Immediate Newborn Care

Goals:
1. Establish, maintain, and support respiration.
2. Provide warmth and prevent hypothermia.
3. Ensure safety and prevent injury and infection.
4. Identify actual or potential problems that may require immediate attention.

Principles of Cleanliness at Birth

Clean hands
Clean perineum
Nothing unclean to be introduced into the vagina
Clean delivery surface
Cleanliness in cutting the umbilical cord
Cleanliness for cord care

1. Establish respiration & maintain clear airway

 Wipe the mouth and nose of secretions.
 Suction secretions from mouth and nose.
 Stimulate the baby to cry, a crying infant is a breathing infant.
 Place infant in a position that would promote drainage of secretions.
 Keep nares patent.
2. Stabilize and maintain normal temperature
 Dry head and body and wrap with warm blanket.
 Place newborn under droplight or infant radiant warmer.
 Perform any extensive examination or procedure under radiant heat to
prevent heat loss.
 Perform oil bath and full warm bath hastily and swaddle with warm blanket.
 3. Appraisal of the newborn
 APGAR SCORING – standardized evaluation of the newborn. It is
done at 1 min after birth to determine his general condition of birth and then
at 5 mins. To determine how well the newborn
APGAR Scoring System

ASSESS 0 1 2
Heart rate Absent Below 100 Above 100
Respiration Goo
Absent d cry
Muscle Tone Flaccid Some Active motion
flexion activity
Reflex Irritability
No Grimace Vigorous cry
Color
response
Acrocyanosis
Cyanotic
Pink
NTERPRETATION:

• 7-10 – baby is healthy

• 4-6 – baby’s condition is guarded and

needs oxygen

Cord Care

1. Milk the cord towards the

base.
2. Cleanse the cord with
povidone iodine starting at
the base.
3. Clamp the cord ½ - 1 inch
from the abdomen and cut
using a sterile scissor.
4. Cleanse the cord and the area
around it with povidone
iodine.
5. Leave the cord exposed to air.
6. Cord clamp is removed after
48 hours when the cord has
dried.
7. The cord stump dries and falls
off within 7 – 10 days.
Instruction to the mother on cord care:

1. No tub bathing until cord falls off.

2. Do not apply anything on the cord
except 70% alcohol.
3. Avoid wetting the cord.
4. Leave the cord exposed to air.
5. If the cord bleeds, apply firm
pressure and check the cord clamp
if loose.
6. Report unusual signs and
symptoms: foul odor, discharge,
redness, fever, the cord remains wet
and does not fall off after 10 days.

Anthropometric Measurement
Head circumference : 33 to 35 cm
Usually greater than chest
circumference by 2 cm.
Measured at the level of brow
Chest circumference : 30 to 32 cm
Measured at the level of the nipple
Abdominal Circumference
Weight : 6 to 8.5 lbs (2500 to 4000
g)
Length : 45 to 55 cm

Care of the Eyes

1. Give prophylactic eye treatment

against gonorrheal conjunctivitis or
ophthalmia neonatorum within the
first hour after delivery
2. Use of silver nitrate 1%,
erythomycin or tetracycline eye
ointments
3. Apply over lower lids of both
eyes, then manipulate eyelids to
spread the medication
4. Wipe excess ointment after one
minute with sterile cotton ball
moistened with sterile water.

Prevent Hemorrhage
Routine administration of Vitamin K
(Aquamephyton, Phytomenadione ; 10
mg/ml), usually a single dose of 1 mg IM over
vastus lateralis, prevents all cases of
hemorrhagic disease of the newborn (HDN).

Infant Identification:
• Identification bands are placed
around the infant’s wrist or ankle. It
contains the name of the mother,
date and time of delivery, hospital
number, gender of the baby, and
physician’s name.
• Footprints are obtained and kept with
the other birth records.

