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PEDI 1412 - High Risk Neonate
Terms in this set (95)
one who is susceptible to morbidity or mortality due to:
1) dysmaturity (SGA from placental insufficiency in prolonged pregnancy)
3) physical disorders
4) birth complications
What is gestational age?
Preterm = less than 35 weeks
(Late) Preterm = 35 to < 37 weeks
*preterm (book) = < 38 weeks
Term = 37 to < 42 weeks gestation
Postterm = 42 or more weeks gestation
Sizes relative to gestational age
considers BOTH gestational age AND birth weight
SGA = small for gestational age, i.e., LBW compared to average for that age (< 10th percentile)
AGA = appropriate for gestational age (>10th percentile and <90th percentile)
LGA = large for gestational age (> 90th percentile)
What assessment tools are used in determining gestational age?
Ballard Score (includes neuromuscular maturity and physcial maturity)
aka as Dubowitz-Ballard Scale
What are the neuromuscular and physical characteristics used in determining gestational age (preterm vs post term)?
Appear frail and weak
Extremities are limp, and typiclaly lie in an extended position
Head appears large in comparison with the rest of the body
Lack subcutaneous fat which makes skin appear red and translucent, with blood vessels clearly visible
Nipples and areola may be barely perceptible, but vernix caseosa and lanugo may be adundant
Plantar creases may be absent If less than 24 wks gestation
Pinna of ear is soft and flat, lacking the rolled-over look
Male infant may have undescended tests
90 degree on square window reflex
Dry, cracking, parchment-like skin
Reduced subcutaenous tissue - loose looking skin
No vernix or lanugo
Profuse scalp hair
Long, thin body appearance
Often meconium stained skin, cord, nails
What is the relationship between gestational age and infant size?
Combines the GA, weight, length and head circumference on a graph of intrauterine development.
The infant who is appropriate falls within the 10th - 90th percentile (see prior slide). When outside normal range, nurse must monitor for complications specific to their category.
SGA: Maternal Conditions associated with Risk
1) placental insufficiency
4) smoking, drugs, ETOH
5) severe DM, which can restrict uteroplacental blood flow; usually related to noncompliant management
SGA: Fetal Factors associated with risk
1) multiple gestation, e.g., twins
3) birth defects
4) chromosomal abnormality
SGA: Associated Complications
2) aspiration syndrome (from meconium)
3) hypothermia (less SQ fat and BAT)
4) hypoglycemia (inadequate liver storage of glycogen)
IUGR: Associated Complications
1) congenital malformations
2) intrauterine infections (e.g., TORCH-related)
3) continued growth difficulties
4) cognitive difficulties (it's GOOD if the head is larger than the torso b/c that might indicated adequate brain development)
What are physiologic challenges of premature infant?
*problems with temp maintenance,
*feeding difficulties (immature suck/swallow relfexes, falling asleep during feeding)
*Long term neurodevelopmental disorders
What nursing interventions are necessary to prevent complications in regard to: thermoregulation, feeding and discharge teaching?
Thermo = temp checked q 3-4 hrs. Skin to skin b/t mom and baby, a radiant warmer or incubator may be used if infant cannot maintain body temp.
Feeding= May have immature suck/ swallow coordination, shorter wake periods, may sleep through feedings. It is important to feed q 2-3 hours. Breastfeeding should be evaluated at least twice daily to assure proper latch. Supplementing may be necessary.
I&O = Urine and stool outputs should be monitored as indications of adequate intake.
Blood glucose = monitored closely during first 24 hrs due to risk of hypoglycemia.
Discharge = Should not be discharged before 48 hours. Should be evaluated 24 hrs prior to discharge that vital signs are stable and baby can feed successfully. Bili levels should be reassessed before discharge. Parents should be taught signs of jaundice & dehydration/ what to do if they occur. Teach to keep the infant warm, away from drafts & dressed with more than 1 layer. A carseat study should be conducted before discharge to ensure bradycardia, apnea, or decreased O2 sat does not occur when sitting in a car seat. They are subject to overstimulation, parents should be taught how to minimize overstimulation.
What are the characteristics of the preterm infant?
(Born before beginning of 38th week (book) or 37 at ACC
Appearance = appear frail/ weak, have less developed flexor muscles & muscle tone compare to FT (full term). Extremities are weak & usually lie in an extended position. Head is large in comparison to rest of body. Skin appears red and translucent with blood vessel visible (d/t thinness). Nipple/ areola are barely visible but vernix & lanugo may be abundant. Plantar creases are ABSENT if less than 32 wks. Pinna is soft, flat & contains little cartilage. In female, clitoris & labia minora appear large, the male will have undescended testes w/ small, smooth scrotal sac.
Behavior = little excess energy, easily exhausted from noise & routine activities. Responses vary including lowered O2 sat & stress-related behavior changes. The cry may be feeble.
