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GOOD MORNING!

NCM 102 A
CARE OF THE HIGH
RISK CHILD
CLAIRE ALVAREZ
ONGCHUA RN,MN
CARE OF THE HIGH
RISK
NEWBORN
Newborn classification
Based on
GESTATIONAL AGE
BIRTH WEIGHT
BIRTH WEIGHT AND GESTATION
Classification
Based on Gestational Age
Preterm (premature) born at 37 weeks' gestation
or less
Term born between the beginning of week 38
and the end of week 41 of gestation
Post-term (postmature) born at 42 weeks'
gestation or more
Based on Birth Weight

Low birth weight (LBW) less than 2500 g


Very low birth weight (VLBW) less than
1500 g
Extremely low birth weight (ELBW) less
than 1000 g
Based on Birth Weight & Gestation

Appropriate for gestational age (AGA) weight is


appropriate for the gestational age
Small for gestational age (SGA) smaller than
expected, the weight falls bellow the 5th percentile
for the gestational age
Large for gestational age (LGA) heavier than
expected, the birth weight is above the 95th
percentile for the gestational age
PREMATURE INFANT
Pathophysiology
Preterm newborn exhibits anatomic
and physiologic immaturity in all
body systems; this immaturity
hinders the adaptation to
extrauterine life that the newborn
must make.
Pathophysiology and Etiology
Maternal factors associated with prematurity,
including
Poor nutrition
Diabetes
Drug abuse
Chronic disease
being a multigravida mother younger than age
18, or a primigravida mother older than age 40.
Complications of pregnancy associated with
prematurity include, but are not limited to:
Pregnancy-induced hypertension.
Bleeding.
Placenta previa or abruptio placentae.
Incompetent cervix.
Premature rupture of membranes.
Polyhydramnios/oligohydramnios.
Chorioamnionitis.
Fetal factors associated with prematurity
include:

Chromosomal abnormalities.
Anatomic abnormalities, such as
tracheoesophageal atresia or fistula and
intestinal obstruction.
Fetoplacental unit dysfunction.
The premature infant has altered physiology because
of immature and typically poorly developed systems.
The severity of any problem that occurs depends
somewhat on the gestational age of the infant.
Systems and situations that are most likely to cause
problems in the premature infant include:
Respiratory system.
Digestive system.
Thermoregulation.
Immune system.
Neurologic system.
Physiologic Challenges of the premature
infant

Respiratory and Cardiac


Lack of surfactant
Pulmonary blood vessels
Ductus arteriosus
Physiologic Challenges of the
premature infant
Thermoregulation
Increased body surface
Decreased brown fat
Thin Skin
Lack of flexion
Decrease subcutaneous fat
Physiologic Challenges of the premature
infant
Digestive
Poor gag reflex
Small stomach capacity
Relaxed cardiac sphincter
Poor suck and swallow reflex
Difficult fat, protein and lactose
digestion
Absorption
Physiologic Challenges of the premature
infant
Renal
Decreased glomerular filtration rate
Inability to concentrate urine or excrete
excess
Decreased ability of kidneys to buffer
Decreased drug excretion time
COMPLICATIONS
Apnea. This is a pause in breathing for 20 seconds or
more. Premature babies sometimes have apnea. It
may happen together with a slow heart rate.

Respiratory distress syndrome (RDS). This is a


breathing problem most common in babies born
before 34 weeks of pregnancy. Babies with RDS dont
have a protein called surfactant that keeps small air
sacs in the lungs from collapsing.
COMPLICATIONS
Intraventricular hemorrhage (IVH). This is bleeding in the
brain. It usually happens near the ventricles in the center of
the brain. A ventricles is a space in the brain thats filled with
fluid.

Patent ductus arteriosis (PDA). This is a heart problem that


happens in the connection (called the ductus ateriosus)
between two major blood vessels near the heart. If the
ductus doesnt close properly after birth, a baby can have
breathing problems or heart failure. Heart failure is when the
heart cant pump enough blood.
COMPLICATIONS
Necrotizing enterocolitis (NEC). This is a problem
with a babys intestines. It can cause feeding
problems, a swollen belly and diarrhea. It sometimes
happens 2 to 3 weeks after a premature birth.

Retinopathy of prematurity (ROP). This is an


abnormal growth of blood vessels in the eye. ROP can
lead to vision loss.
COMPLICATIONS
Jaundice. This is when a baby's eyes and skin look yellow.
A baby has jaundice when his liver isn't fully developed or
isn't working well.

Infections. Premature babies often have trouble fighting


off germs because their immune systems are not fully
formed. Infections that may affect a premature baby
include pneumonia, a lung infection; sepsis, a blood
infection; and meningitis, an infection in the fluid around
the brain and spinal cord.
COMPLICATIONS
Anemia. This is when a baby doesnt have enough
healthy red blood cells to carry oxygen to the rest of the
body.

Bronchopulmonary dysplasia (BPD). This is a lung


condition that can develop in premature babies as well as
babies who have treatment with a breathing machine.
Babies with BPD sometimes develop fluid in the lungs,
scarring and lung damage.
Nursing Assessment and Interventions
Notice physical characteristics of the premature neonate:
Hair - lanugo, fluffy.
Poor ear cartilage.
Thin skin; capillaries are visible (may be red and wrinkled).
Lack of subcutaneous fat.
Poor Muscle tone , possibly weak reflexes
Soft fingernails.
Head is disproportionately large.
Breast buds 5 mm.
36 weeks' gestation - none.
38 weeks' gestation - 1 inches (3 cm).

Testes - undescended.
Labia majora - undeveloped.
Rugae of scrotum - fine.
Sole of foot is smooth.
36 weeks' gestation - anterior 1/3 of foot is creased.

38 weeks' gestation - 2/3 of foot is creased.

Abdomen - relatively large.


Thorax - relatively small.
Obtain accurate body measurements.

Head circumference
Abdominal girth
Heel to crown.
Shoulder to umbilicus - used to calculate
proper length of catheter for umbilical arterial
catheter placement.
Weight in grams.
Assess gestational age using a tool such as the Ballard
scoring system (recommended by Committee of Fetus
and Newborn of American Academy of Pediatrics):

Observation of physical and neurologic


characteristics that change predictably with growth
and maturation. Ideally done in the first 12 to 24
hours of life.
Assist with laboratory testing as indicated for blood
gases, blood glucose, complete blood count or
hemoglobin and hematocrit, electrolytes, calcium,
bilirubin.
Monitor closely for respiratory or cardiac
complications.

1. Respirations above 60 per minute may indicate


respiratory difficulty.
2. Expiratory grunting, retractions, chest lag, or
nasal flaring should be reported immediately
3. Watch for cyanosis and other signs of respiratory
distress.
4. Increased (more than 180 bpm) or irregular heart
rate may indicate cardiac or circulatory
difficulties.
5. Muscle tone and activity should be evaluated.
6. Hypotension, indicated by blood pressure
measurement, may be caused by hypovolemia.
7. Hypoglycemia may result from inadequate
glycogen stores, respiratory distress, and cold
stress.
Institute cardiac monitoring and care for
infant in isolette or radiant heater. Omit bath
until infant's temperature has stabilized.

Observe for early signs of jaundice and check


maternal history for any blood
incompatibilities. Also be aware of maternal
factors that can lead to additional
complications, such as drug use, diabetes, and
infection.
ISOLETTE / RADIANT WARMER
Once the infant is admitted to the nursery, be
aware that the first 24 to 48 hours after birth is
a critical time, usually requiring constant
observation and intensive care management.
Make the following observations:

1. Note bleeding from the umbilical cord -


apply pressure, and notify health care
provider.
2. Note first voiding - may occur up to 36 hours
after birth; after first voiding, report any 4- to
6-hour period when voiding does not occur.

3. Note stools - abdominal distention and lack of


stool may indicate intestinal obstruction or
other intestinal tract anomalies. Measure
abdominal girth at regular intervals.
4. Note activity and behavior - look for sucking
movement, and hand-to-mouth maneuver, which
can help to determine oral feeding initiation.
5. Observe for a tense and bulging fontanelle; feel
suture lines, noting separation or overriding -
may indicate intracranial hemorrhage. Be alert to
twitching and seizures.
6. Note color skin for cyanosis and jaundice, rashes,
paleness, ruddiness.
7. Carefully monitor, record, and report vital signs.
Have available resuscitative equipment,
oxygen, and suction apparatus.
1. A rubber ear bulb syringe is usually all that is
necessary for clearing the mouth.
2. Frequent suctioning of the pharynx may not be
necessary.
Position neonate to allow for easy ventilation, paying
careful attention to maintaining body alignment and
facilitating hand-to-mouth positioning.
1. Elevate head and trunk to decrease pressure on
diaphragm from abdominal organs.
2. Change position from side to side.
Provide oxygen therapy with moisture in the
percentage necessary to maintain appropriate blood
gas values.
1. Monitor oxygen with analyzer continuously to
ensure consistency in percentage used.
2. Pulse oximeter correlates well with oxygen (O2)
saturation of arterial hemoglobin) of the blood.
Monitor for apnea versus periodic breathing (regular
repetition of breathing pauses of less than 15
seconds, alternating with breaths of regularly
increasing then decreasing amplitude for 10 to 15
seconds). Theophylline may be given to reduce
apneic episodes.
Protect the infant from infection by following
scrupulous hand-washing policy, minimizing
neonate's contact with unsterile equipment, and
minimizing the number of people who come in
contact with the neonate.
Provide good skin care using water for bathing, an
approved emollient for the skin, avoiding adhesives,
and providing adequate hydration.
Avoid cranial deformity by using gel head pillow,
frequent turning, and upright position.
Protect the neonate's eyes from bright lights.

