nancy pares, rn, msn metro community college. discuss pathophysiology and nursing process for high...
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NURS 2410 Unit 4Nancy Pares, RN, MSN
Metro Community College
Discuss pathophysiology and nursing process for high risk newborn
Objective 1
Low socioeconomic level of the mother Limited or no prenatal care Exposure to environmental dangers Preexisting maternal conditions Maternal factors such as age or parity Medical conditions related to pregnancy Pregnancy complications
Identification of At-risk Newborn
Feeding Guidelines
Early Feeding Skills (EFS)
Inadequate surfactant production Muscular coat of pulmonary blood vessels is
not completely developed Greater risk for the ductus arteriosis to
remain open
Preterm Infant: Respiratory Alterations
Nonreassuring fetal heart rate pattern Difficult birth Fetal scalp/capillary blood sample-acidosis
pH<7.20 Meconium in amniotic fluid Prematurity Macrosomia or SGA
Fetal/Neonatal Risk Factors for Resuscitation
Respiratory Distress Assessment
Respiratory Distress Assessment
Respiratory Distress Assessment
Male infant Significant intrapartum bleeding Structural lung abnormality or
oligohydramnios Congenital heart disease Maternal infection Narcotic use in labor
Fetal/Neonatal Risk Factors for Resuscitation (continued)
An infant of a diabetic mother Arrhythmias Cardiomyopathy Fetal anemia
Fetal/Neonatal Risk Factors for Resuscitation (continued)
Deficiency or absence of surfactant Atelectasis Hypoxemia, hypercarbia, academia May be due to prematurity or surfactant
deficiency
Respiratory Distress Syndrome (RDS)
Figure 33–5 RDS chest x-ray. Chest radiograph of respiratory distress syndrome characterized by a reticulogranular pattern with areas of microatelectasis of uniform opacity and air bronchograms. SOURCE: Courtesy of Carol Harrigan, RNC, MSN, NNP.
Maintain adequate respiratory status Maintain adequate nutritional status Maintain adequate hydration Education and support of family
RDS: Nursing Care
Figure 33–9 Premature infant under oxygen hood. Infant is nested and has a nonnutritive sucking pacifier. SOURCE: Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.
Failure to clear lung fluid, mucus, debris Exhibit signs of distress shortly after birth Symptoms
◦ Expiratory grunting and nasal flaring◦ Subcostal retractions◦ Slight cyanosis
Transient Tachypnea of the Newborn (TTN)
Maintain adequate respiratory status Maintain adequate nutritional status Maintain adequate hydration Support and educate family
TTN: Nursing Care
Mechanical obstruction of the airways Chemical pneumonitis Vasoconstriction of the pulmonary vessels Inactivation of natural surfactant
Meconium Aspiration Syndrome (MAS)
Assess for complications related to MAS Maintain adequate respiratory status Maintain adequate nutritional status Maintain adequate hydration
MAS: Nursing Care
Blood shunted away from lungs Increased pulmonary vascular resistance
(PVR) Primary
◦ Pulmonary vascular changes before birth resulting in PVR
Secondary◦ Pulmonary vascular changes after birth resulting
in PVR
Persistent Pulmonary Hypertension (PPHN)
Minimize stimulation Maintain adequate respiratory status Observe for signs of pneumothorax Maintain adequate nutritional status Maintain adequate hydration status Support and educate family
PPHN: Nursing Care
Figure 33–10 Chest x-ray of a left-sided pneumothorax. A rupture of the alveoli sacs allows air to leak through the pleura, forming collections of air outside the lung (air shows on x-ray as dark area over lung). SOURCE: Courtesy of Carol Harrigan, RNC, MSN, NNP.
Genetic disorders◦This information will be discussed in greater detail later in the course.
