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LEC - NCM 109 > NURSING CARE OF A CHILD WITH LIFE THREATENING CONDITIONS/ACUTELY > Flashcards

NURSING CARE OF A CHILD WITH LIFE THREATENING CONDITIONS/ACUTELY Flashcards

1
Q

Classification of High-Risk Newborns

A

Gestational Age
• Preterm
• (Late Preterm)
• Term
• Post term

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2
Q

Physiologic Challenges of the premature infant

A

• Respiratory and Cardiac
• Thermoregulation
• Digestive
• Renal

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3
Q

RESPIRATORY AND CARDIAC

A

• Lack of surfactant
• Pulmonary blood vessels
• Ductus arteriosus

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4
Q

Respiratory - Nursing Interventions

A

• Maintain airway
• Administer O2
• Monitor O2 saturation
• Monitor heart/respiratory rates

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5
Q

S/S respiratory distress

A

• Cyanosis
• Tachycardia
• Retractions
• Expiratory grunting
• Nasal flaring
• Apneic episodes

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6
Q

THERMOREGULATION

A

• Increased body surface
• Decreased brown fat
• Thin Skin
• Lack of flexion
• Decrease sub-q fat

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7
Q

Thermal Neutrality – Nursing Interventions

A

• Incubator or radian warmer
• Warm surfaces
• Warm humidified oxygen
• Warm ambient humidity
• Warm feedings
• Keep skin dry and head covered

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8
Q

DIGESTIVE

A

• Poor gag reflex
• Small stomach capacity (calamansi-size)
• Relaxed cardiac sphincter
• Poor suck and swallow reflex
• Difficult fat, protein and lactose digestion
• Absorption

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9
Q

Nutrition and Hydration – Nursing Interventions

A

• Daily weights
• Monitor I&O
• Accurate IV rates
• Accurate OGT feedings
• Monitor urine pH and specific gravity

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10
Q

Signs of dehydration

A

• Weight loss
• Poor skin turgor
• Dry oral mucus membranes
• Decreased urinary output
• Increased specific gravity

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11
Q

Pre-feeding assessment

A

• Measure abdominal girth
• Bowel sounds
• Gastric residual
• Sucking and gag reflexes

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12
Q

RENAL

A

• Decreased glomerular filtration rate
• Inability to concentrate urine or excrete excess
• Decreased ability of kidneys to buffer
• Decreased drug excretion time

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13
Q

Prevention of Infection – Nursing Interventions

A

• Initial scrub / strict hand washing
• Visitors & staff
• Reverse isolation
• Single infant equipment
• Short / no artificial nails
• Maintain sterile technique
• IV start and dressing changes
• Procedures
• Clean incubators weekly
• Position changes; use of sheepskin
• Judicious use of tape on skin

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14
Q

Signs and Symptoms of Infection
Behavioral changes
Physiological changes:

A

• Tonus
• Color
• Temperature
• Skin
• Feeding
• Hyperbilirubinemia
• Heart rate
• Respiratory rate

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15
Q

FACILITATING PARENT-INFANT ATTACHMENT

A

• Prepare parents for first visit
• Establish safe/trusting environment
• Encourage visitation
• Involved in care taking
• Repeat explanations
• Promote touching, talking, rocking, cuddling
• Refer to infant by name
• Allow parents to phone as desired

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16
Q

DISORDERS OF INFANTS IN NICU

A

• SGA and IUGR
• Infants of Diabetic Mothers
• Postmature Infant
• Infants of Addicted Mothers
• Respiratory Distress Syndrome
• Meconium Aspiration Syndrome
• Hyperbilirubinemia
• Retinopathy of Prematurity
• Necrotizing Enterocolitis
• Infectious Diseases – TORCH (Toxoplasmosis,
Other diseases, Rubella, Cytomegalovirus, Herpes)

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17
Q

Associated Complications of SGA

A

• Asphyxia
• Aspiration syndrome
• Hypothermia
• Hypoglycemia
• Polycythemia

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18
Q

Associated Complications of IUGR (Intrauterine
Growth Restriction)

A

• Congenital malformations
• Intrauterine infections
• Continued growth difficulties
• Cognitive difficulties

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19
Q

Nursing Interventions of Associated Complications of SGA and IUGR

A

Monitor heart rate, respiratory rate, temperature and blood glucose.

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20
Q

INFANTS OF DIABETIC MOTHERS

A

• Clinical manifestations IDM
• Ruddy color
• Macrosomia
• Excessive adipose tissue
• Hypoglycemia

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21
Q

Why Hypoglycemia in INFANTS of Diabetic Mother?