NEWBORN ASSESSMENT:
• Head
 Fontanels
 Molding
 Cephalhematoma (resolve 3-
6 wks)
 Caput Succedaneum (3-4
days)
• Ears and Eyes
 Blue or gray
 Transient strabismus
  Tearless cry upto 2 months
 The level of the top part of
the ear should be in line with
the inner and outer canthus
of the eyes.
 Ears should be firm with
cartilage and recoil rapidly.
• Mouth
 Scant saliva
 Epstein Pearls (pinhead-
sized, white or yellow,
rounded elevation)
 Neck
 Short & weak with deep folds
 Symmetric and flexible
enough to allow free
movement of head
• Chest
 It looks smaller in relation to
the head
 Breast nodule is 5 – 10 mm in
diameter, prominent, well-
formed and symmetrical
 Witch milk
 Abdomen
 Symmetrical with some
protrusion
 BS heard few hours after
birth
 Frequent regurgitation
 Umbilical cord
• Liver normally
palpable at right
costal margin
• Genitalia
 Male: rugae on the scrotum,
scrotal edema, urinary
meatus at the penile tip
• Epispadias – dorsal
surface
• Hyposapdias –
ventral surface
 Female: prominent labia
majora and minora:
discharges
 Voiding on 2nd-3rd day
 Extremities
 ROM
 Symmetrical
• Hyperflexibility of
joints – Down
syndrome
• Polydacyl
 • Syndactyl
 Palms: usual crease
Simian crease
• Anus
 Patent
 Meconium passed within 24
hours
 Midline
• Dimpling at the base
(spina bifida)
• Skin
 Thin layer of subcutaneous
fats
 Active sebaceous gland
 Brown fats
 Minimal action of sweat
glands not until 4 weeks old
and above
 Common findings:
• Milia
• Acrocyanosis
• Lanugo
• Vernix caseosa
• Erythema toxicum
neonatorum
• Telangiectasia
• Nevus fallmus
• Strawberry angioma
• Sudamina or miliaria
• Mongolian spot
• Cutis marmorata
• Neurologic
 Intact reflexes
• Rooting
• Sucking
• Moro
• Babinski
• Palmar grasp
• Stepping
• Hematopoietic
 Prolonged coagulation time
 Immunologic
 IgM – produced at birth & first
to respond to infection
• Hepatic
 Physiologic Jaundice –
appears after the 1st 24 hours
and disappears at 7 days (9-
10 days in preterm)
 Pathologic Jaundice – within
24 hours
 Vital signs
 RR- 30 to 50 cpm
  HR (Apical) – 110 to 160 bpm
 Temp
• Rectal – 35.6 to 37.5
• Axillary – 36.4 to 37.2

 BP
• SBP – 60 to 80
mmHg
• DBP – 40 to 50
mmHg
NEWBORN SCREENING
• Done to detect metabolic disorders
that can cause mental retardation or
death if left untreated
• Ideally done on the 48 to 72 hours of
life
• Interpretation
 (-) – normal
 (+) – further testing needed
Disorders Detected:
1. Congenital hypothyroidism (CH)
“Cretinism”
 Lack or absence of thyroid
hormones
 Causes severe mental
retardation
2. Congenital Adrenal Hyperplasia (CAH)
 Severe salt loss, dehydration
and abnormally high levels of
male sex hormones in both
males and females. Baby
may die in 7th-14th day if not
treated
Galactosemia (GAL)
 Inability to process galactose
which causes liver damage,
brain damage and cataracts
 Causes death or cataracts
4. Phenylketonuria (PKU)
 Body cannot properly use
phenylalanine (building
blocks of CHON)
 Causes severe mental
retardation
5. Glucose-6 Phosphate Dehydrogenase
Deficiency (G6PD)
 Condition where the body
lacks G^PD enzyme
 Cause severe anemia,;
kernicterus
Prepared by: Amelia A. Almodovar,RN.,MAN.

