Nursing care of the neonate

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1. NURSING CARE OF THE NEONATENURSING ASSESSMENTDelivery of effective neonatal care is enhanced by communication of pertinent informationabout the mother and her infant…
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  • 1. NURSING CARE OF THE NEONATENURSING ASSESSMENTDelivery of effective neonatal care is enhanced by communication of pertinent informationabout the mother and her infant to the pediatrician or other health care provider. It isimportant that the obstetric staff record the following information on the medical record thataccompanies the neonate during any transfer of care.Pertinent Maternal History  Mothers age, socioeconomic status, ethnic or cultural group, educational level, marital status.  Mothers/familys past medical history.  Mothers past obstetric history.  Mothers prenatal history with this pregnancy includes rubella status, hepatitis B testing, history of psychiatric disease, domestic violence, or history of previous child abuse or neglect. Also includes other maternal test results relevant to neonatal care (ie, human immunodeficiency virus test results and colonization with group B-hemolytic streptococci).  Labor and delivery. (Includes intrapartum maternal antibiotic therapy, along with type and dosage of antibiotics.)Physical Assessment Findings and Physiologic FunctioningPosture  Full-term neonate assumes symmetric posture; face turned to side; flexed extremities; hands tightly fisted with thumb covered by fingers.  Asymmetric posture may be caused by fractures of clavicle or humerus or by nerve injuries commonly of the brachial plexus.  Infants born in breech position may keep knees and legs straightened or in frog position, depending on the type of breech birth.LengthAverage length of full-term neonate is 20 inches (51 cm); range, 18 to 22 inches (46 to 56 cm).WeightAverage weight of male neonates is 7 ½ lb (3,400 g); female neonates, 7 lb (3,200 g). Weightrange of 80% of full-term neonates is 6 lb 5 oz to 9 lb 2 oz (2,900 to 4,100 g).SkinExamine under natural light for:  Hair distribution—term infant will have some lanugo over back; most of the lanugo will have disappeared on extremities and other areas of the body.  Turgor—term infant should have good skin turgor; ie, after gently pinching small portion of skin and releasing it, the skin should return to its original position.  Color
  • 2. o Cyanosis—acrocyanosis, bluish color in palms of hands and soles of feet, is common because of immature peripheral circulation. This condition is exacerbated by cold temperatures. o Pallor—may indicate cold, stress, anemia, or cardiac failure. o Plethora—reddish (ruddy) coloration may be caused by a high level of RBCs to total blood volume from intrauterine intravascular transfusion (twins), cardiac disease, or diabetes in the mother. o Jaundice—physiologic jaundice caused by immaturity of liver is common beginning on day 2, peaking at 1 week, and disappearing by the 2nd week. It first appears in skin over the face or upper body, then progresses over a larger area; it can also be seen in conjunctivae of eyes. o Meconium staining—staining of skin, fingernails, and umbilical cord indicates passage of meconium in utero (possibly caused by fetal hypoxia in utero). Dryness/peeling—marked scaling and desquamation are signs of postmaturity. Vernix—in full-term infants, most vernix is found in skin folds under the arms and in the groin under the scrotum (in males) and in the labia (in females). Nails—should reach end of fingertips and be well developed in the full-term infant. There should be no evidence of pits, ridges, aplasia, or hypertrophy. Edema—some edema may occur over buttocks, back, and occiput if the infant has been supine; pitting edema may be caused by erythroblastosis, heart failure, and electrolyte imbalance. Ecchymosis—may appear over the presenting part in a difficult delivery; may also indicate infection or a bleeding problem. Petechiae—pinpoint hemorrhages on skin caused by increased intravascular pressure, infection, or thrombocytopenia; regresses within 48 hours. Erythema toxicum (newborn rash)—small white, yellow, or pink to red papular rash that appears on trunk, face, and extremities; regresses within 48 hours. Hemangiomas—vascular lesions present at birth; some may fade, but others may be permanent. o Strawberry (nevus vasculosus)—bright red, raised, lobulated tumor that occurs on the head, neck, trunk, or extremities; soft, palpable, with sharp demarcated margins; increases in size for approximately 6 months, then regresses after several years. o Cavernous—larger, more mature vascular elements; involves dermis and subcutaneous tissues; soft, palpable, with poorly defined margins; increases in size the first 6 to 12 months, then involutes spontaneously. Telangiectatic nevi (stork bites)—flat red or purple lesions most commonly found on the back of the neck, lower occiput, upper eyelid, and bridge of the nose; regress by age 2, although the ones on the neck may persist through adulthood. Milia—enlarged sebaceous glands found on nose, chin, cheeks, brow, and forehead; regress in several days to a few weeks. They appear as multiple yellow or pearly white papules, approximately 1 mm in diameter. When found in the mouth, they are referred to as Epstein pearls.
