Upload
stuart-smith
View
64
Download
5
Tags:
Embed Size (px)
DESCRIPTION
RSPT 2353 Neonatal and Pediatric Respiratory Care. Neonatal Assessment and Examination. Objectives. At the conclusion of this class the student will understand : Antenatal/PerinatalAssessment of the neonate NRP procedures for the Resuscitation of the newborn and neonate - PowerPoint PPT Presentation
Citation preview
RSPT 2353 Neonatal and Pediatric Respiratory Care
Neonatal Assessment and Examination
ObjectivesAt the conclusion of this class the student will
understand:• Antenatal/PerinatalAssessment of the neonate• NRP procedures for the Resuscitation of the newborn
and neonate• Apgar Score assessment parameters• Perinatal and intrapartum monitoring of the neonate• Routine stabilization of the newborn in L and D• Potential abnormalities of the neonate• Risk factors for High Risk Deliveries• Examination and assessment of the pediatric patient• Differences between neonate and pediatric
assessment
Antenatal Assessment of the Newborn
Assessment of the newborn begins before the actual delivery, with the mothers history
• Maternal history- Term of pregnancy (pre/post term)- Incompetent cervix- Toxic habits during pregnancy- Hypertension and diabetes Mellitus- Infectious diseases- Placenta, Umbilical Cord and Fetal Membranes- Disorders of amniotic fluid volume
Antenatal Assessment of the Newborn
Assessment of the newborn begins before the actual delivery
• Several procedures and monitoring techniques are used to assess the fetus in-utero- Ultrasound- Amniocentesis- Non-stress test and Contraction Stress test; Fetal Heart rate monitoring- Fetal Biophysical Profile see pg. 26
Intrapartum Monitoring
During complicated, high risk delivery labor it is typical to monitor for
Fetal Heart Rate to assess the status of the fetus prior to birth- Decelerations (variable or late “decels”) of the fetal heart rate indicate hypoxia or acidemia that are clinically significant
Scalp Blood pH are drawn with severe variable or late decels and more precisely defines the immediate risk to the fetus. If > 7.25 forceps or C-section may be avoided
High-Risk ConditionsRisk factors for preterm delivery include• Previous preterm delivery• Premature rupture of membranes PROM• Maternal genital infections• Non genital infections• Chorioamnionitis (infection of fetal membranes or
amniotic fluid)• Conditions that over-distend the uterus
- Multiple gestations- Polyhydraminos
• Placental conditions• Abnormalities of the cervix• Fetal anomalies• Incompetent cervix
Preterm LaborPreterm labor is defined as labor before 37 weeks
of gestational age. It complicates around 8% of pregnancies and is associated with significant neonatal morbidity including
• Sepsis NEC• RDS Visual and hearing dysfunction• IVH Cerebral palsy• ROP• BPDThe lower the gestational age the more severe the
risk become
Examination and Assessment of Neonatal Patient
Physical Examination– Auscultation of the heart and lungs– Vital signs- Hr 110-160, temperature 97.6F,
RR 45-60 +/-– Acrocyanosis- blue hands and feet with
decreased perfusion to extremities– Mottling- irregular areas of dusky skin,
alternating with areas of pale skin– Vernix caseosa- gray-white cheeselike
substance
The 5 Factors of APGAR
The previous 5 factors of assessment of a newborn are the APGAR score
• APGAR scores are assessed at 1 min and 5 min intervals
• APGAR of 7 or better baby is considered in good condition. Transfer to NBN
• APGAR of 6 or less indicates baby might have problems. Transfer to NICU
Neonatal Assessment and Resuscitation
Preparation is the key to effective L and D room management
• Equipment in delivery room must be present prior to the birth
• The appropriate personnel must be present• The efforts of the OBY/GN and Neonatologist
must be coordinated and professional• The RN and RT must work as a team with the
MD to ensure all appropriate interventions are available to EVERY newborn that is considered to be high - risk