Congenital Heart Disease

Is a structural malformation of the heart or great vessels present at birth, but not necessarily detected at
that time.
ETIOLOGY:
 exact cause is unknown.
 a result of multifactoral inheritance: genetic & environmental factors.
 Maternal factors - results from embryonic dev’t. or the persistence of fetal structure beyond the
time of normal involution.
Structural changes at birth:
 Foramen Ovale – normally closes when pressure from left atrium exceeds right atrium, closes
within the first weeks after birth w/ the deposit of fibrin.
 Ductus Arteriosus – starts to close in the presence of high O2 concentration in the blood due to
pulmonary dilation, usually 24 hours after birth.
 Ductus venosus – constrict within 3-7 days after birth & eventually becomes ligamentum
venosum.
ASSESSMENT:
 A. HISTORY:
 1. Family history
 2. History of pregnancy
 3. Child’s health history
 B. Physical Examination
 C. Lab./Diagnostic Tests
 D. Possible complications
2 MAJOR CLASSIFICATION OF CHD
 Acyanotic:
 A. Obstruction to blood flow from ventricles
o 1. Aortic Stenosis – A narrowing or stricture of the aortic valve
 Drug of choice: Prostaglandin E1
 Non-Surgical Tx. – Aortic Valvotomy or Balloon angioplasty.
 Surgical Tx. – Ross Procedure & Prostethic valve replacement.
o 2. Pulmonic stenosis –A narrowing or stricture of the pulmonary valve
 Drug of choice: Prostaglandin E1
 Non-surgical Tx. – Pulmonic Valvotomy or Ballon Angioplasty.
 Surgical Tx. – Prostethic valve replacement.
o 3. Coarctation of aorta – A narrowing of the lumen of the vessel (the aorta)
 Drug of choice: Prostaglandin E1
 Non-surgical Tx. – Balloon angioplasty
 Surgical Tx. – Surgical resection w/ end to end anastomosis.
 B. Increased Pulmonary Blood Flow (Left-Right shunts)
o 1. Patent Ductus Arteriosus - Failure of the fetal ductus arteriosus to close after birth.
 Drug of choice: Indomethacin (Prostaglandin inhibitor)
 Surgical Tx. – Ligation of PDA
o 2. Ventricular Septal Defect (VSD)- An abnormal opening between the right & left
ventricles
  Non-Surgical Tx. – Cardioseal
 Surgical Tx. – Patch Closure
o 3. Atrial Septal Defect (ASD) – An abnormal opening between the right & left atria.
 Non-surgical & Surgical Tx. – same w/ VSD
 Cyanotic:
 A. Decreased pulmonary blood flow (Right-Left shunts)
o 1. Tetralogy of fallot – Four defects that occur together: (PVOR) Pulmonic stenosis,
Ventricular septal defect, Overiding aorta & Right ventricular hypertrophy.
 Surgical Tx.: Palliative – Blalock-Taussig shunt
 : Total Correction (Brock Procedure)
o 2. Tricuspid atresia
 Surgical Tx. : Palliative – Creation of small ASD
 : Fontan Procedure
 B. Mixed blood flow
o 1. Transposition of great arteries – The pulmonary artery arises from the left ventricle &
the aorta arises from the right ventricle.
 Drug of choice: ProstaglandinE1
 Surgical Tx.: Palliative- Rashkind Procedure/Balloon Atrial Septostomy
 : Arterial Switch Procedure
 : Intraatrial baffle repairs
o 2. Hypoplastic Left heart syndrome – Underdevelopment of the left side of the heart,
resulting in a hypoplastic left ventricle & aortic atresia.
 Surgical Tx.: Norwood Procedure & Fontan Procedure
o 3. Truncus Arteriosus – Failure of normal septation & division of the embryonic bulbar
trunk into the pulmonary artery & the aorta, resulting in a single vessel that overrides both
ventricles.
 Surgical Tx.: Rastelli Procedure – closure of VSD w/ excision & translocation of
pulmonary artery & aorta.
Other Congenital Heart Defects:
Dextrocardia
Ectopia Cardis
NURSING INTRVENTIONS:
 1. Prevent complication – CHF.
 2. Promote adequate oxygenation.
 2. Reduce workload of the heart.
 3. Provide adequate nutrition.
 4. Prevent infection.
 5. Meet teaching needs of patient & family.

NURSING CARE OF THE CHILD WITH A HEMATOLOGIC ALTERATION

RBCs are pale and smaller

Iron Deficiency Anemia
Most common anemia caused by improper iron intake
Giving cow’s milk instead of baby formula is main culprit during the first year
Adolescent girls are at risk because of menstruation
Causes poor growth, poor test scores later
Treatment
Ferrous Sulfate for two months
Restoration takes three months
Retic count will increase 7-10 days after starting therapy
Education
Give between meals for better absorption
Vit C increases absorption
Milk and tea with meals reduces absorption

Macrocytic Anemias
RBCs are larger than usual
Megaloblastic Anemias
Folic Acid Deficiency
Causes in children
Low birth weight
Intake of powdered or goat’s milk
Defective absorption
S/S
Poor weight gain
Chronic diarrhea
Management
Folic acid

