Presented By: GROUP 2 Leader: Rizalyn Joy C. Gadugdug Helen Grace G. Villacin Jelanie B. Mangombaya Aminoden B.

Camarudin Rafsanjani Umpa Newsryn Ducay Genila Marie O. Bait-it Ma. Lorelyn Pendang Gwendolyn T. Mabaquiao Sheena Claire D. Gentallan Sheena 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 newborn. 2. Describe the state of a newborn. 3. Perform newborn assessments such as the APGAR, Ballard and Silverman Test. 4. Implement nursing care to a normal newborn, such as administering a first bath or instructing parents on how to care for their newborn. 5. Describe the nursing management of the newborn: respirations, maintenance of temperature, prevention of infection, and optimal nutrition. 6. Discuss initial identification, registration, and screening procedure for the newborn. 7. Relate the importance of the bonding process to the newborn babys and parents adjustment to each other. 8. Develop a teaching plan for parents of a newborn specific to home care. 9. Discuss the importance of breastfeeding to the mother and family. 10. Apply correct nursing intervention necessary for newborn care. I INTRODUCTION NEWBORN 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 neonates 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 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. Nurse 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 his/her family.

DEFINITION OF TERMS: Habituation - the gradual adaptation to a stimulus or to the environment, with a decreasing response. Orientation - awareness of one's 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 quality of movement and tone. Range of state measure of general arousal level or arousability of infant. Regulation of state how infant responds when aroused. Autonomic stability 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. Whartons 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 is the transfer of body heat to a cooler solid object in contact with a baby. Convection is the flow of heat from the newborn/s body surface to cooler surrounding air. Radiation is the transfer of body heat to a cooler solid object not in contact with the baby. Evaporation is loss of heat through conversion of a liquid to vapor. Attachement is the mode of contact between babys mouth and the mothers 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 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 child's 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 SIGNS Heart rate Respiratory effort Muscle Tone Reflex Irritability Color SCORES 0-3 46 7 10 Severe Distress Moderate Difficulty Absent in Difficulty - is the most frequent in assessing the newborns immediate adjustment to extra uterine life (Papile, 2001) 0 Absent Absent Limp No response Blue, Pale 1 Slow, < 100 beats / min Irregular, slow, weak cry Some flexion of extremities Grimace Body pink, extremities blue 2 Beats / min Good, strong cry Well flexed Cry, sneeze Completely pink

TRANSITIONAL ASSESSMENT Newborn exhibits behavioral and physiological characteristics that can at first appear to be signs of stress. During newborns 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. - heart and respiratory rate - temperature - 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 - heart and respiratory rate - Gag reflex is active - 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 with thumb supporting back of arm below wrist, apply gently pressure index and third fingers on dorsum of hand without rotating infants wrist. Measure angle between base of

Square window

with 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 numb and - 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 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 Heel to ear - with infant supine, support head in midline with one hand; use other hand to pull infants arm across the shoulder so that infants hand touches shoulder. Determine location of elbow in relation to midline. Score: elbow does not reach midline = 4 - 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, MINOR ABNORMALITIES POTENTIAL SIGNS OF DISTRESS MAJOR ABNORMALITIES

GENERAL MEASUREMENTS Head circumstance: 33-35 cm (13-14 in) 1in About 2-3cm (1 in) larger than chest circumference Chest circumference 30.5-33cm (12-13 in) Crown-to-rump length: 31-35cm (12.5-14in); Approximately equal to head circumference Head-to-heel length: 48-53cm (19-21in) Birth Weight: 2700-4000g (6-9 lb)

Molding after birth altering head circumference Head and chest circumference equal for first 1-2days after birth

Head Circumference <10th or> 90th percentile

Loss of 10% of birth weight in first week; regained in 10-14days, Depending on feeding method

Birth weight <10th or> 90th percentile

VITAL SIGNS Temperature, axillary 36.5-37C (97.9-98F) Heart rate, apical:120-140 beats/min

Crying increasing body temperature slightly Radiant warmer falsely increasing axillary temperature Crying increasing heart rate, sleep decreasing heart rate During 1st period of reactivity (6-8hr), rate up to 190 Bpm Crying increasing respiratory rate; sleep decreasing respiratory rate During 1st period of reactivity (6-8hr), rate up to 80 Bpm Crying and activity increasing BP Placing cuff on thigh agitates ionfant Thigh BP higher then arm or calf BP by 4-8mmHg

