Premature Infant

The Premature Infant:
Nursing Assessment
and Management,
2nd Edition
Lyn E. Vargo, PhD, NNP, RNC
Carol Wiltgen Trotter, PhD,
NNP, RNC
Slides prepared by Margaret Comerford Freda, EdD, RN, CHES, FAAN
Preterm Births United States

Percent
27 percent increase from 1981 to 2001

2006, March of Dimes
March of
Dimes
Objective
Healthy
People
Objective
Transition to Extrauterine Life

Requires many physiologic changes for the
infant
Nurses need to understand general
principles of delivery-room management,
resuscitation and thermoregulation for
premature infants.
Certification
by the Management
Neonatal Resuscitation
Delivery-Room
Program (NRP) of the American Heart
Association (AHA) and the American Academy
of Pediatrics (AAP) is essential for all nurses
who work with premature infants.
Delivery-Room
Risks
Tendency to haveManagement
difficulty with transition
Vulnerable to cold stress

More lung immaturity and RDS
More intracranial hemorrhage
More hypoglycemia
Potential for oxygen-related injuries
High risk of developing NEC
Delivery-Room Management
Precautions
Follow resuscitation from NRP guidelines.

Avoid rough handling during resuscitation.
Reduce heat loss even if resuscitation is
not required.
Preterm infants may require endotracheal
intubation and surfactant administration
soon after birth.
Delivery-Room Management
Precautions (Continued)
Administer medication slowly as
recommended by NRP guidelines.

Follow glucose levels carefully. Glycogen
stores may be decreased. Infant may
experience hypoglycemia secondary to
perinatal compromise.
Maintain normal oxygen range after
resuscitation.
Major Physiologic Problems

of
the
Premature
Infant
RDS, BPD, apnea of prematurity and
chronic lung disease

PDA and hypotension
ROP
Immune-system immaturity that increases
the risk of infection
P-IVH
Additional Physiologic Problems

of the Premature Infant
Skin immaturity and fragility

Thermoregulation
GI issues
Fluid and electrolyte imbalances related
to immature renal function
Acid-base disorders
Pain management
Developmental issues related to the CNS
Impact of the NICU environment
RDS
Incidence 10% for all premature infants
Incidence 50% for 26 week to 28 weeks
Risk factors:
Low gestational age
Male
Born to diabetic mothers
Born after an asphyxial insult before birth
Born after maternal-fetal hemorrhage
Multiple gestation
RDS
(Continued)
Complex respiratory disease characterized

by diffuse alveolar atelectasis of the lungs,
primarily caused by a deficiency of
surfactant. This leads to higher surface
tension at the surface of alveoli, which
interferes with normal exchange of oxygen
and carbon dioxide.
NIH Recommendations
for
Use
of pregnant
Antenatal
Steroids
Give
to all
women
24 to 34
weeks gestation who are at risk for
preterm delivery within 7 days:
2 doses of 12 mg of betamethasone IM 24
hours apart OR
4 doses of 6 mg of dexamethasone IM 12 hours
apart
Repeat courses of corticosteroids should
not be given routinely in pregnant women.

Chain of Events with Surfactant

Delivery
Signs and Symptoms of RDS

Difficulty in establishing normal respiration,
especially if infant has risk factors for RDS

Expiratory grunting while the infant is not
crying
Intercostal and sternal retractions due to
increased rib cage compliance and decreased
lung compliance
Signs and Symptoms of RDS

Nasal flaring
Cyanosis
Tachypnea
(Continued)

Thermoregulation
RDS
Treatment
Fluid balance and nutrition

Skin care
Pain assessment
Developmental care
Family care
RDS Treatment
(Continued)
Focus is to prevent and minimize atelectasis.

Minimize untoward effects of oxygen and
barotrauma or volutrauma.
Treat underlying cardiovascular infectious
and other physiologic problems.