Megaloblastic Anemias
Pernicious Anemia
Causes
Lack of intrinsic factor, must be deficient ~ 2 years for symptoms to develop
Management
Vitamin B12 1mg daily x 1-2 weeks, then once weekly until H&H are normal, then monthly for life

Hemolytic Anemias
Sickle Cell Disease
Autosomal recessive, sickle shaped RBCs
Asymptomatic in infancy prior to 5-6 months
Clinical course characterized by episodic crises
Management
Pain relief, hydration, oxygenation

DISORDERS OF BLOOD COAGULATION

Hemophilias
Hemophilia A (Factor VIII deficiency)
Sex-linked recessive
S/S
Soft tissue bleeding and bleeding into joints
Management
Administration of factor VIII

Von Willebrand’s disease

Autosomal dominant
Factor VIII defect, inability of platelets to aggregate, and inability of blood vessels to constrict

S/S
Bleeding, esp, from m.m.
Management
Factor VIII replenishment or DDAVP

Christmas disease (Hemophilia B, Factor IX deficiency)

Sex-linked recessive
Treated with factor IX

Hemophilia C (Factor XI deficiency)

Autosomal recessive
Symptoms are mild when compared to other types

Immune Thrombocytopenia Purpura or Idiopathic Thrombocytopenia Purpura

• Acquired disorder characterized by low platelet count

• Etiology
– Can be drug-induced or follows a febrile illness
• S/S
– Bruising and petechiae
• Therapeutic Management
– Usually self-limiting but may require steroids, IV immunoglobulin, or splenectomy
• Nursing considerations
– No IM injections
– No rectal temps
– Avoid meds that kill/interfere with platelet production

Aplastic Anemia

• Bone marrow ceases production of all cells

• S/S
– Petechiae, pallor, fatigue, bruising
• Etiology
– Congenital, exposure to drugs/chemicals, idiopathic
• Therapeutic Management
– Transfusions, stem cell transplant, chemotherapy
• Nursing Considerations
– Low-platelet considerations plus reverse isolation

Prepared by: Amelia A. Almodovar,RN.,MAN.

GENITOURINARY DISORDERS

Focused Health History

Single umbilical artery
Chromosomal abnormality
Congenital anomalies
Ear tags
Toilet training history
Family history
Growth patterns

Pediatric Urine Collector

Urinalysis
Protein
Leukocytes
Red blood cells
Casts
Specific Gravity
Urine Culture for bacteria

Diagnostic Tests:
Urinalysis
Ultrasound
VCUG – Voiding cysto urethrogram
IVP – Intravenous pyelogram
Cystoscopy
CT Scan
Renal Biopsy

Treatment Modalities:
 Urinary diversion
 Stents
 Drainage tubes
 Intermittent catheterization
 Watch for latex allergies
 Pharmacological management
 Antibiotics
  Anticholinergic for bladder spasm

PEDIATRIC GENITO-URINARY DISORDERS:

 CONGENITAL:
 HYPO/EPISPADIAS
 EXSTROPY OF THE BLADDER
 CRYPTORCHIDISM
 ACQUIRED:
 AGN
 NEPHROTIC SYNDROME
 ARF
 CRF
 INFECTIOUS: UTI
 CANCER: WILM’S TUMOR

Hypospadias:
Incomplete formation of the anterior urethral segment.
Most common anomaly
Incomplete formation of the anterior urethral segment
Urethral formation terminates at some point along the ventral fusion line.
Cordee – downward curve of penis

Newborn:
 Circumcision not recommended.
 Foreskin may be needed for reconstructive surgery.
Tight Chordee
Tight chordee causes curvature of the penis.