Continue to provide I.V. and oral feedings


according to neonate's needs. Assist the
mother with breast pumping as needed, and
encourage both parents to hold and feed
infant.
Continue to monitor for complications, such as
1. Hypoglycemia
2. Hyperglycemia
3. RDS
4. Apnea
5. Infection
6. Hypocalcemia
7. Cardiac abnormalities
8. Necrotizing enterocolitis
9. Intracranial hemorrhage
10. Hyperbilirubinemia.
Long-term complications may include
1. retinopathy of prematurity
2. chronic lung disease
3. hearing loss
4. learning disabilities

Do not neglect the needs of the parents. Instead,


make every effort to include them in the infant's care
and update them frequently on the infant's condition.
Classifications Usedfor SelectedInterventions
Restoresnaturallyoccurring Theusualdoseis4mL/kg
Lungsurfactant lungsurfactanttoimprovelung intratracheallyin4dosesatleast6
Beractant compliance hoursapartinthefirst48hoursof
(Survanta) life.
Usedtopreventortreat
respiratorydistresssyndromein Suctiontheinfantsairwaybefore
prematureinfants administrationanddelayfurther
suctioningaslongaspossible.
Assesstheinfantsrespiratoryrate,
arterialbloodgases,andcolor
beforeadministration.
Changetheinfantspositionevery2
hourstopromoteflowtobothlungs.
Assesstheinfantsrespiratoryrate,
color,andarterialbloodgasesafter
administration.
Monitorforsideeffects,whichmay
includetransientbradycardiaor
rales.
Care of Preterm newborns
OPTIMAL MANAGEMENT AT BIRTH:
Attended by a senior pediatrician
Air passage cleared of mucus
Clamp cord quickly. Delayed cord clamping
helps in improving iron store but led to
hypovolemia and heperbilirubinemia
Promptly dry, keep effectively covered and
warm
Vit. K 0.5mg IM
MONITORING
Vital signs
Activity and behavior
Color
Tissue perfusion:
Pink color
capillary refill over upper chest <2 sec
warm and pink extremities
normal BP
urine output>1.5 ml/kg/hr
absence of metabolic acidosis
lack of disparity between PaO2 and SPO2
ABG and electrolyte
Tolerance of feeds: vomiting, gastric residuals
and abdominal girth
Look fro development of apnic attack, sepsis
Weight gain velocity
PROVIDE IN UTERUS MILIEU
1. Create soft comfortable nestled and
cushioned bed
2. Avoid excessive light, sound, rough handling
and painful procedures. Use effective
sedation and analgesia for procedures
3. Provide warmth and ensure asepsis
4. Prevent evaporative skin losses by effectively
covering the baby, application of oil or liquid
paraffin
5. Provide effective and safe oxygenation
6. Provide parenteral nurition partially and give
trophic feeds with EBM (Expressed breast milk)
7. Provide tactile and kinesthetic stimulation- skin
to ski contact, interaction, music caressing and
cuddling
POSITION OF THE BABY : PRONE POSITION

1. Most love to lie in a prone position, cry less


and feels more comfortable
2. Relives abdominal discomfort by passage of
flatus and reduce risk of aspiration
3. Increased ventilation and increase dynamic
lung compliance and enhance arterial
oxygenation
4. NURSING ALERT: Unsupervised prone
positioning beyond neonatal period
recognized as a risk factor for SIDS.
THERMAL COMFORT

1. Prewarmed open care system or incubator


should be available
2. Care in a thermo neutral environment (36.5C)
3. Application of oil or liquid paraffin reduce
convective heat loss and evaporative water
loss
4. As soon as condition stabilizes effectively
clothe the baby
5. Partial kangaroo
care to prevent hypothermia
6. Extremely low babies covered
with a cellophane or thin
transparent plastic sheet to prevent
convective and evaporative losses from
skin
OXYGEN THERAPY

Oxygen should be administered with a head


box/hood when saturation is < 85% and
withdrawn gradually when > 90%
PHOTOTHERAPY
Jaundice is common due to immaturity, hypoxia,
hypoglycemia, infections and hypothermia
Due to immaturity of blood brain barrier.
Hypoproteinemia and perinatal distress factors
bilirubin brain damage may occur at relative lower
level
Initiate phototherapy early
PREVENTION OF NOSOCOMIAL INFECTION

Handling should be reduced to minimum


Vigilance maintained on all procedures
IMMUNIZATION

The dose is not reduced in preterm babies


FAMILY SUPPORT
Family should be constantly informed and
involved in care of baby
Mother should be encouraged to touch and
talk with her baby and provide routine care
under guidance of
nurse
Assist to provide
kangaroo care
POSTMATURE
NEWBORN
Clifford
Syndrome
Stewart H. Clifford
in 1954
A post-term pregnancy is one that extends
beyond 42 weeks gestation.
The post-term infant may be
LGA
AGA
SGA
or Dysmature - relating to or characteristic of
an infant whose birth weight is inappropriately
low for its gestational age.
(depending on placental function.)
Etiology
Mostly unknown.
Error in menstrual dating
Previous post term pregnancy
After one post term pregnancy, the risk of recurrence in the
subsequent birth is ed 2 to 3-fold;4 folds after 2 prior
post term pregnancies
Rare cause of post term pregnancy
Anencephaly
Congenital primary fetal adrenal hypoplasia
Male fetal gender
ANENCEPHALY
Pathophysiolgy
If the placenta continues to function well, the
fetus will continue to grow, which results in an
LGA infant who may manifest problems such as
birth trauma and hypoglycemia.
If placental function decreases, the fetus may not
receive adequate nutrition. The fetus will utilize its
subcutaneous fat stores for energy. Wasting of
subcutaneous fat occurs, resulting in fetal dysmaturity
syndrome. There are three stages of fetal dysmaturity
syndrome.
Stage 1- Chronic placental insufficiency
Dry, cracked, peeling, loose, and wrinkled skin
Malnourished appearance
Open-eyed and alert baby
Stage 2- Acute placental insufficiency
Allfeatures of stage 1 except point iii
Meconium staining

Perinatal depression

Stage 3- Subacute placental insufficiency


Findings of stage 1 and 2 except point iii

Green staining of skin, nails, cord, and

placental membrane
A higher risk of fetal inrapartum or neonatal

death
The newborn is at increased risk for developing
complications related to compromised uteroplacental
perfusion and hypoxia (e.g., meconium aspiration
syndrome MAS)

Chronic intrauterine hypoxia causes increased fetal


erythropoietin and red blood cell production resulting
in polycythemia.

Post-term infants are susceptible to hypoglycemia


because of the rapid use of glycogen stores.
RISK TO FETUS
Perinatal death
Post maturity syndrome
Fetal distress and Oligohydramious
Macrosomia
MAS
Fetal growth restriction
Uteroplacental insufficiency
Maternal Risk
Severe perineal injury with macrosomia
Increased C/S delivery
Puerperal infection, PPH
Anxiety
Assessment Findings
Clinical manifestations include:

A long, thin newborn with wasted appearance


Dry, cracked, peeling, parchment-like skin
meconium-stained skin, nails, and umbilical cord.
Fingernails are long and hard
Creases on the babys palm and soles of the feet
Absent vernix and decreased lanugo
Abundant scalp hair
Meconium aspiration syndrome is
manifested by:
fetal hypoxia,
meconium staining of amniotic fluid,
respiratory distress at delivery,
meconium-stained vocal cords.
Nursing Management
1. Manage meconium aspiration syndrome.

Suction the infants mouth and nares while the head is on


the perineum and before the first breath is taken to prevent
aspiration of meconium that is in the airway.
Once the infant is dry and on the warmer, intubate with
direct tracheal suctioning.
Perform chest physiotherapy with suctioning to remove
excess meconium and secretions.
Provide supplemental oxygen and respiratory support as
needed.
2. Obtain serial blood glucose measurements.
3. Provide early feeding to prevent
hypoglycemia, if not contraindicated by
respiratory status.
4. Maintain skin integrity.
Keep the skin clean and dry.
Avoid the use of powders, creams, and lotions.
Avoid the use of tape.
7. Provide education and emotional support.

