Premature infant & High risk infants Flashcards
1
Q
Late preterm age
A
34-36.6 weeks
2
Q
Early term age
A
37-38.6 weeks
3
Q
Full term
A
39 - 40.6 weeks
4
Q
Late term
A
41.7 - 41.6 weeks
5
Q
Post term
A
42 - beyond
6
Q
What will a preterm infant flexion be like?
A
There will be a lack of flexion which indicates the immaturity
7
Q
How much vernix will a preterm infant have?
A
Vernix or the white coating is produced at 20-24 weeks but goes away around the 36 week mark.
So young or early babies will have more if they are before 36 weeks.
8
Q
How much vernix will a pst term baby have?
A
No vernix
9
Q
What will the skin of a preterm infant look like?
Why is this?
A
Thin & transparent with veins that are easy to see and an overall reddish tone to them bc of it
The fat deposits on a fetus don’t develop until 36 weeks and the vessels only begin to form at 37 weeks. So if you’re born early you won’t have these fully formed.
10
Q
What will skin look like in post term infants?
A
Wrinkled dry and cracked or desquamation from the the fluid disappearing
11
Q
What will the presence of lanugo or body hair be like in a preterm infant?
A
The baby will have more of it. It covers the entire body at 20 weeks, is greatest at 28-30 ish weeks and thins closer to term leaving bald spots
12
Q
What will hair such as eyelashes, brows, and on head be like for a preterm?
A
The hair, eyebrows and eyelashes develop at 20-23 weeks and so they should have it if they aren’t super early.
13
Q
What will sole creases look like in preterm infants?
A
They develop from toes to heals , so if they are preterm they’ll be high.
If term they’ll be all the way down to heel.
14
Q
When do eyes open?
A
26 weeks gestation
15
Q
What will ears look like if you are a preterm infant?
A
If early, the pinna will be paper thin. As the fetus ages it should have thickened
16
Q
What will nipple tissue be like if you are a premature infant?
A
Smaller than 5mm .
- should be 5-10 mm in term babies
- either gender
17
Q
Gestational age where testes begin process of descent from the abdomen
A
28 weeks
18
Q
Testes high in the scrotum gestational age
A
37 weeks
19
Q
Testes completely descended and scrotum covered in rugae gestational age
A
full term
20
Q
What happens to scrotum as fetus gets older gestational wise
A
Becomes more pendulous
21
Q
What if the testes are undescended at term
A
Urology consultant needed for risk of infertility concerns
22
Q
Why are respiratory complications common in premature infants?
A
The lungs are one of the last organs to develop and function due to the need for surfactant
- which lubricates alveoli and allows them to open
Pulmonary vessels are also very immature and can rupture
23
Q
When does surfactant start to develop?
What can no surfactant cause?
A
Surfactant starts to develop around the 28 weeks but it is the 35-36 weeks where they have enough to actually breathe on their own and replace old surfactant
Atelecatasis
24
Q
Small ways to improve respiratory function in infants?
A
Position w shoulder roll
Suctioning their nasal area and airway
Prone positioning or on tummy to allow the mattress to help them breath
25
tool to assess respiratory functioning?
Silverman Anderson index tool
26
When and who does RSD or respiratory distress syndrome only occur in?
Premature infants due to it having to develop within 6 hours of birth
27
RDS signs
RR
Muscle tone
Breathing
Skin
RR - tachypnea so over 60
Hypotonia muscles
Retractions, grunting, nasal flaring, apnea, and even obvious decreased air entry
Pallor skin early on
Cyanosis if late
28
Why can't you tell if infant has RDS right away?
The infant may have surfactant at birth but once they use it up, they have none and that is when they show symptoms
29
What effects does RDS have on the lungs?
Can cause atelectasis in lungs
| Loss of residual lung capacity
30
How does RDS effect the body systemically?
What state(s) can the body go in?
Hypoxemia and cyanosis
Respiratory acidosis followed by metabolic acidosis
31
How does RDS effects the heart?
It can cause the ductus arteriosus and former vale to reopen due to stress of being hypoxic
An increase in pulmonary vascular resistance and right to left shunting occurs
32
What does RDS do to perfusion?