Goals of Treatment:
 Release of tight chordee
 Placement of urethra opening at head of penis
 Surgery recommended at around six to nine months of age
 Long term outcomes:
 Leaking at the site
 Body image

EPISPADIAS:
 Congenital defect in which the urinary meatus is not at the end of the penis
but on the upper side of the penile shaft.
 Less common than hypospadias

Exstrophy of the bladder:

 Interrupted abdominal development in early fetal life produces an exposed
bladder and urethra, pubic bone separation, and associated anal and genital
abnormalities.
 Occurs is 1 of 30,000 births
 Congenital malformation in which the lower portion of abdominal wall and
anterior bladder wall fail to fuse during fetal development.
Clinical Manifestations:
 Visible defect that reveals bladder mucosa and ureteral orifices through an
open abdominal wall with constant drainage of urine.
Treatment:
 Surgery within first hours of life to close the skin over the bladder and
reconstruct the male urethra and penis.
 Urethral stents and suprapubic catheter to divert urine
 Further reconstructive surgery can be done between 18 months to 3 years of
age
Goals of Treatment:
 Preserve renal function: prevent infection
 Attain urinary control
 Re-constructive repair
 Sexual function
Long-Term Complications:
 Urinary incontinence
 Infection
 Body image
 Inadequate sexual function

CRYPTORCHIDISM:
 Unilateral or bilateral absence of testes in scrotal sac
 Hidden testicle
 3 to 5% of males
 High incidence in premature infants
 Goals of treatment:
 Preserve testicular function
 Normal scrotal appearance
Treatment:
 Most testes spontaneously descend.
 Hormone therapy – human chorionic gondadotropin
 Surgical procedure, orchipexy, if testicles do not descend into the scrotal sac
by 6 to 12 months of age
 Slightly higher risk of testicular cancer if untreated
 In the teen or adult the testicle would be removed
Long-term:
 Monthly testicular self-examination is recommended for all males beginning
in puberty, but is essential in males with history of undescended testicle.

URINARY TRACT INFECTION:

 Most common serious bacterial infection in infants and children
 Highest frequency in infancy
 Uncircumcised males have a ten-fold incidence
Etiology:
 Anatomic abnormalities
 Neurogenic bladder – incomplete emptying of bladder
  In the older child: infrequent voiding and incomplete emptying of bladder or
constipation
 Teenager: sexual intercourse due to friction trauma
 Most common in females
 Short urethra
 Improper wiping
 Nylon under pants
 Current guidelines – do ultrasound with first UTI followed by VCUG if
indicated
 Infant males
 Needs to be investigated
 VCUG – ureteral reflux
 Ultrasound of kidneys – hydronephrosis or polycystic kidneys
 Higher in un-circumcised males
Uncircumcised Males
 Instruct parents to gently retract foreskin for cleansing
 Do not force the foreskin
 Do not leave foreskin retracted or it may act as tourniquet and obstruct the
head of the penis resulting in emergency circumcision
Clinical Manifestations:
1. Urinary frequency
2. Hesitancy
3. Dysuria
4. Cloudy, blood tinged
5. Must smell to urine
6. Temperature
7. Poor feeding / failure to grow
8. The neonate may only exhibit 6 & 7
Interventions:
 Antibiotic therapy for 7 to 10 days
 E-coli most common organism 85%
 Amoxicillin or Cefazol or Bactrim or Septra
 Increase fluid intake
 Cranberry juice
 Sitz bath / tub bath
 Acetaminophen for pain
 Teach proper cleansing

Nephrosis (Nephrotic Syndrome)

• It is a chronic renal disease w/ no known cause & cure.
• It involves leakage of protein into the urine resulting in:
1. Massive proteinuria
2. hypo albuminemia
3. edema
4. hyperlipedemia

Causes:
 1. 80% idiopathic
2. Congenital
3. Drug toxicity
4. Sequelae of various diseases
5. 60% affected are males, 2-5 y/o

Assessment:

1. Insidious weight gain

2. Severe edema: periorbital, facial, bipedal, ascites, scrotal or labia
3. Respiratory difficulty due to pleural effusion
4. Oliguria
5. proteinuria, hyperlipidemia, hypoproteinemia
6. Irritable
7. Anorexia
8. Diarrhea
9. Increased susceptibility to infection

Medications:

1. Prednisone
a. Reduce proteinuria & edema, induce remission & promote diuresis
b. 2 mg/kg/day until urine is free from urine
c. SE: immunosuppression, potassium loss, gastric ulcer, HTN, growth failure, Cushing’s
syndrome
d. NC: taper doses, administer w/ meals, monitor fluid balance, protect from infection
2. Antibiotics
3. Albumin infusion
The child will be free from infection & skin breakdown
Monitor VS & lab values
Keep away from infected persons
Administer antibiotics as ordered
Provide good skin care
Support edematous areas w/ pillows or towels
Change position frequently
Place in semi-fowler’s position
Cleanse edematous eyelids w/ saline
B. The child will conserve energy & play quiet activities suitable for age.

a. bedrest w/ edema, activity as tolerated

b. provide quiet activities for age.
c. observe for signs of fatigue

C. Child will maintain fluid balance.

a. measure I & O.
b. measure abdominal girth.
c. Weigh daily
d. assess changes in edema.
e. limit fluids to 1 – 1.5 L/day.

