NORMAL NEONATES - NURSING ASSIGNMENT

INTRODUCTION

        A health infant born at term should have an average birth weight for the country cries, immediately following birth, establishes independent rhythmic respiration and quickly adapts to the changed environment.

        The weight is very variable from country to country but usually exceeds 2500gm. In India, the weight varies between 2.7 to 3.1kg with a mean of 2.9 kg. The length is 50-52 cm. The length is a more reliable critersion of gestational age than the weight. Head circumference measures about 35 cm and the biparietal diameter measures about 9.5 cm.

       

DEFINITION

        A healthy infant born at term (between 38-42 weeks) should have an average birth weight for the country, cries immediately following birth, establishes independent rhythemic respiration and quickly adapts to the changed environment.

PHYSICAL FEATURES AT BIRTH

1. Examination of Vital Signs:

      i.            Temperature: is recorded and the site (eg: rectal, oral or axillary) is mentioned.

   ii.            Respiration: Normal 30-60 breaths/min

iii.            Pulse: Normal 100-160 beats/min and when asleep it is around 70-80 beats/min

 iv.            Blood Pressure: Normal range 45-60/25-40 mm of Hg. BP is directly related to gestation age and birth weight of the infant.

2. General Examination:

Skin Colour: It is the single most important parameter of cardio respiratory function.

a.    Pallor may be due to anaemia, birth, asphyxia or shock.

b.   Cyanosis

·        Central Cynosis: (Bluish skin, including the tongue and lips) is caused by low oxygen saturation. It may be due to congenital heart or lung disease.

·        Peripheral Cyanosis: (Bluish skin with pinks lips and tongue) may be due to drugs or hereditary. It is often associated with methemoglobinemia (haemoglobin oxidizes from ferrous to ferric form)

·        Acrocyanosis: (Bluish hands and feet only) may be normal immediately following birth. It may be due to cold stress.

·        Plethora: Commonly seen in infants with polycythemia. It may be seen in an over heated or over oxygenated infant.

c.    Jaundice: Bilirubin level >5mg/dl

d.   Extensive Bruising: May be due to difficult or traumatic delivery.

Skin Rashes:

a.    Milia: Seen on the nose, cheeks and fore head are due to plugged sweat glands.

b.   Mongolian Spots: Are bluish often large, commonly seen on the back, buttocks or thighs. Usually present in blacks and Asians. They disappears by four years of age.

c.    Erythema Toxian: These are popular lesions with a erythematous base commonly seen after 48 hours of birth. They resolve spontaneously.

d.   Diaper Rash: Usually the skin folds are involved. It appears as erythematous plaques and the edges are well demarcated it form a irritant contact dermatitis. It may be infected with candida albicans.

3. Head

Fontanelles

a.    Large fontanels are associated with hypothyrodism, osteogenesis imperfect of a or chromosomal anomalies. Bulzing fontanelle may be due to increased intracranial pressure, meningitis or hydrocephalus. Depressed fontanelles are seem with dehydration. A small fontanelle may be due to hyperthy-roidism.

b.   Caputsuccedaneum: It should be differentiated from cephalhaematoma

c.    Moulding: Seen with prolonged labour usually holding subsides with in 5 days

d.   Cephalhaematoma: It is due to sub periosteal haemorrhage resulting from a traumatic delivery. It never extends beyond the suture line. X-ray and CT scans should be taken to exclude skull fracture. Haematocrit and bilirubin levels should be estimated. Aspiration of haematoma is rarely needed as they of offen resolve in 4-6 weeks time.

e.    Raised Intra Cranial Pressure: It is diagnosed by the following signs

a.    Bulging anterior fontanelle

b.   Seperation of suture lines

c.    Paralysis of upward gaze

d.   Prominent veins of the scalp

Craniosynostosis

        It is a premature closure of one or more of sutures of the skull on palpation, a bony ridge is felt over the suture line and the cranial bones cannot be moved.

4. Neck

        It is checked for movements, goitre, thyroglossal cysts, sternomastoid haematoma or short  neck

5. Face and Mouth

        Face is looked for hypertelorism or low set ears or facial nerve injury. Mouth is checked for clefts, natal teeth, lingual frenulum, macroglossia or oral thrush. Thrush is treated with nystatin suspension

6. Eyes

        Eyes are examined for congenital cataract, brushfield’s spots in the iris or subconjunctiva haemorrhage and conjunctivitis

7. Chest

        Chest is examined for any asymmetry, tachypnea, grunting, intercostal retractions, pectus exacavatum and the breath sounds. The new born breast may be enlarged due to maternal oestrogen. The white discharge from nipple is commonly known as ‘Witch’s Milk”.

8. Heart

        Heart is examined for rate, rhythm, the quality of heart sounds and presence of any murmur. Fetal enho cardio graph at 18-20 weeks gestation can make the antenatal diagnosis in utero. Fetal cardiac intervention in utero is new and promising method of treatment

9. Abdomen

        Abdomen is examined for any defect. Eg: omphalocele, hepatomegaly, splenomegaly or any other mass. A scaphoid abdomen may be due to diaphragmatic hernia.