◦For the purposes of this unit, know that certain disorders are genetic
Congenital Anomalies
Congenital Anomalies
Congenital Anomalies
Congenital Anomalies
Congenital Anomalies
Congenital Anomalies
Congenital Anomalies
Congenital Anomalies
Cardiac Defects
Cardiac Defects
Cardiac Defects
Cardiac Defects
Cardiac Defects
Infants at Risk for HIV/AIDS
Prematurity SGA Failure to thrive Enlarged spleen and liver Swollen glands
Infants Born to HIV/AIDS Infected Mothers: Consequences
Recurrent respiratory infection Rhinorrhea Recurrent GI problems Persistent or recurrent candidiasis
Infants Born to HIV/AIDS Infected Mothers: Consequences
Provide comfort Keep the newborn well nourished Keep the infant protected from infections Facilitate growth, development, and
attachment
Nursing Care of the Infant Born to HIV/AIDS Infected Mothers
Risk factors◦ Maternal infection (group B streptococcus most
common)◦ Long labor, prolonged rupture of the membranes◦ Maternal fever, chorioamnionitis◦ Fetal distress, aspiration
Sepsis
Assessment findings◦ Unstable temperature, poor tone, poor sucking
Management◦ Antibiotics◦ Supportive care
Sepsis (continued)
Lethargy or irritability Hypotonia Hypotension Pallor, duskiness, or cyanosis Cool and clammy skin
Signs and Symptoms of Sepsis
Temperature instability Feeding intolerance Hyperbilirubinemia Tachycardia followed by apnea/bradycardia
Signs and Symptoms of Sepsis (continued)
Rhinitis Red rash around the mouth and anus Irritability Generalized edema and
hepatosplenomegaly Congenital cataracts SGA and failure to thrive
Symptoms of Syphilis
Initiate isolation Administer penicillin Provide emotional support for the family
Syphilis: Nursing Management
Symptoms◦ Conjunctivitis◦ Corneal ulcerations
Nursing management◦ Administration of ophthalmic antibiotic ointment◦ Referral for follow-up
Gonorrhea
Small cluster vesicular skin lesions over the entire body
DIC Pneumonia Hepatitis Hepatosplenomegaly Neurologic abnormalities
Symptoms of Herpes
Careful hand washing and gown and glove isolation
Administration of IV vidarabine or acyclovir Initiation of follow-up referral Support and education of parents
Herpes: Nursing Management
Symptoms◦ Pneumonia◦ Conjunctivitis
Nursing management◦ Administration of ophthalmic antibiotic ointment◦ Referral for follow-up
Chlamydia
Maternally TransmittedInfections
Maternally TransmittedInfections
Antibiotic/antiviral Therapy
Neonatal abstinence scoring Monitoring VS and pulse oximetry until
stable Small frequent feedings IV therapy if needed Positioning on the right side-lying or semi-
Fowler’s Monitoring frequency of diarrhea and
vomiting
Nursing Care of the Drug-Exposed Newborn
Weigh infant every 8 hours during withdrawal
Swaddle infant Protect face and extremities from
excoriation Place infant in quiet, dimly lighted area of
the nursery Administration of medications
Nursing Care of the Drug-Exposed Newborn
Newborn Withdrawal
Neonatal Abstinence
Neonatal Abstinence
Figure 33–14 Potential sites for heel sticks. Avoid shaded areas to prevent injury to arteries and nerves in the foot and the important longitudinally oriented fat pad of the heel, which in later years could impede walking.
Figure 33–15 Heel stick. With a quick, piercing motion, puncture the lateral heel with a microlance. Be careful not to puncture too deeply.
