Module 4: Austin Flashcards
What is SGA, LGA and IUGR?
- LGA: infant is above the 90th percentile on a standard growth chart
- SGA: infant is below the 10th percentile on a standard growth chart
- IUGR: refers to the deviation and reduction in expected fetal growth pattern
When is should term IUGR used?
- term IUGR should be used when there is evidence of abnormal genetic or environmental influences affecting growth.
- Thus, infants can be SGA without IUGR, and infants can suffer from IUGR and not be SGA
What is the common cause of IUGR?
- Uteroplacental insufficiency
- fetus will respond to a lack of oxygen supply and nutrients first by decreasing subcutaneous tissue, then by decreasing in length, lastly the head and brain growth will be affected
What are the two types of IUGR?
symmetrical: occurs early in pregnancy
- This type of growth restriction occurs early in pregnancy and is associated with a decreased number of fetal cells.
- It is marked by inadequate growth of the head, body, and extremities.
- Infants are born with fewer brain cells and tend to have poorer outcomes.
- Etiologies include genetic or chromosomal causes, early gestational intrauterine infections (TORCH), and maternal alcohol use.
Asymmetrical: occurs in the third trimester
- This type of growth restriction usually occurs early in the third trimester and is associated with impaired growth of the body, with normal growth of the head and extremities
- It is the result of failure of the cells to increase in size, resulting in less fat and smaller abdominal organs.
- This is due to extrinsic influences that affect the fetus later in gestation, such as preeclampsia, chronic hypertension, and uterine anomalies.
What kind of cognitive/learning problems is caused with IUGR in full term infant? preterm infant?
- full term: show more language problems, learning disabilities, neuromotor dysfunction, hyperactivity, and attention and behaviour problems than full-term infants of an average size.
- Preterm infants: who are also IUGR demonstrate the disadvantages of both prematurity and IUGR, showing higher rates of major disability and learning disability
What are 4 problems that infants are at risk for by being IUGR/SGA?
- hypoxia due to placenta insufficiency
- hypothermia due to small size and reduced brown fat stores
- hypoglycemia due to reduced hepatic glycogen stores
- polycythemia due to increased erythropoiesis (too many RBC/ increase in Hgb levels)
What is apnea?
- Apnea is defined as a non-breathing episode lasting longer than 20 seconds and accompanied with cyanosis and/or bradycardia
What are the two types of apnea?
- primary apnea: refers to apnea that is not associated with any other diseases (for example, apnea of prematurity)
- secondary apnea: may be associated with a particular disease or in response to a procedure
***primary apnea responds to the initial steps of Neonatal Resuscitation Program (NRP), whereas secondary apnea does not respond to stimulation, drying, or suctioning and requires initiation of intermittent positive pressure ventilation (IPPV).
What is apnea of prematurity?
- severity of apnea attacks in premature infants correlates with gestational age
- apnea occurs most frequently during the sleep state and is especially prevalent during active sleep
What two characteristics of sleep states of premature infants put them at risk for developing apnea?
- Active sleep, or REM sleep, is the predominant sleep state of premature infants
- infants less than 32 weeks spend 80% of their time asleep.
How is peripheral catecholamines a contributing factor in apnea in premature infant?
- Premature infants have a decreased amount of peripheral catecholamines (epinephrine and norepinephrine), and this has also been implicated as a cause of apnea.
- When infection is present, catecholamine stores are further depleted, putting infected premature infants at a very high risk for developing apnea
How is muscle fatigue a contributing factor in apnea of prematurity?
- Premature infants have very compliant chest cages and less compliant lungs than full-term infants, and this means increased work of breathing for premature infants
What is secondary apnea?
- Rather than being due to prematurity, apnea may be the first sign of an underlying disorder.
- When an infant suddenly starts having apneic spells, it is important to investigate for possible underlying disorders before jumping to the diagnosis of apnea of prematurity and initiating drug therapy.
- Apnea seldom occurs in first 24 hours of life, even in premature infants.
- Therefore, the appearance of apneic spells in the first 24 hours is usually a sign of an underlying disorder.
- Apnea is rare in infants of greater than 34 weeks gestation and needs to be promptly investigated
What are the order sequence of assessment and intervention that should be proceeded when responding to infant who is apneic/bradycardia?
- look at the infant: if infant looks fine then check monitor, the leads.
IF infant not fine then
- check breathing and if infant apneic then
- provide gentle stimulation by rubbing infant back/foot.
- check airway (ensure its patent): sniffling position.
IF that didnt work then provide intermittent positive pressure ventilation (IPPV) with a bag and mask
check heart rate:
once infant breathing check HR, if below 100 bpms
- continue with or start with PPV with bag and mask.
once infant breathing and HR>100 then
- check colour and oxygen saturation: If pale or cyanosed with low oxygen saturation, provide oxygen (~10% higher than what the infant is receiving).
As long as the heart rate is greater than 100 and the infant is breathing, bag and mask ventilation is no longer required.