Hypothermia Hypothermia Bradycardia: Resting reate below 80-100 Bpm Tachycardia: Rate above 160-180 Bpm Irregular rhythm Tachypnea: Rate >60 Bpm Apnea: 20 sec or more

Respiration 30-60 Bpm

Blood pressure (BP), oscillometric 65/41 mmHg in than Arm and calf

Oscillometric systolic pressure in calf 6-9 mmHg less in upper extremity (sign of coarctation aorta)

GENERAL APPEARANCE Posture: Flexion of head and extremities, which rest On chest and abdomen SKIN At birth, bright red, puffy, smooth 2nd-3rd day, pink, flasky, dry Vernix caseosa Lanugo Edema around eyes, face, legs, dorsa of hands, feet, And scrotum or labia Acrocyanosis: Cyanosis of hands and feet Cutis marmorata: Transient mottling when infant is Exposed to decreased temperature

Frank breech: Extended legs, abducted and fully rotated thighs. Flattened occiput, extended neck Neonatal jaundice after first 24hr Ecchymoses or petechiae caused by birth trauma Milia: Distended sebaceous glands that appear as tiny white papules on cheeks, chin, and nose Milaria or sudamina: Distended sweat (eccrine) glands that appear as minute vesicles, especially on face Erythema toxicum: Ping popular rash with vesicles superimposed on thorax, back, buttocks, and abdomenl May appear in 24-48 hr and resolve after several days Erythema toxicum: pink popular rash with vesicles superimposed on thorax, back, buttocks, and abdomen may appear in 24-48 hrs and resolve after several days. Harlequin Color change: clearly outlined color change as infant lies on the side; lower half of body becomes pink and upper half is pale. Mongolian spots: irregular areas of deep blue pigmentation usually in sacral and gluteal regions, seen predominantly in newborn of African, native American, asian, or Hispanic descent. Talengiectatic nevi (stork bite): flat, deep pink localized areas usually seen on back of neck. molding after vaginal delivery third sagital (parietal) fontanel bulging fontanel because of crying or coughing caput succedaneum: edema of soft scalp tissue cephalhematoma: hematoma between periosteum and skull bone

Limp posture: Extension of Extremities

Progressive jaundice especially in first 24hr Generalized cyanosis Pallor Mottling Grayness Plethora Hemorrhage, ecchymoses, or petechiae that persist Sclereme: Hard and stiff skin Poor skin turgor Rashes, pustules, or blisters caf au lait spot: light brown spots nevus flammeus: port-wine stain

HEAD Anterior fontanels: Diamond shape: size varies form barely palpable to 4-5 cm Posterior fontanels: triangular, 0.5-1cm Fontanels flat, soft, and firm Widest part of fontanel measured from bone to bone, not suture to suture EYES Lids usually oedematous

fused sutures bulging or depressed fontanels when quiet widened sutures and fontanels craniotabes: snapping sensation along lambdoid sutures that resembles indentation of ping-pong ball

epicanthal folds in asian infants

pink color of iris

Color: slate gray, dark blue, brown Absence of tears Presence of red reflex Corneal reflex in response to touch Pupillary reflex in responsing to light Blink reflex in response to light or touch Rudimentary fixation on objects and ability to follow to midline

searching nystagmus or strabismus subconjuctival (sclera) hemorrhage: ruptured capillaries, usually at limbus

purulent discharge upward slunt in non-asians hypertelorism hypotelorism congenital cataracts constricted or dilated fixed pupil absence of red reflex Absence of papillary or corneal reflex Inability to follow object or bright light to midline Yellow sclera low placement of ears absence of startle reflex in response to loud noise minor abnormalities possible signs of various syndrome especially renal

EARS Position: top of pinna on horizontal line with outer canthus of eye Startle reflex elicited by loud, sudden noise Pinna flexible, cartilage present NOSE Nasal patency Nasal discharge: Thin white mucus Sneezing MOUTH AND THROAT Intact, high-arched palate Uvula in midline Frenulum of tongue Frenum of upper lip Sucking reflex: strong and coordinated Rooting reflex Gag reflex Extrusion reflex Absent or minimum salivation cry Vigorous cry NECK Short, thick, usually sorounded by skin folds Tonic neck reflex

inability to visualize tympanic membrane because of filled aural canals pinna flag against head Irregular shape or size Pits or skin tag Flattened and bruised

