Care of High-Risk Newborns Flashcards
Why are preemies more susceptible to hypothermia?
Lack of white fat to keep them insulated
Lack of brown fat, (develops at 28-30 weeks)
Babies don’t shiver (which normally produces heat)
Immature CNS, immature temp regulator in the brain (H1=hypothalamus)
Greater surface area (premature infants don’t flex)
Thin skin - blood vessels are closer to the surface of the skin (losing heat/vasoconstriction)
more than 1/3 of all infant deaths are related to preterm T or F
True
Causes related to high risk infants
Substance abuse Diabetes Teen Moms Illness (sepsis) Multiple pregnancies Unknown
What will we see in a baby experiencing hypothermia
Changes in feeding behavior lethargic or irritable (change from norm) respiratory difficulty hypoglycemia mottled/pale appearance
what happens in cold stress
baby has decreased body temp
babies need to increase metabolic rate to produce heat; using up a lot of glucose and oxygen, resulting in hypoglycemia and resp. distress
babies are increasing their caloric & oxygen use - which they need just to sustain life
non-shivering thermogenesis
vasoconstriction
trt/prevention of hypothermia/thermo-regulation
kangaroo care (skin to skin)
signs of respiratory distress
grunting nasal flaring retractions cyanosis (lips) see-saw respiration's (chest goes down, belly goes up)
A serious complication of hypothermia
cold stress
Respiratory Distress Syndrome (RDS) is a
lung disorder affecting preterm infants
insufficient surfactant production
RDS is found in this population more often
big babies (born to diabetic moms) - insulin blocks cortisol, cortisol is involved in surfactant production male babies - androgen's (male hormones) inhibit surfactant production
incidence and severity of RDS is reduced by giving
Maternal steroids - maternal betamethazone, acts as cortisol in the baby to get surfactant production going
S/S of RDS appear within
at birth or within the first 6 hours - quickly
treatment for AOP
caffeine - IV loading dose, then PO
Rate of death from RDS went from 100 - 10% of babies after surfactant trt was found T or F
true - considered golden treatment
ROP retinopathy of prematurity cause
Blood vessels in the eye become injured; still grow, abnormally, can rupture causing a leak and bleed, scar tissue forms which actually puts traction on retina, causing cause retinal detachment and blindness.
Don’t know the exact range; prolonged oxygen/ventilation support can put them at an increased risk and cause ROP
condition which inhibit/interferes with surfactant production
birth asphyxia
c-section
treatment of RDS
surfactant replacement therapy through ET tube, intubate them
two complications of oxygen therapy/ventilation support
retinopathy of prematurity
chronic lung disease
treatment of CLD (chronic lung disease)
supportive/palliative
antibiotics (prn)
broncho-dilators
provide support for parents as well
With IVH, patients are likely to develop
developmental delays
neurological abnormalities
Intraventricular (IVH) hemorrhage cause
because blood vessels are fragile they will rupture/burst; we will see bleeding in the brain
any hypoxic injury to the brain (systolic)
fluctuations in BP
fluctuations in cerebral blood flow
over the course of 2 years, having had CLD, what can you expect
chronic respiratory/lung infections
pneumonia’s
s/s of CLD (chronic lung disease)
tachycardia
resp acidosis
CLD prevention
maternal steroids -beta methadone
decreases inflammation in airways
minimize exposure to oxygen/ventilation
Screening/mgmt of IVH
day 7 ultrasound
oxygen/ventilation therapy
stage 4 IVH will present with
neurological abnormalities
what causes fluctuation in blood flow in IVH patients
crying
diaper changing
oxygen/ventilation support
prevention of IVH
maternal steroids - beta methazone
when will we s/s of IVH
within 72 hours birth; otherwise no evidence of a problem
Nursing interventions for IVH
cluster care minimum to care for these patients measure head circumference observe for chg in neurological status elevate head 30* - decreasing intracranial pressure parental support
if a baby has symptoms with IVH what would they be
lethargy poor muscle tone respiratory deterioration w/apnea or cyanosis(hypo glycemia/thermia) seizures (last sign) decreased reflexes tenting/bulging fontanel
complication of IVH
hydrocephalus (water on the brain); requires a shunt
what is NEC
infection of the intestines - gas forming bacteria invade intestinal wall; pockets form in intestine as well as food those areas of intestine begin to die
sepsis/systemic infection can occur
what causes nec
unknown -
immature GI system?
