The complexity of a new life, the Neonate
September 18, 2018
In the following nursing journal ahead will include key topics of discussion, and will be outlined for you with the following criteria. What are the critical elements of neonatal assessment? Gestational age assessment with considerations related to SGA & LGA. Lab and diagnostic tests for the neonate. Various nutritional aspects related to the neonate. What are common congenital anomalies seen in the newborn? What is hyperbilirubinemia & Group B Streptococcus in the newborn & what is the treatment for each? Substances used during pregnancy that have an adverse effect on a newborn and what in general are the effects? Develop a discharge teaching plan for parents of a newborn including but not limited to first time parents prior to discharge.
The complexity of a new life, the Neonate
The Critical Elements of the Neonate Assessment
The neonate or newborn period is an infant less than 28 days old , the newborn is classified as any preterm, term and post term infants. The preterm neonate has more than one sub group and are defined as follows “preterm/premature infant is born after 20 weeks and before 37 weeks (36 6/7 weeks) of gestation. More specific classifications include: Very preterm infant an infant born before 32 completed weeks of gestation. Late preterm infant an infant born between 34 and 37 weeks of gestation (34 0/7-36 6/7 weeks)”(Maternal Newborn Nursing, pg 131). Term gestation is classified as 37 to 42 weeks and beyond 42 weeks is considered post-term neonates.
The gestational age of the infant at birth is going to directly affect the neonates development. When a neonate is born prematurely they will not have fully developed organs and are at risk for fetal complications, hospitalizations and death. When the neonate is born post-term they are at risk for hypoxia, malnourishment, hospitalization and death related to the aging placenta. So the recommended age range is the 37-42 week period, at this time the organs have had the time to fully develop and has a very high survivability to extrauterine life.
No matter the gestational age the all neonates will undergo a complete assessment to ensure that every part of their body is functioning properly. In the next few paragraphs I will highlight what is entailed in the neonate assessment pre and post birth.
Prior to birth the neonate has already undergone numerous assessments in utero such as but not limited to the following with the very most important initial assessment with the ultrasound. During an ultrasound evaluation the fetus is measured and assessed along with maternal evaluation and estimated gestational age. Doing an ultrasound allows medical professional to locate and prepare for possible complications.
After birth the very first initial assessment of the infant that is not in immediate life threatening danger is the APGAR scoring evaluation. The APGAR assess the respiratory effort, heart rate, muscle tone, reflex activity and color. These are completed within 1 and 5 minutes post birth. The respiratory assessment would include things such as patency of the nares and the complete respiratory system with chest wall symmetry, pattern and rate of respirations. The circulatory system begins to be assessed when the umbilical cord is cut and the reaction/actions with the neonate. The very first assessment will be of the umbilical cord to assess for two arteries and one vein to ensure adequate perfusion in utero. The heart rate, rhythm and sound will be completed along with all extremities will receive their one blood pressure evaluation cap refill and skin color will also be included. Thermoregulation will be monitored to detect if the neonates is suffering from cold stress and the neonates ability to maintain body temperature. Metabolic system elevation glucose will be the main source of energy for the brain that has been stored in the liver for the past 2 months as glycogen. The neonate may need blood sugar monitoring to assess for hypo and hyperglycemia. The fetal age, SGA and LGA somewhat predetermines what the neonate is at risk for hypo or hyperglycemia. The hepatic system will be assessed for bilirubin levels to prevent kernicterus. Interventions for hyper-bilirubin includes phototherapy. Gastrointestinal system will be fully assessed from the mouth to the anus with feeding and meconium stools. Genitourinary system includes the renal system and the ability to urinate adequately with the normal 6-10 wet diapers per day, and genitalia. Musculoskeletal assessment will be completed which assess the joints extremities length and symmetry including any abnormalities. The skin assessment includes lanugo, acrocyanosis, skin pigmentation, color related to ethnicity, milia, including abnormalities. The head and total body will be completely assessed including the fontinales, shape, measurements of the head and chest. Length, weight, correct gestational age and the neurological systems will be assessed with the reflexes and hearing will be screened. Every aspect of a neonate needs to be complete and accurate as this will be the groundwork for this infants life.