D. Child will maintain nutritional intake.

a. offer high biological value protein intake (0.8 g/kg/day).
 b. high potassium intake
c. restrict sodium and fats
d. serve small, frequent and, attractive meals.

E. Child will accept body image.

a. provide feedback about body changes.
b. encourage to verbalize feelings.
c. teach child that changes are caused by medications & disease process;
and will diminish once in remission.

F. Child & family will be prepared for home care.

a. allow family to verbalize concerns.
b. refer to support groups.
c. teach about urine analysis, side-effects of drugs, prevention of infection,
diet therapies.
d. emphasize importance to maintain follow-up care.

Acute Glomerulonephritis

1. An immune complex disease as a reaction to the group A beta hemolytic Streptococcus.

2. It is an inflammation of the kidneys causing transient damage to the glomerulus.
3. Peak age is 6-7 y/o; two times higher in males.
4. History of impetigo, URI, and scarlet fever
Assessment:

1. Periorbital edema in the morning.

2. Moderate edema in extremities.
3. Amount of bloody/brown-colored urine
4. Hypertension
5. Pallor/lethargy
6. Anorexia/malaise
7. Abdominal pain/vomiting
8. fever

Medications:

1. Penicillin (elevated ASO titer)

2. Antihypertensives & diuretics for BP control
3. Digitalis (CHF)
4. Anticonvulsants (HTN encephalopathy)
A. Child will be free from infection
a. Monitor temperature
b. Keep away from infected persons
c. Administer antibiotics as ordered
d. Record frequency of UO
e. Measure I & O
f. Restrict fluids w/ anuria
g. Test voided urine for hematuria
B. Child will regain & maintain good nutrition within dietary limitations.

a. offer high biological value protein and low sodium diet

 b. offer small, frequent meals
c. restrict potassium foods during anuria

c. Child will maintain tissue perfusion

a. monitor VS esp. BP
b. monitor UO
c. observe skin color, capillary refill time
d. weigh daily
e. monitor arterial pulses
f. administer antihypertensives as ordered
g. keep environment calm

d. Child & family will be prepared for home care

a. allow family & child to verbalize concerns.

b. refer to support groups
c. teach about urine testing, drug side effects, and diet therapies.
d. maintain follow-up care
e. obtain throat cultures for family members

Wilm’s Tumor (Nephroblastoma)

1. A malignant, embryonic tumor of the kidneys & is the most common form of renal cancer in
children.
2. Commonly occurs between 2 & 5 years of age; males are usually affected
3. Increase incidence among twins.
4. Usually unilateral
5. 90% survival rate once detected if it’s still encapsulated.
Assessment:

1. Palpable abdominal mass

2. Abdominal distention
3. HTN (excess renin)
Treatment:

1. Nephrectomy, Adrenalectomy, & Staging

2. Chemotherapy: Actinomycin D, vincristine
3. Radiation

Pre-op Nursing Care:

1. No abdominal manipulation/palpation because the tumor is highly friable & palpation increase
the risk of metastasis.
2. Monitor kidney function (I&O, Spec. grav., BP, BUN, Crea, electrolytes)

Post-op Nursing Care:

1. Measure I & O
2. Monitor urine spec. gravity/daily weight.
3. Monitor BP, IV infusions &, fluid level.
4. Monitor for infection, body temp &, observing surgical wound.

Child & Family Education:

1. Educate family the need to avoid unnecessary palpation of the abdomen prior to surgery.

2. Discuss with parents & child the need to protect the remaining kidney, s/sx of UTI &, avoidance of
contact sports with which injury to the kidneys might occur.

Prepared by: Amelia A. Almodovar,RN.,MAN.