Explain the possible causes of intrauterine growth


retardation.
Inform parents of the infants goal weight for
discharge.
Provide instruction on managing the infant at home.
Explain how to prepare a higher calorie formula or
breast feeding.
Explain the importance of follow-up with a
developmental specialist who will screen for
milestone achievements.
Small-for-gestational
age Newborn (SGA)
An SGA infant is one whose length, weight,
and had circumference are below the 10th
percentile of the normal variation for
gestational age as determined by neonatal
examination.

The SGA infant may be preterm, term, or post-


term.
Maternal conditions associated with SGA
babies include:

Hypertension
Cardiac, pulmonary, or renal disease
Diabetes mellitus
Poor nutrition
Use of alcohol, tobacco, or drugs
Maternal conditions associated with SGA
babies include:

Age
Multiple gestation
Placental insufficiency
Placental fetal abnormalities
Pregnancy occurred at high altitudes
Fetal conditions associated with SGA infants
include:

Normal genetically small infant


Chromosomal abnormality
Malformations
Congenital infections, especially rubella and
cytomegalovirus
Assessment Findings

1. Clinical manifestations
Soft tissue wasting and dysmaturity
Loose, dry, and scaling skin
Perinatal asphyxia (due to a small placenta that is
less efficient in gas exchange)
Plethora, respiratory distress, and central nervous
system (CNS) aberrations (if the infant has
polycythemia)
Congenital anomalies (occurring in as many as 35%
of SGA infants who suffered insults early in gestation)
2. Laboratory and diagnostic study findings

Glucose testing will reveal decreased glycogen


stores, which increases the potential for
hypothermia and hypoglycemia.

Hematocrit level may be increased (65%),


which indicates polycythemia as a result of
chronic fetal hypoxia.
Nursing Management

1. Provide adequate fluid and electrolytes and


nutrition.
Provide a high calorie formula for feeding
(more than 20 calories per ounce) to promote
steady weight gain (15 to 30 grams per day
growth plotted on curves shows a normal
growth rate).
If the infant is breast feeding, add human
milk fortifier to expressed breast milk.
2. Decrease metabolic demands when
possible.
Provide small frequent feedings.
Provide gavage feedings if the infant does
not have a steady weight gain.
Provide a neutral thermal environment.
Decrease iatrogenic stimuli.
3. Prevent hypoglycemia

Monitor glucose screening.


Provide early feedings.
Provide frequent feedings (every 2 to 3
hours)
Administer IV glucose if blood sugar does
not normalize with oral feedings.
4. Maintain a neutral thermal environment.
5. Monitor serum hematocrit (normal is 45% to 65%).
If an initial high hematocrit was obtained by heel stick
capillary sample, a follow-up sample should be done
by venipuncture.
Observe for signs, symptoms, and complications of
polycythemia
Ruddy appearance

Cyanosis

Lethargy, jitteriness, and seizures

Jaundice

Provide adequate hydration to prevent hyperviscosity


6. Assess the prenatal history for possible
toxoplasmosis, rubella, cytomegalovirus, and
herpes simplex infections during pregnancy.
Assess maternal and infant antibody titers. Use
isolation precautions when congenital
infections are suspected.
7. Provide education and emotional support.

Explain the possible causes of intrauterine growth


retardation.
Inform parents of the infants goal weight for
discharge.
Provide instruction on managing the infant at home.
Explain how to prepare a higher calorie formula or

breast feeding.
Explain the importance of follow-up with a

developmental specialist who will screen for


milestone achievements.
Large-for-Gestational
Age (LGA) Newborn
A LGA newborn is one weighs more than
4,000 g, is above the 90th percentile, or is two
standard deviations above the mean.

The LGA infant can be pre-term, term, or post-


term.
Etiology
Predisposing factors include:

Genetic predisposition
Excessive maternal weight gain during
pregnancy.
Poorly controlled maternal diabetes
secondary to high levels of maternal glucose
that cross the placenta during pregnancy.
Pathophysiology
Infants who are large for gestational age have been
subjected to an overproduction of growth hormone in
utero. This most frequently happens with infants of
diabetic mothers who are poorly controlled. It may also
occur in multiparous pregnancies because with each
pregnancy babies tend to grow larger.

Other associated conditions include transposition of the


great vessels, Beckwith syndrome and congenital
anomalies.
Assessment Findings
Clinical manifestations include:

Complications associated with maternal diabetes


Birth injuries due to disproportionate size of newborn to
birth passageway
a. Fractured clavicle
b. Facial nerve injury
c. Erb-Duchenne palsy or brachial plexus paralysis
d. Klumpke paralysis
e. Phrenic nerve palsy
f. Possible skull fracture
Nursing Management
1. If IDM, observe for potential complications
2. Monitor for, and manage, birth injuries and
complications of birth injuries.
a. Clavicle fracture
Confirm by x-ray.
Assess the infant for crepitus, hematoma, or deformity over
the clavicle; decreased movement of arm on the affected
side; and asymmetrical or absent. Moro reflex.
Limit arm motion by pinning the infants sleeve to the shirt.
Manage the pain
Clavicle fracture
b. Facial nerve injury

Assess for symmetry of mouth while crying.


Wrinkles are deeper on the unaffected side.
The paralyzed side is smooth with a swollen
appearance.
The nasiolabial fold is absent.
If the eye is affected, protect it with patches
and artificial tears.
c. Erb-Duchenne palsy and Klumpke paralysis

Erb-Duchenne palsy. Refers to paralysis of the


upper brachial plexus. Assess for adduction of
the affected arm with internal rotation and
elbow extension. The Moro reflex is absent on
the affected side. The grasp reflex is intact.
Klumpke paralysis. Refers to paralysis of the
lower brachial plexus. Assess for absent grasp
on the affected side. The hand appears claw-
shaped.
Erb-Duchenne palsy
(Brachial Plexus Birth
Palsy)
c. Erb-Duchenne palsy and Klumpke paralysis
Management includes:
X-ray studies of the shoulder and upper arm to
rule out bony injury
Examination of the chest to rule out phrenic
nerve injury
Delay of passive movement to maintain range of
motion of the affected joints until the nerve
edema resolves (7 to 10 days)
Splints may be useful to prevent wrist and digit
contractures on the affected side
Klumpke paralysis
d. Phrenic nerve palsy

Assess for respiratory distress with


diminished breath sounds.
X-ray usually shows elevation of the
diaphragm on the affected side.
Provide pulmonary toilet to avoid
pneumonia during the recovery phase (1
to 3 months).
e. Skull fracture.
Assess for soft-tissue swelling over fracture site
visible indentation in scalp
Cephalhematoma
positive skull x-ray, and CNS signs with intracranial
hemorrhage (e.g., lethargy,seizures, apnea, and
hypotonia).
ACUTE CONDITIONS OF
THE
NEONATE
RESPIRATORY DISTRESS
SYNDROME
(RDS)
HYALINE MEMBRANE DISEASE
(HMD)
Respiratory distress syndrome (RDS) is a
syndrome of premature neonates that is
characterized by progressive and usually
fatal respiratory failure resulting from
atelectasis and immaturity of the lungs.
Pathophysiology
Primaryabsence, deficiency or alteration in
the production of surfactant
Surfactant, atelectasis = lack of gas
exchange
Leads to hypoxia and acidosis which
further inhibit surfactant production and
causes pulmonary vasoconstriction.
RDS occurs most commonly in premature
neonates
RDS can be fatal; those who survive are at risk
for chronic respiratory and neurologic
complications.
RDS is ultimately the result of decreased
pulmonary SURFACTANT, incomplete structural
development of lung, and a highly compliant
chest wall.
SURFACTANT
A substance composed of lipoprotein that is
secreted by the alveolar cells of the lung and
serves to maintain the stability of pulmonary
tissue by reducing the surface tension of fluids
that coat the lung.
Contributing factors are any factor that
decreases surfactant, such as:

Prematurity and immature alveolar lining


cells.
Acidosis.
Hypothermia.
Hypoxia.
Hypovolemia.
Diabetes.
Elective cesarean delivery.
Fetal or intrapartum stress that
compromises blood supply to fetal lungs:
vaginal bleeding, maternal hypertension,
difficult resuscitation associated with birth
asphyxia. (Some situations, such as steroid
therapy or a heroin-addicted mother, result
in the acceleration of surfactant.)
RDS due to non-pulmonary factors such as:
cardiac defects, sepsis, airway obstruction,
intraventricular hemorrhage, hypoglycemia,
and acute blood loss.

RDS is usually a self-limiting disease, and


symptoms peak in about 3 to 4 days, at which
time surfactant synthesis begins to accelerate,
and pulmonary function and clinical appearance
begin to improve.
Moderately ill infants or those who do
not require assisted ventilation usually
show slow improvement by about 48
hours and rapid recovery over 3 to 4
days with few complications.
Severely ill and very immature infants who require
some ventilatory assistance usually demonstrate
rapid deterioration, such as
decreased cardiac inflow
decreased arterial pressure
apneic episodes
cyanosis
pallor,
and flaccid, unresponsive shocklike state.
Ventilatory assistance may be required for several
days, and chronic lung disease and other
complications are common.
Risk for RDS
He was born before 37 weeks.
He was born to a mother with diabetes.
His sibling had RDS.
He did not get enough oxygen before,
during, or just after birth.
Clinical Manifestations
Symptoms are usually observed soon after birth and
may include those listed here.

