Chapter 30: High Risk Newborn: Acquired and Congenital Conditions Flashcards
1
Q
asphyxia in the newborn
A
- insufficient O2 and excess CO2 in the blood and tissue
- can occur in utero, at birth, or after birth
- many causes:
- maternal: HTN, infection drug use
- placental conditions: placenta previa, abruption, or postmaturity
- fetal causes: cord problems, infection, prematurity, multifetal gestation
- lack of O2 to the cells–>lactic acid production and metabolic acidosis develops when inadequate bicarb available
- results in ischemia to major organs
- quick intervention is needed to prevent brain damage and death
2
Q
what are problems that may occur as a result of asphyxia?
A
- asphyxia leads to ischemia of major organs; therefore, pulmonary ischemia occurs which results in the inability to produce surfactant–>inc risk of RDS,
- intrauterine stress may cause passage of meconium and meconium aspiration syndrome
- hypoglycemia
- feeding and thermoregulation problems
- seizures
- hypoTN
- pulmonary HTN
- metabolic acidosis
- renal problems
- fluid and electrolyte imbalances
3
Q
manifestations of asphyxia
A
- rapid respirations followed by cessation of respirations and a rapid fall in HR
- stimulation (alone or with O2) may restart respirations
- if no intervention, gasping respirations may resume until the infant enters a period of secondary apnea
- in secondary apnea, O2 levels continue to dec, infant loses consiousness, and stimulation is ineffective
- resuscitative measures must be started immediately
4
Q
infants at risk for asphyxia
A
- if complications occurred during pregnancy, labor, or birth
- if mother received narcotics for analgesia, may depress infant’s CNS
- if infant has a normal color and HR but depressed respirations, and the mother received opiates w/in 4 hours of birth, given naloxone
5
Q
neonatal resuscitation
A
- ABC’s and prevent heat loss
- ventilate over nose and mouth at 40-60/min
- do compressions if HR<60 at 90/min
- maintain thermoregulation
- warm infant slowly over 2-4 hours as rapid warming can cause apnea
- umbilical line
- administer sodium bicarb (to help with acidosis) and epinephrine as ordered
- use the lowest O2 concentration possible
6
Q
transient tachypnea of the newborn (TTN)
A
- infants develop rapid respirations soon after birth from inadequate absorption of fetal lung fluid
- usually resolves in 24-48 hours
- risk factors: C/S, macrosomia, multiple gestation, excessive maternal sedation, prolonged or precipitous labor, male gender, maternal diabetes or asthma
- cause unknown: possibly delay in absorption of fetal lung fluid which means decreased lung compliance and air trapping
7
Q
manifestation of TTN
A
- tachypnea w/in 6 hours of birth
- grunting
- retractions
- nasal flaring
- mild cyanosis
- CXR: shows hyperinflation, perihilar streaking
8
Q
TTN: management and nursing considerations
A
- oxygen
- gavage feeding when RR is high in order to prevent aspiration and conserve energy
- watch for signs of sepsis and RDS
9
Q
meconium aspiration syndrome (MAS)
A
- condition in which there is obstruction, chemical pneumonitis, and air trapping caused by meconium in the lungs
- risk factors: asphyxia, post-term, SGA, being compromised with placental insufficiency with decreased amniotic fluid and cord compression
- causes: MAS occur when hypoxia causes inc peristalsis of the intestines and relaxation of the anal sphincter, so meconium is passed and it is aspirated into the lungs
- airways can be complete or partially blocked and the obstruction may occur in utero or at birth
10
Q
severe MAS
A
- when meconium is below the vocal cords which results in respiratory distress
11
Q
complications of MAS
A
- atelectasis: if small airways are completely blocked
- pneumothorax or pneumomediastinum: occurs when overdistended alveoli (due to air being inhaled but being blocked from exhalation by meconium in the airway) have a leak
- inhibition of surfactant production–>resp distress