hypoxia - lack of air to the belly?
feeding too much, to soon?
prevention of NEC
breast-milk (formula w/probiotics)
maternal betamethazone
s/s of nec
abdominal distention- loops of bowel can be seen
respiratory distress - diaphragm pushing against lungs
spitting up feedings
NEC mgmt
stop feedings immed - call physician (iv nutrition) antibiotics decompress belly surgery may be necessary - ostomy? long-term gi problems
birth asphyxia - what is it
lack of oxygen/increased carbon dioxide in blood
hypoxia vs asphyxia
hypoxia - lack/decreased amt of oxygen
asphyxia - increased carbon dioxide (acidosis)
what does asphyxia cause
ischemia to organs
possible causes of asphyxia
insufficient surfactant
maternal fxrs (htn, infection)
placental fxrs (insufficient, abruption, previa)
fetal fxrs (congenital anomalies, cord problems, prematurity)
Stress puts baby at risk for asphyxia
birth asphyxia manifestations
rapid breaths then nothing (resuscitating when nothing is happening)
rapid fall in HR
gasping
loss of consciousness
what do we want to prevent (goal) for birth asphyxia
prevent further brain damage - secondary cell death
intervention to prevent secondary cell death to the brain in birth asphyxia
therapeutic hypothermia - controlled cooling w/cap or blanket
decreasing biological processes - metabolism
must be done within 6hrs of birth
must be 36 weeks in utero
cooled for 72hours
must slowly increase their temperatures (seizures if done too fast)
34-35*C
babies are monitored w/EEG, iv fluids, sedation
helps mild to moderate cases, not much improvement for significantly impaired cases
other complications w/birth asphyxia
hypo-thermia/tension/glycemia
feeding problems
seizures
fluid/electrolyte imbalances
nursing care for birth asphyxia
sedation
ventilation
parental support
difference between transient tachypnea and respiratory distress syndrome is
TTN - really called wet lung amniotic fluid leftover in lungs (wet lung), usually resolves on its own in 12-72 hrs
RDS - surfactant problem
transient tachypnea of the newborn (TTN) cause
amniotic fluid leftover in lungs (wet lung), resolves on its own in 12-72 hs
risk fxrs for TTN
male babies
c-section w/o labor (labor process pushes fluid along)
maternal diabetes/asthma
most common respiratory problem seen in NICU
TTN - transient tachypnea of the newborn
population affected w/TTN
term
late pre-term
if a babies respiratory rate is greater than 60 will we feed them?
NO. IV fluids/continue checking xrays
Meconium Aspiration Syndrome MAS is caused by a stress event such as asphyxia/hypoxia - anal sphincter relaxes causing release of stool, baby aspirates meconium in utero or at birth. t or f
true
what is MAS
meconium fluid enters lungs during fetal life or at birth
what does MAS result in
obstruction of airway (meconium is thick/tarry)
infection/inflammation of the airway
nursing intervention for MAS
gives lung rest/support (oxygen/ventilation)
npo
Viagra (helps w/vaso-dilation of lungs)-off label use
last resort trt for MAS
extra corpral membrane oxygenation (ecmo) heart/lung bypass machine
hyperbillirubinemia can cause
brain damage
positive direct coombs test
monitors bilirubin levels
direct = babies test - not moms
(+) = maternal antibodies were found on babies RBCs;
moms blood cells were attacking babies antigens (rh incompatibility/hemolytic disorders)
1 cause of hyperbilirubinemia
HEMOLYTIC FXRS - Rh incompatibility; sometimes ABO
causes of hyperbilirubinemia
hemolytic fxrs (#1 cause)
infection
hypoxia
diabetic mom
pathological vs physiologic hyperbilirubinemia
TIMING Pathological (disease process going on) - appears in 1st 24 hrs - acidosis seen a lot (interferes w/ blood/brain barrier) - picks up albumin - no albumin to conjugate the bilirubin Physiologic - after 24hrs of birth - norm RBC process (breaking down) fetus has to make more RBC then is needed extrautero - babies breaking down its fetal hemoglobin the byproduct is bilirubin
conjugated vs un-conjuguated bilirubin
Conjugated = good - liver makes bilirubin water soluble, excrete through urine/stool Un-conjugated = bad - toxic - bilirubin builds up - give albumin (trt)
kernicteris
chronic brain damage from hyperbilirubinemia (jaundice on the brain)
byproduct of RBC is
bilirubin
hyperbilirubinemia can lead to what acute and chronic conditions?
