Professional Documents
Culture Documents
Newborn or neonate
– a baby in the neonatal period (the first 28 days of life)
Nursing Diagnoses
Profile of a Newborn
X “All newborns look alike.”
“ Every child is unique.”
Warmth
–At birth, the newborn must begin thermoregulation (maintenance of body temperature).
3 Factors :
a. Heat production
b. Heat retention
c. Heat loss
1. HEAT PRODUCTION
Thermogenesis – through
o general metabolism
o muscular activity
o nonshivering thermogenesis (unique to the newborn)
- Newborn may cry and have muscular activity when cold, but there is no voluntary control of
muscular activity.
BROWN FAT
√ special tissue/ fat found only in newborns
√ highly vascularized giving it a brown color
√ oxidized to produce or conserve heat
√ increasing metabolism
√ located at the back of the neck, intrascapular region, thorax, around the kidneys and
adrenals, in the axilla, around the heart and abdominal aorta and perineal area
√ Once the brown fat has been metabolized, the infant no longer has this method of heat
production available.
2. HEAT RETENTION
3. HEAT LOSS
Newborn
- thin skin with blood vessels close to the surface and little subcutaneous fat to prevent heat loss
increased metabolism
significant increase in need for oxygen
newborn may experience hypoxia
** There may not be enough oxygen for the metabolic rate to increase, and the newborn will not
be able to maintain body temperature.
1. Convection - flow of heat from the newborn’s body surface to cooler surrounding air
2. Radiation - transfer of body heat to cooler solid object not in contact with the baby
3. Conduction - transfer of body heat to cooler solid object in contact with the baby
4. Evaporation -loss of heat through conversion of liquid to a vapor
APGAR SCORE
SIGN 0 1 2
CONGENITAL ANOMALIES :
1. Choanal Atresia
- a complete blockage or severe narrowing of the nasal airway at the posterior nares
2. Tracheobronchial fistula
- there is a fistula between the trachea and the distal portion of the esophagus
3. Cleft lip and cleft palate
Substances
1. drugs
2. smoking
3. alcohol
2. SQUARE WINDOW: Flex the hand at the wrist. Exert pressure sufficient to get as much
flexion as possible. The angle between the hypothenar eminence and the anterior aspect of the
forearm is measured and scored:
3. ARM RECOIL: With the infant supine, fully flex the forearm for 5 seconds, then fully extend
by pulling the hands and release. Score the reaction:
4. POPLITEAL ANGLE: With the infant supine and the pelvis flat on the examining surface,
the leg is flexed on the thigh and the thigh fully flexed with the use of one hand. With the other
hand the leg is then extended and the angled scored:
5. SCARF SIGN: With the infant supine, take the infant's hand and draw it across the neck and
as far across the opposite shoulder as possible. Assistance to the elbow is permissible by lifting it
across the body. Score according to the location of the elbow:
6. HEEL TO EAR: With the infant supine, hold the infant's foot with one hand and move it as
near to the head as possible without forcing it. Keep the pelvis flat on the examining surface.
Score as shown in the diagram above.
PHYSICAL MATURITY ASSESSMENT CRITERIA
Problems:
a. Respiratory adaptation
b. Susceptibility to infection
c. Hyperbilirubinemia
d. Cold stress
e. Hypoglycemia
Physical Examination:
√ Skin and subcutaneous tissue -thin, transparent
√ Increased lanugo
√ Decreased plantar creases
√ Breast bud scarcely felt
√ Pinna flat and shapeless
√ Scrotum not pigmented
√ Testes not descended
√ Labia majora widely separated
Management
√ Maintain patent airway
√ Incubator care
√ VS monitoring
√ Oxygen therapy
√ Feeding
√ Infection precautions
Nursing Intervention
√ Meet physiologic needs
√ Meet psychological needs
√ Foster healthy family relationships
√ Provide education
PROPER IDENTIFICATION
– done in D.R. before being brought to the Nursery
Special Care
1. Initial Bath – temp stabilizes 36.5ºC 6-8 hrs after birth
√ vernix caseosa - use oil
√ warm water during the 1st week
√ Don’t use soap
2. First bath
–For the next 10 days to 2 weeks – sponge bath.