Nonpatent canals Thick, bloody nasal discharge Flaring of nares (alae nasi) Copious nasal secretions or stuffiness (may be minor) cleft lip cleft palate large, protruding tongue or posterior displacement of tongue profuse salivation or drooling Candidiasis (thrush): white, adherent patches on tongue, palate, and buccal surfaces Inability to pass nasogastric tube Hoarse, high-pitched, weak, absent or other abnormal

nasal teeth: teeth present at bith; benign but may be associated with congenital defects Epstein pearls: Small, white epithelial cysts along midline of hard palate

Torticollis (wry neck): head held to one side with chin pointing to opposite side

Excessive skin folds Resistance to flexion Absence of tonic neck reflex

Fractured clavicle; crepitus CHEST Anteroposterior and lateral diameters equal Slight sterna retractions evident during inspiration Xiphoid process evident Breast enlargement Funnel chest (pectus excavatum) Pigeon chest (pectus carinatum) Supernumerary nipples secretion of milky substance from breast (witchs milk) Depressed sternum Marked retractions of chest and intercostals apaces during respiration Asymmetric chest expansion Redness and firmness around nipples Wide-spaced nipples Inspiratory stridor Expiratory grunt Retractions Persistent irregular breathing Periodic breathing with repeated apneic spells Seesaw respirations (paradoxical) Unequal breath sounds Persistent fine, medium, or coarse crackles Wheezing Diminished breath sounds Peristaltic bowel sounds on one side, with diminished Sounds on same side Dextrocardia: Heart on right side Displacement of apex, muffled Cardiomegaly Abdominal shunts Murmur Thrill Persistent central cyanosis Hyperactive precordium abdominal distention Localized bulging Distended veins Absent bowel sounds Enlarged liver and spleen

LUNGS Respirations chiefly abdominal Cough reflex absent at birth, present by 1-2 days Bilateral equal bronchial breath sounds

Rate and depth of respirations may be irregular; periodic breathing Crackles shortly after birth

HEART Apex: 4th-5th intercostals space,lateral to left sterna Border S2 slightly sharper and higher in pitch than S1

Sinus arrhythmia: Heart rate increasing with inspiration and decreasing with expiration Transient cyanosis on crying or straining

ABDOMEN Cylindric in shape Liver: palpable 2-3 cm (0.8 to 1.8 in) below right Costal margin Spleen: Tip palpable at end of 1st week of age Kidneys: palpable 1-2 cm (0.4 to 0.8 in) above

Umbilical hernia Diastasis recti: Midline gap between recti muscles Wharton jelly: unusual thick umbilical cord

Umbilicus Umbilical cord: Bluish white at birth with 2 arteries And vein Femoral pulse: equal bilaterally

Ascites Visible peristaltic waves Scaphoid or concave abdomen Moist umbilical cord Presence of only one artery in cord insertion site Periumbilical erythema Palpable bladder distension after scant voiding Absent femoral pulses Cord bleeding or hematoma Omphalocele or gastroschisis:Protrusion of abdominal abdominal wall defect

contents FEMALE GENITALIA Labia and clitoris usually edematous Urethral meatus behind clitoris Vernix caseosa between labia Urination within 24 hours. Pseudomenstruation: Blood-tinged or mucoid discharge Hymenal lag Enlarged clitoris with urethral meatus at tip Fused labia Absence of vaginal opening 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 Testes palpable in each scrotum Scrotum usually large, edematous, pendulous, and covered with rugae; usually deeply pigmented in dark-skinned ethnic groups Smegma Urination within 24 hours Urethral opening covered by prepuce Inability to retract foreskin Epithelial pearls: Small, frim, white lesions at tip of prepuce Erection of priapism Testes palpable in inguinal canal Scrotum Hypospadia: urethral opening on ventral surface of penis Epispadias: urethral opening on dorsal surface of penis Chordee: ventral curvature of penis Testes not palpable in scrotum or inguinal canal No urination within 24 hrs Inguinal hernia 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 curves Trunk incurvation reflex Anal reflex Patent anal opening Passage of meconium within 48 hrs EXTREMITIES 10 fingers and toes Nail beds pink, with transient cyanosis immediately After bith Creases on anterior 2/3 of sole Sole usually flat Symmetry of extremities Equal muscle tone bilaterally, especially resistance to Opposing flexion Equal bilateral brachial pulses Green liquid stools in infant under phototherapy Dekayed passage of meconium in very-low-birth weight neonates. Anal fissures or fistulas Imperforate anus Absence of anal reflex No meconium within 36-48 hrs Pilonidal cyst or sinus Tuft of hair along spine Spina bifida (any degree)