10. Umbilicus

        It is examined for any discharge, redness or infection. A greenish-yellow coloured cord suggests meconium staining. Single umbilical artery indicates genetic and congenital anomalies.

11. Genitalia

        It should be used examined carefully before gender assignment. Male is examined for penis, testis with in the scrotum, any hydroccle or hypospadias prepuce is normally long and phimosis is present. Female is examined for any clitorial enlargement, fused labia with clitorial enlargement. Blood stained vaginal discharge may be due to maternal oestrogen withdrawal. Normally labia majora cover the labia minora and clitoris.

12. Anus and Rectum

        It is checked to rule out imperforation and their position. Meconium should be passed within 48 hours of birth.

13. Extrimities, Spine and Joint

        Extremities, spine and joints are examined for syndactyly, polydactyly, simian crease, talipes equinvarus, hip dislocation.

14. Nervous System

        It is examined for any irritability, abnormal muscle tone, reflexes, cranial and peripheral nerves. Neurological development is dependent on gestational age. The reflexes including more reflex are present at birth.

IMMEDIATE CARE OF THE NEW BORN

Care In Nursery

Observation:

        The infant should be examined systematically but speedily to prevent undue exposure, beginning from the head followed by inspecting the whole body to detect any congenital abnormality.

To Estimate the Gestational Age:

        This may be made soon after delivery

        A baby delivered at 39 weeks or more presents with the following features:

1.   Sole covered with creases

2.   Breast nodule diameter of 7mm

3.   Scalp hair – coarse and silky

4.   Ear lobule – stiffened by thick cartilaze

5.   In male, scortum is full with testes with extensive ruzee.

General Care:

        The baby is placed in a cot where warmth is maintained depending upon the environment. Chilling must be avoided to prevent hypothesmia. The baby should be flat on the cot with the head slightly lowered. Handling should be gentle and be kept to a minimum. Temperature should be frequently recorded until it becomes stabilized.

Baby Bath:

        Routine baby bath is not favoured in many centres to prevent cross infection. The excess vernix, blood or meconium are wiped off from the skin using sterile moist swabs and then make the skin dry by using soft towel. The baby bath may be given on the previous day of discharge. The bathing should be gently performed using bland soap and the skin is dried with soft towel.

Weight

        Immediately following bath or cleansing. The baby should be weighed naked

Clothing:

        The dress should be appropriate for the climate. The extremities should be free for movements. A napkin is applied which should be changed periodically.

Care of the Eyes

        As a prophylaxis against opthalmia neonatorum and Chlamydia trachomatis, applications of gentamicin ophthalmic ointment or crythromycin ophthalmic ointment every 6 hours is usually adequate.

Medication

a) Intramuscular administration of vitamin k 1 mg is given as a routine to minimize haemorrhagic disease

b) Prophylactic antibiotic therapy is considered in

i. Delivery following premature rupture of the membranes

ii. Instrumentation

Close Observation for at least 4-8 hours

i.                  Any excessive mucus secretion from the mouth.

ii.               Any bleeding from the umbilical cord stump

iii.            Hourly temperature until it stabilizes and remains above 36⁰c

DAILY OBSERVATION AND CARE

        As the majority of complications occur during the first 24 hours. The infants are observed and care for as follows:

·        Respiration: is regular, smooth and quiet, the rate being 40/minute.

·        Temperature: is to be taken twice daily

·        Weight: is to be taken every 3^rd day

·        Feeding schedules: as described later are to be followed and difficulties if any, are to be noted and rectified.

·        Eyes: are to be inspected for evidence of early infection suggested by discharge

·        The Mouth: should be inspected daily for detection of early evidence of thrush

·        The Umblical Card: is to be inspected daily and cared as outlined earlier

·        Bath: cleaning the skin may be repeated daily or as frequently as required, specially the buttocks, to the remove the meconium passed. A daily bath is prescribed when the patient is at home.

·        Rooming in: soon after birth if the mother is otherwise fit. The baby is kept in a cot by the bed side of the mother.

·        Number and character of the stools: And rough estimation of the amount of urine passed daily are to be noted. Napkins should be changed immediately following soiling and the local parts should be cleaned dry.

·        Any abnormal features and behaviour should be promptly detected and corrected

·        To elicit reflex behaviour: neurological examination is made 24 hours after birth in babies suspected of having intracranial damages.

Important Reflexes are;

1.   Moro’s Reflex: The infant is held is supine position with head flexed at 30⁰ and then the head is allowed to drop sudden extension and aduction of the limbs with opening of the hands followed by slow aduction and flexion is observed as a positive response in a normal infant.

2.   Rooting Reflex: A normal infant when touched on the check, turns eagerly towards the stimulus and opens the mouth for a feed.

3.   Sucking and Swallowing: A normal infant starts sucking when something touches the palate. Baby swallows when the mouth is filled with milk.

CONCLUSION

        The normal neonate concludes, to elicit reflex behaviour, neurological examination is made 24 hours after birth. Important reflexes are Moro’s reflex, dotting reflex and sucking and swallowing reflexes. The length is more reliable criterion of gestational age than the weight.

BIBLIOGRAPHY

1.   A Text Book of Obstetrics

Fifth Edition of 2011

P.C.Dutta, Page No.479-482.