Perfusion isn't able to be balanced and so the ventilation distribution is uneven to the body
33
How do they diagnose RDS?
What about the chest diameter?
Clinical signs but also a patchy atelectasis from radiology
Increased AP diameter
34
What is RDS treatment like for prevention?
They want to start with prevention with maternal corticosteroids at 24-34 weeks
35
How will they treat infants who have RDS already?
They'll do oxygen therapy
Can do exogenous surfactant phospholipids with an endotracheal tube
Nitric oxide
36
Exogenous surfactant phospolopids requires ___ .
Where do they get the surfactant?
parental consent
porcine or bovine
pig or cow
37
What does the manual bagging do during an Exogenous surfactant phospholipids?
How will the infant respond to the treatment?
Helps distribute the surfactant med
The infant will be coughing and they won't like it bc we are putting fluid in their lungs
38
When an infant has RSD, what can be used to open pulmonary field
Nitric oxide due to its vasodilation ability
39
If giving O2 for RDS, what does the o2 sat need to be in infants
How do we keep the o2 sat low and avoid ROP eye damage?
How do they decide the mode to give O2 by for RDS?
88-93%
- also monitor blood gases too
Oxygen blenders (blends room air and o2 together)
Depends on the need
40
How do they decide the mode to give O2 by for RDS
methods:
Blow by
Nasal cannula
Oxyhood
Nasal or ETT CPAP
Ventilator
- what frequencies?
Depends on the need
Blow by - blowing air directly to face
w og tube
oxyhood - clear plastic hood to blow in the face
nasal etT cpap -cpap machine idk what this is exactly tho
Ventilation on high frequency of 480--1200
or
low frequency 250 -900.
41
Why do we do sepsis evaluation in RSD ?
Due to risk of infection from invasiveness of lab draws and procedures
42
Why do we give give antibiotics in RSD?
Based off culture results
43
Type of nutrition for RSD?
What sort of things will we monitor for RSD that are super important??
TPN (in IV)
I&O
Daily weights
44
What is ECMO that is done for RSD?
How old do you have to be? and why?
Extra-corporal membrane oxygenation but its really when you shunt blood from heart to pump and back to ease breathing so that the lungs can rest and have time to mature.
34 weeks and older due to anticoagulant use and risk of iVH
45
Can a term baby have RDS??
They have be in respiratory distress but they won't have the syndrome
46
What is PDA or patent ductus arteriosus?
How soon does it close?
What is is it triggered by?
A hole between the left pulmonary artery and ascending aorta that shunts blood from lungs to placenta for gas exchange that is meant to close
Should close within 48 hours
Triggered by first breath o2 rising
47
So what cause the PDA to reopen?
What if the PDA is small?
It open when there's stress from hypoxia
May not show symptoms
48
Common PDA histories?
Prematurity *
FAS
Amphetamine exposure
49
What is seen on chest X-ray with pda?
Left ventricle volume overload
Pulmonary edema
Chronic heart failure
50
PDA symptoms:
tachypnea w crackles or bradypnea wo crackles?
systolic murmur or diastolic murmur?
What will pulse be like?
PDA
tachypnea w crackles
systolic murmur left sternum 2-3 IC spaces
femoral and peripheral pulses will be bounding
51
PDA symptoms
What will blood pressure be like? HR?
organs?
skin?
hypotension and tachycardia
hepatomegaly of liver
mottling and cyanosis
52
PDA blood gases
Hypercapnia or elevated CO2
| Metabolic acidosis
53
PDA diagnosis?
Echo to measure blood shunt amount
54
Treatment of PDA
HF symptoms -
Oxygenation -
Patency -
```
Restrict fluids
Diuretics
Respiratory support w ventilator
Prostaglandin synthesis inhibitors
Surgical ligation
```
55
Why do we restrict fluids and give diuretics for PDA?
Due to the heart failure going on with LV overland and pulmonary edema
56
Why do we give respiratory support for PDA treatment
In order to help the perfusion
57
Why do we give prostaglandin synthesis inhibitors?
Which meds?