Primary Signs and Symptoms


Expiratory grunting or whining (when the infant is
not crying).
Sternal, suprasternal, substernal, and intercostal
retractions progressing to paradoxical seesaw
respirations.
Inspiratory nasal flaring.
Clinical Manifestations
Tachypnea less than 60 breaths per minute.
Hypothermia.
Cyanosis when child is in room air (infants with
severe disease may be cyanotic even when given
oxygen), increasing need for oxygen.
Decreased breath sounds and dry sandpaper breath
sounds.
Pulmonary edema.
Clinical Manifestations
As the disease progresses:

Seesaw retractions become marked with


marked abdominal protrusion on expiration.
Peripheral edema increases.
Muscle tone decreases.
Cyanosis increases.
Clinical Manifestations
As the disease progresses:

Body temperature drops.


Short periods of apnea occur.
Bradycardia may occur.
Changes in distribution of blood throughout
the body result in pale gray skin color.
Diminished breath sounds.
Clinical Manifestations
Secondary Signs and Symptoms

Hypotension.
Edema of the hands and feet.
Absent bowel sounds early in the illness.
Decreased urine output.
Diagnostic Evaluation
Prenatal diagnosis: Evaluation of amniotic fluids to
assess fetal lung maturity.
Lecithin/sphingomyelin ratio tests of surfactant
phospholipids in amniotic fluid.
Phosphatidylcholine and phosphatidylglycerol (PG)
phospholipids that stabilize surfactant.
TDX fetal maturity assay determines PG levels in
amniotic fluid or neonatal tracheal aspirates.
Lamellar bodies test measures a storage form of
surfactant in amniotic fluids.
Diagnostic Evaluation
Laboratory tests:
Elevated Partial pressure of arterial carbon dioxide
PaCO2.
Low Partial pressure of arterial oxygen (PaO2) low.
Low Blood Ph due to metabolic acidosis.
Low Calcium
Low Serum glucose
Pulmonary function studies - stiff lung with a
reduced effective pulmonary blood flow.
Diagnostic Evaluation
Laboratory tests:
Chest X-ray - diffuse, fine granularity; whiteout,
very heavy, uniform granularity reflecting fluid-
filled alveoli and atelectasis of some alveoli,
surrounded by hyperdistended bronchioles; ground
glass appearance with prominent air bronchogram
extending into periphery of lung fields. Pulmonary
interstitial emphysema (PIE) is observed in
premature neonates with RDS due to
overdistention of distal airways.
Management

Early recognition is imperative so that


treatment may be initiated to halt the
progression of RDS. Transportation to a
facility providing specialized care is
desirable when possible.
Management
Supportive

Maintenance of oxygenation

Maintenance of respiration with ventilatory


support, if necessary.
Intermittent mandatory ventilations
delivered via ET tube.
Positive end-expiratory pressure (PEEP) via
ET tube.
Continuous positive airway pressure (CPAP)
delivered via ET tube or nasal prongs.
Synchronized intermittent mandatory
ventilation allows the infant to breathe
spontaneously between mechanical breaths.
Continuous positive airway pressure (CPAP)
delivered via ET tube or nasal prongs.
Management
Maintenance of normal body temperature.
Maintenance of fluid, electrolyte, and acid-
base balance -metabolic acidosis buffered with
sodium bicarbonate.
Maintenance of nutrition - I.V. dextrose 10% in
water usually required.
Antibiotics as needed to treat infection.
Management
Constant observation for complications -
pneumothorax, disseminated intravascular
coagulation (DIC), patent ductus arteriosus
(PDA) with heart failure, chronic lung disease.
Care appropriate for a small, premature
neonate.
Prevent hypotension.
Maintain a hematocrit of 40% to 45%.
Management
Aggressive

Administration of exogenous surfactant into


lungs early in the disease.
Available preparations: bovine (Survanta)
and synthetic (Exosurf) surfactant.

Administered into the ET tube.


Management
Extracorporeal membrane oxygenation (ECMO) -
indicated in infants with reversible cardiac or
respiratory failure. ECMO is a modified heart-lung
bypass machine used to allow gas exchange outside
the body.

Ventilatory support modalities for RDS currently


under study: nitric oxide, liquid ventilation (tidal or
partial), and perfluorocarbon assisted gas exchange.
Management
Bronchodilators: This may be given to open up your
baby's airways so that he can breathe easier.
Diuretics: This may be given to help your baby's body get
rid of extra fluid or water. This may help your baby
breathe easier.
Pain medicine: This may help keep your baby calm and
comfortable if he has pain.
Sedatives: This helps keep your baby calm while he gets
better.
Nursing Assessment
Review the birth history.
Apgar scores 1 and 5 minutes after birth.
Type of resuscitation required.
Treatments or medications administered.
Medications or anesthesia administered to the
mother during labor.
Estimated gestational age.
Maternal history - contributing factors or
complications.
Nursing Assessment
Carefully assess the infant's respiratory status to
determine the degree of respiratory distress.
Determine the degree and severity of
retractions.
Count the respiratory rate for 1 full minute, note
level of activity, and determine if they are regular
or irregular.
Identify periods of apnea, length, and type of
stimulation necessary.
Nursing Assessment
Carefully assess the infant's respiratory status to
determine the degree of respiratory distress.
Listen for expiratory grunting or whining sounds
from the infant when quiet. This indicates an
attempt to maintain PEEP and prevent alveoli from
collapse.
Note nasal flaring.
Note cyanosis - location, improvement with
oxygen.
Auscultate chest for diminished breath sounds and
presence of crackles.
Nursing Assessment
Determine the infant's cardiac rate and rhythm.
Count the apical pulse for 1 full minute.
Note irregularities in the rate or bounding pulses.
Observe the infant's general activity.
Lethargic or listless.
Active and responds to stimuli.
Infant's cry.
Assess the skin for cyanosis, jaundice, mottling,
paleness or grayness, and edema.
Nursing Diagnoses with Interventions
1. Impaired Gas Exchange related to disease process
Promoting Adequate Gas Exchange
Have emergency equipment readily available
for use in the event of cardiac or respiratory
arrest.
Institute cardiorespiratory monitoring to
continuously monitor heart and respiratory
rates.
Administer supplemental oxygen.
Incubator with oxygen at prescribed
concentration.
Plastic hood with oxygen at prescribed
concentration when using radiant
warmer.
CPAP, if indicated, using nasal prongs
or ET tube.
Assist with ET intubation, and maintain
mechanical ventilation as indicated.

Measure oxygen concentration every hour


and record.

Monitor ABG levels as appropriate.


Institute pulse oximetry, if available, for
continuous monitoring of the blood's arterial
oxygen saturation (SaO2).
Avoid using adhesive to secure the sensor when
the infant is active. Wrap it snugly enough to
reduce sensitivity to movement but not tight
enough to constrict blood flow.
If transcutaneous PaO2 monitor is used, reposition
the probe every 3 to 4 hours to avoid burns caused
by heating the probe to achieve sufficient
arterialization.
Measure oxygen concentration every hour
and record.
Observe the infant's response to oxygen.
Observe for improvement in color, respiratory rate
and pattern, and nasal flaring.
Note response by improvement in arterial or
capillary blood gas levels.
Observe closely for apnea.
Stimulate infant if apnea occurs. If unable to
produce spontaneous respiration with stimulation
within 15 to 30 seconds, initiate resuscitation.
Position the infant to allow for maximal lung
expansion.
Prone position provides for a larger lung volume
because of the position of the diaphragm, decreases
energy expenditure, and increases the time spent in
quiet sleep; however, it may be contraindicated due
to placement of the umbilical catheter.
Change position frequently.
Suction as needed because the gag reflex is
weak and cough is ineffective.
Try to minimize time spent on procedures and
interventions, and monitor effects on
respiratory status. (Infants undergoing multiple
procedures lasting 45 minutes to 1 hour have
shown a moderate decrease in PaO2.)
The decision to suction should be based on
assessment of the infant, such as auscultation
of chest, decrease in oxygenation, excessive
moisture in the ET tube, and irritability.