Maintain a balanced physiologic
environment.
Surfactant Therapy
Surfactant coats the inside of the alveoli.
It prevents collapse (atelectasis) and

keeps alveoli open at the end of
expiration.
It is given via endotracheal tube.
Prophylactic therapy appears more
beneficial than rescue therapy.
Surfactant Therapy
(Continued)
Criteria for identifying at-risk infants who
would benefit from prophylactic

treatment are unclear.
Multiple doses lead to improved clinical
outcomes.
Adjunct Treatments for RDS

CPAP
A method of assisting lung expansion with
continuous distending pressure
A valuable adjunct when spontaneous
breathing is adequate and pulmonary
disease is not excessive
Increases transpulmonary pressure;
improves oxygenation and ventilation
Reduces tachypnea and grunting
Adjunct Treatments for RDS
(Continued)
HFV
Allows the use of small tidal volumes (smaller than
anatomic dead space) and high frequencies.
Rates of 150 to 3,000 breaths per minute can be
used depending on the type of HFV.
HFV limits large tidal volumes and wide ventilator
pressure swings associated with volutrauma/
barotrauma caused by traditional mechanical
ventilation.
Oscillation
RDS Nursing Care

Any nurse caring for an infant with RDS must:
Be familiar with RDS pathophysiology
Recognize symptoms of RDS
Initiate interventions as indicated
RDS Nursing Care
(Continued)
Maintain paO2 and oxygen saturation levels.

Recognize importance of weaning oxygen
and other ventilator parameters.

Recognize complications arising from RDS,
intubation and mechanical ventilation.
Utilize proper endotracheal suctioning
techniques.
RDS Nursing Care
(Continued)
Provide mouth and skin care.

Maintain proper positioning.
Provide adequate fluid and electrolyte
balance.
Monitor blood glucose levels.
Reduce environmental stressors.
Provide parental support.
BPD
A significant problem for premature
infants
Uncommon after 32 weeks gestation
A secondary disease that develops in
neonates treated with positive pressure
ventilation and oxygen for primary lung
problems such as RDS
7,500 new cases every year in the United
States
10% die by 1 year of age
Signs and Symptoms of BPD

Hypoxemia with prolonged oxygen
requirement
Hypercapnia, tachypnea with increased work
of breathing
Episodic bronchospasm with wheezing
In severe cases, CHF with cor pulmonale
Abnormal postures of neck and upper trunk
Cascade of Events Occurring in

BPD
BPD Treatment
Therapy is preventive and supportive.
Preventive measures begin prenatally with
preventing prematurity and using a single

course of antenatal steroids.
Includes early, careful management of RDS,
use of low ventilator pressures, and careful

use of oxygen and exogenous surfactant
treatment.
AAP/CPS Summary/Recommendations on
Postnatal Steroids
Systemic administration of dexamethasone
to mechanically ventilated premature

infants decreases incidence of chronic lung
disease and extubation failure. Does not
decrease overall mortality.
Dexamethasone treatment for VLBW infants
is associated with complications (impaired
growth and neurodevelopmental delay).
Postnatal Steroids (Continued)
Use of inhaled corticosteroids to prevent CLD
has not shown benefits.

Routine use of dexamethasone for the
prevention of BPD in VLBW infants is not
recommended.
Postnatal use of systemic dexamethasone for
the prevention of BPD should be limited to
carefully designed randomized double-masked
controlled trials.
Postnatal Steroids (Continued)
Outside the context of a randomized
controlled trial, the use of postnatal
corticosteroids should be limited to
exceptional clinical circumstances (an infant
on maximal ventilatory support). Parents
should be fully informed about the shortand long-term risks and agree to treatment.
BPD Nursing Care

Prevent further lung damage.
Wean ventilator and oxygen support
slowly.
Recognize that stressful situations can
minimize hypoxemia-inducing events.
Use sucrose with nonnutritive sucking
before painful procedures to decrease
pain.
BPD Nursing Care
(Continued)
Preoxygenation (increasing FiO2 just
before suctioning) may help prevent

hypoxemia with suctioning.
A consistent caregiver is helpful to parents.
Use fortified breastmilk or premature
specialty formula for a consistent weight
gain of 10 g to 30 g per day.
Kangaroo care promotes bonding.
Kangaroo Care
Improvement in gas exchange and
temperature in premature infants