Why does the preterm infant have difficulty with breathing?
Insufficient production of surfactant (starts producing at 24-27 weeks, but not sufficient until at least 34 weeks up to 36)
Immaturity of alveolar system
Immaturity of musculature and insufficient calcification of bony thorax
*respirations = 40-60, shallow, irregular, usually diaphragmatic
What are the signs of respiratory distress? What is the difference between periodic breathing and apnea?
tachypnea, nasal flaring, retractions, cyanosis, grunting on expiration
Periodic = cessation of breathing for 5 - 10 seconds w/o other changes
Apnea = lack of breathing more than 20 seconds OR accompanied by cyanosis, pallor, bradycardia or hypotonia
What are the nursing interventions used to maintain respiratory function in the preterm infant including:
a) Respiratory equipment
c) Suctioning secretions
a) O2 given by nasal cannula to infant who breathes well alone. O2 MUST be humidified to PREVENT insensible water loss & drying of delicate mucous membranes. It can be warmed to maintain body temp. CPAP may be necessary to keep alveoli open & improved expansion of the lungs. Pulse oximetry is used to provide continuous info.
**BUT, O2 sats that are at high levels (>95) can cause retinal damage d/t O2 free radicals = in preterms, highest O2 sats are not desirable
1) "sniffing" position: supine with head slightly elevated and neck slightly extended
2) Side lying & prone facilitate drainage of secretions. (usually done in NICU only). Prone also increases oxygenation & enhances respiratory control, while reducing aspiration risk
c) Check equipment at beginning of shift. Only suction when NECESSARY. Suction GENTLY to avoid traumatizing the delicate mucous membranes. Trauma could lead to edema, decrease air passages. Also provides an entry for organisms & decreases O2 during the procedure. Suction should ONLY be done for 5 - 10 sec at a time, increased O2 should be provided before & after each attempt. Mouth is ALWAYS suctioned BEFORE the nose.
Why are preterm infants at a greater risk for heat loss?
Temperature center in brain is immature
Higher ratio of body surface in proportion to body weight
Lack of subcutaneous fat and decreased BAT
Poor capillary response (vasoconstiction) to environmental changes.
Thinner skin, capillaries closer to surface
What are complications associated with inadequate thermoregulation?
impaired surfactant production,
Calories used for heat production are unavailable for growth & weight gain.
Preterm infant: Desirable Temperatures
Axillary: 97.3 - 98.4 F (36.3 - 36.9 C)
Abdominal: 96.8 - 97.7 (36 - 36. 5 C)
Signs of Inadequate Thermoregulation
2) respiratory distress
*both usually first signs
3) poor feeding/feeding intolerance
6) weak cry or suck
7) SKIN: cool, pale, mottled or acrocyanotic
8) poor weight gain
9) weak muscle tone
What are the nursing interventions used to maintain a neutral thermal environment?
Neutral thermal environment minimizes oxygen consumption required to maintain a normal core temperature, prevents cold stress, and facilitates growth.
Polyurethane bag (less than 29 wks, placed in bag before infant is dried after birth) = decreased insensible water loss
Incubator or radiant warmer with skin probe
Warm humidified oxygen
Warm ambient humidity
Keep skin dry and head covered
Alarms should be on at all times to detect too high or low temps
What are signs of fluid imbalance, dehydration and overydration, in the preterm neonate?
Fluid imbalance = differences in intake & output of fluids, including blood taken for lab tests that suggest dilution or concentration
*urine output <2 ml/kg/ hr,
*urine specific gravity >1.01
*weight loss greater than expected,
*dry skin & mucous membranes, sunken anterior fontanel, poor tissue turgor,
- blood: elevated sodium, protein, & Hct levels RT concentration
* urine output > 5ml/ kg/hr,
*urine specific gravity <1.002, edema,
*weight gain greater than expected,
*moist breath sounds, difficulty breathing
- blood: decreased sodium, protein, Hct levels
How is intake and output measured?
Ouput: The weight of a dry diaper subtracted from the weight of a wet diaper. 1 gram = 1 mL of urine. Urine is collected by placing cotton balls at the perineum to check for specific urine gravity. Gastric output, stool, and blood drawn for labs are also added.
Input: total of medications, iv fluids, feedings, oral fluids
What are specific nursing interventions maintain hydration?
Monitoring of IV fluids with rate of 0.1 ml/ hr to prevent fluid overload. IV sites must be assessed q hour for signs of infiltration. Small blood transfusions may be necessary to replace blood drawn for frequent lab tests.
What are the consequences of an immature renal system?
DECREASED glomerular filtration rate (GFR)
Inability to concentrate urine
DECREASED ability of kidneys to buffer (poor electrolyte regulation)
DECREASED drug excretion time
What nursing interventions are used to protect the skin?