Nasopharyngeal, tracheal, or ET tube suctioning


should be done gently, quickly, 5 seconds or less,
with intermittent suction applied as the catheter is
withdrawn.
To prevent hypoxemia, observe oximeter before,
during, and after the procedure.
Suctioning of the ET tube is done to maintain a
patent airway. When suctioning, do not insert the
catheter beyond this predetermined length. This
will prevent damage to the mucosa.
Observe for complications of suctioning:
bronchospasm, vagal nerve stimulation,
bradycardia, hypoxia, increased intracranial
pressure, trauma to airway, infection, and
pneumothoraces.
2. Imbalanced Nutrition: Less than Body
Requirements related to prematurity and
increased energy expenditure on breathing
Promoting Adequate Nutrition and Hydration
Administer I.V. fluids or enteral feeding as ordered,
and observe infusion rate closely to prevent fluid
overload.
Observe I.V. sites for infiltration or infection; use
meticulous technique to prevent sepsis.
If umbilical artery catheter is in place,
observe for bleeding.
Provide adequate caloric intake (80 to 120
kcal/kg/24 hours) through the following:
Nasojejunal tube (best tolerated by VLBW
neonates).
Nasogastric tube.
Parenteral nutrition - D10W or hyperalimentation
fluid usually required, especially in the acute phase
of illness.
Monitor for hypoglycemia, which is especially
common during stress. Maintain serum
glucose greater than 45 mg/dL.
Monitor intake and output closely.
Include amount of blood drawn (small infants can
become anemic due to frequent blood sampling).
Apply urine collection bag to obtain sample of
urine, and measure specific gravity periodically.
Weigh the infant daily.
3. Ineffective Thermoregulation related to
immaturity

Maintaining Thermoregulation
Provide a neutral thermal environment to maintain
the infant's abdominal skin temperature between
(36.1 and 36.7 C) to prevent hypothermia, which
may result in vasoconstriction and acidosis.
Adjust Isolette or radiant warmer to obtain
desired skin temperature. For the infant
weighing less than 1,250 g., the radiant
warmer should be used with caution
because of increased water loss and
potential for hypoglycemia.
Prevent frequent opening of Isolette.
Ensure that oxygen is warmed to a
temperature between (30.9 and 34 C) with
60% to 80% humidity
4. Impaired Parenting related to separation from
the neonate due to hospitalization
Encouraging Parental Attachment

Identify factors that may prohibit the parents'


visitation and communication: geographic distance,
lack of transportation, care of siblings, employment
restrictions, economic issues, lack of telephone in
the home, fear. Refer to social services for
assistance and intervention.
If the neonate was transported to a tertiary
care center immediately after birth, send the
mother a photograph of the neonate.
Call the parents daily to update them on the
infant's condition until they are able to visit the
child. Emphasize positive aspects of the
infant's status.
Refer to the child by his first name when
speaking with the parents
Prepare the parents for the neonatal intensive care
unit (NICU) environment and how their child will
appear before their first visit.
Assist the parents to participate in the child's care as
appropriate.
Demonstrate for the parents how they can touch and
speak to the child while the child is in an Isolette.
Allow the parents to hold the infant as soon as
possible.
If the mother plans to breast-feed, assist her
with pumping, and use the breast milk to feed
the infant when enteral feedings are initiated.
If the infant has siblings, provide the parents
with information on how to discuss the infant's
illness with them.
If unit policies allow and the situation is
appropriate, encourage sibling visitation with
adequate preparation.
Provide the parents with information
concerning the disease process, expected
outcomes, and usual course of the NICU stay.
Encourage the parents to ask questions and
participate in the care plan.
Help parents work through their grief at the
birth of a premature child.
PREVENTION
Administration of corticosteroids may help
speed up lung maturity in the developing baby.
They are often given to pregnant women
between 24 and 34 weeks of pregnancy
MECONIUM ASPIRATION
SYNDROME
Meconium Aspiration Syndrome
Meconium aspiration syndrome (MAS) is a
condition that occurs when a newborn infant
aspirates a mixture of meconium and amniotic fluid.
Typically occur with the first breath or while the
neonate is in utero.
Meconium in the lungs causes air to become
trapped and results in alveoli over-distension and
rupture.
Meconium Aspiration Syndrome

Meconium is a newborn infant's first bowel


movement, which is sticky, thick and dark
green and is typically passed the first few days
after birth. May be seen in the amniotic fluid
after 34 weeks gestation.
Factors that promote the passage of
the meconium in utero
Placental insufficiency
Maternal hypertension
Preeclampsia
Oligohydramnios
Maternal drug abuse
Maternal infection/chorioamnioticitis
Fetal gasping 2nd to hypoxia
Causes of meconium passage

Intrauterine stress causing:

Fetal hypoxia : hypoxia causes increased


gastrointestinal peristalsis and relaxed anal
sphincter tone
Asphyxia, and
Acidosis
Causes of meconium passage
Other factors:
Increased maternal age
Previous reproductive casualities
Prenatal complications
Prolonged gestation
Obesity
Toxemia
Hypertension
Anemia
Post partum aspiration

Inadequate removal of meconium from the


airway prior to the breath
Use of PPV prior to clearing the airway of
meconium
Pathophysiology
Aspiration induces hypoxia via 3 major pulmonary
effects:
Airway obstruction
Chemical pneumonitis
PPHN (persistent pulmonary hypertension)
Surfactant dysfunction

Resulting in Acidosis, Hypoxemia and Hypercapnea and


infection
Causes
Commonly related to fetal distress during labor.
Advance gestational age (greater than 40 weeks)
Difficult delivery
Fetal distress
Intrauterine hypoxia
Maternal diabetes
Maternal hypertension
Poor intrauterine growth
Assessment Findings
Fetal hypoxia as indicated by altered fetal
activity and heart rate.
Dark greenish staining or streaking of the
amniotic fluid noted on rupture of
membranes.
Obvious presence of meconium in the
amniotic fluid
Assessment Findings
Greenish staining of the neonates skin (if the
meconium was passed long before delivery) or
placenta.
Signs of distress at delivery, such as the neonate
appearing limp, an Apgar score below 6, pallor,
cyanosis, and respiratory distress.
Coarse crackles when auscultating the
neonates lungs.
DIAGNOSTICS
ABG analysis shows hypoxemia and
decreased pH.
Chest X-ray may show patches or streaks
of meconium in the lungs, air trapping, or
hyperinflation
GENERAL MANAGEMENT
Maintain an optimal thermal environment - the use
of a radiant warmer to help your baby maintain
body temperature
Minimal handling to prevent right to left shunting,
leading to hypoxia and acidosis
Continue respiratory care
Oxygen therapy via hood or positive pressure
Mechanical ventilation
Broad expectrum antibiotics
SUPPORTIVE TREATMENT
IV dextrose
Fluids restricted as much as possible to
prevent cerebral and pulmonary edema
Electrolytes correction
ensure adequate nutrition and prevent
essential amino acid and essential fatty acid
deficiencies
VENTILATORY SUPPORT
Provide sufficient O2 to prevent
Pulmonary Arterial Hypertension (PAH)
SURFACTANT THERAPY
Available preparations: bovine (Survanta) and
synthetic (Exosurf) surfactant.
Administered into the ET tube
Benefits of surfactant: decreased oxygen
requirement and mean airway pressure;
decreases pulmonary leaks.
Nursing assessment with surfactant
administration: suctioning delayed for 1 hour
or as indicated by protocol.
SURFACTANT
ALBUMIN/BILE acid blockers

Albumin and Bile acid that binds to lipids and


free fatty acids are administrered into the
trachea, thereby reducing the pulmonary
toxicity.
May be coupled with surfactant
ECMO
Extracorporeal membrane oxygenation is
employed if all other therapeutic options have
been exhausted
ECMO is a lung bypass system that allows for
oxygenation of blood while the lung recovers.
The blue cannula takes de-oxygenated blood, which has circulated
through the body, out of the heart and into the ECMO machine, which
adds oxygen to it.
COMPLICATIONS
Pneumothorax, makes it difficult to reinflate the lung.
persistent pulmonary hypertension of the
newborn (PPHN). High blood pressure in the vessels of
the lungs restricts blood flow and makes it difficult for
your baby to breathe properly. PPHN is a rare, but life-
threatening condition.
Permanent brain damage. Severe MAS may limit oxygen
to the brain.
Nursing Interventions
During labor, continuously monitor the fetus
for signs and symptoms of distress.
Immediately inspect any fluid passed with
rupture of the membrane.
Assist with immediate endotracheal
suctioning before the first breaths, as
indicated.
Nursing Interventions
Monitor lung status closely, including breath sounds
and respiratory rate and character.
Frequently assess the neonates vital signs.
Administer treatment modalities, such as oxygen and
respiratory support as ordered.
Institute measures to maintain a neutral thermal
environment.
Provide the family with emotional support and
guidance.
Measures for Prevention of Meconium Aspiration
Maternal and Fetal monitoring before delivery
to determine uteroplacental insufficiency and
fetal distress.
Timing of delivery: induction as early as 41
wks may help prevent MAS
Upon delivery of the head of the baby,
carefully suctioning of the posterior pharynx
decreases the potential for aspiration of
mecomium (no longer recommended)
Measures for Prevention of
Meconium Aspiration
If THICK meconium, after delivery of the infants body

Crying Not crying

- Stimulate - Do not stimulate


- Suction with - Visualize the vocal cords and
bulb syringe provide direct suction with
endotracheal tube, then stimulate.

If THIN meconium, no visualization performed.

