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**Terms for the High Risk Newborn
Large for gestational age (LGA): Above 90% for weight; check for respiratory distress
Appropriate for gestational age (AGA): Between 10-90% for weight
Small for gestational age (SGA) (IUGR): Less than 10th% for weight; check for fetal distress
**The Preterm Infants.
- Less than 24 weeks
- 24-30 weeks
- 31-34 weeks
- 36-37 weeks (late preterm)
- -> 38 weeks of gestation are TERM babie
- -determined by ballard scale
- -BW infleuences motality, lower =Higher mortality
**Respiratory ImplicationsFactors Associated With the Development of the Respiratory System:
- -lungs not fully developed until 37-38 weeks
- -surfactant production: prevents lungs from collapsing; surfactatnt gives you residual airs
- -Muscular coat of pulmonary blood vessels incompletely developed. Arterioles don’t constrict to hypoxia; and also remain in persistent fetal circulation because ductus remails open , "Ductus Arteriorus".
- Lungs full of lots of blood b/c not fully developed so give Indomethacin (NSAID usually for arthritis)
=> The opening, called the ductus arteriosus, is a normal part of a baby's circulatory system before birth that usually closes shortly after birth. If it remains open, however, it's called a patent ductus arteriosus.
=> A small patent ductus arteriosus often doesn't cause problems and might never need treatment. However, a large patent ductus arteriosus left untreated can allow poorly oxygenated blood to flow in the wrong direction, weakening the heart muscle and causing heart failure and other complications.
-Ductus may remain open (supposed to close normally!)-at 24 weeks, you don't have surfactants, only made in the last trimester.
Factors That Predispose the Newborn to Hypothermia
=> Cold Stress??
Low body fat so nothing to keep heat in
Inadequate functioning of metabolic process that require oxygen to produce necessary body heat
Infant posture they're spread out at the nicu rather than normal babies that are swaddled up.
-temp sensitive, placed in warmers with seran wrap to prevent people walking back and forth to avoid drafts that would make them colder.
=> Cold stress: oxygen consumption increased and pulm/peripheral vasoconstriction occur, decreasing oxygen uptake by lungs and oxygen delivery to the tissues; anaeorobic glycolysis increases and there is a decrease in Peripheral O2 leading to Metablic ACIDOSIS.
-Newborns don't shiver to produce heat
-Prevent heat loss resulting from evaporation by keeping the newborn dry and well wrapped in blankie, shield from drafts, take newborn's axillary temp every hour for first four hours and Q4H for first 24 hours.
**Metabolic System for Newborn:
-THey are able to digest simelple carbs bur not fats because of lack of lipase
-Proteins broken down partially; may serve as antigens and cause allergic reaction
-small stomach capacity, fast rapid intestinal peristalisis (2.5-3 hours poop)
-breast feeding should be done every 2-3 hours, bottle feeding 3-4 hours
**Nutritional Needs of the Preterm Infant
Methods of feeding depends on infant’s gestational age, health and physical condition, and neurological status
- => Bottle: Infants with coordinated suck 34 weeks and continue; To gain 20-30g/d may be fed by bottle;takes no longer than 15 to 20 minutes
- -can't feed babies with bottle until they have coordinated the suck and swallow reflex.
- -nurses at nicu try to group up babies because you can't bother them too much b/c that will burn up their calories.
(only for ) infants with demonstrated suck and swallow reflex, consistent wt gain,& control body temp
- =>Gavage Feedings: infants < 34 weeks, poor suck swallow, ventilator dependent,
- -OG tube placed down stomach, babies constantly lying down so they can get refux so put down a transpyloric tube to avoid aspirating
feeding with stomach bypassed- used with infants with reflux, unable to tolerate gavage feeds
=>Total Parenteral Nutrition:
Infants where using GI tract is contraindicated: anomalies, surgery, NEC (necrotized entercolitis?) , extreme premie-mostly for preterms.
- => Fluid requirements
- Day 1 100cc/kg/d
- Day 2 100-120cc/kg/d
- 3rd 120-150cc/kg/
-don't start them on a mass of fluids imeediately because of their small size
**Physiological Factors Affecting the Preterm Infant
=> Immune System
- =>Kidney- Immature; poor concentration of urine unable to excrete metabolites and drugs-longer time frames for getting meds b/ c liver can't metabolize drugs and kidney can't excrete them so it takes longer.
- -gentamycin & vancomycin : you can lose hearing
- =>Immune system- little immunity a/g infections-"elbow scrubs"
- -CRP every monday (C-Reactive Protien) b/c you can't tell when they have infections (not like normal people) Related health deviations
**Hematological System: Physiological Factors Affecting the Preterm Infant
- Increased capillary fragility
- Prolonged prothrombin time
- Decreased production of RBC’sLoss of blood to frequent blood draws (always nightly-tpn lipids-chem panel daily)
- Decreased levels of abumin (observe for..)
