View
218
Download
0
Category
Preview:
Citation preview
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
1/43
HIGH RISK NEWBORN
Lecture 13
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
2/43
LEVELS OF NICULevel I
Basic neonatal care; minimum requirement for afacility that provides inpatient maternity care. Able to perform neonatal resuscitation. Evaluate healthy newborns; provide standard care. Stabilize newborns til transfer to intensive care
Level II AKA Special Care Nurseries Basic care to moderately ill infants; ~ 32 42 wks. Step down from level III NICU; infants recover
Level III Newborns
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
3/43
National studies show: 30% survival rate for 23 wk preemies.
52 % for 24 wks. 76 % for 25 wks. African American women: twice as likely todeliver early, but babies more likely to survive.
High risk newborns in NICU: Use cardiac & apnea monitors; radiant warmers; O2 sat,
VS, BP monitoring. Assessed q 1-2 hrs. or continuously
^ risk of infections: GBS, septicemia, thrush Moms encouraged to visit NICU daily Skin care to prevent breakdown. Good hand washing - parents/staff.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
4/43
RDS Pre-Term Resp.distress syndrome: aka hyaline membrane disease
In preemie, insufficient surfactant in alveoli causing lungs tocollapse; not enough O2.
Most common disorder of preemies.
^ resistance causes fibrous tissue in bronchioles & alveoli
poor O2/CO2 exchange.
Self-limiting; ~ 72-96 hrs in most late preterm or full term.
VLBW (ELBW) - RDS can persist days/weeks. D/T immaturelungs, non-compliance, and low surfactant levels.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
5/43
Causes ofRDS - Term
In term infant: Sepsis [GBS] Persistent Pulmonary Hypertension of
Newborn (PPHN) ductus arteriosus doesnot close.
Meconium aspiration r/t oligo,uteroplacental insufficiency, &fetal distress
Infants of diabetic moms.
May need resuscitation @ birth.In Pre-term infant: Immature lungs,
non-compliance, & low surfactant levels.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
6/43
S/S of RDS (In PRETERM)
Retractions - drawing back of chest muscles with breathing.Infant works harder at lung expansion. SOB and expiratory gruntingself-induced by infant - maintains ^
pressure in
lungs by causing expiratory braking using vocal cords(glottis partially closes increasing alveolar surface tension)
Nasal flaring; TTN [transient tachypnea = ^ 60 R/min.]
Management: ABGs, O2 sats, CBC, bl.cx
Skin/mouth care
Suctioning (prn)
Support for family Adequate fluids and electrolytes Replace surfactant [Curasurf man made; ET tube] O2 therapy [Oxyhood; CPAP; ventilator] [CPAP= cont.+ airway
pressure] helps keep small air sacs from collapsing; suction prn
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
7/43
Terms
AGA - Approp. for gestational age [5.7 9.1]SGA - Small for gestational age. ~ < 5.7 lbs.
LGA - Large for gestational age. ~ > 9.1 lbs.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
8/43
SGA: weight < 10th percentile compared to others of
same gestational age. [38 wk. weighs 5 lbs.]
Aka IUGR aka Failure to thrive. Most common cause: placental anomaly; placenta not receiving
sufficient nutrition from uterine arteries or placenta.
Severe DM, pre-eclampsia, poor nutrition, smoking,cocaine. Decreases blood flow to placenta.
Fundal height lower than expected for gest.age.
Bio Physical Profile: assesses placental function.
If infant not thriving in utero, will do C/S; weighpros/cons.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
9/43
SGA infant: wasted look, dull hair, small liver [^^ bilis],
poor skin turgor, low glucose, low temp.
Mature neuro responses, sole creases, + ear cartilage.
Lab findings: ^ HCT {low plasma levels} & ^ RBC
{polycythemia} Causes thicker blood making heart work
harder; ^ chance of thrombosis. Prolonged acrocyanosis.
Manage: ^ fluids & freq.feedings.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
10/43
LGA: aka macrosomic infant. > 90% percentile.