How is sniffling position achieved?
- gently lifting the chin to slightly extend the neck.
What are some potential reasons for premature infant apnea and bradycardia (3)?
- prematurity—CNS immaturity, sleep patterns, catecholamine deficiency, fatigue
- positioning—sometimes infants obstruct their airways when their chin falls to their chest or when their necks are hyperextended
- hypoxia—depresses the respiratory centre anemia—insufficient oxygen carrying capacity
- sepsis—all premature infants have the potential to develop infections because of the immaturity of their immune systems
- neurologic—depressed respiratory centre
- hypothermia—Austin is very small with very little ability to self-regulate his temperature
- hypoglycemia—Austin will have low glycogen stores because of prematurity and because of his SGA
- gastro-esophageal reflux
What would a nurse assess further about infant to determine cause of apnea (3)?
- oxygen: pulse oximetry, Hgb, and Hct
- check infants position
- complete set of vital signs, especially temperature
- blood work: blood cultures, CBC/differential, electrolytes, glucose
- tone, level of alertness
What would you do if you notice infant is not breathing (the steps)
- quickly opens the porthole door and
- gently rubs infants back but infant doesn’t respond.
- turns infant over onto his back and places him in a sniff position. With this, infant opens his eyes, gasps weakly, and begins breathing.
- will make note of infants heart rate and colour are satisfactory and
- then will turn infant back on his stomach
What is Methylxanthines used for?
- Methylxanthines (caffeine citrate, theophylline, aminophylline) are the primary treatment option for apnea of prematurity (AOP)
- They are cardiac, respiratory, and CNS stimulants and smooth muscle relaxers, with the effect on apnea being related to the CNS stimulation
What are 3 reasons why caffeine citrate the drug of choice for apnea of prematurity (AOP)?
- once a day dosing,
- earlier onset of action,
- wide therapeutic range,
- no alterations in cerebral blood flow
- fewest side effects
What are the nursing care when monitoring infants respiratory status when administering caffeine citrate?
- Monitor work of breathing, oxygen saturation, hemoglobin, ventilation, blood gases, colour, HR, RR, air entry, chest movement.
- Monitor apnea: frequency, duration, stimulus required, oxygen saturation, and HR.
- Administer caffeine citrate and ensure correct dosage for weight.
- Maintain saturations between 88% and 95%.
- Ensure adequate volume and hemoglobin.
- Ensure developmentally supportive and family-centred care.
What are the functions of mature digestive system?
- salivary glands: moistens and lubricates food
- mouth: break up food particles
- pharynx: swallows
- esophagus: transports food
- stomach: stores and churns food
- liver: breaks down and builds up molecules
- gall bladder: stores biles
- pancreas: hormones regular blood glucose level
- small intestine: completes digestion, absorbs nutrients
- large intestine: reabsorbs water. forms and store feces
- rectum: stores and expels feces
- anus: opening for elimination of feces
How are the GI tracts of preterm infants immature (4)?
The GI tracts of infants are immature because:
- they have delayed gastic emptying,
- decreased enzyme activity,
- decreased parastalsis,
- decreased normal flora.
What type of infants should be NPO and not fed at all (3)?
infants who:
- are asphyxiated with persistent hypoxemia and metabolic acidosis
- are hypotensive with or without the need for BP medications
- are persistently and severely hypoxemic
- are clearly septic with evidence of necrotizing enterocolitis (NEC)
- have congenital anatomic GI anomalies
- may require surgery, especially GI surgery
What does early enteral feeding important in neonatal management supports (3)?
supports:
- GI development,
- somatic growth,
- metabolic homeostasis,
- prevention of infection,
- neurological development, and
- future health
If premature infant is NPO and are not on full feeds, what IV nutrition should be given?
- D10W: provide sugar and water but does not provide protein, fat or electrolytes
- If an infant will be NPO for an extended period, TPN should be given.
** does not have adequate suck/swallow/breathe coordination as this does not develop before 33–36 weeks gestation
If infant cant be breastfed or bottle feed, whats another feeding option?
- can be fed by an oral or nasal gastric tube
- Infants fed by a gastric tube are at risk for intolerance because they have no control over the amount or frequency of feeding.
- They must be closely observed for tolerance of feeds.
What is donor milk?
- Donor milk is breastmilk that has been pasteurized and
- usually frozen for distribution to hospital units.
What 2 reasons would an infant need to be started on donor human milk (DHM)?
- low supply of maternal breastmilk or
- the mother has chosen not to pump
** recognized that DHM is the best replacement for mother’s milk, with infant formula offering a third option if needed.
What is informal milk sharing?
- when milk is acquired by the parents and it has not been pasteurized or screened by a regulated source.
- the Canadian Paediatric Society does not endorse informal milk sharing as there are several risks associated with giving milk that has not been through a full screening and pasteurizing process
What are some indications for initiating IV therapy in infants (3)?