It can cause the PDA to constrict
Indomethacin
Neoprofen
58
Indomethacin risks
When giving Indeomethacin what are the requirements for the patient?
how many doses?
intestinal perforations, decreased urine output, decreased blood flow to gut, and IVH
NPO
3 doses maximum
59
Neoprofen
Why use it over Indomethacin?
Average dose
this is pediatric IV ibuprofen
Lesser effect on kidneys but not as effective
Average dose is 500-1500 g less than 32 weeks
60
When will they do surgical ligation for PDA?
With drug failure
61
Transient Tachypnea is what?
Usually is when a schedule c section baby gets fluid in their lungs and can't clear them
- must be c section schedule bc the fluid has to be there or it can't be pushed out by going down the birth canal
so failure to clear lung fluid, mucus, debris
62
Other reasons besides scheduled c section that have transient tachypnea of the newborn or TTN?
TTN can be from LGA, diabetes infants, near term infants
63
What will happen to baby shortly after birth if they are TTN or transient Tachypnea?
Symptoms?
They will show signs of distress due to fluid in the lungs
- grunting, nasal flaring
- subcostal retractions
- slight cyanosis
- tachypnea
64
How is TTN or transient tachypnea diagnosed?
You may see hyper-aeration of the alveoli. what does this mean?
On xray
- you will see a flattened counter of diaphragm
- dense streaking pattern known as patchy Atelectasis
over expansion of the lungs but it clears overtime
65
TTN nursing care priorities ?
what will nutrition look like?
What do we provide to the family?
Maintain respiratory status and nutrition
- will have to be on TPN first then bottle feeding
Support and educate family bc it is a quick recovery really
66
What is PPHN or Persistent Pulmonary Hypertension?
| What type of infants is it seen in?
When the pulmonary vascular bed doesn't relax but instead vasoconstricts
Term or post term infants with tachycardia and cyanosis
67
What happen to the heart in Persistent pulmonary hypertension
How does the PPHN occur?
The increased pulmonary resistance from constriction then causes the right Ventricle hypertension and the foramen oval and ductus arteriosus are used again.
Response to a trigger of some sort
68
Persistent pulmonary hypertension
Pulmonary hypertension due to the lack of blood staying moving
Hypoxia , tachycardia, cyanosis
Acidemia
69
Diagnosis of Persistent pulmonary hypertension?
how is confirmed?
O2 sat in right arm and leg at 24 hrs of age
- should be equal or nearly the same
preductal will be higher than post ductal
confirmed on echo
70
Firs thing to do with Persistent pulmonary hypertension?
When does assessment happen?
Review the mom and baby's health history
Assess within 24 hours of life
71
T/F
Baby's with persistent pulmonary hypertension will have RDS symptoms
true but they won't respond to oxygen
72
Meds for Persistent pulmonary hypertension
IV
Meds
O2 and nitric oxide both will vasodilate to decrease PVR
Vasopressor Dopamine will increase SVR
73
What can they place with a Persistent pulmonary hypertension ?
What can they do to address oxygen and compliance for PPHN?
Is stimulation ok with PPHN?
What if baby isn't responding to treatment?
Place a umbilical catheter
ventilator with sedation and paralyzing agent s
It is best not to allow stimulation or keep it minimal
They will need ECMO
74
Wha tis Bronchopulmonary dysplasia?
Lung field problems due to baby being born premature to the point they require O2 therapy for up to 28 days or longer
- remember o2 just needs to be around the 89-93 mark
75
What is the cause of bronco pulmonary dysplasia tho?
How do we keep this from happening now?
The premature baby has no surfactant and so they need O2. But that O2 is causing scarring and a bad cycle of damage.
Keep this from happening by keeping O2 levels lower
76
Main symptoms of BPD or bronchopulmonary dysplasia?
Care for ventilator?
Resp symptoms but the main part is they NEED that ventilator to the point that you can't even wean them off of it
Infection risk from ventilation use so be aware of pseudomonas
77
How are pulmonary fluid levels controlled in BPD or BPD or bronchopulmonary dysplasia?
What electrolyte replacements can counteract diuretics?
Diuretics and fluids
Potassium to keep fluids from being pulled from lungs
78
Meds for BPD or bronchopulmonary dysplasia??