Routine Stabilizing the NewbornInitial Stabilizing of the neonateDrying – Immediately dry the fluids of the patient
- Necessary to prevent cold stress- Use pre-warmed towels in a stack of 5
Warming- Cold stress increases oxygen consumption and impedes effective resuscitation- Hyperthermia increases in oxygen consumption
Airway- Bulb syringe nose and mouth- Suction catheter for NT/NG suctioning 6f- 10f gauge- Negative pressure should not exceed 80 to 100 mm hg- Meconium (if present) suction infant’s mouth, pharynx, and nose as the infant’s head is delivered- Can the catheter pass down both nares? (choanal atresia)Stimulation- Flicking the bottom of feet, rubbing the back, and drying with the towel all serve to safely stimulate the newborn
Assessing the NewbornRespiratory Effort
- RR & breathing pattern- Presence of retraction, flaring, grunting- Normal: RR 45 – 60, mild intercostal retractions no nasal flaring, grunting or wheezing
Heart Rate- Primary indicator of distress- If less than 100 apply PPV- If less than 60 begin compressions with PPV- If zero, full NRP protocol must be initiated immediately
Color- Baby should “pink up” within 30 secs of blow-by 1.0 FiO2- Acrocyanosis may persist, blue hands and feet- Mottling indicates poor perfusion, hypovolemia, cardiac problems or hypothermia
Tone- Flexion of the extremities is normal, baby moves all - Babies muscle tone floppy indicates problems
Reflex - Baby should cough, sneeze or react visibly to NT suction catheter- A slight grimace is acceptable- No reaction at all is indicative of baby being very depressed
Self-inflating bag- Refills without supplementary gas flow- Has intake valve, room air dilutes the oxygen concentration delivered by the bag- Inappropriate for newborn, neonatal or pediatric use
Anesthesia bag- Inflates only from a compressed gas source of air, oxygen, or both, usually attached to a device called a “blender”- Anesthesia bag offers the advantage of being able to provide a more precise control of oxygen concentrations- Lung compliance can be better assessed
Self-Inflating AMBU vs. Anesthesia Bags
Intubation Indications
• Endotracheal intubation- indicated when bag-mask ventilation is ineffective, tracheal suctioning is required,
• For thick meconium in a respiratory depressed neonate for the purpose of suctioning the meconium prior to 1st breath
• When prolonged ventilation is anticipated• Always based on the babies APGAR and
other scores along with clinical presentation
NRP MedicationsFew Newborns require a full NRP approach to
resuscitation, but when drugs are used:Epinephrine
-Cardiac arrest-AsystoleVolume expanders
- To correct hypovolemia- NS is used most frequently
Naloxone- Narcotic depressed neonate
Sodium Bicarbonate- Metabolic acidosis- Watch for acute vasodilation resulting in low blood pressure
Fluid resuscitation- 20cc/Kg body wt.
Thorax Deformities
Chest Deformaties are usually rare and non – life threatening:
Pectus carinatum- A protruding sternum and or xiphoid process- Pigeon Breasted
Pectus excavatum- a concave asymmetry of the chest wall- Funnel chested
Ballard Score
• Used for estimating gestational age
• Derived from neurologic and physical signs
• Is the most universally accepted assessment of gestational age performed post partum
Score Week
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50 44
Correlation of Ballard Score with Gestational Age
Silverman Score
• Used for assessing the magnitude of respiratory distress
• Pg. 49, fig 5-3
Abnormal Cardiac Sounds Murmurs
Murmurs, clicks, rubs and other Abnormal Cardiac Sounds
• Described as a soft to loud harsh sounds and are a result of:– Ductus arteriosus (PDA)– PPHN (persistent pulmonary hypertension of the
newborn) combination of PDA and left to right shunting, resulting in a persistent fetal circulation
– Atrial septal defect (ASD)– Ventricular septal defect
Abdomenal Abnormalites at Birth
• Distention- characterized by tightly drawn skin through which you can easily see engorged subcutaneous vessels.