No use of alcohol or betadine on skin
All skin/disinfectant products should be rinsed off with water
No use of adhesives, use pectin barriers and back tape with cotton
Use semi-permeable adhesives such as tegaderm.
Bathing: Limit; if <32 weeks then warm water ONLY for first week
Reposition frequently (pressure points) as tolerated
Why is the premature neonate prone to infection?
Exposure to maternal infection
Skin is fragile & permeable = offers little protection from pathogens
Lack of transfer of immunoglobulin G (IgG) from the mother during 3rd trimester
Immature immune response to infection
- Also exposed to invasive procedures such as IVs and catheters
What are the nursing interventions used to prevent infection/sepsis?
Initial scrub / strict handwashing from Visitors & staff
Single infant equipment
Short / no artificial nails
Maintain sterile technique: IV start and dressing changes, procedures
Clean incubators weekly
Position changes; use of sheepskin
Judicious use of tape on skin
What are the signs and symptoms of infection / sepsis in the preterm infant?
General: Temp instability, nurse's feeling that infant is not doing well
Resp: Tachypnea, Resp distress (nasal flaring, retractions, grunting), Apnea
Cardio: Color changes (cyanosis, pallor), tachycardia (initially), hypotension, decreased peripheral perfusion, edema
Gastro: Poor feeding, vomiting, increased gastric residuals, diarrhea, abdominal distension, hypo/hyper-glycemia
CNS: decreased or increased muscle tone, lethargy, irritability, full fontanel, high-pitched cry
Advanced infection signs: jaundice, evidence of hemorrhage (petechiae, purpura, pulmondary bleeding), anemia, enlarged liver & spleen, respiratory failure, shock, seizures
What are signs of pain in the premature neonate?
Increased or decreased HR & RR; apnea
decreased O2 saturation
High-pitched, intense, harsh cry
Eyes squeezed shut
Bulging or furrowing of the brow
Tense, rigid muscles or flaccid muscle tone
Rigidity or flailing of extremities
Sleep-wake pattern changes
What nursing interventions are used to provide comfort for the preterm neonate?
Prepare for potentially painful procedure by waking them slowly & gently & using containment.
Containment = SWADDLE
stimulates the enclosed space of the uterus & is comforting. Involves keeping the extremities in a flexed position & midline by swaddling, positioning devices or the nurses hand. One of the infants hands should be near it mouth for suckling.
- Should be allowed to rest before & after
PACIFIER or give sucrose (stimulates endorphin cascade) placed on the paci; or given orally 2-3 min before a painful stimulus.
- Talking softly, holding, rocking or prone positioning are other methods
MEDS: Morphine, fentanyl, tylenol and topical anesthesia can also be used
Usually want to UNDER-stimulate
minimal stimulation in the first 3-5 days
*cluster care to prevent sleep disruption; reduce noise; reduce touching (often associated with painful events)
What are signs of overstimulation in the preterm neonate? What measures are implemented to reduce stimuli?
BP, pulse & respiratory instability
cyanosis, pallor or mottling
decreased O2 saturation levels
sneezing, coughing, hiccupping (teach parents; this is one of the more overt signs)
**changes from BASELINE
Stiff, extended arms & legs
fisting of the hands or splaying (spreading wide apart of the fingers)
alert, worried expression
turning away from eye contact (gaze aversion)
regurgitation, gagging, hiccupping
Why do premature neonates have difficulty maintaining adequate nutrition?
Gag and suck reflexes may be weak and poorly developed (usually develop at 32 weeks)
Suck and swallow reflexes may be uncoordinated.
Hypotonic cardiac sphincter = reflux
Small stomach capacity - 2ml. in 1200 gm. 15ml. in 2000 gm. baby.
Vomiting more likely to occur.
Poor ability to tolerate fats.
Immature absorption of nutrients; decreased amounts of HCL.
Objective data: abdominal girth, bowel sounds, gag/suck reflexes and check for gastric residual
What feeding methods are used?
- Parenteral: IV infusion of solutions
- Enteral: Feeding into the gastro tract by feeding tube or orally
- Gavage: Usually started before oral feeding. Soft, small catheter is inserted into the nose or mouth to provide intermittent or continuous feedings
= Oral: MUST have function gag reflex and ability to suck/ swallow with breathing.
What assessments are important prior to breast feeding?
Respirations = should be <60 per min(with tachypnea, chances of aspiration increase)
Measure abdominal girth and assess for abdominal distention
Sucking on gavage tube, finger or paci
Presence of gag reflexes
Able to tolerate holding
What are measures to assist the mother of the preterm neonate with lactation, storage of breast milk, and breastfeeding?