Partial syndactyly between 2nd and 3rd toes 2nd toe overlapping into 3rd toe wide gap between 1st (hallux) and 2nd toes Deep crease on plantar surface of foot between 1st and 2nd toes Asymmetric length of toes Dorsiflexion and shortness of hallux

Polydactyly: extra digits Syndactyly: fused or webbed digits phocomelia: hands or feet attached close to trunk Hemimelia: Absence of distal part of extremity Hyperflixibility of joints 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 Extension of extremity followed by previous position of flexion Head lag while sitting, but momentary ability to hold head erect Quevering or momentary tremors Hypotonia: Floppy, poor head control, extremities limp Hypertonia: Jittery, arms and hands tightly flexed, legs stiffly extended, startles easily Assymmetric posturing (except tonic neck reflex) Opisthotonic posturing: Arched back Signs of paralysia Tremors, twitches and myclonic jerks Marked head lag in all positions.

ASSESSMENT OF REFLEXES IN THE NEWBORN

REFLEXES LOCALILZED Eyes Blinking or corneal reflex Pupillary Dolls eye Nose Sneeze Glabellar Mouth and Throat Sucking Gag Rooting Extrusion Yawn Cough EXETREMITIES Grasp

EXPECTED BEHAVIORIAL RESPONSES 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. Touching palms or soles near base of digits causes flexion of hands and toes; palmar grasp lessens after age 3 months to be replaced by voluntary movement; plantar grasp lessens by 8 months of age.

Babinski Ankle clonus MASS Moro

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 (beats); eventually no beats should be felt. 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.

Startle Perez

Asymmetric tonic neck When infants 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. Trunk incurvation (Galant) reflex Striking infants back alongside spine cause hips to move toward stimulated side; disappears by age 4 weeks. Dance or step 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. Crawl When place on abdomen, infant makes crawling movements with arms and legs; disappears at about age 6 weeks. Placing 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

Increased PO2 Closer of Foramen Ovale (pressure in the left side of hearth greater than in right side)

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 newborns large surface are relative to his or her weight facilitates heat loss to the environment. 2nd, the newborns thin layer of subcutaneous fat. 3rd, the newborns mechanism for producing heat. Mechanism of Heat loss a.) Convection Is the flow of the heat from the newborns 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 85 ml/kg, 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 newborns 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 cows milk. Human milk, despite its 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(7.5 pounds [3.4 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 infants first stool, composed of amniotic fluid and its 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 day. o In breast-fed infants stools are yellow to golden, are pasty in consistency, and have an odor similar to that of sour milk. o 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 its 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 1.020.

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 newborns 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 (witchs 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 newborns back, trunk or extremities. Slapping the newborns 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 neonates chest, brisk recoil of the thorax occurs. Air enters the upper airway to replace the lost fluid. In the alveoli, the fluids 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 acidbase 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 newborns sensory functions are remarkably well developed and have a significant effect on groth and development, including attachment process. Vision. At 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 eyes 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 age. The 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 infants 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 20/100 and 20/400, depending on the vision measurement techniques. The 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. Hearing Once 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 newborns response to sounds of low frequency and high frequency differs the former, such as heartbeat, metronome, or lullaby, tends to decrease an infants motor activity and crying, whereas the latter elicits an alerting reaction. Smell Newborns 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 mothers 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. Taste

The 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. Touch The 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 doesn't 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 newborn's 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 sized 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 newborns 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 infants 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 neonates 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 skinto-skin contact(kangaroo care), is physically beneficial in terms of observing newborn heat and fostering maternal attachment and breastfeeding. 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 infants 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, mothers admission number, date and time of birth) against the birth records and the childs actual gender. PROTECTION FROM INFECTION AND INJURY: EYE CARE (CREDES PROPHYLAXIS)