Bronchodilators
- albuterol
Long term steroids d/t chronic lung disease
79
Why do serial echos for BPD or bronchopulmonary dysplasia??
Exercises therapy for BPD or bronchopulmonary dysplasia??
But what can suctioning lead to ?
Evaluate affect on heart
Chest physiotherapy and suctioning
negative oral sensations bc the baby doesn't want anything in their mouth meaning they dont want to nipple so may need speech therapy too
80
What do infants with BPD or bronchopulmonary dysplasia have higher risk of once discharged?
the key to preventing BPD?
Respiratory infection risk
prevent the premature brith in the first place
81
What is ROP?
Retinopathy of Premature meaning infants get oxygen therapy they can damage their eyes in premature infants under 30 weeks
- again 30 weeks is important here
82
Why is ROP more common in premature infants less than 30 weeks?
More common due to retina not being vascularized and vessels develop abnormally
83
What does the ROP cause in the eye?
Abnormal vascularization w bleeding
| Fluid leakage that results in hemorrhages , scar tissue, and disruption of retina and macula
84
Dreaded potential of ROP?
retinal detachment due to impaired vision/blindness
85
How to prevent ROP?
Keep oxygen on lowest O2 possible 89-93 or just prevent the prematurity that caused the need for oxygen in the first place
- it is a multi factor cause tho
- really make sure to monitor the oxygen to make sure no accidents happen too
86
So just to make things clear - the need for o2 after birth can damage what two organs?
Eyes & Lungs
87
How is it that we can keep o2 levels at a lower level in infants?
1) In utero the oxygenation was not at 100% so they don't really need it that high
2) their RBC's have higher affinity for oxygen
88
What can be used to help make suer O2 levels aren't too high in infants?
Oxygen blenders
89
What will the ophthalmologist notice on exam ? And when is this exam done?
How many exams will there be?
They will notice retinal changes
Exam is 4-6 weeks after birth
Just do repeat exams if there's any issues in order to monitor progression
90
What happens to most ROP cases?
They regress spontanesouly
91
ROP treatment that stops growth of blood vessels
Avastin
92
ROP treatment that is considered to be more permanent suppression of blood vessel growth
Laser Therapy
93
All treatments for ROP?
main goal of tx?
Avastin Injection
Laser Therapy
Cryotherapy
Just prevent vision loss
94
Why are infants/newborns at risk of alteration in thermoregulation that they can't control?
Higher ration of body surface to body weight
Less SQ fat
Thin skin
Immature temp regulation in brain
Decreased ability to constrict vessels
95
How does posture flexion affect thermoregulation?
Flexion keeps you warm where by decreasing surface area
| And if you're extended and not flexed, heat can be lost quicker
96
How does the higher ratio of body surface to weight cause heat loss?
Bc there's more body surface, its more opportunity for heat to get out but the smaller weight means the heat loss affects them more
97
How does thin skin cause heat loss
There is a greater amount of insensible water loss and heat loss
98
What type of environment is needed to address temp-control?
What is the state we are wanting to prevent?
How to prevent cold stress?
Hypothermia is an early sign of ____.
Neutral thermal environment
Preventing hypoglycemia
as well as cold stress.
Monitor baby's temp
early sign of sepsis
99
Oxygen intervention for thermal regulation
Provide warm and humidified oxygen
100
Incubator intervention for thermal regulation
Double walled incubator
101
How can you help temp regulation as far as using scales and x rays?
Pre-warm them
102
What state do you want baby's skin in for temp regulation?
| What can you have them wear?
Keep the skin dry bc if they're wet they lose more heat
Wear a cap for temp regulation
103
How should you monitor the baby's temp for thermoregulation?
Use temp probe bed set on servo control
104
What temp should feedings be before you give them and why?
Warm bc if cold, it can affect baby's temp.
105
What lighting equipment can be used for thermoregulation of infants?
Micro premies tent ?
Heat lamps
For micro premies - use plastic tents for insensible water loss
bc plastic keeps temp in
106
What can cause an increased risk of aspiration in infants?
Poor gag reflex, suck swallow reflex, esophageal sphincter that doesn't work
107
How does an infants small stomach capacity affect GI?