–NB are not generally given tub bath until the cord has fallen off and healing is complete
–Nurse giving the first bath to NB must wear gloves to comply with standard precautions
regarding contact with blood or body fluids
Signs of Omphalitis:
* Application of sterile cord clamp - prevent bleeding within 1st 24 hours (Omphalangia)
4. Crede’s Prophylaxis
Medications:
a. Ophthalmic drops – Silver Nitrate or AgNO3 1% 1-2 drops
- lower conjunctival sac
- wash with sterile NSS after 1 minute to prevent chemical conjunctivitis
b. Ointment
1. Terramycin
2. Gentamycin
3. Chloramphenicol
4. Erythromycin
Erythromycin
√ pull eyelids downward
√ 0.5-1 cm
√ Inner to outer canthus
√ Wipe excess away
5. Vitamin K Injection
- sterile GIT
- facilitates production of clotting factor
- 1 mg. Aquamephyton
- IM - lateral anterior thigh (Vastus lateralis)
ANTHROPOMETRIC MEASUREMENT
Causes
1. No longer under influence of maternal hormones
2. Voids and passes out stools
3. relatively low nutritional intake
4. beginning difficulty establishing sucking
Initial Feeding
o 1-6 hours after birth
o 1 oz of sterile water
o Subsequent feeding – by demand
o Breastfed infant recaptures birth weight within 10 days
o Formula fed infant recaptures weight gain with in 7 days
o Then continues to gain weight of 2lb/month( 6-8oz/ wk) for the 1st 6 months of life
Breastfeeding Advantages:
1. bonding
2. uterine contraction
3. colostrum
4. Contraceptive
5. Cheap
6. Right temperature
7. Antibacterial – Lactoferrin, Lactobacillus bifidus, lysozyme, macrophage, T lymphocytes,
Lactoperoxidase
Differences Between Human and Cows Milk
CHON 8% 20%
Fats 50% 50%
Carbohydrates 42% 30%
Na 7 mEq/l 25 meq/l
K 14 mEq/l 36 mEq/l
Ca 12 mEq/l 61 mEq/l
Phosphorus 9 mEq/l 53 mEq/l
Cl 12 mEq/l 34 mEq/l
Contraindications of breastfeeding:
1. An infant with galactosemia ( can’t digest lactose in milk)
2. Herpes lesion on a mother’s nipple
3. Maternal diet is nutrient restricted, preventing quality milk production
4. Maternal medication inappropriate for feeding
5. Maternal exposure to radioactive compounds
OTHERS:
o Football hold
o Side lying position
o Across lap Breastfeeding
o Latching on
o The mother should use the infant's rooting reflex to allow positioning of the nipple in the
infant’s mouth
o Brushing the nipple against the infant’s lower lip will cause the infant to open the mouth.
o When the mouth is wide open and the tongue is down, the mother quickly brings the
infant closer to the breast so the infant can latch on the nipple and areola.
o Breastfeeding
Length of feeding
-Varies with each mother /infant unit
BREASTFEEDING BOTTLEFEEDING
BURPING
ALL INFANTS REQUIRE BURPING TO EXPEL THE AIR SWALLOWED WHEN THE
INFANT SUCKS SOME INFANT SWALLOW MORE AIR THAN OTHERS AND REQUIRE
MORE FREQUENT BURPING.
Physical Assessment
1. Vital Signs
a. Pulse
- 1 full minute; use apical pulse
- irregular, rapid >160-180 at birth
- NORMAL: 120–160 bpm
- During sleep - 90-110 bpm
- If crying, up to 180 bpm
Pulse : heart rate in utero- 120 t0 160bpm after 1 hr newborn settles, heart rate stabilizes to an
average of 120 to 140 bpm
- remains irregular because of immaturity of cardiac regulatory center in the medulla
- crying, rate might increase to 180 bpm, 90 to 110 bpm during sleep
- femoral pulses are more appreciated than radial and temporal pulses ( always palpate for
the femoral pulses; their absence suggests coarctation of aorta)
b. Respirations
- 1 full minute
- irregular, shallow, rapid w/ brief apneic spells < 15s
- 60-80 breaths/min at birth
- NORMAL: 30–60/minute
- Respiration : average is 30 to 60 breaths per minute
- respiratory rate, rhythmn, depth are likely to beirregular and short periods of apnea
(periodic respiration) are normal
- coughing and sneezing are present at birth to clear the airway
- newborns are obligate nose-breathers
c. Blood Pressure - not usually measured
*not routinely obtained except for suspicion of Coarctation of the Aorta.
80–60/45–40 mm Hg at birth
100/50 mm Hg at day 10
d. Temperature
Normal range: 36.5C–37.5C (axilla)
Axillary: 36.4C–37.2C
Skin: 36.0 C–36.5C
Rectal: 36.6C–37.2C
* Temperature 37.2 at birth
Crying - increase body temperature slightly
Radiant warmer - falsely increase axillary temperature
√ General appearance
√ Skin √ Ears √ Abdomen √ Extremities
√ Head √ Neck √ Genitalia
√ Eyes √ Chest √ Back
I. SKIN
1. Dark red – prematurity
2. Acrocyanosis – up to 48 hours
3. Central cyanosis – indicates decrease O2
4. Generalized mottling
5. Gray color - infection
6. Pale color - anemia
7. Yellow color –jaundice
8. Harlequin sign – pale and pink
Pallor
* Excessive blood loss when cord is cut
* Untimely cutting of the cord
* Inadequate iron stores because of poor maternal nutrition
* Blood incompatibility
Jaundice ;
Types:
1. Physiologic Jaundice / Icterus Neonatorum
2nd day – 7th day - TERM
2nd day – 10th day - PRE-TERM
Causes:
a. Hemolysis
b. Decreased conversion of bilirubin to urobilirubin
c. Decreased uptake of free bilirubin by hepatic cells
2. Pathologic Jaundice
before the first 24 hours of life
Most accurate method of assessing the presence of jaundice: Use natural light and blanch
skin on the chest or tip of the nose.
Causes:
a. Infection
b. Hemolytic disorders
c.Inability of the newborn to conjugate bilirubin
Breastfed babies have longer physiologic jaundice because human milk has
PREGNANEDIOL which depresses the action of glucoronyl transferase (enzyme responsible
for converting indirect bilirubin to direct bilirubin)
KERNICTERUS
–Accumulation of bilirubin in the brain tissues
–SEIZURES
–MENTAL RETARDATION
–EXCHANGE TRANSFUSION
Management
Goal of treatment: to decrease the bilirubin levels
1. Early feeding
2. Phototherapy (Bililight)
- Cover eyes with opaque mask to prevent blindness.