Gestational age assessment including SGA and LGA.
There are several factors that come into play when determining the gestational age of a neonate including the mothers menstruation, ultrasound and the neonates exam with the Ballard scoring which includes posture, square window, arm recoil, popliteal angle, and scarf sign as well as heel to ear. Physical maturity will also be include in the determination of the neonates age which includes skin, lanugo, planter surfaces, breasts, ears, eyes and genitalia. Lastly we would always assess for pain and the infants response to stimuli.
SGA is an abbreviation for small for gestational age, this neonate would be below the 10th percentile and LGA is large for gestational age and that infant is above the 90th percentile. These percentiles include height and weight. The SGA infant may have been caused due to the lack of nutrients related to placental insufficiency also lack of amniotic fluid and congenital abnormalities, also maternal malnutrition. LGA can be cause from a diabetic or an obese mothers, polyhydramnios.
Lab and diagnostic testing for the neonate.
The initial testing following birth include blood tests that will screen for genetic and inherited metabolic disorders, and infections. PKU is tested with a neonate heel stick which if reactive indicates the neonates inability to digest milk and will lead a lifetime on a special diet due to the body’s inability to metabolize phenylalanine. Toxic buildup can occur with this disorder and will cause permanent brain damage. A hearing test will be preformed to ensure the infant can hear prior to discharge from the hospital. Cord blood sampling can also be completed after delivery.
The nutritional aspects of the neonate.
The two options for the healthy neonate infant includes breast and bottle feeding. The infants maturity, size and the ability to suck would all play a part in how the infant would feed. For instance an infant with a cleft palate there are elongated nipple to assist with feeding or droppers can be used. Now lets’ discuss the preterm neonate or the neonate that have the inability to feed these infants would be given nutrition though an IV, or NG access. Neonates feed frequently especially breastfeeding infants. Parents need to be educated on what the mother can ingest because certain substances can transmit to the infant through breastfeeding. We would also want to educate the parents on proper mixing and storing of formula including the storing of breastmilk.
Common congenital anomalies seen in the neonate.
In this section I will discuss Trisomy 21 (Down syndrome) the major complications seen with these neonates is heart defects feeding and respiratory issues. Trisomy 18 (Edwards syndrome) the characteristics of this would be growth deficiency and severe heart defects. Trisomy 13 (Patau syndrome) indictive of severe heart defects and average life span is 3 days. Turner syndrome only affects girls indicative of heart and reproductive abnormalities they will have notable swelling or puffiness of hands and feet. These infants and parents need special care and guidance. Some parents terminate the pregnancy prior to birth once a genetic disorder is detected. Most of these infants will be born via cesarean section and will immediately go to the NICU. Palliative and hospice care will be initiated with some of these infants as there congenital defect is terminal.
Hyperbilirubinemia & Group B Streptococcus and Treatment
Hyperbilirubinemia during birth the neonates turnover with RBC is very faster because the neonate in turn creates more bilirubin to breakdown the excess RBC’s this is caused from the immature livers inability to keep up with the excess RBC count. As the RBCs are destroyed the liver accumulates the iron for the RBCs that were destroyed this then in turn creates the sun tan effect of the neonate. Jaundice is treated by phototherapy with artificial lights or sunlight. The infants skin will be under the lamps to break down the excess bilirubin. The most important thing to remember is the infants eyes must be protected from the artificial rays of the phototherapy.
Group B Streptococcus is transmitted from the mother to infant during a vaginal delivery it is most commonly found in the vagina or rectum. Group B strep can occur anywhere on the body and will not be harmful for a healthy adult. However, neonates can contract this and suffer from things such as meningitis, pneumonia, sepsis, breathing difficulties, seizures. This can be prevented if the mother does a IV course of antibiotics such a penicillin or cesarean section preformed. If the neonate becomes infected it to will be treated with IV antibiotics.