- chemical pneumonitis
- persistent pulmonary HTN
12
Q
manifestations of MAS
A
- respiratory distress can be mild to severe:
- tachypnea
- cyanosis
- retractions
- nasal flaring
- grunting
- rales
- barrel shaped chest r/t hyperinflation
- radiography: patchy infiltrates, atelectasis, consolidation, hyperexpansion
- yellow green nails, skin, umbilical cord
13
Q
MAS: management and nursing considerations
A
- if good APGARs, routine care
- if poor APGARs, warmed O2, endotracheal tube to remove meconium, ventilation
- may have to use ECMO if severe MAS which oxygenates blood while bypassing the lungs ot allow the infant’s lungs to rest
- nurse should notify physician during labor is meconium in fluid
- NICU RN/neonatologist may be needed for birth
- be sure O2 and suction are working before birth
- monitor baby for infection and monitor thermoregulation
14
Q
Persistent Pulmonary HTN of the Newborn (PPHN)
A
- condition in which pulmonary vasoconstriction occurs after birth and elevates vascular resistance of the lungs, so it causes a rise in pressure on the right side of the heart–>R to L shunt of unoxygenated blood that flows thru foramen ovale–>aorta: so this blood bypasses lungs and metabolic acidosis occurs which makes for more pulmonary vasoconstriction
- causes changes to neonatal circulation
- develops w/in 12 hours
- causes:
- most often in term or preterm infants
- abnormal lung development, maternal use of NSAIDs or SSRIs
- also assoc with hypoxemia and acidosis from asphyxia, MAS, sepsis, polycythemia, hernia, RDS
15
Q
PPHN: manifestations
A
- tachypnea
- respiratory distress
- progressive cyanosis that becomes worse with handling/stimulation
- O2 sats are dec, PaCO2 is inc, acidosis is present
- echocardiogram indicates R to L shunting of the blood
16
Q
PPHN: management and nursing considerations
A
- tx underlying cause of poor oxygenation and relieve vasoconstriction
- sedation, ventilation, surfactant therapy
- can use inhaled NO to dilate vessels
- ECMO
- maintain thermoregulation to prevent cold stress which will require need for more O2
- keep handling and noise to a minimum to prevent inc hypoxia
- assess for hypoglycemia, anemia, acidosis
17
Q
what is hyperbilirubinemia (pathologic)?
A
- when total serum bilirubin is >5-6, then jaundice appears
- it is considered abnormal when the TSB rises more rapidly or to a higher level than expected or remains elevated
- usually seen during 1st 24 hours
- may lead to bilirubin encephalopathy which can lead to kernicterus (brain damage from bilirubin toxicity)
- more likely in infants who have had hypoxemia, resp acidosis, infection, dehydration
18
Q
causes of hyperbilirubinemia
A
- hemolytic dz of the newborn is more common cause: caused by Rh or ABO incompatibility of the mom and baby
-
erythroblastosis fetalis: occurs when Rh incompatibility causes the Rh antibodies the mom has formed to cross the placenta, attach to the fetal RBCs, and hemolyze them–>causes severe anemia
- hydrops fetalis: can result from this if too many RBCs destroyed, causes HF and edema
-
erythroblastosis fetalis: occurs when Rh incompatibility causes the Rh antibodies the mom has formed to cross the placenta, attach to the fetal RBCs, and hemolyze them–>causes severe anemia
- infection
- hypothyroidism
- polycythemia
- G6PD deficiency
19
Q
therapeutic management of hyperbilirubinemia
A
- need to prevent bilirubin encephalopathy and kernicterus
- Rh negative mother has indirect Coombs test to check for antibodies against fetal blood
- if an infant is jaundiced, a direct coombs test is done using cord blood
- if positive, this means mother’s antibodies have attached to infant’s RBCs
- TC bilirubinometers are used to screen the TC bili level–noninvasive
- frequent feedings–every 2-3 hours
- phototherapy (infant wears only diaper and covers over the eyes, monitor hydration and temp)
- exchange transfusions
20
Q
what are side effects of phototherapy?