• Enterocolitis- a bowel infection by sepsis, peritonitis, bowel perforation, and significant mortality
• Diaphragmatic hernia- abdominal contents displaced in the chest
Congenital Diaphragmaic Hernia
• Prunebelly syndrome- lack of abdominal musculature
• Omphalocele- protrusion of membranous sac that encloses abdominal contents through an opening in the abdominal wall into the umbilical cord
• Gastroschisis- a defect in the abdominal wall lateral to the midline with protrusion of the intestines
Abdomenal Abnormalites at Birth
Examination of the Head, Neck, Eyes/Ears and Throat
HEENT examination indicates several abnormalities
Includes all the structures of the head, throat, posterior neck
• Examination of the ears- Low-set ears indicative of many syndromes
• Examination of the eyes• A modified Age-specific Glascow Coma Scale
can be used to assess a newborns neurological status
Musculoskeletal System, Spine and Extremities
MS system and Extremities give many indications of internal abnormalities:
• Skin tags
• Clubfoot
• Spina bifida- failure of the embryonic neural tube to form correctly in the third to fifth week of gestation
• Myelomeningoceles- defect over the spine
Cry
A newborn or infants cry is one of the primary indicators of abnormalities:
• Loud and vigorous- healthy infant• Grunting cry- RDS• Hoarse cry-laryngeal edema• Cat like cry- chromosme abnormality• High-pitched cry- neurological deficit
– Neurologic assessment- Moro reflex- startle reaction to sound or touch similar to lowed to fall back slightly
Pediatric AssessmentPediatric assessment is based more on
historical data and information gathering, as well as the presenting complaint(s) to include:
• History and assessment
• Chief complaint
• Medical history
• Family history
• Environmental history
Pediatric Assessment Once a RELIABLE history is obtained, pediatric
assessment becomes a matter of physical assessment:Inspection
- RR- Retractions- AP diameter- Digital clubbing
Palpation- Tactile fremitus- Position of trachea- Diaphragmatic excursion
Percussion- Pneumothorax- Pleural effusion
Auscultation- Breath sounds- Bowel sounds- Heart sounds
Pediatric Assessment
Once a thorough history and physical examination have been completed, further assessment is performed incorporating:
Lab values- CBC, ABG, H/h, etc.- CXR- PFT- CScan, MRI- Specialized testing specific for differential diagnosis
Pediatric AssessmentIn cases where an obvious diagnosis isn’t
clear from examination and evaluation of the aforementioned data the clinician is able to offer a:
Working Diagnosis
and or a
Differential Diagnosis
RSPT 2453 Neonatal and Pediatric Respiratory Care
Neonatal L and D Emergenc
NEONATAL EMERGENCIES
Delivery Room ManagementFollow the principles of the Neonatal
Resuscitation Program• A = establish an airway• B = assess breathing• C = evaluate color
• Time is of the essence!• No matter what the defect, the basics of
ABC’s apply
NEONATAL EMERGENCIESHypoxic-Ischemic Encephalopathy
(HIE) – Mild: increased irritability and jitteriness,
exaggerated primitive reflexes, lasting <24 hrs.
– Moderate: lethargy, +/- seizures, suppressed primitive reflexes, lasting >24 hrs.
– Severe: stupor or coma, seizures absent primitive reflexes, lasting > 5 days
NEONATAL EMERGENCIES
HIE (cont)– Treatment
• Respiratory: avoid pulmonary hypertension• Minimal handling• Maintain normal systemic arterial pressure and
adequate cerebral perfusion• Treat seizures if present• Maintain normoglycemia• Avoid fluid overloading
NEONATAL EMERGENCIES
Neonatal SeizuresEtiology
• Onset 0-3 d: HIE, intracranial hemorrhage,, hypoglycemia, hypocalcemia
• Onset 4-10 d: Infection, cerebral dysgenesis, hypocalcemia
• Uncommon: Most drug withdrawals, intoxication from maternal local anesthetics, benign familial neonatal seizures
NEONATAL EMERGENCIES
Seizures (cont)– Treatment: minimize physiologic and
metabolic derangements• Support ventilation and perfusion• Correct metabolic derangements• Phenobarbitol: 20 mg/kg load; additional doses of
5 mg/kg until total of 40 mg/kg• Others: Phenytoin, benzodiazepines
NEONATAL EMERGENCIESAcute Respiratory Disorders of Any Type
Require Assisted ventilation or oxygen to attain adequate gas exchange and oxygenation via:
• Oxygen administration• CPAP• Mechanical Ventilation• High frequency ventilation (oscillator)• ECMO• NO Administration• Liquid Ventilation
NEONATAL EMERGENCIES
Acute Respiratory DisordersRespiratory Distress Syndrome (RDS)
• Etiology: decreased alveolar surfactant causing atelectasis, loss of functional residual capacity, alterations in ventilation-perfusion ratio and uneven distribution of ventilation. Hyaline membrane formation.