- Have mother begin to pump as soon after birth as possible & to pump at least 8x a day for 10-15 min
- Give her sterile containers to store her milk, show her how to label her milk & where to take it when she brings it to NICU
- When she goes home, tell her to place the milk in the frigdge if infant will receive w/i 24 hrs or in the freezer if it will be more than 24 hrs
- Encourage her efforts in BF & remind her that even full-term infants must learn to BF
- Make assessments during BF: fatigue, bradycardia, tachypnea, or apnea may show lack of readiness to BF
*may need supplemental nursing system (SNS) to promote BF and to provide adequate nutrition
(bottle with tubing placed near the nipple)
What are specific nursing interventions to facilitate and promote parent-infant attachment with the high risk/preterm neonate?
Prepare parents for first visit ( describe equipment, tubes etc)
Establish safe/trusting environment
Provide support, reassurance, encouragement based on infant's condition
Encourage visitation as much as possible
Involved in care taking
Promote touching, talking, rocking, cuddling
Refer to infant by name
Allow parents to phone as desired
What is the pathophysiology involved with RDS.
Caused by insufficient production of surfactant (lipoprotein combo of lecithin and spingomyelin that lines the alveoli).
With too little surfactant, the alveoli COLLAPSE each time the infant EXHALES. The lungs & thorax become noncompliant or stiff & resist expansion.
**results in severe retractions with each breath b/c the chest wall is very compliant & the weak muscles of the chest wall are drawn inward.
As fewer alveoli expand, atelectasis, hypoxia, and hypercapnia (increased CO2) occur = pulmonary vasoconstriction & decreased blood flow to the lungs
What are the clinical manifestations of RDS?
(Breath sounds may be decreased, rales may be present)
What are treatment options and related nursing interventions for RDS including:
a) Oxygenation, ventilation
b) Surfactant replacement therapy
a) Supplemental oxygen, given through prongs placed in the newborn's nostrils or through a small plastic hood (oxygen hood) filled with oxygen, which is placed over the head. Continuous positive airway pressure Oxygen via intubation with endotracheal tube, and the newborn's breathing may need to be supported
b) May be instilled into the trachea by an ET tube IMMEDIATELY after birth or as soon as signs of RDS become apparent. Doses are repeated as necessary. Infants treated with surfactant have higher survival rates but it DOES NOT reduce complications of prematurity such as bronchopulmonary dysplasia.
*only good for first 3 days of life
c) Maintenance of temperature regulation - KEEP WARM!
RDS: Feeding & Teaching
OGT or IV parenteral feeding
Teach: parents should be allowed to hold and feed when possible
*decrease fears: anticipatory teaching, e.g., NB may need surfactant interventions
What is the pathophysiology of intraventricular hemorrhage (IVH)?
Rupture of fragile blood vessels in the germinal matrix, located around the ventricles of the brain.
*occurs in 30% of preterms <1500 g
Associated with rapidly increased or decreased BP or hypoxia
Rapid blood volume expansion, hypercapnia, acidosis & hyperglycemia are other causes.
- Diagnosed via cranial ultrasound
Graded on scale of 1 to 4:
1 = very small bleed at germinal matrix
2 = hemorrhage extends into the lateral ventricles
3 = distention or dilation of ventricles
4 = outside of matrix
**generally 1 or 2 has good outcome
What are the clinical manifestations of IVH?
May have no signs (if small bleed) or may show lethargy
Poor muscle tone
Deterioration of respiratory status w/ cyanosis or apnea
Drop in Hct level
What is the therapeutic management and related nursing interventions for a neonate with IVH?
- Most hemorrhages occur during the first week, u/s is often performed on the at risk preterm infant at 7 days old.
- Hydrocephalus can develop d/t blockage of CSF flow
- Nurse must avoid situations that increase the risk of IVH (excessive handling, allowing baby to cry)
*NB must be supine for 3 days to avoid sudden change in BP
- Daily measurements of FOC & observation for changes in neurological status
- Pain & stress should be reduced as much as possible
**may need ventriculoperitoneal shunt to peritoneal cavity
What risk factors contribute to the development of Retinopathy of prematurity (ROP)? What is the physiology behind ROP?
May result in visual impairment or blindness ---- Most often occurs in infants weighing less than 1000g & < 29 wks gestation. *
One risk factor is high levels of oxygen
Results from injury to retinal blood vessels. Immature blood vessels in the eye constrict & are obliterated. The new vessel proliferate throughout the retina & into the vitreous humor in some infants. Fluid leakage & hemorrhages may cause scarring, traction on the retina and retinal detachment.
What nursing interventions assist with preventing ROP?
Infants born at 30 wks or less or those weighing less than 1500g at birth, should be screened for changes of the eyes 4 wks after birth or at 31 wks gestational age.Laser surgery to destroy abnormal vessels is the current treatment of choice.
