Ma’am Martinez 7/27/19

Establishment and Maintenance of Patent

Sign 0 1 2
Airway
Appearance Blue
Airway, Breathing, Circulation Pink all
or Blue/pale extremities
over
- Suctioning with proper position color , pink body
- Institute standard precautions Pulse or
absent <100 >100
- Cardiopulmonary adaptation heart rate
No
Grimace Strong
response
grimace when cry/
Airway and Breathing to
stimulated sneeze
stimulation
- Suction gently and quickly using a bulb Some
Limp, Well
syringe or suction catheter activity flexion of
flaccid flexed
- Starts in the mouth then, the nose to extremities
prevent aspiration (can cause Good,
Respiratory
absent Weak cry strong,
bradycardia) effort
lusty cry
- Stimulate crying by rubbing back and
sole of the foot
- Position properly (side-lying / modified Essential New born Care
tredelenberg)
1. Unang Yakap
- Suction if all resort are not effective
- Is the care that every newborn baby
regardless of where it is born
- A simple, concise, straightforward
Maintain appropriate body
protocol that is backed by solid research
temperature
evidence.
1. Wrap new born immediately and
- Administrative order 2009-0025
place under droplight or radiant
warmer
FOUR CORE STEPS
2. Dry the infant completely for at
-Immediate drying
least 30 seconds (ENC) and remove
-Skin to skin contact
wet cloth
-Proper cord clamping and cutting
3. Provide warmth (early skin to skin
-non-separation
contact including newborn via
Ceasarean section) put a cap
Immediate & thorough drying of
newborn for first 30 seconds-1minute warms
APGAR SCORE the newborn and stimulates breathing.
- 1952, Virginia Apgar
-prevents hypothermia
- Quick overall assessment of newborn
- Standardized evaluation of the newborn -starts from eyes down
Involves 5 indicators:
A-appearance 2. Early Skin to Skin Contact

P- pulse -contact between mother and newborn

G- grimace -prevent hypothermia, infection, and

hypoglycemia
A-activity
-delayed washing or bathing for at least 6 hours
R-espiration

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3.Properly timed cord clamping and cutting

- washing for the cord pulsation to stop BALLARD Scoring

(between 1-3 min.)
Maturity of Neonate
-prevents anemia and protects against brain Premature <34 weeks
hemorrhage in premature newborn. Late Premature 34-37 weeks
Early 37-38 weeks
4.Non separation of newborn from mother for Full term 39-40 weeks
early breast feeding initiation and rooming-in Late term 41-42 weeks
Post term 42 weeks
- protects infants from dying from infection

Silverman-Anderson Scoring system

Following practices shouldn’t done anymore:
- Evaluate 5 parameter
1. Manipulation such as routine suctioning - The lower the total score the better the
of secretions if the baby is crying and baby
breathing normally. Doing may cause - (0) best in each category
trauma or introduce infection. - (2) worst
2. Putting newborn on a cold or wet - Score > 7 respiratory failure
surface. - Score 4-7 distress
3. Wiping or removal of vernix caseosa
4. Foot printing ANTHROPOMETRICS
5. Bathing earlier than 6 hours of life  Weight
6. Unnecessary separation of newborn - 5.5-9.5 lbs (2500-4300g)
primarily for weighing, anthropometric - Caucasian 7lbs
measurements, IM administration of - Filipino 6.5lbs
Vit. K, Hepa B and BCG. - 70-75% total body weight is water
7. Transferring of newborn to the nursery - LBW= below 2500g, regardless of
or the neonatal ICU without any AOG
incubation.
 Length
-46-54cm
Temperature

- dry immediately  Head circumference

- discard wet cloth
- put on mother’s tummy for skin to skin
contact (kangaroo style) for 90 minutes
-put on bonnet on baby’s head
- wrap warmly
-chills indicate need for oxygen
Effects of Colds
- Metabolic acidosis
- Hypoglycemia
-34-35cm
- Most prominent part of the
occiput to above eyebrow
4. Chest Circumference
- 36-33cm (12-13 inches)
- lower edge of the scapula to over
the nipple line
- chest circumference should be= 0
< 2cm than head circumference
5. Abdominal Circumference