No adverse affect on physiologic stability
Improvement in lactation outcomes in
mothers wishing to breastfeed premature
infants
Positive impact on the parenting process
Apnea of Prematurity
50% of NICU infants
Periods of cessation of respiration for
longer than 10 seconds to 15 seconds

Apneic episodes frequently accompanied
by cyanosis, bradycardia, pallor or
hypotonia
Exact cause unknown but thought to be
due to immature CNS
Types of Apnea in Premature Infants

Central:
Absent breathing movements/ effort

Obstructive:
Breathing movements but no air flow
Mixed:
Mixture of obstructive and central apnea
Apnea Treatment
Cardiac and respiratory monitoring until no
apnea episodes for 5 to 7 days

Neutral thermal environment
Careful positioning; avoid flexion and
hyperextension of the neck
Apnea Treatment
(Continued)
Attention to gastric tube placement and
infusion rate during tube feeding

Nasal CPAP
Methyxanthines (oral to intravenous
aminophylline, theophylline and caffeine)
Apnea Nursing Care

Assess infants color, perfusion, respiratory
rate, heart rate, position and oxygen

saturation.
Document frequency and severity of episodes
and type and amount of stimulation required

to interrupt the event.
Ensure bag and mask set-ups with oxygen
available at infant bedside.

PDA
The most common cardiac complication
in premature infants
Incidence inversely related to
gestational age
Occurs in 45% of infants with a
birthweight <1,750 g
Occurs in 80% of infants with a
birthweight <1,200 g
Signs and Symptoms of PDA

Signs and symptoms of congestive heart
failure, increased need for oxygen and

inability to wean from ventilator
Widened pulse pressure, an active
precordium, bounding peripheral pulses and

tachycardia with or without a gallop
Echocardiogram most useful to evaluate
PDA
Left-to-Right Shunt Through PDA
PDA Treatment
Treatment is controversial.
Medical management with fluid restriction
and diuretics may be the initial approach.

Indomethacin has been effective in closing
PDAs (dosage depends on weight,

gestation and renal function).
PDA Nursing Care

Continually assess high-risk infants for pulse,
heart rate, pulse pressure, perfusion, and

auscultation for the presence of a murmur.
Know dosage and contraindications for
indomethacin.
Assess infant after indomethacin for ductal
closure, decreased urine output and

thrombocytopenia.
Teach and reassure parents.
ROP
A significant cause of blindness in children
initiated by delay in retinal vascular

growth
The more premature the infant, the more
likely the infant is to have ROP.

82% of infants weighing <1,000 g at birth
develop ROP.
ROP (Continued)
47% of infants weighing 1,000 g to 1,500 g
at birth develop ROP.

Other risk factors: prolonged mechanical
ventilation and oxygen administration,

hyperoxia, hypoxia, sepsis, acidosis, shock
Long-Term Consequences of ROP

Myopia (nearsightedness)
Strabismus (crossed eye)
Amblyopia (lazy eye)
Astigmatism
Glaucoma
Late retinal detachment
Blindness
AAP: Screening Premature

Infants for ROP
First exam occurs 4 to 6 weeks after birth
or 31 to 33 weeks postconceptional age.

Two exams after pupillary dilation using
indirect ophthalmoscopy if:

Weight at birth <1,500 g or gestational age
<28 weeks
High-risk event and weight at birth 1,501 g to
2000 g or gestational age 29 to 36 weeks
ROP Treatment
ROP progresses at different rates in
different infants.
The goal of treatment for ROP is
prevention of blindness.
Surgical therapiesLaser photocoagulation
and cryotherapy
Characteristics of Neonatal Sepsis

