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What is the definition of the "high risk newborn"
Any neonate who is in danger of serious illness or death as a result of prenatal, perinatal or neonatal condition regardless of birth weigh or gestational age
What classifies a baby as "low birth weight?"
< 2500 gms or 5.5lbs
What classifies a baby as "very low birth weight?"
<1500 gms or 3.3lbs
What classifies a baby as Extremely low birth weight?"
<1000 gms or 2.2lbs
What does AGA stand for? SGA? IUGR?
appropriate for gestational age; Small for gestational age ( weight < 10th percentile); Intrauterine Growth restrictions
What is symmetric IUGR? Asymmetric?
- S= weight, length and head circumference are all affected
- A= Head circumference is normal but weight is < the 10th percentile
Gestational age: what is considered preterm according to Gosling? full term? post term?
- < 37 weeks;
- > 38 weeks- 42 weeks;
- >42 weeks
what kind of care does the level 1 nursery provide? level 2? level 3?
- 1= provides basic newborn care;
- 2= care for infants with moderate- high risk problems;
- 3= provides care for extremely high risk infants
What is the best way to transport a newborn from one facility to another?
- If possible, it is more desirable to transport the baby when still in utero;
- sick neonates are transported in isolette or warmer via ambulance, helicopter, or airplane
- care is provided by a team of nurses, physicians and respiratory therapists
How can the nurse promote development in a newborn older than 34 weeks?
- Encourage visits
- encourage parent-infant attachment (skin to skin contact-"kangaroo care")
- Infant toys
Prematurity is dangerous because it affects all organ systems. What complications occur?
- Resp: it lacks surfactant is compromised by small muscle mass and immature nervous system
- Brain: susceptible to hemorrhage and anoxia
- Cardio: difficulty maintaining blood pressure, renal perfusion, and oxygenation
- GI: lacks enzymes for protein metabolism; suck reflex is absent weak or ineffective
- Immune: deficient; increased risk for infection
What is the pathophys of preterm births?
- 50% no etiology
- rupture of membranes accounts for roughly 25-30%
- Maternal complications (some modifiable and some non modifiable)
What maternal complications dealing with preterm birth are modifiable?
unplanned pregnancy, single, low education, poverty (or unsafe environment), domestic violence, life stress, number of implanted embryos in assisted fertility, low pre-pregnancy weight, obesity, incompetent cervix, GU infections, infections, periodontal disease, substance/alchoal abuse, long hours of employment/standing, late or no prenatal care, air pollution, and some health issues (HTN, diabetes, anemia, clotting problems
What maternal complications dealing with preterm birth are non-modifiable?
Previous preterm, multiple abortions, race/ethnic group, uterine/cervical anomaly, multiple gestation, polyhydramnios, oligohydramnios, PIH, placenta previa (after 22 weeks), DES exposure, short interval between pregnancies, abruptio placenta parity (0 or >4), premature ROM, bleeding in first trimester
The subtle changes that the nurse should look for in the high risk newborn?
- change in feeding behaviors
- in activity
- color (circomoral)
- O2 stats
- vital signs
what does an Apgar of 0-3 mean?
what does an Apgar of 4-6 mean?
what does an Apgar of 7-10 mean?
- 0-3: severe distress
- 4-6: moderate difficulty
- 7-10: should adapt to extrauterine life
what should the initial assessment include?
- Apgar score
- look for congenital anomalies
- birth weight
- gestational age (estimation of maturity)
What is the therapeutic management for the preterm neonate?
- assess vitals
- continuous pulse ox
- O2 therapy
- skin integrity
how do you monitor BP in the preterm?
- arterial catheter
- umbilical venous catheter
how do you measure I&O in newborns/preterms?
- urine bag
- can obtain urine sampling using cotton ball placed in diaper
- weigh diapers (1gm=1mL)
- include meds and blood products, every mL counts
Most common labs in the neonate?