- Observe for pale skin
- Poor weight gain
- Premature infants are at high risk for infection
- Strict hand washing
- Personnel with infection illnesses are barred from the units
- High susceptible to infection due to decreased humoral immunity
- Infant response to infection is vague to decreased immune response
As a result diagnosis and treatment may be delayed so we look for : Hypothermia, lethargy irritability, apnea, feeding intolerance
-Gavage feedings: residuals will increase, indicates septic (more commonin NICU)
- Anticipatory grief related to possible loss of the infant
- - some parents respond to this by not visiting a lot, don't want to get too attached to baby if it'll die.
- Mother accepting failure to give birth to healthy term infant
- Resume process of relating to the infant
- Learning how infant differs
- Adjusting home environment to reduce exposure to pathogens
- Must deal with grief of grandparents
- Sibling bewilderment and anger toward parents by the amount of attention paid to the preterm infant
-keep track of how often parents come to visit, if they don't visit, social worker will track them down. Incidence of physical and emotional abuse is greater because the infant is separated from the parents at birthEmotional abuse from lack of interest to outright dislike of infantAppropriate resources should be made available to the parentsFactors surrounding birth may predispose the parents to anxiety or overtly rejecting infantUnmet expectations of birth processHeavy financial burden due to high cost of care
**The Post-term Infant
Post-maturity syndrome: Greater than 42 weeks; dates are so important in OB; Health deviations
- -placenta doesn't work as well as it did previously, at risk for increased size and birth trauma, meconium aspirationNursing systems
- -higher mortality than preterm kids
Hypoglycemia, Parchment like skin (dry and cracked) without lanugo, Long finger nails, wasting of fat and muscle in extermities, miconium staining possibly present on nails and umbilical cord
-Monitor for meconium aspiration
**Meconium Aspiratiion Syndrome
-Occurs in posterm babies, release of meconium into the amniotic fluid causing aspiration in utero or with the first breath
-Assessment: RDS at birth, tachypnea, cyanosis, retractions, nasal flaring, grunting, crackles, and rhonici
-Interventions: Suctioning Immmediatly after head is deliver and before the first breath is taken-may benefit from extracorporeal membrane oxygenation (uses modified heart
-lung machine and provided oxygen to the circulation, allowing the lungs to rest and decreasing pulm hypertension and hypoxemia in some conditions, such as meconium aspiration)
**The Premature Infant Stats & Health Devs
Born Less than 37 weeks
Incidence in US 8%, Socioeconomically deprived 15%higher incidence in single and adolescents
Causes - unknown; don't know why.
- => Health Deviations
- Alteration in CV & Respiratory Physiology
- Alteration in Thermoregulation
- Alteration in GI physiology: Marked danger of aspiration, Difficulty meeting high caloric and fluid needs due small stomach capacity, Inability to handle high osmolaity formulas-Donated breast milk, tell moms to start pumping
A Multiparous woman has a preterm infant who was born at 28 weeks of gestation and was transported to a special care nursery. The woman does not live in the city where the tertiary center is located, and she is to be discharged tomorrow. It is anticipated that the infant will require a stay in the NICU for at least 8 more weeks and will likely require oxygen therapy at home after discharge. What information should the transport team provide the parents? What kinds of assistance will this mother need now and after the infant goes home? Identify resources in the community that may have services she use.
--> Phone number, and address of the hospital, places around the hospital to stay, give them oxygen before going home.
**Activities to Promote Attachment
Based on your knowledge of the physiologic adaptations and behavioral characteristics of newborn infants, plan activities that promote parent-infant attachment in a parent at risk for altered parenting. Risk for altered parenting could include such factors as adolescence, substance abuse, or postpartum depression
**Health Deviations of the Premature Infant: GI Continued
Difficulty absorbing saturated fats due to decreased bile salts and pancreatic lipase
Difficulty with lactose digestion initially; Can digest most simple sugars by first few days of life
Deficiency in Calcium and phosphorus: 2/3 of these deposited in the last trimesterIncreased BMR and increased 02 requirements due to fatigue associated with sucking
Feeding intolerance and NEC (necrotized enterocollitis) due to hypoxemia
**Health Deviations of the Premie Continued: Alteration in Renal Physiology
GFR lower: decreased renal blood flow
Limited in ability to concentrate and excrete excess amounts of fluid
Excrete glucose at lower serum glucose level
Buffering capacity of kidney limited: predisposed to metabolic acidosis
-kidney's acid/base balances: major buffer and kid capacity is limited..Immature kidney function: affects infants ability to excrete drugs, excretion time longer so drugs are given at longer intervals
- => Saunders:
- -The immature kidneys are unable to concentrate urine
- -weight loss of 5-10% during first week of life occurs as a result of water loss and limited intake, birth weight should be regained by 10-14 days after birth
- -weigh newborn daily
- -assess for signs of dyhydration.