Appears healthy; may be gestationally immature
{immature neuro responses & respiratory effort}.
Assess: larger than average uterine size for gestational age
Do sono to estimate size. Check dates.
C/S for CPD or shoulder dystocia.Causes: GDM, omphalocele, transposition great vessels.
Appearance: possible fx clavicles; facial/head
bruising, facial/neck palsy, caput, cephalohematoma.Observe: hypoglycemia, polycythemia, irregular
HR, cyanosis [in transposition]
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
11/43
Preterm Infant
90% term births [full-term] & 11% preterm [< 37 wks]Calculated by gestational age; not weight.
Maturity determined by physical findings: sole creases,skull firmness, ear cartilage, neurologic findings &
pregnancy dates. SGA & Pre-terms: 2 different causes w. diff. problems.
Preterm: fetus has been doing well in utero but triggerinitiates labor & infant is born early.
Problems: poor thermoregulation, hypoglycemia,intracranial bleed, RDS, NEC, immature kidney function,infection.
80-90% of infant mortality in 1st yr. life esp. VLBW infants
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
12/43
Risk Factors of Preterm Delivery
Women of middle/upper socioeconomic: ~ 4-8% Lower socioeconomic levels: ~ 10-20% Inadequate nutrition; lack of money & knowledge about
good nutrition; lack of support.
American Academy of Pediatrics: live-born infantweighing 2500 g. or less.
World Health Organization (WHO) & American College ofObstetricians and Gynecologists (ACOG) both define itas infant born prior to 37 wks.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
13/43
Appearance of Preterm Infant24-36 weeks
Small, underdeveloped, head disproportionately large;skin thin & ruddy [little subcut. fat]; veins noticeable;prolonged acrocyanosis. vernix depends on gest.age.
< 24 wks.vernix not formed.
None/few sole creases.
Ear cartilage immature; no quick rebound of pinna. Extensive lanugo.
Suck/swallow absent, weak cry < 33 wks. BallardGestational scale to estimate age.
Infection decreased maternal antibodies Skin fragile; limit alcohol; rinse with water. Adhesives
cause skin tearing. Use skin barriers to protect skin.Tegaderm tape. Handwashing a must !
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
14/43
13 year old femaleEx-24 week preemie
BPD, trach/vent
15 mos in NICUG-tube 3 yrs
Decannulated at age 4
Intensive learning support
Eating age-typical diet
Mild articulation errors
**Former Extreme Premature Teen**
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
15/43
Thermoregulation:
risk for hypothermia r/t large surface in relation to
body weight.Limited stores of brown fatDecreased or absent reflex control of skin capillariesImmature temperature regulation in brainKangaroo care [skin to skin contact]Assess Respiratory EffortMay need intubation to maintain respirations. < 32 wks: irregular respiratory pattern normalSurvanta in ET tube
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
16/43
Urinary/Elimination
Have high insensible water loss d/tlarge body surface compared w/ totalbody weight. Lower GFR d/t immature
kidneys. Fluid overload or dehydration. Strict I/O
Immature kidneys secrete glucose
slowly > hyperglycemia can result.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
17/43
Insensible Water Loss[Approx. water loss in body]
Age group Water
Premature infant 90%
Newborn infant 70-80%
12-24 months 64%
Adult 60%
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
18/43
Nutrition: promote normal growth & development
Tries to maintain rapid rate of intrauterine growth.
Lack of cough reflex: can aspirate formula.
Have weak sucking, swallowing, gag reflexes
Weak abdominal muscles; weak gag reflex
^ aspiration risk
^ BMR - High caloric needs but small stomachcapacity
Limited store of nutrients
Decreased ability to digest proteins and absorb
nutrients, and immature enzyme systems. TPN, PPN, Gavage, or IV feedings
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
19/43
Feeding
Caloric requirement: PT: 95-130 kcal./kg/day. Term infant: 100-110.
Smaller stomach capacity: sm.,freq. feedings [q 2-3hrs].