- 32-33cm
-Umbilicus (based)

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- Clean eyes of the baby
- Dry face prior
- Remaining amount should be discarded
- Encourage mother to view her baby
prior to application
Vital signs normal variation
- Shade the child
Temperaure 36.5-37.5C(a) Crying and - Squeeze the ointment
radiant
warmer
increase Vitamin K Administration
tempearture - Facilitates production of clotting
Pulses 120-160bpm When crying factors
or sleeping - Control bleeding
- 0.5-1g IM
Respiration 30-60cpm Be warn of - Obtain prothrombin time
pattern
- Treatment of prophylaxis
BP 80-60/45- Activity of - Note for the dosage, route and site
40mmHg the baby - Vitamin K and Hepa B should be given
after birth on the different side
100/50mmH
g after 10
days Hepa B vaccine

- 12 hours after birth

Newborn Identification - 2nd dose (1st motnh) 3rd dose (6th
month)
- After delivery, gender should be
determined
- Pertinent records should be completed Newborn physical assessment
including ID bracelets.
Skin
- Before transferring, put ID tags
Dark red- plethora,
polycythemia
Initial bath done once temperature
Central cyanosis- decrease O2
stabilizes
Gray- infection
- Vernix caseosa- use oil
Pale color/pallor- anemia
- Warm water during first week
Yellow- jaundice
- 6 hours after birth
 Acrocyanosis
-bluish discoloration of palm of hands
Initial cord dressing
and soles of feet
- Dry cord care
- Immature peripheral circulation
- Use 9 cotton applicator, 3 on each sides
- Inspect for blood vessels
 Physiologic jaundice
- Perform aseptic technique
-FT: after 1st 24 hours (2-7 days)
- Use sterile water
- PT: after the first 48 hours
- Done every after diaper change
- peaks at 5-7 days and disappears by
- Note time to slough off or fall off
the second week
- Check for signs of infection or bleeding
- immaturity of the liver
- found over the face, upper body and
Eye prophylaxis conjunctiva of the eyes

- Prevention of conjunctivitis  Pathologic jaundice

- Erythromycin and tetracycline
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- 1st 24 hours - Open sebaceous gland usually
- Early hemolysis of RBC found at the tip of nose and chin
- FT: 1 week of the baby
- PT: 2 weeks - (-)2 -4 weeks

The head
 Harlequin sign
- -immature blood circulation - largest part of the human body
- Newborn who is lying on his or her - ¼ of the total body length
side appears red - Forehead is large and prominent
- Chin is receding when startled or crying
 Vernix Caseosa Fontanels
-greasy white substance that covers 1. Anterior fontanels- diamond
the skin until the 38th week of 2. Posterior fontanels- triangle
gestation
 Lanugo Sutures
 Desquamation -separating lines of the skull
- Peeling of skin at birth or post
maturity Craniosynostosis