- distance - 18-20 in from source of light.
- Monitor V/S especially temp
- Cover genitalia to prevent PRIAPISM (continuous erection).
- Adequate hydration
- Turn NB q 2º to expose all body surfaces
Common Marks
1. Harlequin Sign
→BECAUSE OF IMMATURITY OF CIRCULATION, AN INFANT WHO HAS BEEN LYING ON
HIS SIDE WILL APPEAR RED ON THE DEPENDENT SIDE & PALE ON THE UPPER SIDE.
2. Mongolian spots
→ bluish gray or dark nonelevated pigmentation area over the lower back and buttocks present
at birth, primarily nonwhite, disappear at SCHOOL AGE
3. Milia
→Unopened sebaceous glands; tip of nose and chin of the baby.
→Newborn sebaceous gland is immature. At least one pin-point white papule (a plugged or
unopened sebaceous gland) can be found in the cheek or across the bridge of the nose of
every newborn.
→Disappears by 2-4 wks of age as the sebaceous glands mature and drain.
→Parents should be instructed to avoid scratching or squeezing the papules to prevent
secondary infection.
4. Lanugo
→Fine downy, hair that covers a newborn’s shoulder, back and upper arms
→Found also in the forehead and ears.
→The newborn of 37-39 wks has more lanugo than the 40th wks old infant.
→Post-mature infants have rarely have lanugo
→By age of 2 wks, It disappears
5. Desquamation
→peeling; at birth, postmaturity
→Within 24 hrs. of birth, the skin of most newborns has become extremely dry
→The dryness is particularly evident on the palms of the hands and soles of the feet.
→ This is normal and needs no treatment.
6. Vernix Caseosa
→White, cream-cheese-like substance that serves as a skin lubricant, usually noticeable on a
newborn skin. Prominently seen in the skin folds, at birth in a term neonate.
10. Nevi
→Stork bites or Telangiectasia Nevi; pink or red flat areas of capillary dilatation at upper
eyelids, nose, upper lip, lower occiput bone, nape and neck. Can be blanched by the pressure
of the finger; usually fade during infancy- 1st and 2nd year.
2. Posterior
o triangular in shape
o junction of the parietal bones and the occipital bones.
o 1 cm
o closes by end of 8th-12th week of life
Sutures
1. Lambdoid (2)
2. Coronal (2)
3. Frontal (1)
4. Sagittal (1)
CRANIOSYNOSTOSIS
- suture lines separated or fontanels prematurely closed; leads to mental retardation
Molding
–overlapping of sagittal and coronal suture line
Craniotabes
– localized softening of cranial bones; indented by pressure of a finger. Corrects w/o t
treatment in weeks or months. Common to first borns because of early lightening
IV. EARS
-Top of ear should align with inner and outer canthus of the eye
- sense of Hearing – highly developed in NB
VI. MOUTH
- open evenly when crying. If not, suspect CN VII Paralysis (Bell’s Palsy).
- Palate intact; no breaks on the lip - cleft palate; cleft lip
- Eptein’s Pearls – small round glistening cysts; palate and gums, d/t extra load of maternal Ca
– If with tooth (NATAL TOOTH= not covered with gum membrane) should be extracted to
prevent aspiration
Oral thrush – white gray patches on the tongue and sides of cheeks due to Candida albicans
acquired during the passage of the baby through the birth canal of his mother who has untreated
MONILIASIS; ORAL MONILIASIS.
VII. NECK
- Thyroid gland not palpable
- soft, palpable and creased with skin folds
- Head - rotate freely on the neck and flex forward and back. (+) rigidity of the neck-
VIII. CHEST
- As large as or smaller than the head
- Symmetrically expands (retraction indicates respiratory distress)
- Breasts may be engorged (due to maternal hormones) There could be passage of thin,
transparent watery fluid known as WITCH’S MILK.
IX. ABDOMEN
- Dome shaped;
- If scaphoid - DIAPHRAGMATIC HERNIA
- Bowel sounds should be present within 1 hour after birth
- Liver, spleen and kidneys are palpable at birth.
X. EXTREMITIES
- symmetric and of equal length
- Fingers and toes equal count
Supernumerary = polydactyly;
fused or webbed = syndactyly
Simean line
- Asymmetrical movement of upper and lower extremities - ERB – DUCHENE PARALYSIS
- congenital hip dislocation: Ortolani’s Maneuver
- Observe for clubfoot deformities
SIMEAN CREASE
A. Ortolani test
→In this maneuver, the infant is examined in the supine position.
→The examiner holds the infant's pelvis with one hand to stabilize it during manipulation.
→The examiner then slowly and gently abducts the infant's opposite hip with the other hand,
pulling the femur forward and using the greater trochanter as a fulcrum.
→In the infant with an unstable hip, the examiner will feel a sudden shifting sensation and may
hear or feel a "clunk" simultaneously as the hip reduces anteriorly.
→Ortolani’s Test
B. Barlow test
In the infant with an unstable hip, a similar "clunk" may be felt as the hip subluxes
posteriorly.