Early Onset
<7 days
Late Onset
7 days to 3
months
Late, Late
Onset
>3 months
Intrapartum
complications
Often present
Usually absent
Varies
Transmission
Vertical; organisms
often acquired from
mothers genital tract
Vertical or via
postnatal
environment
Usually postnatal
environment
Clinical
manifestations
Fulminant course,
multisystem
involvement,
pneumonia
Insidious, focal
infection, meningitis
common
Insidious
Case-fatality
rate
5 percent to 20 percent
5 percent
Low
M.S. Edwards, 2002a. Reprinted with permission.
Deficiencies in Neonatal Host Defenses

that Predispose to Infection
Anatomic barriersInjuries during delivery
(skin abrasions)
Invasive procedures in the nursery (umbilical
artery catheters, endotracheal tubes)

that Predispose to Infection,
Continued
Phagocytic cells
Small PMN leukocyte storage pool

Decreased PMN leukocyte adherence
Decreased PMN leukocyte and monocyte
chemotaxis
Decreased phagocytosis in stressed neonates
Decreased PMN leukocyte intracellular killing
in stressed neonates

Continued
Complement
Decreased levels of complement
Decreased expression of complement receptors
Cellular immunity
Possible defects in T-cell immunoregulation

Continued
Humoral immunity
Decreased IgA, IgM

Decreased IgG in premature neonates
Impaired antibody function
Decreased levels of fibronectin
Decreased levels of cytokine (interferon,
tumor necrosis factor)
Meningitis
Severely debilitating illness in VLBW infants
Caused by the same pathogens that cause
sepsis
Incidence of culture-proven meningitis: 1.8%
Occurs in neonates with lower mean birthweights and gestational ages
Residual major neurologic abnormalities and
subnormal scores on MDI on the Bayley Scales
of Infant Development
Meningitis
(Continued)
Most common etiology is hematogenous
spread from the bloodstream to the

meninges.
Can be early- or late-onset
Mortality is usually higher with early onset
disease.
Signs and Symptoms of Meningitis

Lethargy
Hypotonia
Temperature instability
Increased oxygen requirements
Apnea
Bradycardia
Feeding intolerance
Seizures
Pneumatocele
Pneumonia in a Premature Infant
Pneumonia
Developed:
In utero through transplacental transfer of
organisms and aspiration of pathogens from
amniotic fluid of mothers with chorioamnionitis
During/After delivery through aspiration of
infected materials
Postdelivery through inhalation of particles from
individuals or equipment; through contaminated
endotracheal tubes; through hematogenous
spread from pathogens in the bloodstream
Most common cause is GBS.

Signs and Symptoms of Pneumonia

Early signs are the same as for sepsis:
Lethargy or irritability
Poor feeding
Temperature instability
Poor color
Respiratory signs--tachypnea, apnea, cyanosis,
retractions, grunting, nasal flaring and retractions
Treatment of Sepsis, Meningitis

and Pneumonia
Early identification of neonate at risk is
essential for prevention of morbidity and

mortality.
Develop a culture of prevention of
infection in NICU.
Eradicate the pathogen with medications.
Minimize sequelae.
Nursing Care of Sepsis, Meningitis

and Pneumonia
Monitor respiratory status, oxygen
support, mechanical ventilation.

Watch for worsening apnea/bradycardia.
Suctioning PRN
Volume replacements PRN with isotonic
solutions
Nursing Care of Sepsis, Meningitis

and Pneumonia, Continued
Blood products PRN
Minimal handling to avoid extra stress
Watch for seizures.
NEC
The most common neonatal intestinal
emergency
Characterized by intestinal ischemia, most
often involving the terminal ileum
Pathogenesis is uncertain.
Three major factors: bowel wall ischemia;
bacterial invasion of the bowel wall; enteral
feedings
Pathogenesis of NEC
Three Stages of NEC

1. Generalized symptoms of early sepsis, including
temperature instability, lethargy, apnea and
bradycardia, feeding intolerance, abdominal
distention, and stools that test positive for occult
blood
2. Severe abdominal distention and tenderness,
visible bowel loops, grossly bloody stools,
metabolic acidosis, poor perfusion and a mottled
skin color
3. Fulminant signs of SIRS, including shock, mixed
acidosis, DIC and neutropenia
NEC Treatment
Goals:
Stabilize the neonate.
Treat the infection.
Rest the intestinal tract.
Discontinue feedings.
Initiate IV access for fluids and antibiotics.
NG tube to decompress GI tract
NEC Nursing Care