A
  1. High levels of glucose cross the placenta
  2. In response, fetus produces high levels of
    insulin
  3. High levels of insulin production continues after
    cord cut
  4. Depletes the infant’s blood glucose
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22
Q

Nursing Interventions for Hypoglycemia
Assess for signs/symptoms:

A

• Tremors
• Cyanosis
• Apnea
• Temperature instability
• Poor feeding
• Hypertonia / Lethargy
Assess blood glucose
• Intervene if < 40mg/dl: Feed infant
• If no improvement: IV of D10W

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23
Q

POST MATURE INFANT
Physical manifestations:

A

• Dry, cracking, parchment-like skin - Loose appearing skin
• No vernix or lanugo
• Long fingernails
• Profuse scalp hair
• Long, thin body appearance

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24
Q

POST MATURE INFANT
Complications of post term:

A

• Hypoglycemia
• Meconium aspiration
• Congenital anomalies
• Seizure activity
• Cold stress

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25
Q

POST MATURE INFANT
Nursing considerations:

A

• Monitor blood sugars per protocol
• Evaluate respiratory status
• Assess for seizure activity
• Treat cold stress

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26
Q

INFANTS OF ADDICTED MOTHERS
Clinical Manifestations of Infant Withdrawal:

A

• Irritability:
- Hyperactivity
- Shrill cry
- Exaggerated reflexes
- Facial scratches
- Short non-quiet sleep
• Sneezing, coughing, yawning
• Poor feeding:
- Disorganizedvigoroussuck
- Vomiting
- Diarrhea
• Tachypnea
• Sweating
• Excoriated skin

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27
Q

INFANTS OF ADDICTED MOTHER
Nursing Interventions for Infant Withdrawal:

A

• Swaddle with hands near mouth
• Offer pacifier
• Place in quiet dimly lit area of the nursery
• Protect skin from excoriation
• Monitor V/S
• Provide small frequent feedings
• Position with HOB elevated
• Weigh every 8 hours (if vomiting & diarrhea)
• Assess with Finnegan Abstinence Scale
• Administer: morphine, phenobarbitol,
methadone

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28
Q

Fetal Alcohol Syndrome – FAS
Facial Characteristics

A

• small head
• short eyelid opening
• flat midface
• smooth philtrum
• underdeveloped jaw
• thin upperlip
• short nose
• low nasal bridge
• epicanthal folds

29
Q

Fetal Alcohol Syndrome – FAS
Clinical Manifestations:

A

• Jitteriness
• Abdominal distention
• Exaggerated rooting and sucking reflexes

30
Q

FETAL ALCOHOLIC SYNDROME – FAS
Affected body systems:

A

• Central Nervous System (CNS)
• Gastrointestinal System (GI)

31
Q

Fetal Alcohol Syndrome – FAS
Long-term Psychosocial Implications:

A

• Feeding difficulties
• Mental retardation

32
Q

Respiratory Distress Syndrome – RDS Pathophysiology

A
  • Primary absence, deficiency or alteration in the production of surfactant

decreased surfactant, increased atelectasis = lack of gas exchange

Leads to hypoxia and acidosis which further inhibit surfactant production and causes pulmonary vasoconstriction.

33
Q

Respiratory Distress Syndrome – RDS
Clinical Manifestations:

A

• Cyanosis
• Tachypnea
• Nasal flaring
• Retracting
• Apnea

34
Q

Meconium Aspiration Syndrome

A

Meconium-stained amniotic fluid

• Aspirated into the trachobronchial tree
• Occurs either in utero or after birth with the first
breaths.

Meconium in the lungs causes air to become trapped and results in alveoli over-distension and rupture.

35
Q

Measures for Prevention of Meconium Aspiration

A

• After delivery of the infant’s head but before shoulders
• Suction oropharynx and nasopharynx (no longer recommended)

36
Q

Measures for Prevention of Meconium Aspiration

A

• If THICK meconium, after delivery of the infant’s body

Crying:
- Stimulate
- Suction with bulb syringe

Not crying
- Do not stimulate
- Visualize the vocal cords and provide direct suction with endotracheal tube, then stimulate

• If THIN meconium, no visualization performed.

37
Q

Meconium Aspiration Syndrome
Nursing Interventions:

A

• Maintain adequate oxygenation and ventilation
• Regulate temperature
• Accurate IV fluid administration
• Assess for hypoglycemia
• Administer antibiotics
• Provide caloric requirements
• Provide support care if on ECMO

38
Q

Hyperbilirubinemia
Pathophysiology

A

Bilirubin is released in serum when RBC lyse Conjugation in liver = water soluble & excretable Rate & amount of conjugation dependent upon:
• Rate of hemolysis
• Bilirubin load
• Maturity of liver
• Presence of albumin-binding sites

39
Q

Hyperbilirubinemia

A

occurs when the body cannot conjugate the bilirubin released into the serum.
Results in jaundice where the unconjugated bilirubin is deposited in the tissue.

40
Q

Hemolytic Disease (Pathologic Hyperbilirubinemia)

A

• Results from incompatibility between mother’s blood type or Rh factor and that of the fetus
• Maternal antibodies develop from + fetal antigen
• Antibodies cross placental into fetal circulation
• Antibodies attach to and destroy fetal RBCs.
• Fetal RBCs lyse & release bilirubin into fetal circulation.