* Assessment on the R and L hips may be done simultaneously
Clubfoot
A birth deformity in which the front portion of the foot is deformed and turned inward. It can
be benefited greatly by surgery.
a. Breast fed infant stool – loose golden yellow in color with sweet odor; 2-3 times a day
b. Bottle fed infant stool – formed, pale yellow w/ a typical odor; usually passed 1-2 times a day
Lack of passage of stool on first few days indicates an inborn error of metabolism. Ex.,
Cystic fibrosis, Hirschsprung’s or Aganglionic Megacolon
Procedure:
1. Vitamin K injected IM
2. Infant is restrained; penis is cleansed with soap and water
3. clamp is used
4. Petroleum gauze dressing is applied to prevent adherence of circumcised site to the diaper
while applying pressure to prevent bleeding
Nursing Care:
- Check hourly for bleeding
- Do not attempt to remove exudates which persist for 2-3 days; just wash with warm water.
- Diaper must be pinned loosely during the 1st 2-3 days when the base of the penis is tender.
XIII. BACK
- On prone appears flat
- Note for mass, hairy nodule and dimple along axis - Spina Bifida.
Causes: Management
Overfeeding Feed by demand
Gas distention Burp infant
Too much carbohydrates Feed in upright position
May need to change formula
Diaper Rash
Miliaria
Seborrheic Dermatitis
Occasional “Crossed Eyes”
Clothing
Sleep Pattern
I. CARDIOVASCULAR SYSTEM
Fetal Circulation
–Oxygen exchange occurs in placenta
–pressure on the left side of the heart < right side
–(+) accessory structures
Accessory Structures
a. Foramen ovale
b. Ductus arteriosus
c. Ductus venosus
d. Umbilical vein
e. Umbilical arteries
1.Cardiovascular system
→changes in the cardiovascular system are necessary because the lungs must oxygenate the
blood that was formerly oxygenated by the placenta.
→As the lung inflates for the 1st time, pressure decreases in the chest, decreased pressure in
the pulmonary artery leads to closure of ductus arteriosus, as pressure increases in the left
side of the heart from increased blood volume, closure of foramen ovale ensues.
Several circulatory changes are necessary for successful changes from FETAL circulation to
NEONATAL circulation
B. Ductus Arteriosus
- reversal blood flow increased pressure in aorta and increased O2 in the blood more blood
flowing through the pulmonary arteries for oxygenation.
- closure complete w/in 24H
- permanent : 3-4 weeks
C. Foramen Ovale
→closes within minutes after birth because of the higher pressure in the LA than in the RA
increase blood flow in the lungs decreases pressure in the RA the return of blood
from the lungs increases the pressure in the LA
→Closure : permanent approximately 3 months
D. Ductus Venosus
Cord clamped blood ceases flowing from umbilical vein to ductus venosus and into IVC
blood now flows through the LIVER and is filtered as in adult circulation
Increased pressure on the left side of the newborn’s heart results in:
√ Closure of the foramen ovale (fossa ovale)
√ Change of the ductus arteriosus into a mere ligament (ligamentum arteriosum)
√ Ductus venosus becomes ligamentum venosum
√ Since no more blood goes through the umbilical vein and arteries, these blood vessels
atrophy and degenerate
√ Umbilical vein, umbilical artery, and ductus venosus – no longer receive blood,these
atrophy over the next few weeks
√ (+) acrocyanosis ( cyanosis of infant feet and hands) for the 1st 24hrs due to sluggish
peripheral circulation
Blood Values:
o blood volume- 80 to 110 ml per kg of body weight or about 300 ml total
o (+) leukocytosis - about 15,000 to 30,000 cells/mm3
Blood Coagulation –(+) prolonged coagulation or prothrombin time due to lower vit. K
Most newborn are born with a prolonged coagulation or Prothrombin time, because their
blood levels of Vitamin K are lower than normal. It takes 24 hrs. for flora to accumulate and
vitamin K to be synthesized
After the 1st breath ,breathing becomes much easier for a baby requiring only 6 to 8cm h20
pressure
BREATHING
In utero – fetus relied on PLACENTA and Mother’s respirations for gas exchange
11th wks AOG – chest wall muscle and diaphragm developed
35th wks AOG – surfactant produced by alveoli is sufficient in amount (L/S ratio: 2:1) to
allow the alveoli to remain partially expanded when the newborn begins to breathe at birth .
1. Physical factor
aka… Mechanical
Factors include: Compression of the chest as it moves through the birth canal- squeezes
fluid from the lungs increase intrathoracic pressure chest wall recoil (w/c occur as the
newborn trunk emerges) thus creating negative pressure ( w/c causes a small amount of air
to replace the fluid that was squeezed out of the lungs and some lung fluid to move across the
alveolar membranes into the interstitial tissue of the lungs.
ALL OF THE ALVEOLAR FLUID IS ABSORBED WITHIN THE FIRST DAY AFTER
BIRTH
Chemical factor
Cord is clamped
Stimulate respiration
Initiation of breathing
MLNG CELESTE, RN, MD 193
3. Thermal factor
The change in temperature from the intrauterine environment to extrauterine environment
A decrease of more than 20F is stimulus to breathing.
Colder temperature stimulates nerve endings and the newborn breaths as a response.