**Alteration in Hepatic and Hematologic Physiology
- Liver Immature: glycogen stored in liver used for energy: high risk for hypoglycemia
- Iron stored in liver last trimester: low iron stores, subject to hemorrhage & anemia - blood samples
- -high deficiency anemia
- Bilirubin conjugation impaired b/c liver is impaired
- => All blood taken for samples must be recorded: Total blood volume ranges 85cc-110cc/kg
- When blood loss 10%, a decision made if infant requires transfusion
=> Hepatic: Normal or physiological aundice appears after the first 24 hours in full term newborns and after the first 48 hours in pretern newbornds, Jaundice occuring before this time (patho jaundice) may indicate early hemolysis of RBCs and must be reported to the HCP
-Physio jaundice peaks about the fifth day of life (indirect bilirubin levels 6-7 mg/dL)
-Feed early to stimulate intestinal activity and to keep the bilirubin level low
-Prevent chilling b/c hypothermia can cause acidosis that interferes with bilirubin conjucation and excrection.
-Liver stores the iron passed from mother for 5-6 months AND Glycogen.
-Newborn is at risk for hemorrhagic disorders; coagulation factors synthesized in the liver depend on bit K, which is not synthesized until intestinal bacteria are present.
-Administer intramusc Dose of Vit K to prevent hemorrhagic disorders
**Alternation in Immunologic Physiology
- => Much higher risk for infectionunderdeveloped cellular immune system
- Fetus receives IGG from mother which provides some immunity: but most of IGG acquired last trimester
- => IgA found in breast milk but: does not cross placenta, provides immunity to mucosal surfaces of the GI tract
- Skin very thin: at risk for excoriation & nosocomial infection
- => Regular Newborn receives passive immunity via the Placenta (immunoglobulin G)
- -Passisve immunity from colostrum (immunoglobulin A)
- -Elevation in Immunoglobulin M: Indicate Utero infection-aspeptic technique, stndard precarutions, meticulos handwahsin when caring for newborn.
=> Administer Eye Medication within 1 hour after birth to prevent ophthalmia neonatorum (aka Neonatal conjunctivitis) (usually eryhtromycin or tetra cycline) becuase they are bacteriostatic and bactericidal and provide prophylaxis against Neisseria Gonorhoeae and Chlamydia Trachomatis.
**Alteration in Neurologic Physiology
Brain formed at 6 weeks of gestation: 2nd & 4th mo. Brain’s total complement of neurons proliferate, Final step is covering these neurons with myelin during 2nd trimester and continues to adulthood- touching the nicu baby?
- => Period of most rapid growth occurs during 3rd trimester
- the closer to term the better the neurological prognosis
- At risk IVH (intravent hemm) and ICH (intracranial bleeds)
- -Check for bleeds and may require a VP shunt -osccillator gives them constant puffs.
**Intraventricular Hemorrhage: Bleeding within the ventricles of the brain.-Risk factors: prematurity, respiratory distress syndrome, trauma, asphyxia. -Assessment: diminished or absent moro reflex, lethargy, apnea, poor feeding, high pitched shrill cry, seizure activity-Intreventions: supportive teatment..
Bleeding within the ventricles of the brain.-Risk factors: prematurity, respiratory distress syndrome, trauma, asphyxia.
-Assessment: diminished or absent moro reflex, lethargy, apnea, poor feeding, high pitched shrill cry, seizure activity
-Intreventions: supportive teatment..
**Retinopathy of Prematurity:
Vascular disorder involving graddual rep;lacement of retina by fibrous tissue and blood vessels, primary caused by prematuiry and use of supplmental oxygen (more than 30 days)
-Assessment: Leukocria (white tissue on the tetrolental space), vitrous hemorrhage, myopia, strabismus, catacracs (check for red reflex)
-Interventions: Laser Phocoagulation surgery.
** Periods of Reactivity and Behavioral States
Periods of reactivity are delayed: As infant grows and condition stabilizes, identifying behavioral states and traits unique to each infant becomes increasingly possible
More disorganized in sleep wake pattern
Unable to attend as well to human faces and objects
Neurological responses weaker: sucking, muscle tone, state of arousal
**Infants of Diabetic Mothers Health deviations
- -glycemic control, big babies Nursing care
- Birth trauma
- -the baby isn't diabetic, their pancreas has been producing insulin to control high blood sugar to prevent hyperglycemia (environment of mother) so they're at risk for HYPOglycemia once they come out.