Means they may not be able to get all calories needs met.
| - may have to add more calories and protein to food for nutrition with fortified bread milk or formulas
108
Deficiency of calcium and phosphorus is due to ? Why do we need these?
They both are deposited in last semester so can happen in premature infants.
They prevent rickets and osteopenia (so for bone growth)
109
Feeding intolerance ---
How is max feeding volume found?
How long is nipple feeding ok to do?
What is done with the remained of food?
Adequate nutrition based by weight gain of 10-20 grams/kg/day
30 min per feeding
Gavage feed
110
What is feeding Progresso normally like?
Infants are NPO due to an admit diagnosis for feeding intolerance rt respiratory distress, poor feedings, hypovolemia etc
and kept on IV fluids
Then enteral feedings are started at small volumes until l they tolerance is established
- can increase feeding volume gradually
111
What to monitor with feeding intolerances?
Abdominal girth
Residual w tube feedings
Bowel sounds
112
Signs of a feeding intolerance
```
Residual is increased, blood in stools
abdominal distention w visible bowel loops
lactose in stools
n/v
Waterless stools
```
113
When do infants develop their suck swallow reflex?
34 weeks so if they're born before this, you can have a lack of oral readiness
114
What does the gag reflex need to be like for oral readiness to be achieved
What is an example of non-nutritive sucking?
Gag reflex needs to be strong
pacifier
115
What does skin to skin encourage as far as nutrition?
It encourages the rooting. and sucking reflex onto the nipple for feedings
116
How should oral attempts be attempted for feedings?
What to provide ?
position for oral readiness?
Low and slow
quality over quantity
Cheek/chin support ad pacing
upright position
117
You're starting oral feeds and you notice weight loss. is this bad?
No it is to be expected
| - if it gets too bad fortifier can be added to increase calories
118
What is meconium aspiration?
What happens?
Meconium aspiration is when the fetus swallows their own meconium -- but the meconium is from a asphyxia in utero
- increased intestinal peristalsis w anal sphincter relaxing to relate meconium and it enters lungs
119
What positioning is meconium aspiration common in?
Breech since the butt is squeezed with contractions
| - but we do c sections remember
120
What if they discover meconium on exam?
Will they do an amnioinfusion?
What treatment/management will they do for meconium aspiration?
Increase in assessments
no it won't help
Suction once the head is in sight
121
Exam needed once born if baby to check for meconium aspiration
Laryngoscopic exam that checks to see if vocal cord are meconium stained bc if so, that means risk of aspiration in lungs
122
If an infant has meconium aspiration and is in respiratory distress what is done?
Tracheal incubation w suctioning
| After that transfer to NICU
123
Diagnosis of Meconium aspiration
Lugn x rays
Blood gases
O2 sats
124
What pressure will oxygen be on with meconium aspiration
What meds can be given for meconium aspiration?
high pressure
Nitric Oxide to vasodilate
Antibiotics
125
Why do we do bicarbonate infusion with meconium aspiration?
Treats metabolic acidosis
126
Other nursing care interventions for meconium aspiration
pulmonary hygiene w suctioning
nutrition
neutral temp
supportive care
127
Necrotizing Enterocolitis description
Who is for the majority at risk?
Inflammation disease of the bowels that can lead to ischemia with potential for necrosis and perforation that premature infants are at risk for most of the time
128
How did the sequence happen of Enterocolitis?
Lack of oxygen or asphyxia insult occurs >
| blood shunts from gut/bowel due to stress > bowel damage > ischemia > necrosis > perforation
129
Best treatment for Necrotizing Enterocolitis?
Early prevention. Bc if you feed them formula without knowing it, then you can make them septic not breastfeeding)
- probiotics and breastfeeding can reduce the risk
130
How can you tell Necrotizing Enterocolitis is going on generally?
Abdominal distention ?
Can take days to week for it to develop but you might see a generalized sick changing, coloring is poor, apnea episodes, bradycardia, hypotonia, temp instability.
just not alert
Abdominal distention with erythema and tenderness and increased residual
131
What happens to abdominal wall in Enterocolitis?
Erythema of abdominal wall can occur that can present as tender abdomen and guarding
132
Urine specific gravity trend of necrotizing enterocolitis?
What to check stool for?