Cold stress and respiratory depression result from excessive cooling of the newborn
Sensory factor
–The auditory STIMULATION ASSIST IN THE INITIATION OF RESPIRATION
–Visual
–Tactile
2. Rooting reflex- cheek is brushed or stroked near the corner of the mouth, a newborn infant
turns the head on that direction, disappears in about six weeks of life
3. Sucking reflex - when newborn’s lips are touched, the baby makes sucking motion,
diminishes within 6 months of life
4. Swallowing reflex - food that reaches the posterior portion of the tongue is automatically
swallowed
5. Extrusion reflex - substance that is placed on the anterior portion of the tongue is extruded,
prevents the swallowing of inedible substance, disappears with in 4 months of age
6. Palmar grasp reflex - newborn grasp an object placed in their palm, disappears about 6 wks
to 3 months
7. Step-in-place reflex - newborn who is held in a vertical position with their feet touching a
hard surface will take few alternating step
-disappears by 3 months of age
8. Placing reflex - same as step in place reflex except that it is elicited by touching the anterior
surface of newborn legs against hard surface, newborn makes a quick lifting motion
9. plantar grasp reflex - when an object touches the sole of a newborn’s foot at the base of the
toes, the toes grasp in the same manner as the finger do; disappears about 8 to 9 months
10. tonic neck reflex - when the newborn lies on his back, the head usually turns to one side ,
arm and leg on that side extend and the opposite arm and leg contract, disappears 2nd or 3rd month
of life . aka Fencing reflex
11. Moro reflex - can be stimulated by startling the newborn with loud noise or by jarring the
bassinet, fades on 4th or 5th month of life . Aka Startle Reflex – elicited by sudden disturbance
in the infant’s immediate environment, body will stiffen, arms in tense extension followed by
embrace gesture with thumb and index finger a “c” formation (disappears by 6 mo)
12. Babinski reflex – when the side of the sole of the foot is stroked, fanning of the toes (+)
will result. Stroking the sole of the foot from heel upward like an inverter “J” across ball of foot
will cause all toes to fan (reverts to usual adult response by 12 mo)
13. Magnet reflex - if pressure is applied to the sole of the foot while the newborn is lying in
supine position, he pushes back against the pressure; test for spinal cord integrity
14. Crossed extension reflex - if one leg of the newborn lying supine is extended and the sole
of that foot is irritated by being rubbed, infant raises the other leg and extends it as if trying to
push away the hand irritating the first leg
15. Trunk incurvation reflex - newborn lies on prone position and is touched along the
paravertebral area by probing finger, newborn flexes his trunk and swings the pelvis toward the
touch. aka Gallant Reflex
16. Landau reflex- a newborn who is held in a prone position with a hand underneath
supporting the trunk should demonstrate some muscle tone
(+) 3-6 months
17. Deep tendon reflexes - patellar reflex can be elicited in newborn by tapping the patellar
tendon with the tip of the finger, test for spinal nerve L2-L4
- bicep reflex - place the thumb of your left hand on the tendon of bicep muscles, test for C5
and C6
a. Breast fed infant stool – loose golden yellow in color with sweet odor; 2-3 times a day
b. Bottle fed infant stool – formed, pale yellow with a typical odor; usually passed 1-2x a day
newborn under phototherapy- has bright green stool due to increase excretion of bilirubin
newborn with bile duct obstruction- has clay-colored stool
blood flecked stool- newborn with anal fissure
B.HYPOSPADIA Male urethral opening on the ventral surface of penis, or female urethral
opening in vagina
V. IMMUNE SYSTEM
The newborn is prone to infection
Due to difficulty forming antibodies against invading antigen until they are about 2 mos. of
age.
This inability to form antibodies early also is the reason that most immunization against
childhood diseases are not given to infants younger than 2 mos.
Passive antibodies from the mother that have crossed the placenta are protective to a certain
extent.
VII. SENSES
1. Sight – at birth (9 inches)
2. Hearing-at birth
3. Taste – at birth
4. Smell-at birth
5. Touch-at birth (well developed)
SENSES
Sight – all newborns can see at birth although they cannot see objects past the visual midline
(not until 6-8 weeks). The visual field is 20-22 cm or 9 inches.
Hearing – as soon as amniotic fluid has been absorbed, the newborn can already hear
Taste – as soon as secretions have been suctioned, newborns can already taste
Smell – as soon as the nose has been cleared of mucus and fluid, newborns can smell
Touch – the most developed of all the senses
1. hearing- becomes acute after birth, recognizes mothers voice immediately functional @ birth
as soon as the external ear canal is cleaned
2. vision- focus best on black and white at distance of 9 to 12 inches. Not well developed at birth
4 months of age – clear vision.
7 y/o = 20/20 vision
3. Tactile (touch) starts in early prenatal life on face, then spreads to limbs and finally to the
trunks in cephalocaudal succession.
“…ensure that every baby born in the Philippines is offered the opportunity to undergo
newborn screening and thus be spared from heritable conditions that can lead to mental
retardation and death if undetected and untreated.”