• Treatment: Adequate ventilation and oxygenation: CPAP, positive pressure ventilation, oxygen; close monitoring of pH, pCO2, pO2; exogenous surfactant replacement (~100 mg/kg phospholipid)
NEONATAL EMERGENCIES
Acute Respiratory DisordersMeconium Aspiration Syndrome (MAS)
• Rarely occurs before 38 wk gestation • Presentation: respiratory distress, tachypnea,
prolonged expiratory phase, hypoxemia, meconium staining of nails, skin, umbilical cord, increased A-P diameter
• Persistent pulmonary hypertension frequently associated with MAS
• Pulmonary abnormalities related to acute airway obstruction, decreased tissue compliance and parenchymal disease
NEONATAL EMERGENCIESAcute Respiratory Disorders
– MAS (cont)• Treatment
– Prevention– Rapid correction of acidosis and hypoxemia– Exogenous surfactant– Mechanical ventilation
» Low CPAP/PEEP» Low PIP with rapid rate and short inspiratory
time» High frequency ventilation
– Nitric oxide– ECMO
NEONATAL EMERGENCIES
Acute Respiratory DisordersPersistent Pulmonary Hypertension of the
Newborn (PPNH)• Multiple etiologies primary or secondary• Present with labile hypoxemia inappropriate for the
degree of pulmonary parenchymal disease.• May have documented R -> L shunting• Treatment
– Correction of metabolic acidosis and hypovolemia
NEONATAL EMERGENCIESAcute Respiratory Disorders PPHN (cont)
• Treatment–Minimize agitation–Consider creation of respiratory and/or
metabolic alkalosis: pH > 7.50; pCO2 <20 TORR
–High-frequency oscillatory ventilation–Inhaled nitric oxide–ECMO
NEONATAL EMERGENCIES
Acute Respiratory DisordersPneumothorax
• Can occur in up to 25% of ventilated infants• Presentation: grunting, tachypnea,
cyanosis, retractions• Tension pneumothorax results in SHOCK• Treatment: Needle aspiration to relieve
tension followed by insertion of chest tube.
NEONATAL EMERGENCIES
Acute Respiratory Disorders Congenital Diaphragmatic hernia (CDH)
• 90% occur on left• DO NOT BMV IF YOU SUSPECT A CDH –
INTUBATE IMMEDIATELY• CDH is no longer considered a surgical
emergency; stabilize the infant and adequately ventilate until the pulmonary hypertension is resolved.
NEONATAL EMERGENCIES
Acute Respiratory Disorders Apnea of prematurity
• Must rule out other causes of apnea• Treatment
–Supportive- Oxygen- Fluid resuscitation
–Caffeine citrate: loading dose: 20 mg/kg IV; maintenance dose: 5 mg/kg IV/PO q 24 hours
NEONATAL EMERGENCIES
Metabolic DisordersHypoglycemia: plasma glucose concentration
< 30 mg% first day of life; then < 40 mg%
• Etiology: inadequate glucose production or excessive glucose utilization
• Treatment: 2 – 4 ml/kg 10% D/W followed by 100 ml/kg/day 10% D/W
NEONATAL EMERGENCIES
Metabolic DisordersHypocalcemia
Types: early, late, decreased ionized calcium• Definition: Term < 8 mg %
Preterm < 7 mg %• Treatment: Seizures: 1 ml/kg 10 % calcium
gluconate IV over 10 minutes with constant monitoring of heart rate; oral: 2 – 8 ml/kg/day 10% calcium gluconate in4 divided doses
Post-Resuscitative CareOnce a newborn or neonate has been resuscitated
optimal care must be provided including:• Frequent assessment• Careful monitoring• ABG and other lab studies• Treatment of hypotensive states, seizures
- Volume expanders- Vasopressors
• Maintaining Glucose levels, adequate ventilation and oxygenation, electrolyte balance and many other considerations
Lecture Summary
• Many infants are born with obvious abnormalities at birth, with many being discovered in the L and D room, but not always
• Good assessment skills are required for RTs that respond to High-Risk Deliveries
• Some post partum abnormalities can be resolved simply, other require a high level of intervention
• Anytime an infant or newborn demonstrates respiratory insufficiency intervention must be swift and appropriate to the condition
Lecture Summary
Skills required to work in L and D include- Intubation- Accurate assessment of resp distress- NT/NG suctioning- NRP certification- MV management- ABG interpretation- etc.