  • 3.  Mongolian spots—blue-green or gray pigmentation on the lower back, sacrum, and buttocks; common in Blacks (90%), Asians, and infants of southern European heritage; regress by age 4. May be mistaken for signs of child abuse.  Café-au-lait spots—tan or light brown macules or patches. When less than 1 ¼ inches (3 cm) in length and less than six in number, there is no pathologic significance; if greater than 1 ¼ inches or more than six in number, may indicate cutaneous neurofibromatosis.  Harlequin color change—when on side, dependent half turns red, upper half pale; caused by gravity and vasomotor instability.  Abrasions or lacerations can result from internal monitoring and instruments used at birth.  Cutis marmorata—bluish mottling or marbling of skin in response to chilling, stress, or overstimulation.  Port-wine nevus (nevus flammeus)—flat pink or reddish purple lesion consisting of dilated, congested capillaries directly beneath the epidermis; does not blanch.Head  Examine head and face for symmetry, paralysis, shape, swelling, movement. o Caput succedaneum—swelling of soft tissues of the scalp because of pressure; swelling crosses suture lines. Associated with vacuum-assisted birth. o Cephalohematoma—subperiosteal hemorrhage with collection of blood between periosteum and bone; swelling does not cross suture lines. May result from vacuum-assisted birth (use of the vacuum extractor). o Molding—overlapping of skull bones, caused by compression during labor and delivery (disappears in a few days). o Examine symmetry of facial movements. o Forceps marks—U-shaped bruising usually on cheeks following forceps delivery.  Measure head circumference—13 to 14 inches (33 to 36 cm), approximately ¾ inch (2 cm) larger than chest. Measure just above the eyebrows and over the occiput.  Fontanelles—area where more than two skull bones meet; covered with strong band of connective tissue; also called the soft spot. o Enlarged or bulging—may indicate increased intracranial pressure (ICP). o Sunken—commonly indicates dehydration. o Size—posterior may be obliterated because of molding; generally closes in 2 to 3 months. Anterior is palpable; generally closes in 12 to 18 months.  Sutures—junctions of adjoining skull bones. o Overriding—caused by molding during labor and delivery. o Separation—extensive separation may be found in malnourished infants and with increased ICP.Face  Eyes—examine the following:
  • 4. o Color—sclera in most full-term infants are white; blue sclera is indicative of osteogenesis imperfecta. Eye color usually slate-gray, brown, or dark blue; final eye color is evident by 6 to 12 months. o Hemorrhagic areas—subconjunctival hemorrhages may appear as a red band from pressure during delivery; regress within 2 weeks. o Edema—edema of the eyelids may be caused by pressure on the head and face during labor and delivery. o Conjunctivitis or discharge—may be caused by instillation of silver nitrate (if still used) or infections from organisms, such as staphylococcus, chlamydia trachomatis, or gonococcus. Tear formation does not usually begin until age 2 to 3 months. o Jaundice—may be seen in sclera because of physiologic jaundice or, if severe, blood-group incompatibility. o Pupils—equal in size and should constrict equally in bright light. o Infant can see and discriminate patterns; limited by imperfect oculomotor coordination and inability to accommodate for varying distances. o Red reflex—red-orange color seen when light from an ophthalmoscope is reflected from the retina. No red reflex indicates cataracts. o Brushfields spots—white or yellow pinpoint areas on iris that may indicate trisomy 21 or even a normal variant. o Abnormal placement of eyes or small eye openings can signify a syndrome or chromosomal anomaly. o Strabismus—cross-eyed appearance that is common; nystagmus (constant, rapid, involuntary movement of the eye) is also common and disappears by age 4 months. Nose—examine the following: o Patency—necessary because infants breathe through the nose, not the mouth. o Nasal flaring—abnormal and may indicate respiratory distress. Check for appropriate size and shape of the nose; should be placed vertically midline in face. o Discharge—stuffiness is normal unless chronic nasal discharge is present; may be caused by possible infection. o Sense of smell—infants will turn toward familiar odors and away from noxious odors. o Septum should be midline; low nasal bridge with broad base may be associated with Down syndrome. o Periodic sneezing is common. Ears—examine the following: o Formation—large, flabby ears that slant forward may indicate abnormalities of the kidney or other parts of the urinary tract. o Position in relation to the eye—helix (top of ear) on the same plane as eye; low- set ears may indicate chromosomal or renal abnormalities. o Cartilage—full-term infant has sufficient cartilage to make the ear feel firm.
