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<32 weeks gestation
Very premature
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32-34 weeks gestation
Premature
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34-37 weeks gestation
late premature
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>41 weeks gestation
Post-term
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Maternal Factors affecting birth weight
- Height
- Obesity
- Blood Sugar levels
- BMI (before preg)
- Gestational age
- Pregnancy weight gain
- Tobacco consumption
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Social/Economic risk factors for high-risk neonates
- Maternal age
- Low education levels
- Domestic violence
- Stress
- Poverty
- Smoking
- Substance abuse
- Maternal injection
- Standing long hours
- Late/no prenatal care
- Maternal health problems
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Baby with weight less than 10th %tile for gestational age
SGA (small for gestational age)
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Small for gestational age is not the same as ______
prematurity
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SGA can be due to ____ (symmetric or asymmetric)
Intrauterine growth restrictions
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Proportional reduction in size of organs except heart and brain...occurs early in pregnancy
Symmetric IUGR
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Disproportional reduction in size of organs...late in pregnancy
Asymmetric IUGR
(head looks a lot larger because their brain is normal size, but baby's body is smaller)
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Decreased glycogen stores ____ metabolic demand
increases (hypoglycemia)
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Results from birth asphyxia
Hypocalcemia
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If baby is stressed in utero, it increases risk for
meconium aspiration
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Characteristics of SYMMETRICAL IUGR
Equal HC, Length, and Wt
Appears normally developed for size
- Thin, long, and wasted
- Dry loose skin
- Loss of SQ fat
- Sparse hair
- Elderly facial appearanceLarge/overlapping fontanelThin umbilical cord
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Characteristics of ASYMMETRICAL IUGR
HC normal but seems large
AC decreased due to small liver, spleen, and adrenals
- Thin, long and wasted
- ***Dry, loose skin
- Loss of SQ fat
- Sparse Hair
- Elderly facial appearance
- Large/overlapping fontanel
- Thin umbilical cord
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Baby within or greater than the 90 %ile for gestational age
LGA (large for gestational age)
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Characteristics of LGA babies
- Macrosomic (weighing >4 - 4.5kg)
- Large HC and length compared to AGA infant
- Poor feeding
- Hypoglycemic (gestational dm)
- Risk for birth traumas
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LGA babies are at risk for _____ and ____ bc there is not a lot of extra room in uterus
shoulder dystocia and asphyxia
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Nursing management for SGA babies
- ****Assess resp status
- Maintain normothermic environment (they do not have enough fat reserve so it is difficult for them to maintain body temp)
- Assess/treat for hypoglycemia/hypocalcemia
Daily weights
Early/Frequent feedings
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Nursing management for LGA babies
***Assess resp status!
Assess for birth trauma
Frequent feedings to decrease chance of low BS
Assess for polycythemia (they will have too many RBCs)
Monitor labs: ie bilirubin, hematocrit, and glucose
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2nd leading cause of infant mortality in US
Prematurity and low birth weight babies
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Why are premature babies on the rise
Older Age
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Pre-term Neonatal Assessment Findings:
Flaccid tone
Translucent or Transparent skin
Eyelids may be fused
Lanugo may be present
Undescended Testes
Tremors
Overriding sutures
Weak cry
Absent or diminished reflexes
Immature suck, swallow and breathing
Apnea (>20 sec without breath = true apnea)
Bradycardia
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Respiratory Distress Syndrome is characterized in a Pre-term neonate by
Underdeveloped alveoli
Insufficient surfactant
- Results in Atelectasis -collapse of lung
- (hypoxemia/hypercarbia = High CO2)
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Neonates can develop _____ from being on long term oxygen and becoming dependent
Bronchopulmonary Dysplasia
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Respiratory Assessment of neonate:
Tachypnea
Nasal Flaring
Grunting
Retractions (and head bobbing) -- trying hard/ extra work to breath
Gray/Dusky skin color
Lethargic -- extra work to breath
Respiratory acidosis may result
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Respiratory interventions of the pre-term neonate
- Suction nose
- Positioning
- Check O2 saturation
- Give supplemental oxygen (ventilator maybe)
- Checking blood gases
- Monitoring Temperature -- if baby gets too cold, it will work harder to warm itself
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Breathing with BPD results in difficult delivery of oxygen because it is working against ____
Stiff Lung Tissue
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Ventilator that opens up lungs even more than normal and keeps alveoli open and helps the lungs take a break
Auscillator
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Pre-term neonates usually have a central line through _____
their umbilicus
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Retinas are not fully developed before ___ weeks
28 weeks
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Characteristics of retinopathy of prematurity
- Related to gestational age and weight
- Occurs in neonates <28 weeks
- 82% of neonates are <1000g
- Can result in blindness
(neonates are not given 100% oxygen in the ventilator because this can cause retinopathy of prematurity)
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Risk factors leading to Retinopathy of Prematurity
Prolonged use of high concentrations of oxygen and mechanical ventilation
Maternal DM, Smoking, HTN
Intraventricular Hemorrhage
Sepsis
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Nursing interventions for retinopathy in pre-term neonates
Use of supplemental oxygen to maintain pulse ox parameteres (80s-90s)
Avoid exposure to bright lights
Ensure exact oxygen concentration is used
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Most common forms of intracranial hemorrhage
Intraventricular/Periventricular
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Bleeding in the ventricles of the brain in the pre-term neonate
IVH (intraventricular hemorrhage)
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Which grade of IVH: Small amount of bleeding in the floor of the ventricle, not changing in size of ventricles, vascularity in the ventricles are very fragile and can rupture easily
Grade 1
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Which grade of IVH: Bleeding into ventricles, not enough to change size of ventricle
Grade 2
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Which grade of IVH: Bleeding is substantial enough to interfere with normal flow f CSF
Grade 3
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Which grade of IVH: Bleeding into ventricles has resulted in decreased blood supply to other parts of the brain (will be checking ICP)
Grade 4
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Neurological Assessment on a pre-term baby
Sudden change in condition
Bradycardia
Ox desaturations
Full fontanel (can tell about hydration status...if it is bulging there may be a brain bleed)
Hypotonic
Apnea (can lead to seizures!!!)