Formula: Calories for premie: 24 cal./oz. Term: 20cal/oz.
Breast milk good d/t immunologic properties.
Gavage: nasogastric/orogastric. Gag reflex not
intact til infant 32 wks; avoid over filling stomach;may cause respiratory distress. Use premie nipple.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
20/43
Developmentally SupportiveActivities ** (new) Kangaroo Care/Skin to Skin Care
Non Nutritive Sucking (Significantlyreduced length of hospital stay for
preterm infant)
Non Nutritive at the Breast (pacifer) Parent Education & Support
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
21/43
Non-Nutritive Sucking atBreast ** Improved milk production
Provides sucking experience
Prepares infant for breastfeeding Long term effects:
Increased length of exclusive breastfeeding
Increased length of total breastfeeding
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
22/43
POTENTIAL COMPLICTATIONS of PT InfantAnemia of Prematurity: red blood cell life is short. Low bone
marrow prod. until ~ 32 wks. Frequent blood testing.
Kernicterus: destruction of brain cells by invasion of
indirect bilirubin [bili ~20]. PT infants: low serum
albumin available to bind indirect bili & excrete it.
Persistent Patent Ductus Arteriosus: d/t hypoxia, lack of
surfactant, lack of musculature. Lungs are noncompliant.
^ blood stays in pulmonary artery > pulmonary artery HTN>persistent PDA. Indocin stimulates PDA closure.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
23/43
Bronchopulmonary Dysplasia. (Chronic Lung Disease)
Results from long term O2 & being vented (PPV).
Lungs immature; resp.infection, poor nutrition,
Pressure damages & stretches lung tissue; results in airway
edema & fibrotic buildup. Alveolar walls thicken; buildup of
secretions; pneumonia & atelectasis possible. Decreased
oxygenation results.
S/S: tachypnea, tachycardia, hypoxia, grunting, retractions,feeding & activity intolerance.
TX: prevent further disease; promote oxygenation, promotelung healing.
O2, nutrition, steriods, bronchodilators, diuretics, antibiotic tx;stop PPV; maintain venting @ lowest pressure.
Nitric oxide;Vitamin A
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
24/43
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
25/43
ROP: Retinopathy of Pre-maturity.
Caused by damage to immature blood vessels inretina. Results in scarring. Caused by high O2 levels.Blindness may result. 90% of cases no impairment.Occurs in VLBW
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
26/43
Intracranial Hemorrhage aka IVP germinal matrix made up of fragile & vascular
capillaries. Grades 1-4 (3 & 4 worse)
Bleeding into ventricles d/t hypoxia, ^ BP, ^ fluids. Dx with Cranial ultrasound
Normal brain function assessed > bleed.
IVH occurs in 20-25% of VLBW premies; suffer
more severe grades of IVH
IVH is an important predictor of adverseneurodevelopmental outcome
-3/4 of infants with Grade 3-4 IVH develop CP &75% in some type of special education
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
27/43
NECNEC: necrotizing enterocolitis; common in PT baby;can result in ulcers/tissue necrosis in intestinal wall.Bacteria in bowel>infection>destroys bowel tissue>sepsis.
Primary risk factor: prematurity & tube feedings;RDS, congenital heart defects.S/S abd. swelling, septic infant, emesis, blood in stool.Tx: stop tube feedings, start IVF & TPN, AB [sepsis],ventilator, platelet transfusion [control bleeding]
Prevention: Delayed /Slow feedings: advance < 20ml/kg/day; Enteral Antibiotics; Antenatal Steroids;enteral IgG, IgA; Human Milk Feedings.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
28/43
GDM
Infants [GDM moms] macrosomic if not wellcontrolled during pregnancy; lethargic d/t ^ glucose. Macrosomia: overstimulation of pituitary growthhormone in fetus in preg. d/t ^ maternal insulin. Mom insulin resistant; glucose x placenta; more
insulin made by fetal pancreas. After delivery, glucose levels drop, but insulin
remain ^ for several hours.Infant jittery on admission. Glucose checked for 1st
4 hrs; Hypoglycemia = < 40 mg/100 ml whole blood.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
29/43
GDM
Complications:Immature lungs d/t ^ fetal insulin which interfereswith cortisol release; blocks formation of lecithin &prevents lung maturity. ^ chance of birth injury
d/t ^ size; shoulder dystocia.