-premature closure of one or more

Birthmarks suture line
- Portwine stained/nevusflemmeus
- Seen at birth Craniotabus
- Red-purple
- localized softening of cranial bones or
- Does not blanche on pressure
skull that usually occurs around the
nor disappear
suture line; indented by pressure of the
- Stork bites or telangiectas nevi
finger
- Pink or red flat areas of capillary
- Disappears without treatment within a
dilation
day or few weeks
- Seen under eyelids, nose, lower
occiput bone, nape and neck
Molding
- (-) 1st and 2nd year
-overlapping of sagittal and coronal
- Strawberry mark/nevus vascularis
suture
- 2nd most common type of
1. Caputsuccedarum
capillary hermangioma,
-edema on presenting side
elevated sharply demarcate
2. Cephalohematoma
- Bright or dark-red, rough
-collection of blood between
surface
periosteum
- (+) school age or even longer
- Mongolian spot
EYES
- Dark blue or purple bruise like
- lids- edematous
macular spots usually located
- eyelids of equal size
over the sacrum and buttocks
- iris- gray/blue
- Disappears by 4 years of age
- cry- tearless (1st 3 months)
- Erythema toxilum
- cross-eyed
- Transient newborn rash with
- see objects at 8 inches
numerous small areas of red skin
- VA 20/200-200/500
with yellow or white papule in
the center
EARS
- Nape, back and buttocks
- Flexible pinna; cartilage present
- Disappears without treatment
- Top of ear: align in inner outer canthus
- Milia
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- If lower= kidney malfunction or down
syndrome
- Sense of hearing= highly develop
NOSE
- Nasal obligates: sneezing
- Thin, white mucus
- Sense of smell present at birth
- Note for marked nasal flaring
MOUTH
- Open widely and evenly when crying if
not CN injury
- Palate intact, no breaks on lips
- Epstein’s pearls- small round
- Note for white gray adherent patches
on the tongue and side of the cheeks
- Taste buds develop after birth
NECK
- Thyroid gland not palpable
- Soft, palpable and creased with skin
folds
- Head- rotates freely on the neck and
flex forward and back
- Note for the (+) rigidity of the neck of
newborn and whose membranes
ruptured 24 hours after birth
CHEST
- Symmetrical- APL diameter equal
- Breast may be engorge, note secretion
of milky substance on breast
- Xiphoid process evident
ABDOMEN
- Dome shaped, cylindrical
- Scaphoid= diaphragmatic hernia
- Umbilical cord- bluish white (AVA)
- Liver, spleen and kidneys palpable
ANO-GENITAL AREA
- Patent anal opening and passage of
meconium
FEMAL GENITAL
- Swollen labia and clitoris
- Vernix caseosa between labia
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- Note passage of blood-tinged vaginal
discharged
MALE GENITAL
- Urethral opening at tip of glans penis
covered prepuce
- Note if undescended testes
- Scrotum may be edematous due to
maternal hormone
- Testes is palpable in each scrotum
URINARY SYSTEM
- Female- strong urine stream
- Male- projectile
- First voiding should occur within 24
hours
- 15 ml, maybe pink/ dusky and has
small amount of protein
- SG from 1.008-1.010
- DUO (1st and 2nd day)- 30-60ml
- By week 1, volume rises to 300ml
BACK
- On prone, appears fkat
- Note mass hairy nodule and dimple
along axis
EXTREMITIES
- Symmetric and of equal length; in
full ROM and move symmetrically
- Fingers and toes equal
- Polydactyl- extra digitalis
- Syndactyl- fused or webbed
- Hemimilia- absence of distal
part of extremities
- Ortolanis and Barlon maneuver
Club foot
- Birth deformity in which the front
portion of the foot is deformed and
turned inward
- Can benefited greatly by surgery
NEUROMUSCULAR SYSTEM
Reflex assessment
 Blink reflex
- Rapid eye closure when strong
light is shone
- Tap gently over the forehead
and eyes will blink
 Rooting reflex
Ma’am Martinez
- Cheek is brushed or stroke near
the corner of the mouth,
newborn turn the head on that
direction
- (-) 6 months of life
 Sucking reflexes
- When the newborn lips is
touched, it will make a sucking
motion
- (-) about 6 months
 Extrusion reflexes
- Substance is put on the anterior
portion tongue is extruded.
- (-) 4 months
 Swallowing reflex
- Food that reaches the posterior
portion of tongue is
automatically swallowed
 Tonic-neck reflex
- When the newborn lies on his
back the head usually turns to
one side, arms and legs on that
side extend and the opposite…
 Babinski reflex
- When the side of the sole of the
foot is stroke in an inverted,
fanning of the toes will result.
- (-) 3 months
 Palmar grasp
- Place an object on the pal of
infant’s and the baby will hold
or grasp it