- => Saunders:
- -Infant born to insulin dependent diabetic mom or with gestation diabetes.
- -Hypoglycemia, Hyperbilirubinemia, RDS, hypocalcemia, birth trauma, conggintal anomallies may be present.
- -Assessment: Excessive size (as a result of excess fat and glycoggen in the tissues), Edema or puffiness in the face and cheeks, Signs of hypoglycemia (twitching, apnea, difficulty feeding, lethargy, seizures, cyanosis), Hyperbilirubinemia, and RDS symptoms
- 1. Monitors for signs of RDS, birth trauma, conggeintal anomalies.
- 2. Monitor bilirubin and blood glucose levels
- 3. Monitor weight
- 4. Feed newobrn sofon after birth with glucose in water, breast milk or formula as prescribed,
- 5. Administer glucose intravenously to treat hypoglycemia if necessary
- 6. Monitor for edema
- 7. Mintior for RDS, termors or seizures.
Abnormlally low level of glucose in the blood (<40 mg in the first 72 hours of life or < 45 mg after the first three days)
-normal BG level: 40-60 mg in a 1 day old and 50-90 in older than 1 day.
Increased respirations, twitching nervousness, tremors, unstable temp, lethargy, apnea, seizures, cyanosis
- 1. Prevent low BG level through early feeding
- 2. Administer formula orally or glucose IV as prescribed
- 3. Monitor BG levels as prescribed
- 4. Minotiro for feeding and apneic periods/problems
- 5. Assess for shrill or intermitten cries, lethargy and poor muscle tone.
**Infants of mother using narcotic medications
Every hour 1 drug addicted newborn is born: This a 3 fold increase since 2009
Infants exposed to opiates and time of delivery has increased by X5 in the past 10 years
This is a public health epidemic
Many of these opiates are prescription drugs
It increases the cost of caring for these newborns
Their stay in the hospital averages 6 days after delivery
We don’t know what the long term implications are
**Infants of Chemically Dependent Mothers
- => Implications for nursing care
- provide them with a Quiet environment
- Drug withdrawal symptoms and management- withdrawal scale.
- -give morphine to control withdrawal symptoms for the babies then gradually wean them off.
A newborn can become passively addicted to drugs that have passed through the placenta; Assessment finding wand withdrawal times vary depending on the drugs.
Irritability, Tremors, Hyperactivity, RDS, Vomiting, Highpited cry, neezing, fever, diarrhea, Excess sweatting, poor feeding, Extreme sucking of fists, seizures
- 1. Montior for respiratory and cardiact status frequently, monitor temp and vitals
- 2. Hold newborn firmly and close to the body during feeding and when giving care
- 3. Initiate seizure precautions (pad sides of cri)
- 4. Provide small freq feedings and longer feeding period
- 5. Minitor I/O
- 6. IV hydration if prescribed
- 7. Protect newborn's skin from injurty than can be caused by the constant rubbingg from hyperactijitters. Swaddle newborn
- 8. Quiet room, reduce smimulation.
RDS- Resp Distress SyndromeHypoxemia - Nursing implications-long term ventillator will eventually destroy their lungs; being exposed to to pressure of vent and develop brocopulmonary Displasia and chronic lung disease and this is why we give them synergist (3000 dollars a month)
- => Respiratory Distress Syndrome: Serious lung disorder caused by immaturity and inability to produce surfactant, ressulting in hypoxia and acidosis.
- -Assesment: Can include tachypnea, nasal flaring, expiratory grunting, retractions, seesaw respirations, decreased breath sounds, apnea, pallor and cyanosis, hypothermia, poor muscle tone
- -Interventions: Minotiro, maintain airway and cardiopulm function,
- -Any premature newoborn who required oxygen support should be scheduled for an eye examination before sdischarge to assess for tetinal damage. -suction every 2 hours as necessary-Administer respiratory therapy (perfucsion, vibration)-electric toothbrush-provide nutriont and support bonding
**HypothermiaPredisposing factors .
Cold stress- must be prevented: Prevention and nursing systems-sleeves on the windows
- -put them after bili rights,
- -Once they peak, elevated bilirubin, and then starts to go down, then it's okay to take them off the bili rights (increases metabolism somehow causes bilirubin to come down) Assessment
- Nursing implications
=> Saunders: Elevated serum bilirubin level, evaluation is indicated when serum levesl are greateer than 12 mg/dL in a term newobrn. T
-Therapy is aimed at preventing kernicterus, which results in permanent neurological damage resulting from the deposition of bilirubin in the brain cells
Jaundice, Elebated serum bilirubin levels, enlarged liver, Poor muscle tone, lethargy, poor sucking reflex.