A
- frequent, loose, green stools that result from inc bile flow and peristalsis–>more rapid excretion of bilirubin, but damaging to the skin and causes rapid fluid loss
- so need to inc fluids in infant by 25% during therapy
- macular skin rash
- bronze baby syndrome: grayish brown discoloration of skin and urine
- rebound TSB of 1-2 when phototherapy ends, but monitor for 24 hours and should not inc more
21
Q
explain exchange transfusions to treat hyperbilirubinemia
A
- used when phototherapy cannot reduce bili levels enough quickly
- this tx removes maternal Abs, unconjugated bilirubin, and antibody coated (sensitized) RBCs
- provides fresh albumin with binding sites for bilirubin and helps correct severe anemia
- if Rh incompatibility: use type O, Rh negative blood
- if ABO incompatibility: use type AB blood, so that there are not A/B antibodes to destroy RBCs
- complications: electrolytes and acid base imbalance, infection, dysrhythmias, NEC, bleeding, thrombosis, thrombocytopenia, air embolism
- nurse: prepare equipment, assess infant: cardiac monitor/temperature/etc., teach parents
22
Q
signs of bilirubin encephalopathy
A
- lethargy
- inc or dec muscle tone
- poor feeding
- dec or absent Moro reflex
- high pitched cry
- opisthotonos
- seizures
23
Q
infection in newborns
A
- can be acquired before, during, and after birth
- during pregnancy: rubella, CMV, syphilis, HIV, and toxoplasmosis can pass across placenta
- type of vertical infection
- during labor: GBS, herpes, hepatitis
- type of vertical infection
- after birth: from hospital staff or contaminated equipment, family, visitors
- type of horizontal infection
- ie. MRSA
- during pregnancy: rubella, CMV, syphilis, HIV, and toxoplasmosis can pass across placenta
24
Q
sepsis neonatorum
A
- infection that occurs during or after birth may result in this systemic infection from bacteria in the bloodstream
- newborns have immature immune systems that react more slowly to invaders
- they have fewer Abs and are less able to localized infection, so the organism can spread easily from one organ to the next
- BBB is less effective in preventing entrance of organisms–>CNS infection
25
common causes of sepsis neonatorum
* GBS
* E. coli
* coagulase negative Staphylococcus
* Staph aureus
* Haemophilus influenze
* fungi like Candida albicans
26
early vs. late onset of sepsis neonatorum
* early:
* acquired during birth: from complications of labor like prolonged ROM, prolonged labor, or chorioamnionitis
* show signs during 1st hours after birth, 90% in 24 hours
* rapidly progressive, multisystem, high mortality
* pneumonia and meningitis are often present
* late:
* occurs from 8-90 days after birth in healthy term infants or after 72 hours of life in VLBW infants
* acquired during or after birth
* usually localed infection such as meningitis
* serious long term effects
27
diagnosit testing of sepsis neonatorum
* CBC count: will show inc immature neutrophils, sudden change in number of leukocytes
* elevated IgM
* cross reactive protein: sign of inflammatory process
* can check rise and fall as infection improves
* CXR: differentiate b/w sepsis and RDS
* glucose levels: unstable with sepsis
28
treatment of sepsis neonatorum
* if GBS +, women receive abx during labor
* if develop signs of infection, then treat with IV broad spectrum abx
* and do a culture and sensitivity test in order to determine how to better treat the specific organism
* commonly use: ampicillin, aminoglycoside, cephalosporin, vancomycin
* oxygen
* fluid maintenance
* monitor glucose
29
complications of sepsis neonatorum
* shock
* hypo/hyperglycemia
* electrolyte imbalances
* problems with thermoregulation
30
risk factors for sepsis neonatorum
* prematurity and low birth weight: MOST IMPORTANT
* prolonged ROM or labor
* chorioamnionitis
* foul smelling amniotic fluid
* being in the NICU
* risk of infection in as gestational age and birth weight decrease
31
S/S of infection in the newborn
* early signs are subtle:
* temp instability
* respiratory problems
* changes in feeding or behavior
32
how to prevent infection in a newborn
* handwashing
* teach parents/visitors also to use good handwashing
* disinfect equipment
* sterile technique during invasive procedures
* minimize handling and trauma to the skin
* use separate equipment on each infant
* place infant in incubator which is used as a physical separation
33
nursing considerations with sepsis neonatorum
* prevent infection
* provide abx
* obtain labs
* start IV fluids and administer abx (7-14 days for sepsis, 14-21 days for meningitis)
