ch. 34 nursing care of the high risk infant Flashcards
high risk newborn
1) high risk infants are classified according to the follow factors:
- birth weight (LBW <2500gms, VLBW <1500gms)
- gestational age: preterm/term
- predominant pathophysiologic problems
- symmetric/asymmetric growth restriction
preterm infants
1) majority of high risk infants those born in LESS than 37 weeks
2) organ systems are immature and lack adequate reserves of bodily nutrients
3) potential problems and care needs of the preterm infant weighing 2000 (4/4 Ibs at 33 weeks) differ from those of the term or post term infant of equal weight
4) extremely low birth weight (ELBW)
- birth weight is 1000g or less (2/2 Ibs)
- practical and ethical dimensions of resuscitation
- ethical questions associated with resuscitation of such infants include: should resuscitation be attempted. and to what extent should it be continued? who shoud decide? is the cost of resuscitation justified? do the benefits of technology outweigh the burdens in relation to the quality of life
TIP:
- LUNGS mature: 28 weeks surfactant
- more success at extrauterine life
- weight + age
physiologic functions
1) respiratory function (MUST establish)
- respiratory distress
- main issue
- 30-60 breaths/minute
- TIP: decreased alveoli, no surfactant, small lumen)
- look for: intercostal retractions, grunting, circumcyanosis
2) cardiovascular function (major changes)
- pulses
- murmurs -> hasn’t transitioned fetal -> adult
3) thermoregulation:
(a) goal: neutral thermal environment (hat, swaddle, warmer, skin to skin, isolet (humidity/heat available for preterm)
(b) cold stress:
- symptoms: apnea, bradycardia, central cyanosis, hypoglycemia, hypotonia, lethargy, irritability, metabolic acidosis, etc.)
4) central nervous system function:
- risk for brain injury d/t trauma birth
- signs (sustained): seizure, weak cry, hypertonia, irritability, no suck/swallow/breath
TIP:
- suck/swallow develop at 34 weeks
- periodic: 10 second pause + catch up
- apnea: 20 second pause, blue, decreased HR, hypertonia
physiologic function
1) nutrition:
- complicated by problems with intake and metabolism
- minimal enteral nutrition (MEN) feedings (breath milk/human donor 22kcal/oz) -> gut priming
- NGT/Gavage -> TPN
- listen with stethoscope
- oral aversion: long term NGT
2) renal function:
- immature; not fully functioning
3) hematologic status:
- predisposed to hematologic problems
4) immunity:
- increased risk for infection because they have a shortage of stored maternal immunoglobulins, an impaired ability to make antibodies, and a compromised integumentary system
- “MADE Good”
growth and development
1) corrected age
(a) age of the preterm infant is corrected by adding gestational age and postnatal age
- ex: infant born at 32 weeks 4 weeks ago would be considered 36 weeks
(b) milestones are corrected until 2 1/2
(c) VLBW survivors: at increased risk for neurologic or cognitive disability
(d) the preterm infant experiences catch-up body growth during the first 2 years of life (keep corrected age)
care mgmt (maintaining body temperature)
1) normal: 36.5-37.2
- high risk infant susceptible to heat loss
- unable to increase metabolic rate
- transepidermal water loss is greater
- should be transferred from delivery in a prewarmed incubator
- rapid changes in body temperature may cause apnea and acidosis
TIP:
- babies expend a lot of energy, modeling (checkered skin), pale/cyanotic, cold, breathe too fast/apnea/bradycardia
care mgmt (respiratory)
- neonatal resuscitation (no free flow, no cold, no dry)
- oxygen therapy (warm, humidified, 30-35% O2 blended) (SpO2: 88-92%)
- nasal cannula
- continuous positive airway pressure (CPAP) therapy
- mechanical ventilation (SIMV, volume guarantee): ventilators, set breaths at 30, set pressure, baby breaths and it assists baby, PEEP (positive end expiratory pressure)
- high frequency ventilation
care mgmt (respiratory, surfactant)
1) surfactant administration:
- helps keep alveoli patient/open/round for gas exchange
- 28 weeks
- steroids to increase lung maturation
- exogenous
(a) meds:
- beractant/poractant
- nitric oxide therapy (LAST RESORT): causes potent & sustained pulmonary vasodilation (decreased pressure, opens up airway)