Prophylactic eye treatment against opthalmia neonatorum, infectious conjunctivitis of the newborn, includes the use of (1) silver nitrate (1%) solution; (2) erythromycin (0.5%) ophthalmic ointment or drops, or (3) tetracydine (1%) ophthalmic ointment or drops (preferably in single-dose ampules or tubes). VITAMIN K ADMINISTRATION Shortly after birth, vitamin k is administered as a single intramuscular dose of 0.5 to 1 mg to prevent hemorrhagic disease of the newborn. Normally, vitamin K is synthesized by the intestinal flora. However, because the infants 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 VACCINATION To 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 name General or action Generic name Aquamephat Vitamin K on is used for or the Phytonadion prophylaxi e s and treatment of hemorrha gic disease of the newborn. It is a necessary componen t for the productio n of Indication 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 Mechanism of action An antihemorrhagi c factor that promotes hepatic formation of active coagulation factor. Side effects & Adverse effects CNS: dizziness CV flushing, transient hypotension after IV administration, rapid and weak pulse. Skin: diaphoresis, erythema Drug interaction Anticoagulant: may cause temporary resistance to prothrombindepressing coagulants, especially when large doses of phytonadione are used. Monitor patient closely. Route, Frequency, dosage Prophylax is- 0.5 to 10 mg IM one time immediat ely after birth; treatment for hemorrha gic disease. 1 to 2 mg intramusc ular or subcutan eous

To prevent hypoprothrombinemia related to Vitamin K deficiency in long term parenteral nutrition.

Cholestyramine, Other: mineral oil, or list anaphylaxis or at: may inhibit GI anaphylactoid absorption of reactions, usually oral Vitamin K;

certain coagulatio n factors (II, VII, IX and X) produced by microorga nism in the intestinal tract. Nursing considerations:

To prevent hypoprothrombinemia in infants receiving less less than 0.1 mg/L Vitamin K in breast milk or milk substitutes.

after excessively rapid IV administration, pain, swelling and hematoma in injection site.

separate doses if possible. If unavailable, use together cautiously.

daily.

Check brand name labels for administration, route, and restriction. For I.M administration on adults and other children, give in upper outer quadrant of buttocks; for infants, give in anterolateral aspect of thigh and deltoid region. S.C route is preferred to avoid hematoma transition. Allergic reactions may also occur after I.M or S.C 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, dont delay after measures such as administration of fresh frozen plasma of whole blood. Vitamin K doesnt reverse the anticoagulant effects of heparin. Watch for flushing, weakness, tachycardia and hypotension; condition may progress to shock. Phytonadione therapy for hemorrhagic disease in infants causes fever adverse reactions than other Vitamin K analogues.

Brand name or Generic name Ilotycin or Erythromycin (ophthalmic ointment)

General action Erythromycin, an antibiotic, is effective against gonorrhea and Chlamydia microorganisms, making it the drug of choice for eye prophylaxis at birth.

Indication

Mechanism of action Inhibit protein synthesis; usually bacteriostatic but may be bactericidal in high concentrations or against highly susceptible microorganisms.

Acute and chronic conjunctivitis, other eye infection. Chlamydial ophthalmic infection To prevent opthalmia neonatorum caused by Nesseiria gonorrhea

Side effects & Adverse reactions EENT: slowed corneal wound healing, blurred vision itching and burning eyes. Skin: urticaria, dermatitis Other: overgrowth of non-susceptible microorganisms with long term use

Drug interactio n None significant

Route, Frequenc y, dosage 0.5-1 cm in 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 its effective against infecting microorganisms; dont use in infection of unknown cause. Store drug at room temperature in tightly closed, light resistant container.

EXPANDED PROGRAM ON IMMUNIZATION (EPI) For the Baby Vaccine BCG DPT OPV Hepa B Minimum age at 1st dose Birth or anytime after birth 6 weeks 6 weeks At birth # of Doses 1 3 3 3 4 weeks 4 weeks 6 weeks interval from 1st dose to 2nd dose, 8 weeks interval from 2nd to 3rd dose Minimum interval between doses Route, Dosage, Site ID, 0.05 ml right arm IM, 0.5 ml Thigh (vastus lateralis) Oral, 2 drops Mouth IM, 0.5 ml Thigh (vastus lateralis) Storage temp 2-8 degree celcius in body of ref 2-8 degree celcius in body of ref -15 to -25 degree celcius (freezer) 2-8 degree celcius in body of ref Type/form of vaccine Freeze dried, live attenuated bacteria D- weakened toxin P- killed bacteria T- toxin Live attenuated virus RNA recombinant