Pulse ox reading should be checked frequently for any infant receiving O2. Judicious use of O2 in concentration ordered (per PP)
***85 - 92 % for NB <34 weeks; NO sudden titration changes up or down to avoid complication
What risk factors contribute to the development of necrotizing enterocolitis (NEC)? What is the patho?
The rate of NEC increases with DECREASED GA.
*usually happens around 32 weeks
An Inflammatory disease of the intestinal tract frequently complicated with perforation of the gut.
* NEC develops when there is asphyxia or hypoxia and cardiac output shunts toward the heart and brain and away from the abdominal organs.
*The intestinal cells become ischemic and damaged and stop secreting protective mucus, infection occurs.
*PNEUMOTOSIS results: air bubbles develop in abdomen
***Perforation may occur with overwhelming sepsis.
What assessment findings would the nurse monitor to assist in the detection of NEC?
Increase amount in gastric aspirate: 1/2 of feeding volume or more
Increase in abdominal girth and an increase >1 cm should be reported.
Decrease bowel sounds, abdominal tenderness or rigidity of abdominal wall.
Lethargy, sudden listlessness, temperature instability, decrease urine output, occult blood in stools, poor color, and apneic periods.
Massive abdominal distention, vasomotor collapse.
What is the treatment and nursing care for the neonate with NEC?
Treatment: Abx, discontinuation of oral feeds, gastric suction, IV fluids & use of parenteral nutrition to rest the intestines
Surgery: Resection of necrotic sections and possible temporary colostomy is necessary IF perforation occur of for continued lack of improvement. This allows bowel to recover. Infants with large areas of bowel removed may develop short-bowel syndrome w/ malabsorption & malnutrition.
*may develop strictures EVEN without surgery
PP = NPO with NG tube. Peripheral or central hyperalimentation. Antibiotic therapy. Continue to monitor for changes in condition. Gradually introduce oral feedings at 7-10 day marker
*might low-dose Versed to counteract "hunger pains" experienced by a hungry infant
Infant should be positioned on side to minimize the effects of pressure on the diaphragm from the distended intestines.
What is the definition for the "post term infant".
Those born AFTER the 42nd week of gestation
What are the physical manifestations of postmaturity?
Dry, cracking, parchment-like skin
Reduced subcutaneous tissue -Loose appearing skin
No vernix or lanugo
Profuse scalp hair
Long, thin body appearance
Often meconium stained skin, cord, nails
What complications are associated with a post term infant?
Hypoglycemia (reduced nutrition from expiring placenta)
Seizure activity (ischemic brain tissue)
What is the difference in SGA and FGR (fetal growth restriction)?
What complications are associated with the SGA infant?
SGA = those who fall below the 10th percentile in size on the growth charts
FGR = those who have failed to grow in the uterus as expected
(they are sometimes used interchangeably, of course not all SGA are due to FGR)
Asphyxia - related to chronic hypoxia inutero
Aspiration syndrome - the SGA infant may be 40 weeks gestation but weight <5 pounds. These newborns are usually stressed in utero and will expel the mucus plug leading to meconium stained fluid which can then lead to meconium aspiration
Hypothermia- related to fact that these newborns have no subcutaneous fat stores
Hypoglycemia - increase metabolic rate
Polycythemia - related to chronic hypoxic state in utero
Maternal Condition often associated with LGA
Diabetes; maternal hyperglycemia induces the fetus to produce more insulin and insulin acts like a growth hormone
What are the associated risks and complications for a LGA infant?
Injury during birth or need C/S
*Shoulder dystocia may occur
*Fractures of clavicles or skull
*Damage to the brachial plexus or facial nerve
Congenital heart defects are more common
Polycythemia (rt less placental perfusion)
What risk factors predispose a neonate to asphyxia?
Complications during pregnancy, labor or birth increase the risk.
Mother receiving narcotics shortly before birth
What interventions are implemented at birth when an infant shows signs of primary apnea? What are signs of secondary apnea? What are the steps of neonatal resuscitation?
Primary apnea: Rapid respirations followed by cessation of respirations
- Stimulation alone or oxygen may restart respirations
Secondary apnea = NO RESPONSE to stimulation
* Due to decreased oxygen, infant loses consciousness
MUST use CPAP or chest compressessions IMMEDIATELY to prevent permanent injury to brain or death
*give naloxone (Narcan) 0.1 mg/kg IM to reduce CNS depression RT maternal narcotics during labor
When is the administration of naloxone hydrochloride indicated?
Given to newborns with severe respiratory depression due to the mother receiving narcotics w/i 4 hrs of birth
What causes meconium aspiration?
Meconium stained amniotic fluid aspirated into the trachobronchial tree. Occurs either in utero or after birth with the first breaths.