Hypoglycemia:
Check glucose on admission to NBN: 1, 1, 2, 4hrs. of life. If < 40; stat serum glucose & feedformula [1/2 oz.] Repeat in - 1 hr. as protocol.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
30/43
Transient Tachypnea of Newborn: TTN
Rapid, shallow RR 70-80/min. d/t slow absorption of
lung fluid. Difficulty feeding; infant will not suck d/t rapid
breathing.
Chest x-ray shows fluid in lungs.
Infant must ^ resp.depth to aerate effectively.
Can signify obstruction. VS, O2 sat; give O2.
Send to NICU for close observation if not resolvedwithin 4-6 hrs.of life.
Occurs more w. term C/S & preterm infants.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
31/43
Meconium Aspiration Syndrome:
Present in fetal bowel as early as 10 wks. Infantmay aspirate meconium in utero or with 1stbreath.
Can cause severe respiratory distress,inflammation or blockage of small bronchioles bymechanical plugging
Ductus arteriosus may remain open; causes
blood to shunt from pulmonary artery to aortainstead of passing thru lungs [^ pulmonaryresistance], causing ^ hypoxia.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
32/43
SymptomsTachypnea [RR>60]
RetractionsSOB and expiratory gruntingNasal flaringPeriods of apneaBluish color of skin and mucus membranes
Arms or legs puffy or swollen
PreventionOropharyngeal suctioning of infant > delivery
Laryngoscopic visualizaiton of vocal cords > intubation.Additional suctioning of trachea.Amnioinfusion: dilutes meconium. Thins out particulatemeconium. Do sepsis workup; CBC, bl.cx., chest x-ray. ABtherapy to prevent pneumonia.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
33/43
SIDS: sudden infant death syndrome.
Mainly in adolescent moms, closely spaced pregnancies,
underweight, PT infants. 2nd hand smoke. Appear well nourished. ^ African American males.
Silent death; poss.laryngospasm.
Use of sleep apnea monitor for first few wks.-mos. Peak
age: 2-4 mos. Cause unknown. Theories: HR abnormalities, decreased arousal [moro]
responses, prone position, low surfactant, brain stem
abnorm.
In 2000 Amer. Academy of Pediatrics recommendedback or side position; not prone. Incidence declined 50%
since then. New data: use of pacifier for 2-4 mos.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
34/43
Hyperbilirubinemia ^ levels of unconjugated (indirect) bilirubin in blood.
Breakdown of RBCs > Hgb > heme > Unconjugated bilirubin.
Bilirubin binds with plasma protein (albumin) = bound goesto liver & converts to conjugated or H2O soluble where it sexcreted via bile by feces.
Immature livers which cannot convert indirect to direct;indirect bilirubin remains in bloodstream.
Unbound bilirubin = (indirect) jaundice.
If indirect level rises > 7, yellow color results. Sclera, nail beds, then skin. Cephalocaudal progression: head to toe. Blanch skin
Depends on hours/days of life. Younger infant (4-5 hrs.) high reading more significant; could
rise steadily . Older infant (1-2 days), higher # less significant (more mature
liver).
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
35/43
Pathologic [within 24 hrs.] Bili rises quickly. By 5-7 mg/dl/day or more.
Blood type incompatibilities ; sepsis; birth trauma.Interventions: Early & frequent feedings to speed upexcretion in stool.
Phototherapy - bilirubin becomes water soluble to beexcreted.
Cover genitalia & eyes. Prevent organ damage. Single,double, triple phototherapy.
Kernicterus: Indirect bilirubin of 20 > permanent braindamage; bilirubin encephalophathy.