41
Q

Hemolytic Disease (Pathologic Hyperbilirubinemia)
Additional assessments:

A

• Maternal, paternal, and fetal blood type and Rh factor

42
Q

Hemolytic Disease (Pathologic Hyperbilirubinemia)
Newborn:

A

• Skin color, sclera, oral mucosa
• Hypotonia, diminished reflexes, lethargy and
seizures

43
Q

Hemolytic Disease (Pathologic Hyperbilirubinemia)
Positive Coombs Test:

A

• Direct Coombs test reveals antibody-coated Rh- positive RBCs in the newborn

44
Q

Nursing Interventions for Phototherapy

A

• Exposure of skin
• Cover eyes (remove for feeding/parent visit)
• Monitor temperature
• Increase fluids
• Assess for dehydration
• Perform T-Bili q 12 – 24 hr as ordered

45
Q

Hemolytic Disease (Pathologic Hyperbilirubinemia)
Exchange Transfusion:

A

• Treat anemia
• Remove sensitized RBCs that will soon lyse
• Remove serum bilirubin
• Provides albumin to increase bilirubin binding
sites

46
Q

Hemolytic Disease (Pathologic Hyperbilirubinemia)
Rhogam

A

• Provides temporary passive immunity which prevents permanent active immunity (antibody formation)
• Given within 72 hours of delivery
• Prevents production of maternal antibodies

47
Q

Hemolytic Disease (Pathologic Hyperbilirubinemia
ABO Incompatibility

A

• Occurs when type O pregnant woman with A, B or AB blood type fetus
• If woman has anti A or anti B antibodies, these antibodies cross the placental barrier
• Results in hemolysis of fetal RBCs

48
Q

Complications of Hemolytic Disease:

A

KERNICTERUS – Deposits of conjugated and unconjugated bilirubin in the basal ganglia of the brain
o Neurologic damage

HYDROPS FETALIS – severe anemia
o Marked edema
o Cardiac decompensation o Multipleorganfailure
o Possibledeath

49
Q

Retinopathy of Prematurity

A

• Formation of immature blood vessels in the retina constrict and become necrotic
• Most common in infants < 28 weeks gestation • Also associated with O2 therapy

50
Q

Nursing Interventions to Prevent Retinopathy of Prematurity (ROP)

A

• Administer O2 in concentration ordered
• Ensure proper ventilatory settings

51
Q

Necrotizing Enterocolitis (NEC)

A
  • Inflammatory disease of the intestinal tract caused by ischemia, infection, and/or prematurity of the gut.
52
Q

Preterm infant at increased risk of Necrotizing Enterocolitis (NEC)

A

• undeveloped protective intestinal mucin layer
• slow careful introduction to oral feedings

53
Q

Necrotizing Enterocolitis (NEC)
Early detection:

A

• Measure abdominal girth daily
• Assess color of abdomen
• Assess residual feeding
• Assess bowel sounds
• Assess S/S sepsis

54
Q

Infectious Diseases:
TORCH

A

• Toxoplasmosis
• Other
- Syphilis
- HepatitisB
• Rubella
• Cytomegalovirus
• Herpes Simplex II and HIV/AIDS

55
Q

TORCH

Protozoan infection in the pregnant woman
• Raw or under cooked meats
• Cat feces

A

Toxoplasmosis

56
Q

TORCH

Hepatic Virus

• Crosses placental barrier
• Direct contact at birth

A

Cytomegalovirus

57
Q

Cytomegalovirus
Hepatic Virus

Signs and Symptoms in Newborn:

A

S/S of Newborn:
• Severe neurological problems
• Eye abnormalities
• Hearing loss
• Microcephaly
• Hydrocephaly
• Cerebral palsy
• Mental delays

58
Q

Herpes Simplex II

Transmission:

A

• Direct contact at birth

59
Q

Herpes Simplex II

S/S of Newborn:

A

S/S of Newborn
• Microcephaly
• Mental delays
• Seizures
• Retinal dysplasia
• Apnea
• Coma

60
Q

HIV/AIDS

Transmission: < 2%

A

• Transplacentally
• Exposure at birth
• Breast milk

61
Q

HIV/Aids

Nursing Intervention:

A

• Protect self from body fluids
• Labs - + antibody titer
• Administer AZT
• Provide care like that of any other newborn

62
Q

Toxoplasmosis

Effect on Fetus:

A

• Blindness
• Deafness
• Convulsions
• Microcephaly
• Hydrocephaly
• Severe mental impairment

63
Q

Other

Syphilis
S/S of Newborn:

A

• Rhinitis
• Excoriated upper lip
• Red rash around mouth and anus
• Copper colored rash of face, palms and soles
• Irritability
• Edema
• Cataracts.

64
Q

Other

Syphilis
Treatment in Newborn:

A

• Culture orifices
• Isolation
• Penicillin

65
Q

Other

Hepatitis B
Transmission:

A

• Placental
• Birth
• Breast milk

66
Q

Other

Hepatitis B
Treatment:

A

• If mother + HbSAG administer to newborn
• Hepatitis B vaccine
• HBIG (Hepatitis B Immune Globulin)

67
Q

Rubella

S/S of Newborn

A

• Congenital cataracts
• Deafness
• Congenital heart defects
• Sometimes fatal

68
Q

Rubella

MMR Immunization of mother

A

• Give when not pregnant

LEC - NCM 109 (3 decks)

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