NB screen
Should be done after 24-48 hours of life
After the infant is fed
done through extraction of blood in the heel of the foot
1. CONGENITAL HYPOTHYROIDISM
√ Thyroid hypofunction or enzyme defect
√ reduced T3, T4
√ Females
S/sx
h. short and thick neck,
a. excessive sleeping, i. dull expression,
b. enlarged tongue, j. open mouthed,
c. noisy respiration, k. slow DTR,
d. poor suck, l. obesity,
e. cold extremities, m.brittle hair,
f. slow pulse and respiratory rate, n. delayed dentition,
g. lethargy and fatigue, o. dry, scaly skin
4. GALACTOSEMIA
(-) enzyme that converts galactose to glucose
Galactose 1 phosphate uridyltransefrase
S/sx: wt loss, vomiting, hepatosplenomegaly, jaundice and cataract
Dx: Beutler test
Tx: dec lactose – soy based formula
regulate diet
5. PHENYLKETONURIA (PKU)
- dec phenylalanine hydroxylase w/c converts phenylalanine to tyrosine
S/sx: mental retardation, musty odor, blond hair, blue eyes
Dx: Guthrie bld test
Tx: dec phenylalanine (Lofenalac), regulate diet
Pathologic feature:
hyaline-like (fibrous) membrane formed
respiratory acidosis
Cause of RDS: low level/ absence of surfactant (phospholipid that lines the alveoli and reduces
surface tension on expiration to keep the alveoli from collapsing)
diagnosis:
clinical sign of grunting, cyanosis in room air, nasal flaring, retractions and shock
chest X-ray reveals diffuse pattern of radioopaque areas (ground glass/ haziness)
management
1. Surfactant replacement (ET tube)
2. Oxygen administration- Cx in very immature infant is retinopathy of prematurity
3. ventilation- normally I/E ratio is 1:2,there is difficulty in supplying O2 to stiff
noncompliant lung, so in infant ventilators, it is reverse
- can give Indomethacin
prevention:
√ usually happens on preterm infant; (tocolytic agents; preterm labor;
√ steroids-quicken the formation of lecithin)
√ Betamethasone- 12 & 24 hrs before birth; between wks 24 - 34
Common in:
1. Infant born via CS
2. Infants whose mother received extensive fluid administration during labor
3. Preterm infants
Management:
1. close observation
2. O2 administration
MECONIUM ASPIRATION
infant may aspirate meconium either in utero or in first breath after birth.
Management:
1. suctioning with bulb syringe or catheter while at the perineum
2. severe aspiration- infant might be intubated
3. don’t administer O2 under pressure
4. antibiotic therapy
5. chest physiotherapy and chest clapping
APNEA :
- Pause in respiration longer than 20 secs. with accompanying bradycardia
- commonly seen in:
√ preterm infant
√ infection
√ hyperbilirubinemia
√ hypoglycemia
MANAGEMENT:
1. gently shaking an infant or flicking the sole of the feet
2. close observation
3. resuscitation, if necessary
4. Theophylline or caffeine sodium benzoate to stimulate respiration
Prevention
1. maintain neutral thermal environment
2. use gentle handling to avoid excessive fatigue
3. never take rectal temperature in infant prone to apnea*
4. always suction the secretion gently to minimize nasopharyngeal irritation*
5. use indwelling not intermittent nasogastric tube*
*(may cause vagal stimulation which results to bradycardia)
Contributory factors:
1. Viral respiratory infection
2. Botulism infection
3. Brain stem abnormalities
4. Neurotransmitter deficiency
5. Heart rate abnormality
6. Decrease arousal responses
7. Possible lack of surfactant in alveoli
8. Sleeping prone
Mother’s immune system produces Rh antibodies in response to Rh+ fetal blood cells
If a tear in the placenta occurs and there was no treatment, the next Rh+ positive fetus will
have RBCs destroyed by the maternal Rh antibodies.
This causes hemolysis of fetal RBCs and then -anemia which in turn causes fetal edema –
Hydrops fetalis or Erythroblastosis fetalis (a syndrome with a hyperdynamic state,
heart failure, diffuse edema, ascites and pericardial effusion)
RhoGAM
–Rh immune globulin given to gravidas who are Rh(-) if there is suspicion of feto-maternal
bleeding (amniocentesis, miscarriage, vaginal bleeding and delivery), during any trimester, after
delivery and prophylactically at 28 weeks
MATERNAL ANTI BODY FORMATI ON AGAI NST THE RH ANTI GEN
• ABO INCOMPATIBILITY
The problem occurs when the maternal blood enters fetal circulation.
Most common: mother is Type O and the fetus is either Type A, B, or AB
The mother’s plasma naturally contains anti-A and anti B antibodies
With weaker hemolytic effect than Rh antibodies and only affect mature RBC’s
Number of antibodies is limited to the amount of maternal blood that entered circulation
May affect fetus of the 1st pregnancy
Affected newborn will become jaundiced in the first 3 days of life
Management:
-IM administration of 1mg of vit K
-if with severe bleeding, transfusion can be done
RETINOPATHY OF PREMATURITY
- acquired ocular disease that leads to partial or total blindness in children
- due to vasoconstriction of immature retinal blood vessels
- endothelial cells in the layer of nerve fibers in the periphery of the retina proliferate
Denver II TEST- (Denver developmental screening test II) 125 easily administered
developmental test items, with age norm, presented in a convenient one-page format.