Substances used during pregnancy, How they affect the newborn.
Substance abuse during pregnancy ranges from alcohol and tobacco to illicit drugs. Substances consumed by the mother can and will affect the fetus. The particular substance abused will have its own side effects. We are seeing more and more of NAS (Neonatal abstinence syndrome) which is neonatal withdraw. Infants can go through withdraw periods from several hours to weeks and have lifetime lasting effects. These side effects range from deformities such as cleft palate, congenital defects, IUGR, CVA, microcephaly, long term effects can range form behavior problems learning disabilities, SIDS. If the mother is honest about her drug use including what and when she last used the infant has a greater chance of recovery without lasting effects. These babies spend weeks to months in the NICU going through these withdraws and fighting to stay alive.
Discharge teaching for first time parents.
The following topics would be taught to new parents on how to care for a neonate prior to discharge feeding, urination, bowel movements, umbilical cord care, diapering, circumcisions, bathing and skin care, back to sleep, and car seat use to name a few.
This is basic care instructions that would be educated on and feedback demonstration from parents of the neonate. We would want to educate on feeding by how to properly mix formula, storage of milk both breast and bottle. We would educate not to heat it up in the microwave as it will create heat pockets in the formula. We would educate on monitoring proper positioning of the infant to burp and how much the infant consumes in a feeding for length of time they would nurse. The mother would be educated abut the changes in breast milk and what she can have or can’s while breast feeding. The best way to have parents assess hydration and feedings is by counting diapers an infant should have 6 or more wet diapers and more than 3 stools for breastfeed infants and fewer for bottle feed.
We would educate on cord care and that the umbilical stump will fall off within 7-10 days and to assess for signs of infection such as redness or discharge. The proper cleansing would be to wipe around the base of the care at the umbilicus and make sure that the diaper if folded below the cord.
Circumcision care the parents would be educated to cleanse with warm water and to monitor to signs of complications such as bleeding, swelling or odor they should contact a physician. Parents should be educated properly on how to cleanse an uncircumcised penis by never forcibly retracting the foreskin and how to cleanse the vagina of females and the possibility of discharge being present related to maternal hormones.
Bathing the infant the parents should be educated on how to check the temperature on the inner wrist and that infants do not need to have a bath everyday because of the drying effects to the newborns skin. They will be educated on how the vernix protects the skin and a wash cloth bath is appropriate. The will be educated on when not to give their infant a bath until the umbilical cord and circumcision heals.
We would also educate on the importance of not co-sleeping, back to sleep with minimal things in the bed. These are proven to reduce SIDS and also the importance of car seats and the positioning of the seat and that is rear facing until 20 lbs. and 1 year in the motor vehicle.
Finally we would educate on warning signs and when to contact a physician. These things include rectal temp greater than 100.5*f or higher and how to properly use a rectal thermometer. Lethargy and difficulty feeding, signs of dehydration such a reduced wet diapers. What to look for with jaundice and when to contact a physician for instance if the whites of their eyes look yellow. Extreme fussiness with the inability to console the infant. We would also educate on the fontinales a the abnormalities such as bulging and sunken and the importance of it.
With the education that will be provided I would want to provide detailed written information, contact information and resources available to help. I would involve the parents in care of the neonate while in my care to prepare and educate them on how to properly do things.
In the end not matter what always tell them it is okay to ask and seek help from anyone anywhere and not to be ashamed or embarrassed.
Durham, R. F., Chapman, L., & Chapman, L. (2014). Maternal-newborn nursing: The critical components of nursing care. Philadelphia: F.A. Davis Company.
Rudd, K., & Kocisko, D. M. (2014). Pediatric nursing: The critical components of nursing care. Philadelphia: F.A. Davis Company.
ROBERT C. LANGAN, M.D., St. Luke’s Family Medicine Residency Program, Bethlehem, PA
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