Hyperglycemia
Hypotension
Seizures
Diminished activity or LOC
Increased oxygen demand
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Nursing Interventions for Neuro changes/complications
Assess v/s and neuro status
Reduce stress and stimulation (only touch them when absolutely needed...we don't want to utilize their energy for anything other than growth)
Administer volume replacement to decrease hypotension
Maintain neutral head position: if at risk for IVH, any type of brain injury keep in a good position, any issue with blood flow you do not want to increase any more!
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GI disease affecting neonates...inflammation and bowel necrosis (90% in preterm babies)
Necrotizing Enterocolitis
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Causes of Necrotizing Enterocolitis (NEC)
- Hypotension
- Stress
- Hypovolemia
- Hypoxia
- Hypothermia
- Polycythemia (only thing that increases)
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Reasons why Pre-term baby could develop NEC
- GI immaturity
- Immature host defense mechanisms
- Aggressive enteral feedings
- PDA
- Indomethacin therapy
- Mucosal injury (hypoxic-ischemic insults)
- Presence of bacteria within GI lumen
- Nursery/NICU overcrowding
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Reasons why Full-Term neonates could develop NEC
- Congenital heart disease
- Hypothyroidism
- Down Syndrome
- Small Bowel Atresia
- Gastrochisis
- Polycythemia
- Conditions compromising GI oxygenation/blood flow
- Exchange transfusion
- Perinatal "stress"
- Aggressive enteral feedings
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S/S of neonate with NEC
Apnea, Bradycardia, sometimes Tachycardia
Hypoxemia
Temperature instability
Hypotension, Shock
GI disturbances (vomiting, bloody stools, abdominal distension, tenderness, increased gastric residual, discoloration)
Lethargic
Thrombocytopenia and Abnormally high/low WBC cound...can cause septicemia
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Many babies with NEC need:
surgical intervention and go home with G Tubes
*Check abdominal circumference a lot to make sure there isn't any fluid build up!!!
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Nursing Interventions for baby with NEC
Assess abdominal distention (take air out), vomiting, bloody stools
Monitor NPO status (gut isn't working) and IV fluids
Monitor I&O
Gastric decompression with NG tube
Prepare for surgery and possible colostomy
Administer 3 A's: antibiotics, analgesics, antihypertensives
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High levels of bilirubin in the blood
Hyper-bilirubinemia
>5 mg/ dl
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S/S of hyperbilirubinemia
- Serum levels >5mg
- Visible signs of Jaundice
- Complications may include kernicterus (unconjugated bilirubin in their brain which causes blindness!)