Neonatal Sepsis
SEPTICEMIA
NEONATORUM
Neonatal sepsis is a bacterial
infection in the blood. It is found
in infants during the first month
of life. This may become a
serious condition
Causes
Neonatal sepsis is caused by bacteria.
The infant may come in contact with
bacteria during pregnancy, birth, or from
the environment after birth.
EARLY ONSET SEPSIS
Early onset sepsis develops in the first 2-3 days after
birth.
Early onset sepsis is caused by an infection from the
mother. It may pass to the infant from the placenta or
birth canal during birth.
Antibiotics may be given to high risk mothers, during
labor. They have been able to prevent early onset
bacterial sepsis in some infants.
LATE ONSET SEPSIS
Late onset sepsis develops within 3-7 days
after birth.

Late onset sepsis is caused by bacteria from


the caregiving environment.
Risk Factors
The following factors increase your infants chance of
developing neonatal sepsis:

Premature birthmore than three weeks before due date


Early labormore than three weeks before your due date
Infant is in distress before being born
Infant has a very low birth weight
Infant has a bowel movement before being
born and fetal stool is in the uterus
Amniotic fluid surrounding the infant has a
bad smell or the infant has a bad smell right
after being born
Male babies have a greater risk for neonatal
sepsis than female babies
Pregnancy conditions or mother's health issues
that increase your infant's chance of sepsis
include:

Labor complications resulting in traumatic


or premature delivery
Water that broke more than 18 hours before
giving birth
Fever or other infections while you are in labor
Need for a catheter for a long time while
you are pregnant
Presence of group B streptococcal
bacteria in vaginal or rectal areas
Many courses of prenatal steroids
Prolonged internal monitoring during
labor and delivery
Symptoms
In most cases of early onset sepsis, symptoms are
present within 24 hours of birth. In almost all cases,
symptoms will be present within 48 hours of birth. If your
infant has any one of these symptoms, especially in first
week, contact your doctor.
Fever or frequent changes in temperature
Breathing rapidly, difficulty breathing, or periods of no
breathing (apnea)
Lethargy (abnormal sleepiness)
Poor feeding from breast or bottle
Decreased or absent urination
Bloated abdomen
Vomiting yellowish material
Diarrhea
Extreme redness around the belly button
Skin rashes
Difficulty waking your infant or unusual
sleepiness
Jaundiced or overly pale skin
Abnormally slow or fast heartbeat
Bruising or bleeding
Seizures
Cool, clammy skin
Diagnostics
Blood tests such as complete blood count
Cultures of:
Blood
Urine
Cerebrospinal fluidthrough spinal tap
Skin lesions
X-rays of the chest or abdomen
TREATMENT
Antibiotics
Antibiotic medicine may have to be given directly into
the vein (IV).
Intravenous Fluids
IV fluids will help support your infant until the infection
clears. It may include fluids, glucose, and electrolytes.
Oxygen
Your infant may need oxygen therapy. In more severe
cases, a ventilator may be used to support breathing.
Supportive therapy
Observation
isolation,
Hydration
Nutrition
regulation of thermal environment
blood transfusion to correct anemia and shock
and protection from further infection.
Observe for complications such as:
meningitis (very common)
shock
adrenal hemorrhage
DIC
PPHN
metabolic derangements
seizures
pneumonia
UTI
and heart failure
Prevention
Antibiotics can control dangerous bacteria in the mother. It
will prevent the spread of bacteria during pregnancy or birth
to the infant. Your doctor may recommend antibiotics if:
The birth mother has previously given birth to an infant with
neonatal sepsis.
have had a positive bacterial infection test before the due date.
Breastfeeding may also help prevent sepsis in some infants.
Prevent premature labor or birth. Through proper prenatal
care, avoiding drugs and alcohol, and eating a healthy
balanced diet.
HYPERBILIRUBINEMIA
JAUNDICE IN THE NEWBORN
Hyperbilirubinemia: Increased levels of
bilirubin in the blood.
Bilirubin is a by product from the breakdown
of haemoglobin.
Excess serum bilirubin in the newborn due
either to
overproduction of bilirubin, as in excessive
destruction of erythrocytes,
or to reduction in glucuronide conjugation
in the liver.
CAUSES:
Hyperbilirubinemia is primarily caused by
underlying liver or biliary disease.
Hyperbilirubinemia in newborns is caused by a
delay in efficient clearance of bilirubin from the
blood.
Hyperbilirubinemia occurs when the body cannot
conjugate the bilirubin released into the serum.
Results in jaundice where the unconjucated
bilirubin is deposited in the tissue.
RISK FACTORS
Premature Birth- A premature baby may not
be able to process bilirubin as quickly as full-
term babies do.
Bruising during birth-Sometimes babies are
bruised during the delivery process. If
newborn has bruises, he or she may have a
higher level of bilirubin from the breakdown
of more red blood cells.
Blood type. If your blood type is different from your
baby's, your baby may have received antibodies from
you through your placenta that cause his or her blood
cells to break down more quickly.

Breast-feeding. Breast-fed babies have a higher risk


of jaundice, particularly those who are having
difficulty nursing or not getting enough nutrition from
breast-feeding. Dehydration and low intake of calories
from poor breast-feeding may contribute to the onset
of jaundice.
DIAGNOSIS
Complete blood count
Coomb's test- The Coombs' test checks
for antibodies that may stick to the red
blood cells and cause red blood cells to
die too early.
Reticulocyte count
Nursing Assessment and Interventions
Be alert for signs and symptoms of jaundice:
Sclerae appears yellow before skin appears yellow.
Yellow color on the skin, usually starting with the
face, is the main symptom of jaundice. The yellow
color may spread down to the stomach and legs.
Skin appears light to bright yellow.
Lethargy.
Dark amber, concentrated urine.
Poor feeding.
Dark stools.
Make observations in daylight, sunlight, or
white fluorescent light.
Blanch the skin during the observation to
clear away capillary coloration: forehead,
cheeks, and clavicle sites allow for clear
view.
Be alert to the neonate's age in connection
with the appearance of jaundice.
With dark-skinned neonates, observing the
color of the sclera and buccal mucosa is useful
Assist with treatment.
Fluids - ensure adequate hydration.
Exchange transfusion - mechanically remove
bilirubin.
Phototherapy - allow for utilization of
alternative pathways for bilirubin excretion.
Enzyme induction agent - reduce bilirubin
levels by inducing hepatic enzyme system
involved in bilirubin clearance (ie,
phenobarbital).
PHOTOTHERAPY
Provide nursing care related to phototherapy.

Photoisomerization of tissue bilirubin occurs


when the neonate is exposed to 420 to 460
nm of light.
Check light intensity for therapeutic range
daily. Use commercial Bililight.
Have the neonate completely undressed so
entire skin surface is exposed to light.
Keep the neonate's eyes covered, unless
using a biliblanket, to protect from constant
exposure to high-intensity light, which may
cause retinal injury.
Shield gonads.
Develop a systematic schedule of turning
neonate so all body surfaces are exposed (ie,
every 2 hours).
Maintain thermo-neutrality - light
affects the ambient temperature.
Shield the neonate (by Plexiglas) from
direct exposure of lights.
Obtain bilirubin levels as directed. The
diminishing icterus (ie, the lowering of
unconjugated bilirubin from cutaneous
tissue) does not reflect the serum bilirubin
concentration. Lights should be turned off
when blood is being collected to eliminate
false-low bilirubin levels.
If possible, remove the neonate from under
the lights, remove eye covers, and
encourage parents to hold the neonate for
feedings.
A fiber-optic blanket, which delivers
continuous phototherapy by wrapping light
around the neonate's torso, may be used.
This method allows the neonate to remain in
the mother's room in an open crib.
NURSING ALERT
If priapism occurs during phototherapy, turn
the neonate on his abdomen for short periods
of time, and this will cease.

Priapism is a prolonged and painful erection that can


last from several hours up to a few days.
Sudden Infant Death
Syndrome
(SIDS)
Sudden infant death syndrome (SIDS) is
defined as sudden death of an infant
within 1 year of age which is unexpected
by any medical history or which cannot
be explained even after complete
postmortem examination and autopsy.
Sudden infant death syndrome is a
complex or multifactor disorder wherein
the exact cause of death remains
unknown and still remains as one of the
leading causes of post neonatal death
CAUSE

UNKNOWN
RISK FACTORS
Exposure to tobacco, smoke
Alcohol use by the parent [mother]
especially in the first trimester
Use of certain illegal drugs
Improper care during pregnancy
Improper growth of the fetus
Sleeping with parents
RISK FACTORS
Short interval between pregnancies
Lack of use of pacifier at bed time
Prone or side sleeping position
Thermal stress or over heating or over
wrapping
Lack of breastfeeding
Soft sleeping surface or bedding
OTHER RISK FACTORS
Low socioeconomic status of the parents
Lower level of education
Young age
and single marital status
Signs and Symptoms
Infant may present with certain common signs
difficulty in breathing
and change in color (pallor, purple, blue).