- extracorporeal membrane oxygenation (ECMO)
2) weaning from respiratory assistance
TIP:
- meconium aspiration (post term) -> prevents adult ventilation (no oxygenation lungs)
care mgmt (nutritional care)
1) NOT always possible to provide enteral (GI route) nourishment to a high risk infant
2) type nourishment:
- human milk: more NICU’s are moving towards this
- infant formula
3) weight and fluid balance
- insensible water loss (IWL)
4) elimination patterns
5) feeding methods:
- oral feeding
- gavage feeding
- gastronomy feedings
- parenteral nutrition
- advancing infant feedings
6) nonnutritive sucking
care mgmt (skin care/environmental)
1) skin care
- increased sensitivity and fragility
- vernix caseosa has benefits for the preterm infant’s skin (cheesy, white moisturizer for baby)
- neonatal skin condition scoring (NSCS) should be performed daily to minimize skin breakdown
2) environmental concerns:
-NICU infants are exposed to high levels of auditory input
- vision concerns
- ongoing research into these risks
TIP:
- keep sounds to a minimum (38-90 db)
- isolet (50-75 db)
- 85 db: hearing impairment
- skin to care -> take off eye covers
- phototherapy: cover eyes/genitalia
care mgmt (developmental care)
- positioning (side lying/prone, helps with digestion + stability, turn babies, artificially flex babies)
- reducing stimulation
- infant communication
- infant stimulation
- kangaroo care
tip:
- preterm can become overstimulated
- communicate with parents about involvement that won’t overstimulate
care mgmt (parental adaptation to the preterm infant)
1) parental tasks:
- anticipatory grief -> parents have sense of loss for NICU
2) parental responses
3) parental support
4) parental maladaptation
5) parent education
complications in high risk infants
1) respiratory distres syndrome (RDS)
(a) caused by:
- lack of pulmonary surfactant, which leads to progressive atelectasis
- loss of functional residual capacity
- ventilation perfusion imbalance (resolve within 72H, self limiting)
(b) signs: retractions, grunting, nasal flaring, crackles, pale, chest XR (white out)
2) retinopathy of prematurity (ROP)
- complex multifactorial disorder that affects the developing retinal vessels of preterm infants
- BV in eyes susceptible to fluctuating, high O2
- risk ends when vessels develop (16-42 weeks)
- hypoxia -> vascular endothelial, growth factor available -> make vessels develop well
- opthamology: preventative care
3) bronchopulmonary dysplasia (BPD):
- chronic pulmonary condition occuring most commonly in preterm infants requiring mechanical ventilation
- long term ventilation -> hard to wean
4) patent ductus arteriosus (PDA)
- fetal ductus arteriosus fails to close after birth
- PA -> dorsal aorta hole can’t close
- meds: aspirin, indomethacine, ibuprofen, tylenol
- surgical mgmt
5) germinal matrix hemorrhage - intraventricular hemorrhage (GMH-IVH)
- most common type of intracranial hemorrhage
- usually occurs in infants less than 32 weeks
- history of hypoxia, birth asphyxia, RDS, pneumothorax, or other events causing impaired venous return or increased venous pressure
6) necrotizing enterocolitis:
- acute inflammatory disease of the GI mucosa
- intestinal ischemia, bacterial colonization, enteral feeding (human milk, probiotic)
- signs: bloated baby, perforation intestine, can’t tolerate feeds
complications in high risk infants (pain)
1) infant pain responses
(a) pain assessment
- CRIES
(b) memory of pain
(c) consequences of untreated pain in infants
(d) pain mgmt:
- oral sucrose (nonpharm)
- morphine/fentanyl
- tylenol (temp)
(e) signs:
- respiratory distress
- thermoregulation
- nutrition
- hypoglycemia
- hyperbilirubinemia
- infection
2) late preterm infant (LPI):
- born between 34 0/7 and 36 6/7 weeks of gestation
complications in high risk infants (postmature infants)
- postterm pregnancy: beyond 42 weeks
- physical characteristics of post maturity
- meconium aspiration syndrome (MAS)
- persistent pulmonary hypertension of the newborn (PPHN)
TIP:
- can become small d/t decreased nutritional needs being met
- NO elective inductions before 39 weeks (STANDARDS OF CARE)
- induction: 41 1/6 - 41 6/7