- (-) 3-6 weeks
 Moro reflex
- Make an abrupt loud noise or
by jamming the bassinet causes
abduction of both arms and
curling of the fingers
- Startle reflex
- (-) 4-5 months
 Plantar reflex
- Object touches sole of newborn
at the base of the toes, toes
grasp in some corner as to
fingers
- (-) 8-9 months
 Trunk incurvation
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- Newborn lies on prone position
and is touched along the
paravertebral
- Apparent by 5-6 days
 Cross extension reflex
 Stepping or walking reflex
- Present from 3-4 weeks
- (-) 3 months
 Landau reflex
- When prone, the newborn
should demonstrate some
muscle tone
- A test for spinal cord integrity
SENSORY STIMULATION
Hearing
- Suspends alarms quickly; some distance
at bedside
- Own mother’s voice is preferred
- Facilitate sleep
- No to sound
- Eliminate radios for personal use
- Tone down voice during conversation
NEWBORN SCREENING
- Simple procedure to find out congenital
metabolic disorders in newborn
- R.A. 9288 (Newborn Screening Act of
2004)
Newborn screening test
- Ideally done on the 48th hour or at least
24 hours from birth using the heel prick
method
- Specimen is blotted on a special
absorbent filter card
- Results are expected to release on
within 14 working days
- Expanded NBST can detect up to 28
disorder
6 METABOLIC DISORDER
1. CONGENITAL HYPOTHYROIDISM
(CH)
2. CONGENITAL ADRENAL
HYPERPLASIA (CAH)
3. PHENYLKETONURIA (PKU)
4. GALACTOSEMIA (GAL)
Ma’am Martinez 7/27/19
5. GLUCOSE-6-PHOSPHATE - Deficiency of an enzyme needed to
DEHYDROGENASE DEFFICIENCY convert fat to energy
(G6PD) Cystic Fibrosis
6. HOMOCYSTINURIA - Inherited disorder
- Absence of deficiency of the cell
protein manufactured by the body
CONGENITAL HYPOTHYROIDISM (CH) that is called cystic fibrosis
- lacks or absence of thyroid hormone transmembrane conductance
- low thyroid activity at birth regulator (CFTCR)
- may have mental retardation - Absence of this protein causes the
- maternal iodine deficiency mucus and fluids.
CONGENITAL ADRENAL HYPERPLASIA (CAH)
- Genetic disorder affecting 5,000 NURSING CARE OF NEWBORN
newborn
DISCHARGE INSTRUCTIONS
- Defect in production of adrenal gland
hormones  BATHING
- Before feeding (temperature is
stable)
PHENYLKETONURIA (PKU) - Temperature of water must be
- Metabolic disorder checked. Do not immerse
- Cannot use properly phenylalanine immediately the infant in the
amino acid (cystic fibrosis, water
hyperthyroidism) - Apply the principle from clean
GALACTOSEMIA (GAL) to dirty areas
- Unable to process galactose - Exposed areas currently washed
GLUCOSE-6-PHOSPHATE DEHYDROGENASE - Thorough drying and avoid
DEFFICIENCY (G6PD) using baby powder after bath
- Lacks enzyme called G6PD - Never leave a child alone
HOMOCYSTINURIA unattended
- Genetic disease  CHANGING DIAPER
- Deficiency of an enzyme that converts - standard precaution
amino acid homocysteine into - area should be washed and
cystathionine dried well to prevent ammonia
and diaper rash
Additional diseases - remove traces of bowel
Sickle cell disease movement
- Genetic disease where blood become - diaper’s top edge is fold down
sickle-shaped after they give up below the cord
oxygen in the tissue. - place mild ointment
maple Syrup Urine Disease - exposed to air
- inherited error involving metabolism  CLOTHING AND SWADDLING
of (leucine, isoleucine and valine) - Keep newborn warm and dry
- results in mental retardation and - Consider the temperature of
sometimes death the environment or weather
Biotinidase Deficiency - Keep the head cover
- Genetic disorder - Protect from drafts and sun
- Deficiency of the essential vitamin B,  DRESSING AND WRAPPING
Biotin - Mummy
MCAD  CRYING
- Genetic disorder
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- Check first to see any physical Digestible
reason
Immunity
- Assess if the baby is making
sucking movements after Nutritious
feeding
- Burping the baby especially GIT diseases are less guaranteed
after feeding PROPER INFANT FEEDING
- Try wrapping the baby with a
warm blanket or give a warm - Keep the head slightly elevated
bath - Hold bottle in such a way that air does
- Check the diaper not get into nipple. Never drop bottle
- Gently rock - Bring infant to the level of the breast.
 FEEDING CUES Neck not flexed
- Rooting reflex - Newborn whole body is supported and
- Sucking reflex is close to mother’s body
- Extrusion reflex and swallowing - Breaking the suction by placing a clean
reflex finger in the side of infants mouth
before removing the infant from the
breast
BREASTFEEDING VS. BOTTLE FEEDING