  • 5. o Hearing—auditory canals may be congested for a day or two after birth; the infant should hear well in a few days. o Observe for skin tags; preauricular sinus located in front of the ear may be normal or may be associated with genetic disorders.  Mouth—examine the following: o Size—small mouth found in trisomy 18 and 21; corners of mouth turn down (fish mouth) in fetal alcohol syndrome. Mucous membranes should be pink. o Palate—examine hard and soft palate for closure. o Size of tongue in relation to mouth—normally does not extend much past the margin of gums. Excessively large tongue seen in congenital anomalies, such as cretinism and trisomy 21. o Teeth—predeciduous teeth are found on rare occasions; if they interfere with feeding, they may be removed. o Epsteins pearls—small white nodules found on sides of hard palate (commonly mistaken for teeth); regress in a few weeks. o Frenulum linguae—thin ridge of tissue running from base of tongue along undersurface to tip of tongue, formerly believed to cause tongue-tie; no treatment necessary. True congenital ankyloglossia (tongue-tie) is rare. o Sucking blisters (labial tuberales)—thickened areas on midline of upper lip that may be filled with fluid or callous; no treatment necessary. o Infections—thrush, caused by Candida albicans, may appear as white patches on tongue and/or insides of cheeks that do not wash away with fluids; treated with nystatin suspension.NeckExamine the following:  Mobility—infant can move head from side to side; palpate for lymph nodes; palpate clavicle for fractures, especially after a difficult delivery.  Torticollis—appears as a spasmodic, one-sided contraction of neck muscles; generally from hematoma of sternocleidomastoid muscle; usually no treatment required.  Excessive skin folds may be associated with congenital abnormalities such as trisomy 21.  Stiffness and hyperextension may be caused by trauma or infection.  Clavicle—for intactness.  Observe for masses such as cystic hygroma—soft and usually seen laterally or over the clavicle.Chest  Circumference and symmetry—average circumference is 12 to 13 inches (30 to 33 cm), approximately ¾ inch (2 cm) smaller than head circumference.  Breast. o Engorgement—may occur at day 3 because of withdrawal of maternal hormones, especially estrogen; no treatment required. Regresses in 2 weeks.
  • 6. o Nipples and areolae—less formed and pronounced in preterm infants.Respiratory System  Rate—normally between 30 to 60 breaths/minute; influenced by sleep-wake status, when last fed, drugs taken by mother, and room temperature.  Rhythm—respirations may be shallow with irregular rhythm. o Respiratory movements are symmetric and mainly diaphragmatic because of weak thoracic muscles. For example, the lower thorax pulls in and the abdomen bulges with each respiration. o Periodic breathing—resumption of respiration after 5- to 15-second period without respiration; decreases with time; more common in preterm infants. Substernal retractions, if accompanied by gasps or stridor, are indicative of upper airway obstruction. o Observe for abnormal respiratory signs.  Breath sounds—determined by auscultation. o Bronchial sounds are heard over most of the chest. o Crackles may be heard immediately after birth. o Expiratory grunting is indicative of respiratory distress syndrome (RDS).Cardiovascular System  Rate—normal between 110 to 160 bpm (80 to 110 normal with deep sleep); influenced by behavioral state, environmental temperature, medication; take apical count for 1 minute.  Rhythm—common to find periods of deceleration followed by periods of acceleration.  Heart sounds—second sound higher in pitch and sharper than first; third and fourth sounds rarely heard; murmurs common, majority are transitory and benign.  Pulses—examine equality and strength of brachial, radial, pedal, and femoral pulses; lack of femoral pulses indicative of inadequate aortic blood flow.  Cyanosis—examine for cyanosis. Acrocyanosis of distal extremities is common; record location of any cyanosis, color changes with time, and when crying.  BP—neonates who weigh more than 3 kg (6½ lbs) have systolic BP between 65 and 95 mm Hg; diastolic, between 30 and 60 mm Hg. BP is usually higher in the lower extremities than in the upper extremities. BP assessment may not be conducted routinely on healthy neonates. Measurement of BP is essential for infants who show signs of distress, are premature, or are suspected of having a cardiac anomaly.Abdomen  Shape—cylindrical, protrudes slightly, moves synchronously with chest in respiration.  Distention may be caused by bowel obstruction, organ enlargement, or infection.  Palpate abdomen for masses; gap between rectus muscles is common; palpate liver and spleen.