- 1. Monitor for jandice (Press finger over bondy prominence or tip of nose)
- 2. Keep the baby well hydrated to maintain blood volume
- 3. Facilitate early, frequent nfeeding to hasten passage of meconium and encourage excretion of bilirubin
- 4. Report to HCP any signs of jaundice in the first 24 hours of life.
- 5. Prepare for photherapy and monitor the new born closely during treatment.
THe use of light to reduce serum bilirubin levels in the newobrn, Adverse effects from treatment, such as eye damage, dehydration or sensory deprivation can occur.
- => Interventions:
- 1. Edpose as much of the newborns skin as possible
- 2. Cover genitals, eyes, (remove shields at least once during shift to inspect for eye infection)
- 3. Measure lamp energy output to ensure efficacy of treathmetn (done with a special device known as photometer)
- 4. Monitor skin temp closeliy
- 5. Increase fluids to compensate or water loss
- 6. Expect loose green stools
- 7. Monitor the newobrns ksin color with flourescent lights turned off every 4-8 hours.
- 8. Minitor the skin for bronze baby syndrome, a grayish brown discoloration of skin -complication of phototherapy-tell doctor!
- 9. Repositon the newborn Q2H; provide stiumation,
- 10. AFter treatment, continue monitoring for signs of hyperbilirubinemia b/c rebound elebations are normal after therapy is discontinued
- 11. Turn off the phototerapy lights before drawing a blood speciment for serum biiliruiin levels.
Nursing care-start feeding at 1 cc an hour and measure abdominal girth, caused by putting food in gavagecausing blood and hypoxemia (apnea periods--cause gut to swell??)-
- treatment: measuring circum, reduce feedings, notify the doc, check the blood.
- -totally preventable.
- -feeding hypoxic babies cause NEC?
- -check residual.
Acute inflammatory disease of the gastrointestinal tract, usually occurs 4-10 days after birth and is most frequently seen in preterm babies.
- -Assessment: Incrased abdoninal girth, decreased or absent bowel sounds, bowel loop distenstion, vomitting, bile-stained emesis, abdominal tenderness, occult blood in stool
- -Interventions: Hold oral feedings, insert oral gasric tube to decompress the abdoment, IV antibiotics, IV fluids to correct fluid, electrolyte and acid-base imbalance, and surgery is indicated.
PreventionSepsis neonatorumGroup B streptococcus
-check all women at 37 weeks. Given pencillin
Syphilis- check at first prenatal visit
Chlymidia- Check them all.. Treatment and nursing care
-still can get these if sexually promiscuous
-Chlamidial pneumoia for baby after two weeks.
A sexually transmitted infection, congential syphilis can result in premmie delivery, skin lesions, and abornmall skeletal development.
-Causative organism: Treponemia pallidum- a spirochete, is able to cross the placenta through out pregnancy and infect the fetus, usually after 18 weeks gestation
-Risks: preterm birth, still birth and LBW-Congenital effects are irreversible and may include CNS dmaage and hearing loss
-Assessment: Hepatosplenomegaly, Joint swelling, palmar rash, lesions, anemia
**Inborn Errors of Metabolism
=> Phenylketonuria-baby has no enzymes necessary to break down high levels of Phenylalanine and high levels of this (aminoacid) will damage the brain so baby has to have milk feeding?
- -must been with dieetician-essential amino acid so they have to take in SOME phenalaline, but not too much--> mental retardation-used to allow after 6 yrs but not anymore
- -found in meat and milk, wheat?
- -can't breastfeed.
- can't metabollize lactose
- don't produce thyroid hormones, by the time they're active, it'll be permanent. Treatment
A genetic disorder (autosomal recessive disorder) that results in central NS damage from toxic levels of phenylalanine (an essential amino acid in the blood. It is characterized by blood phenylalanine levels greater than 20 mg/dL (Normal level is 1.2 to 3.4 in newborns).
: Digestive problems, vomitting, sseizures, Musty ordor of uruine, mental retardation; In older children: Eczema, Hypertonia, Hypopigmentation of the hair, skin and \irises, Hyperactive behavior.
- => Intervetnions:
- 1. Screen at newborn, 48 hours, 14 days..If diagnosed: - Testrict phenylaline intake; high protein foods (meats and airy products) and aspartame are avoided because they contain large amounts of phenylalanine-