NEWBORN SCREENING FOR DISEASE a. 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 baby's 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 baby's physical growth will be stunted and she/he 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 infants 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 Circumcision RISKS (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 neonates 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 males 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 (formula) 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 growth. 6. Breastfed babies are constantly exposed to a variety of tastes through their mother's milk. 7. Breastfed children are at less risk for chrohn's 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 diabetes.

8. 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-fed. 9. IQ levels are an average of 8 points higher in children who were breastfed. 10. Adult daughters who were breastfed are at less risk for breast cancer. 11. Adults who were breastfed have a lower risk for high cholesterol and asthma. 12. The bond between mother and child seems to be enhanced with breastfeeding. Ten Steps to Successful Breastfeeding Every 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 clinic. For biblio: Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services, a joint WHO/UNICEF 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 infant's softness and appearance is appealing to parents. In "The Nature of the Child's 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 mothers. 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 newborn's 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 feeding 3. formula should be at room temperature for feeding 4. do not prop the bottle; leaking of milk into infants ear can results in infection 5. bubble the infant (upright position) following feeding and during feeding if he appears to be getting air with the feeding 6. 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, 24-31C (75-88F); bath water, 36.6-37.7C (98-100F) 3. use cotton balls or soft disposable wash cloths to wipe eyes, face and outer ear. Eyes are wiped from inside corner outward 4. 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 used. 7. 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 friction. 8. cleanse genital area of female a. use wet cotton ball b. separate labia c. wipe from front to back and discard cotton ball C. discuss with the parents the infants behavioural responses 1. sleeping pattern 2. response to environmental stimuli 3. 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 infants temperature take 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 cyanosis 2. anorexia, vomiting. Diarrhea 3. abnormal respiration 4. 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- Cleansing/antibacterial 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 visit/primary 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 1.5 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, ABO/Rh 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 beats/minute at rest; respiratory rate 30-55 at rest without evidence of sternal retractions, granting, or nasal flurring; temperature 36.3 to 37 degrees Celsius axillary. Position of sleep- back

HEALTH EDUCATION PLAN (HEP)

Objectives: 1. To provide basic knowledge regarding the importance of newborn care. 2. To promote sense of independence to the mother regarding in fulfilling the needs for her baby. 3. To provide information to the mother regarding the specific nutritional diet necessary for the infant. Materials needed: Visual aids General Health Teachings Hygiene Specific Health Teachings *Teach the mother that bathing should proceed from the cleanest to the most soiled areas. *Teach the mother to wash the infants 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 bonding. Stress also the benefits of breastfeeding. *Instruct the mother not to give food or drink other than breast milk. *Instruct the mother not to give pacifiers to breast-feeding infants. *Stress to parents the importance of Newborn Screening. *Encourage mother that the infant must have a complete immunizations as prevention.

Rest

Diet

Follow-up Check-ups

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 26.7, 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-toskin 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). Nurses Pocket Guide 11th ed. Taiwan: iGroup Press Co., Ltd. Hockenberry/Wilson. (2007). Wongs 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 Womens 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: http://portal.doh.gov.ph. National Statistical Coordination Board. MDGWatch. Statistics at a glance of the Philippines Progress based on the MDG indicators. (as of October 2009). Available: http://www. nscb.gov.ph/stats/mdg/mdg_watch.asp. NEDA-UNDP. Philippines Midterm Progress Report on the Millenium Development Goals. (2007). Available: http://www.neda.gov.ph/econreports_dbs/MDGs/midterm/01-96%20UNDP_final.pdf. 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: http://www.pia.gov.ph/? m=12&r=&y=&mo=&fi=p090918.htm&no=59. United Nations Population Fund. (2009). Philippines: Maternal Mortality Rates Not Making Sufficient Progress to Meet MDGs.. Available: http://www.unfpa.org/public/News/pid/2452 World Health Organization Statistical Information System- Detailed database search. Accessed on January 16, 2010. Philippines.. Available:http://apps.who.int/whosis/data/Search.jsp?countries=[Location].Members.