The infant may also have


Vomiting
Cough
and cry constantly.
Diagnosis
Information obtained from the parents of the infant.
Physical examination to identify any abnormality or
malformations
Assess the neurological status.
Record height, weight and head circumference
Investigations include
Blood tests
X-ray
Urinalysis
Treatment
The initial management of SIDS lies in the hands of
parents/caregivers.

Emergency treatment measures may be required if the


infants condition is life-threatening.

Administration of medications such as histamine H2receptor


antagonists may be required.

Surgical intervention in case of severe conditions is a must


Management of feeding
Keeping the child in upright position after
feeding
Adequate burping
Raising the head of the bed for comfort
sleeping
Usage of thickening formulas to increase
consistency of the food.
Nursing Care Plan Prevention
The CDC recommends the following precautions to reduce
the risk of SIDS:
Infants should always be placed on their backs to sleep
when they are left alone; they should be placed on their
stomachs only when they are awake and supervised by
someone responsible.
If the baby sleeps in a crib, the cribs mattress should be
firm and fit snugly into the crib frame. Such other firm
sleeping surfaces as bassinets or cradles are also fine.
Nursing Care Plan Prevention
The baby should be dressed in a sleeper or
pajama to keep it warm rather than being
covered by a blanket.
Parents who co-sleep with a baby should
never smoke, drink alcohol, or use drugs when
sleeping with the baby. It is better to have the
baby sleep in a crib or bassinet next to the
parents bed rather than sharing the bed.
Nursing Care Plan Prevention
Parents should never put a baby on a couch,
waterbed, or pillow for a nap.
Parents should never smoke in the same room
as the baby or allow anyone else to do so.
Caregivers should never place the baby to
sleep or nap with any pillows, stuffed toys,
bumper pads, comforters, quilts, or sheepskins
TORCH SYNDROME
TORCH Syndrome refers to infection of a developing fetus
or newborn by any of a group of infectious agents.
"TORCH" is an acronym meaning
(T)oxoplasmosis,
(O)ther Agents (syphilis, Hepa B, HIV)
(R)ubella (also known as German Measles),
(C)ytomegalovirus, and
(H)erpes Simplex.
TORCH infections are a group of congenitally
acquired infections that cause significant
morbidity and mortality in neonates.
These infections are acquired by the mother
and passed either transplacentally or during
the birth process. While each infection is
distinct, there are many similarities in how
these infections present. It is important to
consider
SIGNS & SYMPTOMS
Enlarged liver
Enlarged spleen
Chorioretinitis
Fetal malformations
Jaundice
Low blood platelet level
Central nervous system abnormalities
Asymptomatic manifestations may occur later in life
TREATMENT
Some of the TORCH infections, such as
toxoplasmosis and syphilis, can be effectively
treated with antibiotics if the mother is
diagnosed early in her pregnancy. Many of
the viral TORCH infections have no effective
treatment, but some, notably rubella and
varicella-zoster, can be prevented
by vaccinating the mother prior to pregnancy.
If the mother has active herpes simplex
(as may be suggested by a pap test),
delivery by Caesarean section can
prevent the newborn from contact, and
consequent infection, with this virus
Toxoplasmosis
Protozoan infection in the pregnant woman
Raw or under cooked meats
Cat feces

Affects on the fetus


Blindness
Deafness
Convulsions
Microcephaly
Hydrocephaly
Severe mental impairment
Other : Syphillis
S/S of Newborn: Treatment:
Rhinitis Culture orifices
Excoriated upper lip Isolation
Red rash around mouth and
anus Penicillin
Copper colored rash of face,

palms and soles


Irritability

Edema

Cataracts.
OTHER: Hepatitis B
Transmission Treatment

Ifmother + HbSAG
Placental

Birth
administer to
newborn
Breast milk Hepitisis B vaccine

HBIG
Rubella
S/S of Newborn
Congenital cataracts
Deafness
Congenital heart defects
Sometimes fatal

MMR Immunization of mother


Give when not pregnant
Cytomegalovirus
Herpatic virus S/S of Newborn
Severe neurological
Crosses placental
problems
barrier
Eye abnormalities
Direct contact at
Hearing loss
birth Microcephaly

Hydrocephaly

Cerebral palsy

Mental delays
Herpes Simplex II
Transmission: S/S of Newborn
Direct contact at Microcephaly
birth Mental delays
Seizures
Retinal
dysplasia
Apnea
Coma
HIV/AIDS
Transmission: < 2% Nursing Interventions
Transplacentally Protect self from
Exposure at birth body fluids
Breast milk Labs - + antibody
titer
Administer AZT,
Retrovir
Provide care like that
of any other newborn
GASTROESOPHAGEAL
REFLEX
GER is a malfunction of the distal end of the
esophagus, which acts as an antireflux barrier,
permitting return of stomach contents into the
esophagus.

This barrier is controlled primarily by pressure at the


lower esophageal sphincter.

Gastroesophageal reflux disease (GERD) is defined as


the symptom complex that results as a complication
of GER.
INCIDENCE
Of all infants with GER,
first 3 months of life - 50% will be
symptomatic (vomiting)
4 to 9 months - 67% will have symptoms
10 to 12 months - 5% will have symptoms
CAUSES
Cause is undetermined in most patients;
however, possible causes include:
Delayed neuromuscular development.
Cerebral defects.
Obstruction at or just below the pylorus (eg,
pyloric stenosis, malrotation).
Physiologic immaturity.
Complication of esophageal surgery.
Increased abdominal pressure; obesity.
Associated conditions that
contribute to reflux include:
Coughing and wheezing from cystic fibrosis,
bronchopulmonary dysplasia, asthma.
Indwelling orogastric or NG feeding tube.
Mechanical ventilation.
Associated conditions that
contribute to reflux include:
Medications that affect lower sphincter and
increase gastric acidity (eg, theophylline,
bronchodilators, antihypertensives).
Position:
supine [24%]
prone [8%])
chest physical therapy positions, seating devices
that place the infant in semisupine position,
increasing the intra-abdominal pressure.
CLINICAL MANIFESTATIONS
Infants
Vomiting
Usually, regurgitation - but can be forceful, not
projectile
Irritability, excessive crying with or without
association with vomiting
Sleep disturbances
Arching, stiffening
Infants
Refusal to eat
Weight loss or failure to gain weight
Dehydration
Recurrent respiratory symptoms; cough,
wheeze, stridor, pneumonia
ALTE: blue spell, decreased responsiveness,
limp, apnea, bradycardia
Eructation
Older Children
In the preschool child, may manifest as
intermittent vomiting
Chronic heartburn or regurgitation
Upper abdominal discomfort; pressure or
squeezing feeling
Chronic cough stridor
Nocturnal asthma, especially after a large
meal
Older Children
Nocturnal asthma, especially after a large meal
Dysphagia: difficulty swallowing
Odynophagia: painful swallowing
Anemia
Hematemesis (vomitus with blood) or melena
(blood in stools)
Hypoproteinemia: low protein in the blood due
to intestinal losses or severe malnutrition.
DIAGNOSTIC EVALUATION
History of infant's or child's feeding habits.
Esophageal pH monitoring - used widely as an index of
esophageal acid exposure. Considered gold standard for
reflux.
Technetium scintigraphy (milk scan) - to document
frequency and duration of nonacidic postprandial reflux,
define gastric emptying, and associated aspiration (oral
aspiration and reflux aspiration).
Endoscopy
Complications

Recurrent pulmonary disease; aspiration


pneumonia
Chronic esophagitis
Failure to thrive
Anemia
ALTE
COMPLICATIONS
Asthma
Hiatal hernia frequently associated with a
chalasia (reflux; relaxation or incompetence of
lower esophageal sphincter)
Esophageal stricture from scarring;
esophagitis
MANAGEMENT
Goal of treatment is to alleviate and relieve
symptoms and prevent complications.

1. Positioning
Infants:
Supine position while sleeping
Prone positioning is acceptable while the
infant is awake
1. Positioning
Infants:
Avoid slumped position, use of infant seat,
car seat (expect while driving), swings, and
bouncers this increases intra-abdominal
pressure, thereby increasing reflux
Thirty-degree elevation is acceptable,
while maintaining straight plane of
alignment.
Older children

Elevation of the bed and left side


positioning may decrease symptoms.
Avoidance of lying down following
large meals.
Should remain semireclining (30
degrees) to upright while awake.
2. Feeding
Infant:
1- to 2-week trial of hypoallergenic formula in the
formula-fed infant. Continuance of breast-feeding
with the mother limiting dairy products is
encouraged.
Thickened feedings with dry rice cereal or
commercial thickening agent. It decreases episodes
of vomiting.
Small, frequent feedings followed by upright
positioning with infant held over the shoulder.
Older child:

Nothing to eat 2 hours before bedtime.