Types of development:
1. Psychosexual development
- Specific type of development that refers to developing instinct or sensual pleasure
2. Psychosocial development
- refers to stages of personality development (Erikson)
3. Moral development
- is the ability to know right from wrong and to apply this to real life situation (Kohlberg)
4.Cognitive development
- refers to the ability to learn or understand from experience, to acquire and retain knowledge, to
respond to new situation, to solve problem.
- measured by intelligence tests, and by observing a child’s ability to function effectively in
his/her environment
Lymphoid tissues develop rapidly, reaching adult size by 6 years of age and continue to
hypertrophy throughout childhood and early adolescence before receding to adult size
The metabolism of medication and child’s response to them change rapidly in the first month
of life and again under the hormonal influences in puberty
Nutritional needs as well as a wide variety of biochemical and hematologic values undergo
marked developmental changes.
1. PSYCHOSEXUAL THEORY
-Psychosexual theory- Freudian theory , the idea of body-centered drives
a. Infancy (0-1yr)--------- oral ( sucking of the first year of life)
b. Toddlerhood (2-3 yr)-- anal (holding on and letting go during the Toddler years)
c. Preschool (3-6 yr)----- oedipal drives (possessiveness toward a parent In the preschool years)
d. School age (6-12 yr)--- Latency
e. Adolescence (12-20)--- adolescence
Oral – infant
oral stimulation for nutrition, enjoyment and release of tension
NI: provide oral stimulation – pacifiers, breastfeeding, thumbsucking
Anal - toddler
elimination is a way of discovery and exerting independence
NI: help achieve bowel and bladder control even if hospitalized
Phallic – preschool
increased knowledge of 2 sexes
NI: accept sexual interest and answer questions about birth or sexual difference
Latent - school age
libido diverted to school
NI: help achieve positive experiences to promote self esteem
Genital - Adolescent
establish sexual aims and finding new love objects
- NI: provide opportunities to relate with opposite sex and allow verbalization about new
feelings
2. PSYCHOSOCIAL THEORY
> recast Freud’s stages in term of the emerging personality
a. Sensorimotor – 1 mo-24 mo
b. Preoperational Thought – 2-7 y/o
c. Concrete Operational Thought – 7-12 y/o
d. Formal Operational Thought – 12 y/o
Sensorimotor
- relate through senses, separate from environment, practical intelligence
Preoperational
- toddler: symbolic thought, simple abstractions, literal thinking, poor concept of time and
distance
Concrete Operational
- systematic reasoning
- memory to learn broad concepts and subgroups
- seriation and classification
- reversibility
- inductive reasoning (specific to general)
- conservation (7 y/o – numbers; 7-8 y/o quantity; 9 y/o – weight; 11 y/o – volume)
1. Preconventional (Level I)
Stage 1 - 2-3 y/o
“mother or father says so”
punishment obedience orientation
- 10-12 yr – maintenance of social order, fixed rules and authority( child finds following rules
satisfying)
“Social Contract”
“Principled conscience”
HARRY SULLIVAN
1. Prototaxic mode – infancy
- undifferentiated thought (unable to separate the whole into parts or to use symbols)
– need for bodily contact and love; anxiety due to unmet needs
DEVELOPMENTAL STAGES
IMPORTANCE OF KNOWLEDGE OF GROWTH AND DEVELOPMENT
B. 2nd
Neonate - birth - 28 days
Infant - 1 month - 1 y/o
C. 3rd
Toddler - 1 - 3 y/o
Preschool - 3 - 6 y/o
D. 4th
School age - 6 - 12 y/o
Adolescence - 13 - 18 y/o
Nursing implications:
1. talk to parents about reactivity patterns
2. Notice temperamental characteristics when hospitalized
II. Environment
a. Socioeconomic level – lack supervision, health care or nutrition
b. Parent-Child Relationship – thrive better if loved
c. Ordinal position in the family – size and position in family
d. Health – debilitating diseases
GROSS MOTOR
2 mos - 45 degree head control
3 mos - 90 degree head control
4 mos - lifts head & chest on prone, - rolls over
5 mos - 6 mos - good head control
o sits with support
8 mos - sits without support
9 mos - pulls self to stand
- creeps
10-11 mos – cruises
12 mos – stands alone
FINE MOTOR
1 mo - eyes to midline
LANGUAGE
1 mo - throaty gurgling sound
3 mos - squeals
12 mos - obeys commands, one word other than mama, dada
PERSONAL SOCIAL
2 mos - social smile
PLAY
– solitary play: self is the interest of activities; alone but enjoys presence of others
Mirror play
Balloon mobiles Peek-a-boo
Being held Rocking
Block play Singing games
Feet & toes games Squeaky toys
Fingers & hand games Pat-a-cake
Listening to stories
Making faces
NUTRITION
Lipase – dec until 1 yr
Amylase – dec until 3 mos
Immature liver – inefficient storage and formation of nutrients
Extrusion reflex – until 4 mos
DAILY CARE
- bathing
- diaper care
- care of teeth
- dressing
- sleep – 10-12 hrs/day; 1 or more naps