Acute - Billirubin Encephalopathy (jaundice of the brain)
Chronic - Kernicterus - neurological abnormalities/developmental delays
This can be prevented
trt for bilirubin
photo-therapy (protect babies eyes/groin) increased feeds (urine and stool excretion) in extreme cases exchange transfusions (remove babies unconguated blood, & replace it, along with albumin)
most common bacterial causing infection in the newborn
group B strep
Sepsis onset
early - s/s within the first 24 hrs of life - worse prognosis
late - after 1st week of life
risk fxr for sepsis (infection)
> 18hr ruptured membranes
foul smelling fluid
preemies
maternal infection (group B)
sepsis (infection) characteristics
hypothermia (early sign)
resp problems
seizures (late sign) - shock
trt for sepsis (infection)
iv antibiotics supportive care (ventilated)
hypoglycemia classification
40
hypoglycemia can cause
brain damage; brain uses glucose for fuel
hypoglycemia risk fxrs
prematurity/late preterm/postmaturity
prematurity - don’t have glycogen stores
post-maturity -they had to use glycogen due to placental insufficiency
normal blood glucose for a term baby
50-90; less than 40 classify hypoglycemia
early s/s of hypoglycemia
jittery/tremors (most common)
resp. difficulty
low temp
late s/s of hypoglycemia
seizures
coma
resp. distress
most common early sign of hypoglycemia
jittery/tremors
prevention of hypoglycemia
monitor (glucose)
early feeds
if s/s of hypoglycemia continue, treat with
IV glucose (dextrose)
risk fxrs for infants of diabetic mothers
prematurity
hypoglycemia
asphyxia
resp distress
mgmt of hypoglycemia
on moms end - control diabetes so baby isn’t affected
monitor glucose
feed early
monitor complications
neonatal abstinence syndrome (NAS) is
drug exposed babies showing signs of withdrawal
method to score babies (around feeding times)
Finnegan Score Sheet for NAS (tool to determine if treatment is needed for withdraw)
characteristics of NAS
resp problems irritable - inconsolable hyperthermia sneezing (3x's in a row) diaper rash (constant stools)
medications for withdrawal (babies)
oral morphine
phenobarbital (due to poly drug use)
nursing care for NAS
cluster care encourage feedings once they sleep - try to allow them to get an hours rest injury prevention involve parents (non judgmental)
what is Gastroschisis***
abdomen doesn’t fully close/fuse
organs are outside the abdomen
this does NOT involve the cord
congenital abdominal anomaly
Gastroschisis can be dx when
in utero
Gastroschisis begins/happens when
at the 6th week gestation
Gastroschisis nursing mgmt
prevent infection/injury to organs
apply warm sterile dressings
wrap in plastic for protection
trt for gastroschisis
silo - gravity pulls organs into stomach area slowly (can take days for this to happen)
what is omphalocele ***
pt with omphalocele have other anomalies (trisomy…)
intestines/organs are housed IN the umbilical cord
omphalocele trt
same as gastroschisis (silo)
congenital diaphragmatic hernia (cdh) where would you hear bowel sounds
chest
congenital diaphragmatic hernia (cdh) where would you hear heart sounds
shifted over - more left
congenital diaphragmatic hernia (cdh) occurs when
there is an opening in the diaphragm, the intestines travel into the chest cavity
left lung doesn’t grow to the optimal level
s/s of cdh
respiratory distress (only 1 lung is functioning properly) barrel chest (aveoli hyper-stimulated)
s/s of MAS
barrel chest (aveoli hyper-stimulated)
mgmt of cdh
oxygen/ventilator
ecmo (extracorporeal membrane oxygenation)
surgery (when stable)
best position for cdh baby
affected side - left side
babies are at risk for what later in life if on ecmo
stroke
treatment on ecmo is usually no longer than
2 weeks
gives lungs a rest to allow the other lung to grow
Glucose protocol
usually every hr/1st 4 hrs; every 4hrs/x’s 2