- glucose, bilirubin, calcium, hematocrit, electrolyes, blood gases
- order single blood test to reduce amount of blood drawn
What is the nursing care for adequate oxygenation?
supplemental O2 and assisted ventilation
What is the nursing care for thermoregulation?
- maintain neutral thermal environment with incubators and warming units
- maintain a core temp with minimal 02 consumption with minimal caloric consumption
- avoid clod stress
- attach thermo sensor to infants abdomen while in incubator
how does the nurse prevent nosocomial infections in the neonate?
- minimizing number of people and equipment who come in contact with neonate
Nursing care for maintaining adequate hydration?
- Iv's, PICCs must be monitored hourly (infiltration of hypertonic solutions could cause severe issue damage)
- monitor for CHF, and pulmonary edema (tachypnea, crackles in lungs, and periorbital edema
How does the nurse maintain skin integrity?
- assess daily, bathe every 2-3 days with neutral pH cleansers
- do not remove vernix
- cleanse eyes, oral, and diaper areas daily
- use adhesives as minimally as possible
- remove iodine after procedures
- no alcohol
- assess for breakdown ( blanchable skin on buttocks, genitalia, legs or feet)
- use transparent dressings to arms, elbows, knees
- use sheepskin or gel beds
- use emolients free of preservatives dyes and perfumes
- NO adhesive remover
How does the nurse assess pain in the neonate
- PIPP scale
- increased HR, RR, BP, ICP
- decreased O2 sats
- cry, grimace, pain
- clenched fists
Pain management in the newborn
- RTC low does morphine
- EMLA cream for invasive procedures (numbs the area but constricts vessels
- concentrated oral glucose solutions
How does the very low birth weight infant feed?
parenteral feedings due to inability to digest formal (minimal enteral feedings)
When is breast milk indicated? Bottle feed? Gavage feed?
- Breast milk: if there is adequate suck and swallow reflexes; if not return to orogastric tube Breast milk feedings
- Bottle: only if able to suck, swallow and breath simultaneously and complete feeding in 30 minutes( if taking longer, too much wasting of energy)
- Gavage: used when oral feeding is not safe syringe; with OG tube, through mouth; check residuals and replace; flow by gravity. place 1-2 drops of milk in mouth during feeding; providing oral stimulation
How to determine readiness for bottle feeding;
- Observe for:
- suck and gag reflex
- sucking on gavage tube
- rooting reflex
- wakefulness before scheduled gavage feeding
How is Hypoglycemia defined in the premature neonate? why is it caused? Risk factors? Diagnostic used?
- def: abnormally low blood sugar in the neonate; <40mg/dL
- cause: access to glucose is limited due to the immature liver enzymes (can't metabolize food) or there is an increase demand for glucose
- risk factors: maternal diabetes, sepsis, shock, perinatal asphyxia, delay of feedings
- Diagnostic: heel stick
How do you treat intractable hypoglycemia?
steroids to stimulate gluconeogenesis or diazoxide given to supress insulin secretion
What are the complications of cold stress?
- metabolic acidosis
What are the clinical manifestations of hypoglycemia
- may be asymptomatic
- high pitched cry
- hypotonia/ floppy
- irregular resps
- lethargy, poor feeding
- temperature instability
what is the nursing care for hypoglycemia
- IV glucose for very low glucose level
- feeding infant for moderate level
- monitor glucose in response to feeding
- decrease stressors: cold stress, respiratory distress
- initiate early feedings in healthy infant
- reassess for hyperglycemia
How is hypocalcemia defined?
- def: serum calcium < 7.0 (in a premie) or < 7.8 in full term infant
- cause: results from inadequate store of calcium
- (preterm or stressed infant may have prolonged hypocalcemia)
What are the clinical manifestations of hypocalcemia
- late signs: tremors twitching seizureshyperexcitiblity, irritability
- high pitched cry, laryngospasm
- EKG changes
Nursing care for infants with hypocalcemia
- parental and oral calcium gluconate
- initiation of feedings will raise levels
- cardiac monitor
- decrease stimuli (that may cause seizure)
- offer pacifier and provide quiet environment
- observe for s/s of hypercalcemia: vomiting, bradycardia, arrythmias
- Any infant who is jittery or twitching get blood glucose and calcium levels!