Monitor vital signs.
Monitor blood gases and pH.
Examine for abdominal distention,
tenderness, emesis, bloody stools,

temperature instability, metabolic acidosis,
apnea, bradycardia.
Support parents.
Encourage mother to pump breasts and
freeze breastmilk.
Intrapartum Antibiotic Prophylaxis

to Prevent Perinatal GBS
Vaginal and rectal GBS screening cultures at 35 to 37 weeks gestation
for all pregnant women (unless patient had GBS bacteriuria during the
current pregnancy or a previous infant with invasive GBS disease).
Intrapartum prophylaxis indicated
Intrapartum prophylaxis not indicated
Previous infant with invasive GBS disease

GBS bacteriuria during current pregnancy
Positive GBS screening culture during current
pregnancy (unless a planned cesarean
delivery, in the absence of labor or amniotic
membrane rupture, is performed)
Unknown GBS status (culture not done,
incomplete or results unknown) and any of
the following:
Previous pregnancy with positive GBS

screening culture (unless a culture was also
positive during the current pregnancy)
Planned cesarean delivery performed in the
absence of labor or membrane rupture
(regardless of maternal GBS culture status)
Negative vaginal and rectal GBS screening
culture in late gestation during the current
pregnancy, regardless of intrapartum risk
factors
Delivery at <37 weeks gestation

Amniotic membrane rupture 18 hours
Intrapartum temperature 100.4F
(38.0C)
GBS Prophylaxis for Women with

Threatened Preterm Delivery
Prevention of Early-Onset GBS

Disease in the Newborn
PBPs for Prevention of

Nosocomial Infections in NICUs
Increased compliance with hand-hygiene
standards
Improved accuracy of the diagnosis of
bacteremia
Reduced line and line connection (hub)
bacterial contamination
PBPs for Prevention of Nosocomial

Infections in NICUs (Continued)
Maximal barrier precautions for central
line placement
Decreased
Number of skin punctures
Duration of IV lipid infusion
Duration of central venous line use
IVH/PVH
50% will die.
Occurs in 25% to 30% of all VLBW infants
discharged from Level III NICUs

Associated primarily with prematurity
Infants <28 weeks gestation are at greatest
risk.
IVH/PVH
(Continued)
Small (Grades I and II)

Grade I hemorrhage is an isolated germinal matrix
hemorrhage.
Grade Il is an IVH with normal ventricular size.
Moderate (Grade III) is an IVH with acute
ventricular dilation.
Severe (Grade IV) is an IVH with parenchymal
hemorrhage.
Venous Drainage of Cerebral

White Matter
Signs and Symptoms of IVH/PVH

Can be subtle; sometimes only decreased
hematocrit or hemoglobin levels

May evolve over several hours and include
decreased activity, hypotonia, altered
consciousness, respiratory disturbances
Can develop rapidly, with seizures,
decerebrate posturing, fixed pupils
IVH/PVH Treatment and

Nursing Care
Optimal treatment is prevention.
Minimize brain tissue destruction.
Minimize pain and stress.
Minimize crying, suctioning, rapid bolus
infusions.
IVH/PVH Treatment and

Nursing Care (Continued)
Maintain neutral thermal environment.
Elevate head 30.
Use sucrose pacifiers, topical anesthetics
for procedures.
Provide parental support.
PBPs for Prevention of IVH and PVL

Administer antenatal steroids.
Optimize peripartum management.
Administer antenatal antibiotics for preterm
rupture of the membranes.