Hypoglycemia Meconium aspiration and oligohydramnios Polycythemia Congenital anomalies Seizures Cold stress
Postmaturity Syndrome
Care of the Premature Infant Delivery prior to 37
weeks’ gestation Factors
◦ Multiple gestation, PROM, incompetent cervix
Physical characteristics Gestational age Maternal prenatal risk factors Delivery risk factors Physical assessment Family assessment
Assessment of the Preterm Newborn
Assessment◦ Gestational age assessment◦ Neurologic assessment◦ Physical characteristics
Thin skin, soft cartilage, absent plantar creases Abundant lanugo and vernix Genitalia characteristic of prematurity
The Premature Infant (continued)
Review of Systems and Potential Complications
Cardiovascular◦ Patent ductus arteriosis◦ Hypotension
Central nervous system◦ Intraventricular hemorrhage◦ Posthemorrhagic
hydrocephalus Hematologic system
◦ Anemia◦ Polycythemia
Hepatic system◦ Hyperbilirubinemia
Phototherapy
Review of Systems (continued)
Gastrointestinal system◦ Dysmotility◦ Necrotizing enterocolitis◦ Gastroesophageal reflux
Immune system◦ Infection
Integumentary system◦ Epidermal stripping◦ Absorption of chemical
agents
Crib with head elevated for reflux
Review of Systems (continued) Ophthalmologic system
◦ Retinopathy of prematurity Renal system
◦ Oliguria◦ Glycosuria
Respiratory system◦ Respiratory distress
syndrome◦ Bronchopulmonary
dysplasia◦ Apnea of prematurity◦ Pneumonia
Preterm infant in an oxygen hood
Poorly developed gag reflex Incompetent esophageal cardiac sphincter Poor sucking and swallowing reflexes Difficulty meeting caloric needs for growth Inability to handle the increased osmolarity
of formula protein Difficulty with absorbing saturated fats
Preterm Infant: GI Alterations
Difficulty with lactose digestion Deficiency of calcium and phosphorous Increased basal metabolic rate and
increased oxygen requirements Feeding intolerance Potential for the development of necrotizing
enterocolitis (NEC)
Preterm Infant: GI Alterations (continued)
Unavailability of glycogen and brown fat Inability to increase oxygen consumption High ratio of body surface area to body
weight Extended position increases body surface
area Decreased ability to vasoconstrict
superficial blood vessels
Preterm Infant: Alterations in Thermogenesis
Lower glomerular filtration rate (GFR) Limited ability to concentrate urine or
excrete large amounts of fluid Excrete glucose at a lower serum glucose
level Buffering capacity is reduced Excretion time of drugs is longer
Preterm Infant: Kidney Alterations
Glycogen stores are used rapidly Glycogen stores are affected by asphyxia
and cold stress Low iron stores Conjugation is impaired
Preterm Infants: Liver Alterations
Immunologic◦ Lack of passive IgG antibodies◦ Skin is easily excoriated
Neurologic◦ Increased risk for IVH & ICH◦ Delayed or absent reactivity
Preterm Infants: Other Alterations
Occipital-frontal baseline measurements Daily head circumferences Skin integrity Signs and symptoms of infection Signs of widening of suture lines
Hydrocephalus: Nursing Assessments
Assist with head ultrasounds and transillumination
Change position frequently Clean skin creases Keeping a sheepskin under the head Postoperatively position head off the
operative site
Hydrocephalus: Nursing Interventions
Intrauterine growth restriction
Small for gestational age
Large for gestational age
Post term infant
Infants <10th percentile for weight at birth May be symmetric or asymmetric Factors may be fetal, maternal, or placental Complications
◦ Hypoxia, hypothermia, hypoglycemia, polycythemia, hyperbilirubinemia, meconium aspiration
Intrauterine Growth Restriction
Nursing implications◦ Prevent heat loss◦ Monitor blood glucose, feed early◦ Monitor for respiratory complications◦ Management of hyperbilirubinemia
Intrauterine Growth Restriction (continued)
Maternal factors Maternal disease Environmental factors Placental factors Fetal factors
Small-for-gestational-age
Triplets Manifesting Different Rates of Growth
Infants >90th percentile for weight at birth Factors
◦ Maternal diabetes, parental obesity Complications
◦ Difficult delivery, birth trauma, hypoglycemia Nursing implications
◦ Assess for birth injury◦ Monitor for hypoglycemia
Large for Gestational Age Infant
LGA SGA Hypoglycemia Hypocalcemia Hyperbilirubinemia
Impact of Maternal Diabetes Mellitus (DM) on the Newborn
Birth trauma Polycythemia RDS Congenital malformations
Impact of Maternal Diabetes Mellitus (DM) on the Newborn
Risk factors◦ Congenital anomalies◦ Macrosomia (>4,000 gm)◦ Hypoglycemia◦ Respiratory distress syndrome
Infants of Diabetic Mothers
Prevention of complications◦ Normoglycemia during gestation and labor◦ Deliver when lungs are mature◦ Prepare for delivery of large infant◦ Monitor for hypoglycemia