BOTTLE FEEDING ADVANTAGES: Teach mother how to determine if

- Permits the partner to feed
- Mother might transfer medication
- Easily replenished when needed
- Newborn intake is easily measured and
recorded
DISADVANTAGES:
infant got an adequate milk
- Infant is gaining weight, satisfied after
- Breasts gets softer during the feeding
- Breastfeeding 8-12 times a day
- 6-8 diapers a day
- Voids 6-8 times a day
- 2-3 bowels

- Costly ELIMINATION
- Extensive preparation and efforts
3 TYPES OF STOOL
- Requiring refrigeration and storage
- No maternal antibodies 1. MECONIUM
- May contribute to colic - Sticky, greenish-black, odorless
sterile stool
- Take note of time when
BREASTFEEDING ADVANTAGES meconium first passed
2. TRANSITIONAL
Best for baby
- Greenish, loose and often
Reduce allergy contain mucus: 3rd to 10th day
3. MILK STOOL
Easily digestible - Usually occur by 4th day
A - Average voiding 2-6 times a day

Safe
Breastfeed vs Bottle feed
Time saving Odor sweet foul
Fresh always, FP (LAM) Color Golden Pale yellow
yellow- to light
Emotional bonding yellow brown
brown
Economical
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consistenc Pasty, soft, Formed, - Irritable, lethargic, crying, twitching which
y loose2-3 firmer 1-2 does not improve with cuddling
times times a day - Yellow coloration of the eyes, chest
extremities
- Blue nails, lips, body
- Vomiting and abdominal distention
- Not defecated or urinated within a day
BURPING TECHNIQUES
1) SHOULDER HOLD
- Support the head and
nape
2) SITTING POSITION
3) LAYINGPRONE ACROSS THE LAP
(alternative position)

CUDDLING AND FEEDING POSITION

1) CRADLE HOLD
- Permits eye contact, provide a sense of
warmth and closeness and provide
security
- Ideal for breastfeeding
2) FOOTBALL HOLD
- Permits eye contact
- Ideal for shampooing, carrying or
breastfeeding
3) SIDE-LYING

SLEEPING POSITIONS
 SUPINE
- 16-20 hours a day

BCG (BACILLE CALMETTE-GUERIN) VACCINE

- Given after birth or any time after

birth

EARLY SIGNS OF SERIOUS DISEASE

WARNING SIGNS:

- Not gaining weight

- Excessive cry or not crying
- Convulsions, twitching eye blinking
- Stiffed neck, body and limbs
- Odor, pus, discharge or swelling of cord
- Eye discharge, boils
- Feverish- temperature: 38C
- Cold baby- temperature: 36.5
- Fast respiration over 60 breaths per minute
- Groaning and chest retraction
- Not accepting feeding or milk

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