* provide supportive care: O2, fluid maintenance, monitor V/S, urine output, gavage feeding
* support parents
34
infants of diabetic mothers (IDM)
* risk depend on type of diabetes and if well controlled or not
* high risk of mortality
* most common problems: cardiac, urinary, GI anomalies; neural tube anomalies; sacral agenesis
* cardiomegaly is common and may lead to HF
* insulin acts as a growth hormone--\>macrosomia
* if mom is hyperglycemic, glucose crosses placenta, but the insulin does not, so the glucose causes the fetus to secrete insulin
* when infant is born, the mother's glucose no longer is available but insulin remains high, so inc risk of hypoglycemia during first 4 hours
* higher risk of asphixia, RDS, hypocalcemia, polycythemia, jaundice, and prematurity
35
characteristics of IDM
* infant's with macrosomia is different from LGA
* IDM: infant's size from fat deposits and hypertrophy of liver, spleen, and heart, but the brain and kidneys are normal in size
* length and head circumference are normal
* LGA: no enlargement of organs, long with large heads
* IDM:
* round face
* red skin obese body
* poor muscle tone at rest but becomes irritable and may have tremors when disturbed
36
therapeutic management of IDM
* controlling mother's diabetes throughout pregnancy to dec complications
* if infant is large, monitor for shoulder dystocia or cephalopelvic disproportion which may require C/S
37
nursing interventions for IDM
* assess for signs of complications, trauma, and congenital anomalies
* monitor for hypoglycemia: jitteriness, tremors, hyporeflexia
* feed infants early and often to prevent this, b/c glucose levels are lowest at 1-3 hours after birth
* keep glucose above 40 (should be 40-60 mg/dL during first 24 hours)
* be alert for signs of RDS, cold stress
* if infant has polycythemia, make sure to provide adequate hydration to prevent sluggish blood flor
* support parents
38
polycythemia in newborns
* hemoglobin greater than 22 and hematocrit greater than 65%
* inc viscosity of the blood causes resistance in the blood vessels and dec blood flow to organs--\>organ damage from ischemia
* results in hyperbilirubinemia due to inc RBC breakdown
* cause: poor intrauterine oxygenation--\>fetus makes more RBCs
* most common in infants who are postterm, LGA, SGA, or have fetal growth restriction
* also in infants of mothers who smoke, have HTN, or DM
39
manifestations of polycythemia in newborns
* most commonly asymptomatic
* if symptomatic: plethoric color, lethargy, irritability, poor tone, tremors
* abdominal distention, dec bowel sounds
* poor feeding
* hypoglycemia
* respiratory distress
* jaundice
40
polycythemia: management and nursing considerations
* if asymptomatic: observe and administer hydration
* if HCT above 70%, mayneed partial exchange transfusion
* phototherapy to tx jaundice
* monitor bilirubin levels
* hydrate infants adequately
41
Prenatal drug exposure
* if infants exposed to drugs before birth, may have neonatal abstinence syndrome (NAS)--experience withdrawal
* most drugs cross placenta
* early abuse of drugs--\>congenital anomalies
* later abuse of drugs--\>poor development or function of organs
* higher risk of long term cognitive, emotional problems, and SIDS
42
how to identify drug exposed infants
* note lack of prenatal care
* NAS occurs most often in infants who had opiate exposure prenatally
* esp if use of heroin, codeine, hydroxyzine, amphetamines, and antidepressants
* signs are usually present 24-48 hours after birth, but may not occur for up to 4 weeks depending on specific drug, dose, and time of last use
43
NAS
* infants are irritable, have hyperactive muscle tone, and have a high pitched cry
* they have tremors, but blood glucose is normal
* infants appear hungry and suck vigorously on fits, but have poor coordination of suck and swallow
* frequent regurgitation, vomiting, and diarrhea are common
* restless, excessive energy
* failure to gain weight
* seizures may occur
44
therapeutic management of prenatal drug exposure
* rule out other conditions with testing: test for sepsis, hypoglycemia, hypocalcemia, neuro disorders
* deal with complications like respiratory problems
* meds: oral morphine, methadone, phenobarbital
* med dosage is gradually tapered until the infant doesn't need it anymore
* gavage/IV feeds b/c suck and swallow reflex is poor
* may need excess calories due to excessive activity
* nursing should obtain a urine sample to test for drug exposure if ordered
* the 1st urination is best!!!
