partially weaned.

119

Lactation Nutrient Needs

Energy Intake

Exercise intense may raise lactic acid concentration of breast milk

and baby may not like the taste

Vitamin and Minerals maintained in breast milk at expense of maternal stores if

poor po intake; B6, B12, A, D;

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Water need plenty of fluids to prevent dehydration drink a glass of fluid at each meal

Nutrient Supplements iron to replace stores often continue prenatal vitamins

Particular Foods foods with strong or spicy flavors may alter flavor of breast

milk. some infants may be sensitive to particular foods that mom eats

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Lactation Nutrient Needs

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During Lactation Don’t:

Don’t drink alcohol Don’t take medications unless OK by Medical Provider Don’t take illegal drugs Don’t smoke Don’t get into environmental contaminants Don’t have caffeine

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Consumer Corner: Formula’s Advertising Advantage

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The End

clinical application for child health nursing nur 327 newborn assessment lecture 1-b +lecture 2

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