- reassess for hypercalcemia
How is neonatal sepsis defined?
- Def: systemic infection
- Cause: occurs when bacteria or their endotoxins gain access to the blood stream; usually prenatally acquired
- early sepsis: 1-3 days of age
- Late sepsis: 1-3 weeks of age
- Diagnostic: cultures of blood, urine, CSF, CBC H&H
- Treatment: aggressive antibiotic therapy
what are the clinical manifestations of Neonatal sepsis?
- Early signs: vague (resp or GI symptoms)
- could be increased or decreased temperature, HR, RR, and BS
- decresed BP
- irregular breathing, grunting, retractions
- pallor or cyanosis, lethargy or seizures
- poor feeding, vomiting and diarrhea
- abdominal distention, enlarged liver or spleen
What is the nursing care for neonatal sepsis?
- Supportive Care:
- O2, fluids/electrolyte balance, temperature
- D/C oral feedings until stable
- hourly urine output
- monitor for development of DIC (serial platelet counts and maintain hematacrit > 40)
- observe and assess response to treatment ( report changes in resp status, muscle tone, feeding intolerance, and temp
How is Retinopathy of Prematurity (ROP) defined?
- In response to hyperoxemia, retina vessels constrict which leads to necrosis that may eventually cause blindness from scar formation and retinal detachment
- progressive vascular regrowth of retina
- ( all premature infants who received supplemental oxygen, were <35 gestation or weighed <1800 grams at birth need and ophthalmologic evaluation for ROP)
What can the nurse due to aid in developmental care (in babies 34-36 weeks)
- Dim lights/photos/decrease stimulation
- sleep 50 mins undisturbed
- kangaroo care
- QUIET environment
- co-bedding of twins
- provide "nesting"
- play soft music for short periods of time
- flexion position, with hands to face at midline
- sling hammock
- avoid quick movements
- cotton ball dipped in breastmilk under nose/pacifier dipped in milk during gavage
- non-nutritive breast feeding
what are signs and symptoms of stress in the neonate?
- mottled, dusky, pale
- hiccups, gagging, choking, yawing
- tremors, startles, twitches
- fluctuationg tone
- arm or leg extension
- hyperextension of neck
- arching of back (severe stress)
- diffuse activity; restless
- physiologic instability
- clenching of fists
- disorganized states
how is postmaturity defined?
def: pregnancy exceeds 42 weeks
Postmaturity places the newborn at risk for problems due to what? what are those complications?
- placental dysfunction secondary to compromised blood flow
- nutritional deficiency
- hypoxia and asphyxia
- growth retardation ( not enough nutrients from placenta)
- loss of subQ fat which leads to wrinkles
- Loss of vernix which leads to macerated skin
- passage of meconium due to inadequate O2 to digestive system
What are the clinical manifestations of Postmaturity?
- growth retardation
- dry, cracked, wrinkled, parchment-like skin
- long thin arms and legs with hanging skin folds
- long fingernails
- advanced hardness of skull
- no vernix or lanugo
- macerated skin
- meconium staining of skin
- hyperalertness or apprehension
- possible seizure activity if stressed during birth
what is the therapeutic management of post maturity?
- Respiratory support/ ventilation
- monitor calcium levels, hematocrit, blood sugar
- aggressive management of fluids and nutrition to avoid further weight loss
- partial exchange transfusions may be necessary due to polycythemia
Nursing care of post mature neonate
- observe for hypoglycemia
- observe for resp distress
- monitor Temp
- Allow skin to slough off naturally; use neutral pH soap only
what are the healthy newborns normal vitals?
- Temp- 97.7 before first bath; stabilizes at 98.6
- Pulse- 125-190
- RR- (no less than 30) 30-40 (up to 60)
- BP- 70/50 (1.5 in cuff)