  • 7. o Liver has decreased ability to conjugate bilirubin (rationale for physiologic jaundice). o Liver has decreased production of prothrombin and factors that depend on vitamin K for synthesis (rationale for neonates predisposition to hemorrhage).  Auscultate abdomen in all four quadrants for bowel sounds; usually bowel sounds occur 1 hour after delivery.  Kidneys—palpate kidneys for size and shape. o Infant has decreased ability of kidney to concentrate urine, excrete a solute load, maintain water and electrolyte balance. o Urine may contain uric acid crystals, which appear on diaper as reddish blotches; uric acid crystals may yield false-positive result when the infants urine is tested for protein.  Umbilical cord o Normally contains two arteries, one vein; single artery sometimes associated with renal and other congenital abnormalities. o Signs of infection around insertion into abdominal wall-redness, discharge. o Meconium staining—associated with intrauterine compromise or postmaturity. o By 24 hours, becomes yellowish brown; dries and falls off in approximately 10 to 14 days. o Umbilical hernia—defect in abdominal wall.  Genitalia o Female  Labia majora cover labia minora and clitoris in full-term female infants.  Hymenal tag (tissue) may protrude from vagina—regresses within several weeks.  Vaginal discharge—white mucus discharge common; pink-tinged mucus discharge (pseudomenstruation) may be present because of the drop in maternal hormones; no treatment necessary. o Male  Full-term—testes in scrotal sac; scrotal sac appears markedly wrinkled due to rugae.  Edema may be present in scrotal sac if the infant was born in breech presentation; a frank collection of fluid in the scrotal sac is a hydrocele— regresses in approximately a month.  Examine glans penis for urethral opening—normally central; opening ventral (hypospadias); opening dorsally (epispadias); abnormally adherent foreskin (phimosis). o Check for patent anus—infant should stool within 24 hours after delivery. If passed meconium in utero, patent anus has been established.Back  Examine spinal column for normal curvature, closure, and pilonidal dimple or sinus; also for tufts of hair or skin disruptions that would indicate possible spina bifida.
  • 8.  Examine anal area for anal opening, response of anal sphincter, fissures.Musculoskeletal System  Examine extremities for fractures, paralysis, range of motion, irregular position.  Examine fingers and toes for number and separation: extra digits, polydactyly; fused digits, syndactyly.  Examine hips for dislocation—with the infant in supine position, flex knees and abduct hips to side and down to table surface; clicking sound indicates dislocation (Ortolanis sign).  Asymmetrical gluteal folds also indicate congenital hip dislocation.  Examine feet for structural and positional deformities, ie, club foot (talipes equinovarus) or metatarsus adductus (inward turning of the foot).Neurologic System  Neurologic mechanisms are immature anatomically and physiologically; as a result, uncoordinated movements, labile temperature regulation, and lack of control over musculature are characteristic of the infant.  Examine muscle tone, head control, and reflexes.  Two types of reflexes are present in the neonate: o Protective in nature (blink, cough, sneeze, gag)—remain throughout life. o Primitive in nature (rooting/sucking, Moro, startle, tonic neck, stepping, and palmar/plantar grasp)—either disappear within months or become highly developed and voluntary (sucking and grasping).Behavioral AssessmentResponse to Stimulation  Neonates exhibit predictable, directed responses in social interactions with nurturing adults or in response to attractive auditory or visual stimuli.  Neonate responses are influenced by states of consciousness, such as: o Quiet, deep sleep (sleep state)—no spontaneous activity, eyes closed, respirations regular, with delayed response to external stimuli. o Light, active sleep (sleep state)—random startles, eyes closed, REMs, frequent change of state with response to stimulation. o Drowsy awake (transitional state)—eyes open or closed, appearing dull and heavy lidded, eyelids flutter, variable activity level, mild startles periodically, delayed response to stimulation. o Quiet alert (awake state)—eyes open, little motor activity, focuses on source of stimulation. Interacts most with environment; respirations regular. o Alert active (awake state)—eyes open, less bright and attentive, much motor activity, increase in startles in response to stimulation.
  • 9. o Crying (awake state)—intense crying that is difficult to interrupt with stimulation; increased motor activity and color changes.Sleeping Pattern  Length of sleep cycles (REM, active and quiet sleep) changes with maturation of the central nervous system (CNS).  Quiet sleep should increase with time in relation to REM sleep.  Neonates usually sleep 20 hours per day.Feeding Pattern  Most neonates eat 10 to 12 times per day with 2 to 4 hours between feedings; establish fairly regular feeding patterns in approximately 2 weeks.  Calor
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