*Meconium in the lungs causes air to become trapped and results in alveoli over-distension and rupture.Leads to respiratory distress syndrome
Meconium Aspiration Syndrome (MAS): Treatment Criteria
Crying: stimulate and suction with bulb syringe
NOT crying: do NOT stimulate
*visualize vocal cords, then direct suction with endotracheal tube followed by stimulation
- In severe cases, ECMO (extracorporeal membrane oxygenation) is used. It oxygenates the blood while bypassing the lungs, allow the infants lungs to rest temporarily & recover
MAS: Nursing Interventions
Administer ABX (meconium may cause trauma and increase infection risk)
Assess for hypoglycema RT increased metabolic demand
Provide supportive care if on ECMO
What precautions do healthcare providers take to prevent the occurrence of meconium aspiration?
After delivery of the infant's head - with the shoulders and chest still in the birth canal, Suction oropharynx and then nasopharynx.
Deliver the thorax then delivery infant's body. (PP)
Book states: suctioning the infant as soon as head is born has not been found to reduce the incidence of MAS.
What is the patho for hyperbilirubinemia? What increases the risk to the neonate?
Breakdown of RBC's = Unconjugated bilirubin.
Hyperbilirubinemia occurs when the body cannot conjugate the bilirubin released into the serum.
Hemolytic disease (Rh and ABO incompatibility)*** most common
Extravascular bleed (cephalhematoma)
Bilirubin conjugation defects (breastmilk jaundice, asphyxia)
Hypoalbumin (bili attaches to albumin)
Physiologic jaundice (occurs after the first 24 hrs of birth. Mainly due to immature liver and lack of glucoronyl transferase).
What are S&S of hyperbilirubinemia?
Sclerae appearing yellow before skin appears yellow - usually in the first 24 hours after delivery
Skin appearing light to bright yellow - advances from head to toe
Dark, amber concentrated urine
Jaundice usually appears when TBL = 5 - 6 mg/dL
Test cord blood for bili
*AVG = 2 mg/dL of unconjugated at birth
--should NOT exceed 5 mg/dL
What does a positive direct Coombs test indicate?
Test done on cord blood to determine infants blood type.
If POSITIVE = indicates that antibodies from the mother have attached to the infants RBCs
the INDIRECT test uses maternal blood to look for antibodies
Explain ABO incompatibility.
Mothers with Type O blood have natural antibodies to types A & B blood. The antibodies cross the placenta and cause hemolysis of fetal RBCs.
The destruction is much LESS severe than with Rh incompatibility and causes milder signs.
Who is the candidate to receive Rhogam? When is it given? What is action of medication?
Provides temporary passive immunity which prevents permanent active immunity (antibody formation)
Given at 28 weeks gestation if mom is Rh (-) and again within 72 hours of delivery if baby is Rh (+)
Prevents production of maternal antibodies
How is the level of jaundice in the neonate assessed?
Level of Unconjugated bilirubin = 2 mg/dl at birth
Bilirubin levels should NOT exceed 5 mg/dL
Careful observation of infant for signs of increased jaundice
Careful observation for and prevention of acidosis/hypoxia and hypoglycemia, which decrease binding of bilirubin to albumin and contribute to jaundice.
Maintain adequate hydration to dilute
Avoid cold stress
Phototherapy - use of "bili" lights, special fluorescent
Exchange Transfusion (in extreme cases)
Why is an exchange transfusion performed?
Dangerously high bili levels that cannot be brought down quick enough by phototherapy.
Treatment = removes sensitized RBCs, maternal antibodies, unconjugated bilirubin & corrects severe anemia.
- Treated with type O- blood (universal) in Rh incompatibility or type O (positive or neg--whatever compatible with mother and infant)
- after treatment, 85% of infants RBCs have been replaced & bili level is reduced by 50%
How is phototherapy administered? What side effects are associated with phototherapy?
Most common treatment, involves placing infant under special lights which allows bilirubin in the skin to absorb the light & change it into a water-soluble product. Most importantly = lumirubin
- these products do not require conjugation by the liver & can be excreted in the bile & urine
Side effects = Frequent loose, green stools, Skin rash similar to erytherma toxicum, Increased basal body metabolism, Dehydration, Hyperthermia
What are the nursing interventions used for an infant receiving phototherapy related to: Environment, Feeding, Safety
Ensure exposure of skin (usually diaper is kept on unless bili levels are too high)
Cover eyes (remove for feeding/parent visit) - check position of patch at least once an hour
Turn off lights & remove patches to assess for skin irritation around/ under patches q 4 hrs
Monitor temperature with skin probe - prone to hyperthermia
Reposition newborn every 2 hours
Increase fluids (feed q 2-3 hrs) RT dehydration from insensible perspiration increases
Perform T-Bili q 12 - 24 hr as ordered
Explain need to keep under phototherapy except during feedings and diaper changes.
Explain to parents and allow them to hold during feedings
What are 2 complications related to hyperbilirubinemia?