Signs: hi-pitched cry, seizures, hypotonia Interventions: Immediate exchange transfusion;
followed by phototherapy & frequent bili levels.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
36/43
Physiologic Jaundice: [> 24 hrs.] 2nd-3rd day.
R/T low albumin (decreased binding sites forbilirubin). ^ levels of RBCs. Yellowing of skincaused by breakdown of fetal red blood cells whichproduces excessive amts. of bilirubin in bloodstream. Excess bilirubin in blood causes jaundice.
Management: frequent feedings, frequent bili
levels. Bili declines within days. Teach parents to place near window to speed up
breakdown of bili. Sunlight will ^ breakdown.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
37/43
Gastroschisis:weakness in abdominal wallcausing herniation of gut on umbilical cordduring early development; most commonly on
right side. Viscera lie outside abdominal cavity;not covered with sac.
1 in 4,000 live births
Mortality: 10%-15% Assoc.w.prematurity; malrotation of
intestines; decreased abdominal capacity;other anomalies rare.
TX: IV & NG tubes immediately; TPN; Silastic
(synthetic covering) over viscera; surgicalclosure after contents returned to abd.cavity.If necrotic bowel present, remove.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
38/43
Nursing Care:
thermoregulation (monitor temps, radiant warmer);sterile technique (cover viscera - warm, sterile,saline gauze & plastic); monitor VS, color, etc.)strict I&O, daily weights, fontanels, pacifier,electrolytes. Minimize movement of area.
encourage bonding asap; developmentalstimulation for long term hosp; support group forparents; teach parents s/s bowel obstruction- ie.vomiting, pain, firm abdomen, anorexia, irritability.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
39/43
Omphalocele:large herniation of gut intoumbilical cord. Viscera outside of abd.cavity& covered with peritoneal & amnioticmembranes
1 in 5,000 to 10,000 live birthsAssoc.w.malrotation of intestines; decreased
abdominal capacity. Stenosis common;cardiac, genitourinary, or chromosomalanomalies common (1/3 to of cases)
Mortality: 20-30%; sepsis & intestinal
obstruction. TX: same as for gastroschisis Nursing Care: Same as for gastroschisis.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
40/43
Bladder Exstrophy:extrusion of urinarybladder to the outside of body through
developmental defect in lower abdominalwall. Assoc.w.genital anomalies: widesymphysis pubis.
Rare & congenital anomaly; bladder is turned
inside out
TX: protect exposed bladder tissue; cover withsaline gauze/plastic wrap til sugery. Prevent
UTI. Reconstruction of bladder & genitalia.Provide support & education
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
41/43
EA (esophageal atresia) TEF (tracheo-esophageal fistula)
Cause unknown. Congenital malformations esophagus ends before
reaching stomach. (TEF) fistula may connect totrachea.
1 in 2,000 - 4,500 live births. 30-50% have otheranomalies (cardiac, GI, nervous sys).
Premature or LBW common EA without TEF : Inability to pass suction or NG
tube catheter @ delivery. Confirm with abd.x-ray;Excessive oral secretions; vomiting; risk ofaspiration; Abdominal distention; Airless/sunken
abdomen. Hx maternal polyhydramnios TEF without EA: food enters trachea; choking;
cyanosis.
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
42/43
Statistics
Esophageal atresia with distal TEF 87%Isolated esophageal atresia without TEF 8%
Isolated TEF 4%Esophageal atresia with proximal TEF 1%Esophageal atresia with proximal and distalTEF 1%
7/28/2019 HIGH RISK NEWBORN 13 student version.ppt
43/43
Management: infant supinew. HOB to decreasesecretions. NG tube for frequent suctioning toprevent aspiration of gastric secretions; IVF; assessVS, resp.distress, measure abd.girth; provideeducation & support to family.
Surgical repair: fistula ligation & end to endanastomosis of atresia.
Provide post op care. IVF, G-tube & foley care; pain;VS, I&O, skin care.
Recommended