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Nursing Management of Jaundice
Assess degree of jaundice
Obtain bilirubin levels
Ensure adequate hydration via feeding
Place under bili lights (phototherapy)
Assess for s/e of phototherapy
***main goal is to flush bilirubin out of their body
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S/E of phototherapy
- Lethargy
- Eye damage
- Dehydration
- Hyperthermia
- Skin Rash
- Loose Stools
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Baby delivered after completion of 41 weeks
Post Term Neonate
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Risk factors leading to post-term neonates
Maternal hx of post-term pregnancies
First pregnancy
Anencephaly (when brain does not develop, maybe born without brain stem)
Grand multiparous
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Main intervention when suspected meconium aspiration:
- Suction mouth/nose
- Admin Ox
Have NICU and respiratory present
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Types of HDN (hemolytic diseases in newborn)
- Rh Incompatibility
- ABO incompatibility
- Destruction of RBCs in fetus
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Management for HDN (hemolytic disease of newborn) is similar to _____
Hyperbilirubinemia
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Infection exposure can occur via:
- Vertical transmission (mother to baby)
- --tranplacental (syphillis)
- --ascending (chorioaminiotis)
- --intrapartal (herpes)
Horizontal Transmission (nosocomial infections)
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Type of transplacental (vertical transmission) infection:
Syphillis
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Type of Ascending (vertical transmission) infection:
Chorioaminiotis
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Type of Intrapartal (vertical transmission) infection:
Herpes (active lesions)
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Example of Horizontal Transmission of infection
nosocomial infections
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Sepsis that occurs within first 7 days of life, usually via vertical transmission
Early Onset Sepsis
(life threatening)
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Sepsis that occurs after 7 days of life
Late onset sepsis
(lower mortality rates)
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Sepsis that occurs after 3 months of age (associated with use of indwelling catheters, etc)
Very late onset sepsis
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Nursing Management of sepsis in newborns
Assess vs for s/s of infection (hypothermia)
Monitor I&O
Administer antibiotics as ordered
Assess respiratory status
Educate family/visitors on hand
Monitor laboratory values
Assist during lumbar puncture
***CHECK FOR GBS
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First sign of infection in newborns
Hypothermia
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Substance abuse (including caffeine) increases risk for:
prematurity and placental abruption
- Breathing problems
- Low Birthweight
- Feeding Problems
- Seizures
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Withdrawal systems may occur within _____ after birth
3 hours - 14 days after birth
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Withdrawal for alcohol
3-12 hours
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Withdrawal time of narcotics:
48-72 hours
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Withdrawal time of Barbituates:
1 day - 14 days
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Babies experiencing neonatal abstinence syndrome (withdrawal) will be:
Hyper reflexive
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S/S of neonatal withdrawal
- Apnea
- Diarrhea
- Fever
- High Pitched Cry
- Irritability
- Seizures
- Sweating
- Yawning
- Difficulty Sleeping
- Poor Feeding
- Inability to console
- Hypertonia
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Abnormal facial features from fetal alcohol syndrome
- short eye opening
- short nose
- flat midface
- thin upper lip
- small chin
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Nursing interventions for neonate withdrawal
Assess for s/s withdrawal
monitor v/s
Obtain Toxicology
Daily Weights
Provide Small/Frequent feedings (higher calorie formula)
Decrease stimulation-- turn down lights, small frequent feedings
Swaddle
Provide pacifier (sucking is soothing)
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Nursing Dx for the high risk neonate
- Impaired gas exchange
- Impaired tissue perfusion
- Impaired thermoregulation
- Nutrition less than body requirements (or >)
- At risk for blood glucose
- Dysfunction Family
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Nursing interventions for High Risk neonates Relating to TEMPERATURE:
- Minimize cold stress
- Maintain skin tem 36.1- 36.7 (96.8-97.7)
- Continuously monitor temp
- Prevent rapid warming or cooling
- Use a cap to prevent heat loss from head
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Nursing interventions for High Risk neonates Relating to FOOD/FLUIDS:
Monitor for hypoglycemia
Assess tolerance of oral or tube feedings
Monitor hydration closely
Assess for gastric residual, bowel sounds, change in stool pattern, abdominal girth
Monitor weight gain or loss
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Nursing interventions for High Risk neonates Relating to RESPIRATORY function:
- Position - semiprone/side lying
- Maintain resp tract patency
- Stimulate-- remind to breathe
- Monitor O2 therapy
- Assess Resp effort (grunting, nasal flaring, cyanosis, apnea)
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Needs of the high risk neonate for Hypothermia treatment/prevention
Radiant warmers
Incubators
Warm blankets, clothes, hats (tell parents to dress babies in one more layer than for adults)
Kangaroo Care
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Needs of the high risk neonate for Cold Stress
More calories...monitor glucose, temp and oxygen!!!
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Needs of the high risk neonate for Oxygen/Ventilation support
- Nasal Cannula
- Oxyhood
- CPAP
- Ventilator (intubation)...conventional or high frequency (200-900 breaths per minutes to keep lungs expanded all the time)
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Needs of the high risk neonate for Nutrition
- IV nutrition (parenteral) mainly for babies with gut issues
- -TPN/Intralipids
- Enteral Nutrition
- -Trophic feeds (NG tube)
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Nursing interventions for baby needing NG tube
Measure from ear to sternum
Insert NG tube
Educate parents on feeding
Assess daily weights (10-20 gram increase per day)
Encourage breast feeding or use of breastmilk
Check gastric residuals prior to/after gavage
Assess for bowel sounds
Assess for abdominal distention
Assess stool for blood
Encourage sucking (pacifier)-- help them remember the sucking reflex because they don't feed for long periods of time
Strictly monitor I&O
Monitor v/s (respirations!) during feeds
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Needs of the high risk neonate for Skin
Assess for breakdown
Use neutral cleanser (no heavy moisturizer!...only light!)
Change diapers often
Frequently change position
Keep skin moisturized
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Needs of the PARENTS of high risk neonates
Realistically perceiving the infant's medical condition and needs
Adapting to infant's hospital environment
Assuming primary caretaking role
Assuming total responsibility for the infant upon discharge
Possible coping with the death of the infant if it occurs
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Facilitating parental attachment with neonates
Facilitating family visits
Allowing the family to hold and touch the baby
Giving the family a picture of the baby
Liberal visiting hours
Encourage the family to get involved in the care (during bath or feeding times)
Encouraging kangaroo care (mom and dads!)
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During parental bonding, you may see what change in baby:
HR and temp increase
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