45
nursing care with feeding for drug exposure
* infants often suck frantically on their fists but are unable to coordinate feeding
* assess the infant's ability to coordinate suck and swallow with breathing
* administer gavage feedings if infnat is agitated, breathing rapidly
* may have inc caloric need due to excess energy, poor sleep
* quiet, low activity area for feedings to prevent distractions
* swaddle infants to help prevent startling
* position infant on right side with HOB elevated to 30-45 deg after feeding
46
nursing care with rest for drug exposed infants
* excessive activity and poor sleep patterns interfere with ability to rest
* excess muscle tone, tremors, and tendency for excessive energy should be assessed
* assess what inc or dec irritability
* keep stimuli to a minimum
* place crib in quietest corner
* swaddle infant in flexed position to prevent startling and agitation
* add new stimuli gradually as able to withstand
* organize nursing care to preduce handling and disturbances--cluster care
* use pacifiers for nonnutritive sucking
47
alterations in behavior states of drug exposed infants
* periods of activity delayed for several days
* disorganized sleep/wake patterns
* unable to attend to human face and objects
* exhibits gaze aversion with over stimulation
* neurologically weaker responses: suck, muscle tone, states of arousal
48
fetal exposure to tobacco
* most common form of substance abuse
* nicotine causes vasoconstriction, transfers across placenta, and reduces placental blood criculation
* reduce O2 delivered to fetus
* maternal effects: dec maternal appetite--\>less weight gain, higher risk of abortion, placenta abruption, premature ROM, placenta previa, perinatal mortality
* infant risks: prematurity, LBW, learning disabilities, asthma, obesity, colic, RDS, nicotine withdrawal, SIDS
49
fetal exposure to caffeine
* causes vasoconstriction of mother's vessels
* the half life is 3x longer in pregnancy
* causes fetal stimulation
* but teratongenic effects are undocumented
50
fetal exposure to marijuana
* active ingredient: THC--\>crosses placenta and accumulates in fetus
* frequently paired with other drugs
* reduces O2 available to fetus
* causes tachycardia and euphoria
* maternal: anemia, less weight gain
* infant: tremors, possible motor skill problems, sleep disturbances
51
fetal exposure to antidepressants (SSRIs)
* SSRIs include: prozac, zoloft, celexa
* prescribed legally for depression and anxiety
* have to weigh the risks vs benefits
* Paroxetine is not longer recommended for use b/c of reports of congenital malformations
* neonatal effects:
* transient respiratory distress
* poor tone
* irritbility
* PPHN
52
fetal exposuse to alcohol
* most commonly used drug--\>easily crosses placenta
* can cause spontaneous abortion and placental abruption
* teratogen that can cause FAS: a group of abnormalities resulting from alcohol exposure as a fetus
* amount and timing influence effects:
* first trimester: structural defects
* third trimester: CNS problems
* binge drinking most dangerous, but no amount of alcohol is safe
53
FAS diagnosis triad
* facial abnormalities
* microcephaly, short palpebral fissures (openings b/w eyelids), epicanthal folds, flat midface w/ low nasal bridge, indistinct philtrum, thin upper lip
* prenatal and postnatal growth restrictions
* noted in length, weight, head circumference
* CNS impairment
* includes intellectual disability, learning disability, high activity levels, short attention span, poor short term memory
54
symptoms in neonate of FAS
* sleepiness
* inconsolable crying
* abnormal reflexes
* hyperactivity
* jitteriness
* excessive mouthing behaviors
* hyperactive rooting
* inc non-nutritive sucking
55
possible long term complication of FAS
* failure to thrive
* dec ability to block out repetitive stimuli
* severe mental retardation
* impulsivity
* cognitive impairment
* speech/language abnormalities
56
fetal exposure to cocaine
* powerful short acting CNS stimulant that blocks the reuptake of NE and dopamine which causes hyperarousal, euphoria, sexual excitement, inc alertness
* causes cardiovascular stimulation and vascoconstriction--\>HTN, tachycardia, tremors, anemia, anorexia
* when euphoria wears off, irritability, exhaustion, lethargy, depression occurs
* maternal effects:
* inc risk of STDs and HIV b/c trading sex for drugs
* b/c of the vasoconstriction--\>placental abruption
* stimulates uterine contractions--\>abortion, premature ROM, preterm labor, preeclampsia, fetal hypoxia, meconium staining
* neonatal effects: CNS signs like lethargy, alternating b/w sleep and agitation, LBW, prematurity, tremors, tachycardia, long term mental/motor/developmental problems
57
fetla exposure to opioids
* these drugs are CNS depressants that cause mental dullness, drowsiness, dtupor
* intrauterine asphyxia occurs during maternal withdrawal--\>fetal withdrawal--\>hyperactivity--\>inc O2 consumption--\>asphyxia
* mother often has poor health, malnourished, anemic, high risk for STDs/HIV
* fetal effects: MAS, hypoxia, fetal growth restriction, preterm labor, premature ROM, fetal distress
* neonatal effects: NAS, LBW, SIDs, neglect/abuse
* methadone use causes fewer infections, larger birth weight
* but withdrawal symptoms may be more severe in methodone exposed infants