Infants of Diabetic Mothers (continued)
Lethargy or jitteriness Poor feeding and sucking Vomiting Hypothermia and pallor Hypotonia, tremors Seizure activity, high pitched cry,
exaggerated moro reflex
Hypoglycemia Symptoms
Routine screening for all at risk infants Early feedings D10W infusion
Hypoglycemia: Nursing Care
Risk Factors for Hyperbilirubinemia
Lab Evaluation of Jaundice
Checklist for in-room Phototherapy
Excess bilirubin in the blood resulting in jaundice
Can be caused by physiologic or pathologic processes◦ Normal RBC breakdown ◦ Rh or ABO incompatibility
Hyperbilirubinemia
Complications◦ Kernicterus◦ Erythroblastosis fetalis◦ Hydrops fetalis
Assessment findings◦ Jaundice, elevated bilirubin levels
Hyperbilirubinemia (continued)
Encourage frequent feedings Exposure to sunlight Phototherapy
◦ Shield infant’s eyes◦ Monitor body temperature◦ Monitor weight◦ Monitor fluid intake◦ Weigh diapers◦ Note frequency of stools
Management of Hyperbilirubinemia
Appears after first 24 hours of life Disappears within 14 days Due to an increase in red cell mass
Physiologic Hyperbilirubinemia
• Appears within first 24 hours of life• Serum bilirubin concentration rises by more
than 0.2 mg/dL per hour• Bilirubin concentrations exceed the 95th
percentile• Conjugated bilirubin concentrations are
greater than 2 mg/dL • Clinical jaundice persists for more than 2
weeks in a term newborn
Pathologic Hyperbilirubinemia
Hemolytic disease of the newborn Erythroblastosis fetalis Hydrops fetalis ABO incompatibility
Causes of Pathologic Hyperbilirubinemia
Resolving anemia Removing maternal antibodies and
sensitized erythrocytes Increasing serum albumin levels Reducing serum bilirubin levels Minimizing the consequences of
hyperbilirubinemia
Treatment of Pathologic Hyperbilirubinemia
Maximize exposure of the skin surface to the light
Periodic assessment of serum bilirubin levels Protect the newborn’s eyes with patches Measure irradiance levels with a photometer Good skin care and reposition infant at least
every 2 hours Maintain an NTE and adequate hydration and
nutrition
Phototherapy: Nursing Care
Figure 33–18 Infant receiving phototherapy. The phototherapy light is positioned over the incubator. Bilateral eye patches are always used during photo light therapy to protect the baby’s eyes. SOURCE: Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.
Nutrition and Fluid Management Fluids
◦ Strict I&O, weigh diapers Electrolyte management
◦ Management of sodium and potassium levels
Glucose homeostasis Feeding
◦ Gavage or nipple method◦ Types: formula or breast
milk
Gavage feeding tube
Developmental Care of the Preterm Infant
Light Sound Temperature Positioning and
containment strategies Handling and touching Nonnutritive sucking
Increase in oxygen requirements Increase in utilization of glucose Acids are released in the bloodstream Surfactant production decreases
Cold Stress
Figure 33–13 Cold stress chain of events. The hypothermic, or cold-stressed, newborn attempts to compensate by conserving heat and increasing heat production. These physiologic compensatory mechanisms initiate a series of metabolic events that result in hypoxemia and altered surfactant production, metabolic acidosis, hypoglycemia, and hyperbilirubinemia.
Observe for signs of cold stress Maintain NTE Warm baby slowly Frequent monitoring of skin temperature Warming IV fluids Treat accompanying hypoglycemia
Cold Stress: Nursing Care
Explain the assessment and nursing interventions associated with birth injuries
Objective 2
Fractures◦ Clavicle, long bones, skull most common◦ Risks
Large infant, breech, difficult labor◦ Assessment
Impaired mobility◦ Management
Immobilization, traction, casting
Trauma and Birth Injuries
Facial Palsy◦ Usually related to use of forceps
Brachial Palsy◦ Usually related to difficult delivery such as
shoulder dystocia◦ Assessment
Impaired mobility of arm◦ Paralysis may be temporary or permanent
Trauma and Birth Injuries (continued)
Realistically perceiving the infant’s medical condition and needs
Adapting to the infant’s hospital environment
Assuming primary caretaking role Assuming total responsibility for the infant
upon discharge Possibly coping with the death of the infant
if it occurs
Needs of Parents of At-risk Infants
Facilitating family visits Allowing the family to hold and touch the
baby Giving the family a picture of the baby Liberal visiting hours Encouraging the family to get involved in
the care
Facilitating Parental Attachment
Figure 33–20 Mother of a 26 weeks’ gestational age infant with respiratory distress syndrome on a ventilator is getting acquainted with her baby. Physical contact is vital to the bonding process and should be encouraged whenever possible. SOURCE: Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.