Kernicterus - Deposits of conjugated and unconjugated bilirubin in the basal ganglia of the brain = neurologic damage
*high-pitched cry is usual first sign
Hydrops fetalis = severe anemia,
* marked edema, cardiac decompensation (reduced circulation), Multiple organ failure, Possible death
how is each of the TORCH infections transmitted to the neonate?
Toxo = Transplacental
*Syphillis = Transplacental IF left untreated
*Gonorrhea/ Chlamydia = during birth
*Group B strep = during birth or ascending infection after rupture of membranes
Rubella = Transplacental; if mom is not immune, she gets MMR AFTER birth to protect future pregnancies
*no pregnancy within 4 weeks of getting live vaccine
CMV = Transplacental, during birth & through breastmilk
Hep B = usually during birth through contact with maternal blood OR breast milk
HIV =Transplacental, during birth from infected blood/ secretions, from breastmilk
HSV 2 = during birth through infected secretions OR ascending after rupture of membranes
What are the clinical manifestations of each TORCHA infection? Toxo, Syphillis, Hep B, Rubella, CMV, HSV 2, AIDS
Toxo = Retinochoroiditis (inflammation of the retina and choroid of the eye). Blindness, Deafness, Convulsions, Microcephaly, Hydrocephaly, Severe mental impairment
Syphilis = Rhinitis (NEVER normal in a NB; almost always caused by syphilis), Excoriated upper lip, Red rash around mouth and anus, Copper colored rash of face, palms and soles, irritability, edema, cataracts
Chlamydia = conjunctivitis 1-2 wks after birth, pneumonia 4-11 wks after birth, otitis media
Gonorrhea = conjunctivitis (ophthalmia neonatorum) w/ red, edematous lips & purulent eye drainage - can lead to blindness
Rubella = congenital cataracts, deafness, congenital heart defects, may be fatal
*blueberry muffin rash
*NB are INFECTIOUS and shed for months = CONTACT isolation
CMV = Severe neurological problems, eye abnormalities, Hearing loss, Microcephaly, Hydrocephaly, Cerebral palsy, Mental delays - may be asymptomatic at birth
**Leading cause of hearing loss
HSV 2 = Cluster of vesicles, Microcephaly; Mental delays, Seizures, Retinal dysplasia, Poor suck, Apnea, Coma
Hep B = Asymptomatic at birth; Become chronic carriers, risk later for liver cancer
HIV = Asymptomatic at birth; signs appear at 12-24 months; enlarged liver & spleen, failure to thrive, lymphadenopathy, persistant yeast infections
What is the treatment for a neonate born to a mother with TORCHA infection?
Toxo = Pyrimethamine, sulfadiazine & folinic acid x 1 year for infant
Syphillis = Penicillin
Chlamydia = Erythromycin eye ointment at birth
Gonorrhea = Erythromycin eye ointment at birth, IV abx
Rubella = CONTACT precautions -supportive treatment
CMV = Supportive treatment, no cure.
HBV = HBV vaccine ( and HBIg, if mom +)
HSV 2 = CONTACT precautions; treat with acyclovir; culture vesicles
HIV = oral AZT, also called ZVD (zidovudine) syrup q 6 hrs for 6 weeks (d/c and start combo if NB is positive)
*serology tests within 48 hours of birth, then at 3 and 6 months
*HIV antibody and ELISA
*Monitor CD4 T-cells
Explain the laboratory tests used in determining the severity of the disease including: Viral load, CD4 count, ELISA
Nucleic-acid Amplification Testing or NAT: detects the DNA of the HIV itself.
ELISA test = identifies antibodies specific to HIV. If positive = person has been exposed and formed antibodies
Western Blot = used to confirm seropositivity when ELISA is positive.
---- both not valuable until 18 months old
Viral load = measures HIV RNA in plasma. It is used to predict severity - lower the load the longer survival.
CD4 cell count = markers found on lymphocytes to indicate helper T4 cells. HIV kills CD4 cells which results in impaired immune system
Discuss the nursing interventions for an infant born to an HIV positive mother including:
b) medications - protocol for administration.
a) Provide care like that of any other newborn - do not need to isolate
b) HIV infected mothers should be identified and begin treatment with ZVD during pregnancy and in labor. All infants born to an infected mother should be treated prophylactically. Zidovudine for at least six weeks orally every 6 hours.
What causes the excessive fetal growth?
Insulin acts as growth hormone. Protein synthesis is accelerated and fat & glycogen are deposited in fetal tissues resulting in macrosomia.
What are the complications associated with the infant of a diabetic mother (IDM)?