- exercise
Concerns
- Constipation
- Teething – cleanliness
- thumb sucking – until school age
- pacifiers – wean after 3 mos
- head banging – begin 2nd half of infancy to preschool, naptime, under 15 min
- sleep problems – breastfed infants wake up sooner
- spitting up
- diaper dermatitis
- miliaria/prickly heat – papular, erythematous on neck, ear, face, trunk
- baby bottle syndrome
- Loose stools – breastfed
- Colic – paroxysmal abdominal pain, < 3 mos, inc in formula fed
- Obesity – 32 oz formula daily, add fiber and water to diet
- Stranger anxiety
REACTION TO ILLNESS
Soothing stimulation
Toys from home
Human contact
Provide/Anticipate needs
TODDLER – 1 –3 y/o
Slowed growth
Wt gain 5-6 lbs (2.5 kg)
5 in (12 cm)
Baby fat disappears
brain 90 % adult size
Baby fat disappears
CC > HC; inc by 2 cm
HR 90 bpm
BP 99/64
Protruberant abdomen
Stomach capacity increases
Control of urinary and anal sphincters
IgG and IgM
20 deciduous teeth
GROWTH AND DEVELOPMENTAL MILESTONES
Gross
24 mos – walks up & down stairs w/ both feet same step, same time
2 ½ yo – tiptoes
3 yo - throws balls, rides tricycles, stands on 1 foot momentarily
LANGUAGE
PERSONAL/SOCIAL
Decrease in appetite
Picky eaters
1, 300 kcal/day
Allow self feeding
Allow choice between 2 types of food
Offer finger food
Risk of aspiration
PLAY – parallel play: plays alongside, but not with another;
has not learned sharing yet
CONCERNS
Toilet Training
bowel control – 18 mos
daytime bladder ctrl – 2-3 y/o
nighttime bladder ctrl – 3-4 y/o
CONDITIONS:
1. control of sphincters
2. cognitive understanding
3. delay immediate gratification
4. mature nervous system
Negativism
Temper Tantrums
Accidents
Rituals
Egocentrism
Sibling rivalry
Discipline
Separation anxiety
REACTION TO ILLNESS and NURSING INTERVENTIONS
HR 85 bpm
BP 100/60
4.5 - 5 kg/yr
2 - 3.5 in/yr
Frequent voiding
GROWTH AND DEVELOPMENTAL MILESTONES
Gross
4 – 4 ½ - climbs stairs
- hops on 1 foot
FINE MOTOR
LANGUAGE
4 y/o – buttons up
4 ½ - dresses w/o supervision
5 y/o – uses a knife
NUTRITION
Slow/Steady growth
Decreased appetite
Offer small servings
Healthy snack food
PLAY – associative play; plays in random without group goal;
follows a leader
Dress up clothes
Housekeeping toys
Dolls and other toys for pretending
Bikes and climbing toys
Paper and crayons
DAILY CARE
- accidents – bicycle safety, seat belts
- dressing – choose own clothes
- sleep – resist taking naps
- exercise – very active
- bathing – can wash and dry hands; need supervision
- care of teeth – independent brushing; 1st dental visit
CONCERNS
- imitation
- Oedipus and electra complex
- gender roles – need exposure to parents of opposite sex
- Socialization – capable of sharing
- Discipline – “time out”
- Common fears – dark, mutilation, separation
- Telling tales
- Imaginary friends
- sharing – define limits and teach property rights
- Regression –reaction to stress
- Sibling rivalry
- sex education
- pre-school center
- broken fluency
- swearing
- High energy level
- Curiosity
–3-5 lb/yr
–1-2 in /yr
–10 yo – brain growth complete
–Adult vision
–Abundant tonsillar and adenoid tissue
–“innocent” heart murmurs
–HR 70 bpm
–BP 112/60
–32 permanent teeth
–Pubertal onset
SECONDARY SEX CHARACTERISTICS
PERSONAL/SOCIAL/PLAY
Competitive play and recreational activities
Good appetite
Food w/ high nutritional value
- more calories and nutrients
- hungry after school – give snacks and make mealtimes enjoyable
DAILY CARE
- dressing – influenced by peers
- sleep – 8-12 hrs; no naps
- exercise – games, bike riding, walking
- hygiene – 8 y/o – capable of bathing alone
- care of teeth – 2x yearly visit to the dentist; brush daily
- safety – bicycle, school bus safety, prevention of falls and sports injuries
CONCERNS
- problems w/ articulation – disappears 9 y/o
- School anxiety and phobia
- Sex education
- Stealing – 7 y/o – importance of money
- Violence/terrorism – education; reassurance
- Bullying
- Recreational drug and alcohol use
- Obesity
REACTION TO ILLNESS
AND NURSING INTERVENTIONS
- Death and disability - Still need comfort
- Unknown events & procedures - Allow to help w/ care & treatment
- Loss of ctrl & independence - Give choices
- Loss of contact w/ peers - Allow visits
- Disruption of school - Talk about interest
- nutrition – allow choices
- dressing – ask opinions on bulk of dressing and where to apply tape
- medicine – teach name and action, allow to choose form if possible
- pain – allow expression of pain, explain source and cause
- stimulation
ADOLESCENT
CONCERNS
- Socialization – falling in love
- Obesity; Diseases – HPN
- Acne
- Body piercing
- Fatigue - emotional fatigue
- Menstrual irregularities
- Sexuality and sexual activity
- Poor posture
- Stalking – educate girls
- Substance abuse
- Suicide
- runaways
Separation from peers and lack of emotional support - Approach w/ caring and understanding,
age compatible roommate, Phone at bedside
Thank You!