- to maintain fluid, electrolyte, and glucose balance when oral fluids are not tolerated or are contraindicated, or as an adjunct to intermittent feeding
- to provide adequate nutrition for growth (usually via TPN)
- to administer medications
- to administer blood or blood products
What are 3 complications of IV therapy for infants?
- Extravasation/ infiltration: most frequent complications
- Infection/Septicemia: more serious complications
- Total Fluids: close monitoring to prevent fluid overload or dehydration
What is extravasation? 3 Signs of extravasation?
- infiltration of intravenous solution into the tissues is usually caused by the dislodgement of the IV catheter.
The signs include:
- swelling,
- edema,
- redness, and/or
- blanching at the site.
- site may be cool to touch
- painful for the infant when touched.
Why are premature infant skin described as “paper thin”?
- immaturity of the skin.
- the veins are very thin and friable with very little or no muscle support.
- They move easily and are very fragile.
- skin thin and unable to lend support to the blood vessels
What are 2 reasons that make extravasation /infiltration most frequent complication with IV therapy for infant?
- immaturity of the circulatory system
- immaturity of the skin
What assessment are included to prevent infiltration of IV therapy? Treatment?
- assessment of the IV site at least hourly,
- adequate taping of the device with transparent dressing/plastic tape so the site is clearly visible
- possibly restraining the limb
Treatment
- to discontinue the IV at the earliest sign of infiltration and elevate the extremity.
- This is to prevent IV burns and scar formation that often results from infiltration.
- Use of moisture, heat, or cold is not recommended because the tissue is vulnerable to further injury at this point
Why is it important to elevate extremity after discontinuing IV therapy at the earliest sign of infiltration (2)?
Elevating the infiltrated areas:
- increases lymphatic and venous drainage,
- helping to decrease edema.
What is Hyaluronidase use for?
- helpful treatment if it is administered within one hour of extravasation.
- This medication is an enzyme that destroys extracellular barriers, allowing rapid diffusion and absorption on the infiltrated fluid (not for use with vasoactive drugs).
- It is injected subcutaneously around the periphery of the site.
How can infection occur during IV therapy? Prevention?
- Infection or septicemia occurs when bacteria, fungus, or viruses invade the bloodstream through the IV site.
Prevention
- proper hand washing,
- following unit procedures for skin preparation,
- changing and accessing IV solutions as per unit policy
How are total fluids ordered for infant on IV therapy?
- Infants are ordered a certain amount of fluid per kilo per day to meet their daily requirements of nutritional support
- Excessive or insufficient fluid amounts will result in either fluid overload or dehydration, and both will not meet the infant’s specific nutritional requirements.
What are some preventions of ensuring sufficient fluids being given to infant via IV therapy?
- Excessive or insufficient infusion of IV fluid can be a result of a malfunctioning infusion pump or an incorrectly set rate.
Preventions:
- checking the infusion pump at least hourly for the amount of fluid infused,
- ensuring the correct rate is set on the infusion pump, and
- checking the physician’s order for total fluids.
What are some nursing care aimed at monitoring infants nutritional requirements (3)?
- Monitor serum glucose for all at-risk infants: SGA, perinatal asphyxia, RDS, hypoxia, infant of diabetic mother (IDM).
- Ensure accurate fluid requirements based on weight.
- Meet fluid and caloric needs with N/G or O/G and IV.
- Slowly increase feeds and decrease IV.
- Monitor tolerance of feeds closely.
- Monitor for signs of NEC.
- Monitor IV site, rate, and type of fluid.
- Minimize glucose utilization by minimizing pain, stress, and handling.
What is TPN composed of (5)?
- electrolytes,
- lipids
- minerals,
- trace elements
- vitamins,
What are some risks/complications of TPN (3)?
- issues with glucose metabolism (hypo/hyperglycemia),
- problems with amino acid metabolism,
- cholestasis (flow of bile from your liver is reduced or blocked)
- hyperlipidemia, and
- infections
Why do premature infants <32 weeks likely require 2-3 weeks of IV therapy to maintain nutritional status?
- have immature gastrointestinal systems.
- While oral feeds (OG/NG) may be started, the progression to fully oral feeds in premature infants is generally quite slow.
- therefore, IV fluids are used to supplement oral feeds –> to help maintain fluid and nutritional status.
What assessment of infants IV therapy should nurse include? how often to check IV site?
- check IV site for redness, swelling and blanching, pain, temperature, leaking
- check around the site, looking at the tapes, the limb board, position
- check physician’s order for total fluids for the day and calculate the IV rates accordingly
- check for correct solutions, rates, and alarms on infusion pumps
- check the IV site at least hourly and more often if concerned about its appearance
- check the site frequently while administering medications
What is the formula to calculate hourly IV rate (mL/hr)?
- Formula for calculating total daily fluids is total fluids ordered × weight in kilograms.
- To calculate the hourly rate, you then divide by 24.