Hypoglycemia (increased NB insulin in response to maternal hyperglycemia; no nutrition after birth)
Hypocalcemia (may be RT to decreased parathyroid hormone production)
Hyperbilirubinemia RT hypoxia-caused polycythemia
Polycythemia (increased metabolic demand = increased O2 demand)
Respiratory Distress Syndrome (causes decreased surfactant production)
Urinary tract, gastro & neural tube defects are common
BIRTH injuries RT LGA
Why are infants of diabetic mothers at risk for hypoglycemia?
Maternal supply of glucose is no longer available but infants high insulin production continues
What are the clinical manifestations and nursing interventions for an infant with hypoglycemia?
Jitteriness, tremors, rapid respirations, low temp, poor muscle tone or no signs at all.
Assess blood glucose: Intervene if < 40 - 45 mg/dl:
-Feed infant breast milk or formula
Reassess glucose levels in 30 - 45 minutes
*If no improvement: IV of D10W
What are the clinical manifestations by systems of an infant experiencing withdrawal? What is neonatal abstinence syndrome (NAS)?
hyperactive muscle tone (exaggerated Moro reflex), high-pitched cry,
appear hungry & suck vigorously, poor coordination of suck/swallow,
frequent regurgitation, vomiting, diarrhea, failure to gain weight,
sneezing, coughing, yawning,
tachypnea, sweating, excoriated skin
NAS: disorder in which neonates demonstrate signs of drug withdrawal from in utero exposure to maternal drugs
What nursing interventions would the nurse initiate?
Swaddle with hands near mouth
Place in quiet dimly lit area of the nursery
Protect skin from excoriation
Provide small frequent feedings
Position with HOB elevated
Weigh every 8 hours (if vomiting & diarrhea; usually not done b/c most NB on minimal stimulation)
Administer morphine, phenobarbital, methadon
**Assess with Finnegan Abstinence Scale (if 8 or more three consecutive times, then Tx)
What are the clinical manifestations of an infant suffering from Fetal Alcohol Syndrome? What is one of the major complications.
Jitteriness, Abdominal distention, Exaggerated rooting and sucking reflexes
*flattened nasal ridge
*smooth philtrum (no ridges on upper lip) and thin upper lip
*small palpebral fissures (small vertical opening between upper and lower eyelids)
*small vermillion border, i.e., demarcation between lip and adjacent skin of the mouth
Smoking Effects on the Fetus
Nicotine: vasoconstriction and reduced placental perfusion
Carbon Monoxide: inactivates fetal and maternal hemoglobin
**reduced O2 to fetus results in prematurity or LBW
A preterm infant with respiratory difficulties should be placed in which position to facilitate drainage?
The prone position is not recommended for normal newborn infants, because it is associated with an increased incidence of sudden infant death syndrome. However, the prone position for a preterm infant can facilitate drainage of respiratory secretions and regurgitated feedings. Prone positions also increase oxygenation and lung compliance and reduce energy expenditure
The most important reason to protect the preterm infant from cold stress is that:
a) It could make respiratory distress syndrome worse
b) Shivering to produce heat may use up too many calories Incorrect
c) A low temperature may make the infant less able to digest nutrients
d) Cold decreases circulation to the extremities
Cold stress may interfere with the production of surfactant, making respiratory distress syndrome worse
What nursing action is especially important for an SGA newborn?
a) Observe for respiratory distress syndrome.
b) Observe for and prevent dehydration.
c) Promote bonding.
d) Prevent hypoglycemia with early and frequent feedings.
SGA infants have poor glycogen stores and are subject to hypoglycemia
As the nurse is assessing a 2-day-old newborn, jaundice is noted on the face only. The nurse can anticipate a bilirubin level of about
a) 5 mg/dL
b) 10 mg/dL
c) 15 mg/dL
d) 20 mg/dL
When the bilirubin level reaches 5 to 7 mg/dL, jaundice is visible in the newborn's face. It moves down the body as bilirubin levels continue to rise.
The infant of a diabetic mother is hypoglycemic. What type of feeding should be instituted first?
a) Glucose water in a bottle
b) D5 W intravenously
c) Formula via nasogastric tube
d) Breastfeeding, or breast milk/formula in a bottle
Breastfeeding or breast milk/formula by bottle should be given first to raise the blood glucose level. Oral feedings are tried first, and intravenous lines would be a later choice if the hypoglycemia continues.
What intervention would make phototherapy most effective in reducing the indirect bilirubin in an affected newborn?
a) Expose as much skin as possible.
b) Increase oral intake of water between and before feedings.
c) Place eye patches on the newborn.
d) Wrap the infant in triple blankets to prevent cold stress.
Expose as much skin as possible to the light. Remove all clothing except a diaper. Turn the infant every 2 hours to expose all areas evenly and prevent skin irritation.
THIS SET IS OFTEN IN FOLDERS WITH...
1412- Reproduction/ Conception
PEDI 1412 - Neurological disorders
RNSG 1412 - Infertility/ Contraception
PEDI 1412 - G&D/ Safety
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