HIGH RISK NEWBORN - FINAL EXAM Flashcards
preterm infants
born less than 37 wks with immature organ systems and lack of nutrients
high risk infants are classified according to
birth wt, gestational age, pathophysiologic problems
extremely lbw
1000 g/2.2 lbs or less
very lbw
less than 1500 g/ 3.3 lbs
lbw
2500/5.5 lbs
very premature
less than 32 wks
late premature
born btw 34-37 wks
premature
born btw 32-34 wks
tone and flexion assessment
increases with gestation, hypotonic and extended tone and posture
skin assessment
translucent, transparent, red
subcut fat assessment
decreased fat leading to thermoregulation issues
lanugo assessment
present btw 20-28 wks and then will disappear
foot creases assessment
not present until 28-30 wks
eye assessment
eyelids fused in very preterm and open btw 26-30wks
overriding sutures assessment
common among prematures, lbw
pina assessment
thin, soft, flat, folded
respiratory and cardiovascular support for neonate
maintain patent airway and thermal environment, assess vitals, labs I/O
nursing action for preterm neonates
NTE, nutrition, fluid/electrolytes, test
cardiovascular support includes evaluation of
HR, rhythm, skin, murmurs, pulses, cap refill, BP, hemoglobin/hematocrit, blood transfusions
maintain fluid and electrolyte imbalances
monitor I/O, IV fluids, determine hydration, add humidity
nutrition needs for preterm
monitor blood glucose, breastfeeding, bonding, feedings
respiratory distress synddrome
alveoli underdeveloped and lifethreatening
L/S ration
determines lung maturity with 2 phospholipids detected in liver
PG test
synthesized from mature alveoli to determine lung maturity
S/S or resp distress
grunting, flaring, retractions, decreased breath sounds, tachypnea, hypotonic, tachycardia, gray skin
nursing actions of resp distress
maintain patent airway, admin O2, low flow or high flow cannula, maintain NTE
bronchopulmonary dysplasia
chronic lung problem form those that have been treated with mechanical ventilation/O2
risk factors
neonates that have been on O2 for more than 28 days
S/S of BPD
low lung compliance, atelectasis, pulmonary resistance, overdistened lungs
intraventricular hemorrhage
bleeding around brain ventricles common in lbw babies
nursing actions of intraventricular hemorrhage
supine position, keep hips below head, NTE, minimize crying
sudden change in condition with intraventricular hemorrhage
bradycardia, hypotonia, low hematocrit, shock, metabolic acidosis, hyperglycemia, full/tense anterior fontanel
signs that bleeding worsened for intraventricular hemorrhage
apnea, low bp, acidosis, seizures, full or tense anterior fontanel, decreased LOC