Avoid spicy and acidic foods (onions, citrus
products, apple juice, tomatoes), esophageal
irritants (chocolate, caffeinated beverages,
peppermint, and second-hand smoke), and
carbonated beverages.
Chew gum (stimulates parotid secretions,
which augment esophageal clearance and
provide a buffering effect).
3. Other Lifestyle Changes

Prevent obesity.
Avoid tight or constrictive clothing.
Avoid nonsteroidal anti-inflammatory
drugs, especially at bedtime.
4. Drug Therapy

Antacids - buffer existing acids and also


increase serum gastrin levels, leading to
increase in lower esophageal sphincter
pressure (symptomatic relief).
Histamine-2 (H2)-receptor antagonists -
reducing hydrochloric acid and pepsinogen
secretion( e.g Tagamet and Zantac)
Proton pump inhibitors (PPI) - block all gastric
acid secretion (Omeprazole,lansoprazole,
pantoprazole

Prokinetic agents - enhances esophageal


peristalsis and accelerates gastric emptying.
(Metoclopramide (Reglan)

Carafate - acts by adhering to mucosal lesions,


reducing symptoms, and promoting healing.
SURGICAL MANAGEMENT
Fundoplication - is the wrapping of the
fundus around the lower esophageal sphincter.
This to revent reflux
A. Nissen the most common
B. Thal
C. Toupet
D. laparoscopic
NURSING ASESSMENT
Obtain history of infant's or child's eating habits,
including formula history, food allergies, volume
tolerated at each meal
Obtain history of complications from GER (ie,
recurrent respiratory infections, asthma, poor weight
gain)
Observe infant's or child's feeding behaviors (Does he
eat with a bottle, spoon, fingers? Can he feed
himself?)
Assess general appearance, skin integrity, and growth
and development.
Nursing Diagnoses
Risk for Aspiration related to reflux of gastric
contents
Imbalanced Nutrition: Less Than Body
Requirements related to decreased oral intake
Risk for Deficient Fluid Volume related to
frequent vomiting
Fear of eating related to distress
ESOPHAGEAL ATRESIA WITH

TRACHEOSOPHAGEAL
FISTULA
Esophageal atresia (EA) is failure of the
esophagus to form a continuous passage from
the pharynx to the stomach during embryonic
development.

Tracheoesophageal fistula (TEF) is an


abnormal connection between the trachea and
esophagus.
Clinical Manifestations of EA/TEF
Infants with congenital forms of EA/TEF usually
present shortly after birth

Copious oral secretions


Coughing
Gagging
Cyanosis
Vomiting
and/or respiratory distress.
OTHER MANIFESTATIONS
Abdominal distension
Poor feeding
Inability to pass catheter through nose
or mouth into stomach
Gross Esophageal atresia classification
Type A - Esophageal atresia without fistula or so-called pure
esophageal atresia (10%)
Type B - Esophageal atresia with proximal TEF (<1%)
Type C - Esophageal atresia with distal TEF (85%)
Type D - Esophageal atresia with proximal and distal TEFs
(<1%)
Type E - TEF without esophageal atresia or so-called H-type
fistula (4%)
Type F - Congenital esophageal stenosis (<1%) (not
discussed in this article)
Causes of EA/TEF
Envionmental (Acquired)
Medications
Infections during pregnancy
Exposure to methimazole during pregnancy
Heritable
chromosomal
Diagnostic Evaluation

Ultrasound scanning techniques


Failure to pass a 10F catheter (smaller
catheters may coil) into the stomach
through nose or mouth. Catheter is left in
situ while an X-ray confirms the diagnosis.
Litmus paper may be used to test for
acid reaction.
Flat plate X-ray of abdomen and chest
Electrocardiogram and echocardiogram
are performed because there is a high
association with cardiac anomalies
Immediate Treatment
Propping infant at 30-degree angle to
prevent reflux of gastric contents.

#10 NG tube remains in the esophagus


and is aspirated frequently to prevent
aspiration until continuous low suction is
applied.
Immediate Treatment
Pouch is washed out with normal saline to
prevent thick mucus from blocking the tube.

Gastrostomy to decompress stomach and


prevent aspiration; later used for feedings.

Nothing by mouth (NPO); I.V. fluids.


MANAGEMENT
Treatment of manifestations:

Initial postnatal intervention is aimed at minimizing


the risk of aspiration pneumonia.

Surgical repair consists of closure of the TEF and


anastomosis of the esophageal segments.

Other abnormalities are treated symptomatically.


COMPLICATIONS
Death from asphyxia
Prematurity
Dehydration and electrolyte imbalance
Pneumonitis secondary to:
Salivary aspiration
Gastric acid reflux
Concomitant lesions (approximately 40% to
50%):
Congenital heart disease
GI anomalies, particularly imperforate anus
Skeletal and muscular deformities
Renal anomalies
Vertebral defects
NURSING ASSESSMENT
Assessment begins immediately after birth.
Be alert for risk factors of polyhydramnios and
prematurity.
Suspect in infant with the following:
Excessive amount of mucus
Difficulty with secretions
Cyanotic episodes (unexplained)
Report suspicion to health care provider immediately.
Nursing Diagnoses
Preoperative

Risk for Aspiration related to structural


abnormality
Risk for Deficient Fluid Volume related to
inability to take oral fluids
Anxiety of parents related to critical situation
of neonate
Postoperative

Ineffective Airway Clearance related to surgical


intervention
Ineffective Infant Feeding Pattern related to defect
Acute Pain related to surgical procedure
Impaired Tissue Integrity related to postoperative
drainage
Risk for Injury related to complex surgery
Risk for Impaired Parent/Infant Attachment related to
prolonged hospitalization
HYPERTONIC PYLORIC
STENOSIS
(HPS)
Hypertrophic pyloric stenosis is a
condition caused by an enlarged pylorus.

The pylorus is a muscle that opens and


closes to allow food to pass through the
stomach into the intestine. .
INCIDENCE
Incidence is 1 in 250 live births
predominant in males (5:1)
more common in first-born males.
It is more likely to affect a full-term infant than a
premature infant.
It is the second most common condition (after
inguinal hernia) requiring surgery, which rarely
occurs before age 2 weeks or later than age 5
months.
Pathophysiology and Etiology
Unknown cause.
Multiple theories of etiology exist, including:
immature or degenerated pyloric neural elements,
variations in infant feeding regimens,
excessive production of gastrin (maternal or
infant), dyscoordination between gastric peristalsis
and pyloric relaxation,
deficiency of nitric acid,
abnormalities in enteric nervous system,
and abnormalities in neurotransmitters.
Increase in size of the circular
musculature of the pylorus with
thickening (size and shape of an olive).
The pylorus muscle becomes elongated
and thickened and is enlarged to about
twice the usual size. On clinical exam,
palpation of an olive is diagnostic.
Hypertrophy of the pylorus musculature
occurs with narrowing of the pyloric
lumen.
Constriction of the lumen of the pyloric
canal (at the distal end of the stomach)
causes the stomach to become dilated.
Gastric emptying is delayed.
Clinical Manifestations
Onset usually occurs between ages 3 and 12 weeks.
Cardinal sign is projectile, nonbilious vomiting.
Initially, occasional regurgitation (similar to GER)
may be present, but eventually vomiting increases
in frequency and intensity.
Vomitus contains milk and gastric juices; however,
it may be blood-streaked or coffee ground in
appearance.
Emesis occurs just after or near the end of a
feeding.
Constipation or decreased quantity of
stools.
Loss of weight or failure to gain weight.
Epigastric distention.
Visible gastric peristaltic waves, left to
right, seen just after infant vomits.
Excessive hunger - willingness to eat
immediately after vomiting.
Dehydration - electrolyte disturbance with
alkalosis, hypoglycemia, hypochloremia.
Decreased urine output.
Palpable pyloric mass in upper right quadrant of
abdomen, to the right of the umbilicus and best
felt during feeding or immediately after
vomiting.
Jaundice.
Diagnostic Evaluation
Palpation of pyloric mass (olive) in
conjunction with persistent, projectile
vomiting is pathognomonic.
Ultrasound - to evaluate the length and
diameter of the pyloric muscle.
Barium upper GI study
Endoscopy
MANAGEMENT
Manage dehydration and electrolyte
imbalance
Surgery
Rammstedt pyloromyotomy standard
procedure of choice
Laparoscopic pyloromyotomy
COMPLICATIONS
Starvation
Dehydration
Severe electrolyte imbalance
Hematemesis
Nursing Assessment
Obtain a thorough history of infant's
feeding behaviors and history of
vomiting.
Assess hydration status and for signs and
symptoms of electrolyte imbalance
Assess and chart growth and
development parameters.
Nursing Diagnoses
Preoperative

Deficient Fluid Volume related to frequent vomiting


Imbalanced Nutrition: Less Than Body
Requirements related to vomiting
Acute Pain related to gastric distention
Anxiety of parents related to illness, hospitalization,
and impending surgery of child
Postoperative
Risk for Injury related to postoperative
complications
Risk for Deficient Fluid Volume after surgery
Impaired Tissue Integrity related to surgical
incision
REMEMBER

SUCCESS ALL
DEPENDS ON THE
SECOND LETTER

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