Delivery-room resuscitation by neonatologists
and an experienced team
PBPs for Prevention

of
IVH
and
PVL
(Continued)
Maintain the babys temperature >36
centigrade.
Maintain cardiorespiratory stability while
administering surfactant.
Optimize direct clinical management by
neonatologists.
Implement measures to minimize pain and
stress responses.
PBPs for Prevention

of IVH and PVL (Continued)
Use developmental care.
Judiciously use narcotic sedation (low dose,
continuous).
Avoid early lumbar puncture (72 hours old).
Use optimal positioning.
PBPs for Prevention

of IVH and PVL (Continued)
In terms of fluid volume treatment of
hypotension, there is no evidence

demonstrating benefit of using MAP 30
rather than MAP > estimated gestational age
weeks.
Use postnatal indomethacin judiciously.
Optimize respiratory management.
Use postnatal dexamethasone judiciously.
Goals of Nursing Care to Promote

Parental Attachment
Opening the intensive care nursery to parents
Transporting the mother to be near her infant
Maternal day care for premature infants
Rooming in for parents
Individualized nursing care plans
Early discharge

Parental Attachment (Continued)
Listening to parents during the infants
hospitalization and after discharge

Parent support groups
Programmed contact and reciprocal
interaction
Transporting the healthy premature infant
to the mother

Parental Attachment (Continued)
Home-based interventions for young
parents
Discussion with parents after discharge
Kangaroo care
Nurse home visitation
March of Dimes
Prematurity Campaign
Multi-year, multimillion-dollar campaign to
help families have healthier babies by:
Funding research to find causes of premature
birth
Educating women about risk reduction
Providing support to families
March of Dimes
Prematurity Campaign
(Continued)
Expanding access to health care coverage
for prenatal care

Helping providers learn ways to help
reduce risk of early delivery
Advocating for access to insurance to
improve maternity care and infant health
outcomes
March of Dimes
NICU Family Supportsm
Provides emotional and informational
resources to families with a newborn in

the NICU
In more than 50 NICUs in the United States
by 2007
marchofdimes.com/prematurity/nicu
March of Dimes
Share Your Story
Online community for families with a child
in the NICU
Users share NICU experiences, participate
in online discussions and meet other NICU
families.
More than 10,000 registered members
marchofdimes.com/share

Premature Infant

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Premature Infant

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The Premature Infant:

Preterm Births United States

27 percent increase from 1981 to 2001

Transition to Extrauterine Life

2006, March of Dimes

2006, March of Dimes

Vulnerable to cold stress

2006, March of Dimes

Follow resuscitation from NRP guidelines.

2006, March of Dimes

recommended by NRP guidelines.

Major Physiologic Problems

chronic lung disease

2006, March of Dimes

Additional Physiologic Problems

Skin immaturity and fragility

2006, March of Dimes

Complex respiratory disease characterized

2006, March of Dimes

Repeat courses of corticosteroids should

not be given routinely in pregnant women.

Chain of Events with Surfactant

2006, March of Dimes

Signs and Symptoms of RDS

especially if infant has risk factors for RDS

2006, March of Dimes

Signs and Symptoms of RDS

2006, March of Dimes

Fluid balance and nutrition

2006, March of Dimes

Focus is to prevent and minimize atelectasis.

and other physiologic problems.

It prevents collapse (atelectasis) and

beneficial than rescue therapy.

2006, March of Dimes

Criteria for identifying at-risk infants who

would benefit from prophylactic

2006, March of Dimes

Adjunct Treatments for RDS

Adjunct Treatments for RDS

RDS Nursing Care

2006, March of Dimes

RDS Nursing Care

Maintain paO2 and oxygen saturation levels.

and other ventilator parameters.

2006, March of Dimes

RDS Nursing Care

Provide mouth and skin care.

2006, March of Dimes

Signs and Symptoms of BPD

2006, March of Dimes

Cascade of Events Occurring in

2006, March of Dimes

preventing prematurity and using a single

use of low ventilator pressures, and careful

to mechanically ventilated premature

has not shown benefits.

2006, March of Dimes

BPD Nursing Care

BPD Nursing Care

Preoxygenation (increasing FiO2 just

before suctioning) may help prevent