Rising w oliguria or less pee
Blood or diarrhea
133
Necrotizing enterocolitis critical status characteristics?
```
Hypotension later on with
metabolic acidosis,
abdominal wall cellulitis,
bleeding disorder (causes bleeding from gut)
```
all bc of critical status
134
Necrotizing enterocolitis diagnosis
Radiologic studies of the bowel w dilated and thickened bowel loop ileum from air in bowels
Pneumatosis intestinal loop on x ray = bacterial invasion
clinical picture + labs + sepsis
135
Why do we give NPO w IV feedings for Necrotizing endocarditis?
to rest the GI tract
136
What should the OG or NG tube suctioning be on /gastric compression for necrotizing enterocolitis
low settings for necrotizing enterocolitis
137
In a necrotizing enterocolitis, what if there is a bowel perforation/obstruction?
What can necrotizing enterocolitis lead to that can cause death?
Surgery will have to be done
- partial colectomy
- peritoneal drain
sepsis
138
What happens due to alteration in renal physiology?
| And the implications?
Takes longer to excrete
Monitor drugs closely
Do smaller doses
Longer dose intervals in between too
139
Dehydration signs
```
Sunken fontanelle
Loss of weight
Poor skin turgor
Dry oral mucous membranes
Decreased urine output
Increased urine social gravity
```
140
How to monitor I&O
weight diapers
keep track of IVF rates , meds, and UO
daily weights
monitor labs
141
What does having an immature liver due to prematurity /infancy mean
You will have decreased glycogen store and increased risk of hypoglycemia
142
What does having low iron stores mean
Iron is stored in liver in 3rd trimester but if you have either a hemorrhage or something that causes decreased iron then you may have anemia of prematurity
143
In anemia of prematurity rt the liver, for how long can you remain low on hub/hct
3-6 months but most premies go home on oral iron supplements
144
Anemia of prematurity treatment
Transfusion of PRBC, oral iron , Erythropoetin (to stimulate rbc production although it is not as common as iron)
145
What does an impaired conjugation of bilirubin in liver do the infant?
Increases risk of jaundice or hyperbilirubemia
146
When is most immunity acquired ?
What does this mean for premies?
3rd trimeter from mom igG
| - so if they are born before this, they are at higher risk of infection
147
Is skin a good barrier to infection in premies?
Why is infection risk higher?
No it is fragile
premature poses more procedures and just the fact you may not have igG from mom.
148
best defense against infection
hand washing
limit visitations
aseptic/sterile technique
Keep the same nurse so they know what to look for
149
Signs & symptoms of sepsis
```
Subtle change in behavior
Lethargy or irritability
Hypotonia
Hypotension
Pale, cyanosis
Clammy skin
+ Cultures
Elevated C reactive protein to protect against inflammatory response
```
WBC low or high with elevated bands
Elevated IGM level s(due to initial infection)
150
What will temp be like in sepsis?
Unstable often low but can be hyperthermic or high
151
Feeding intolerance signs of sepsis?
Decreased intake, abdominal distention, vomiting
Poor sucking and lack of interest in feeding
152
Other trends of sepsis
Hyerpbilirubemia
| tachycardia
153
With sepsis, when do you give antibiotics
what if cultures are negative? and symptoms go away with normal CRP?
Before you even get culture results
- gentamicin and ampicillin
- you can change the drug if needed
You discontinue abx after 48 hours
154
What is main cause if IVH or intraventricular hemorrhage?
Fragile blood vessels in germinal matrix which leads to fluctuations in blood pressure and they can become hypoxic
155
Increased risk of IVH occurs when
Before 34 weeks or at 1500 grams
156
Ototoxic drugs that can cause hearing loss/neurotoxic effects?
What should be screened for in relation to neuro?
Gentamicin and Lasix so don't use them for too long
Meningitis
Hyperbilirubemia
157
Intraventricular Hemorrhage prevention
how do we provide neuro protection
Steroids to mom 24 hours before birth
postnatal surfactant
magnesium sulfate
- both are given to mo mom help baby
158
Intraventricular Hemorrhage diagnosis?
ventricular cranial sonogram 90% bleeds occur happen before 4 days of life
159
Intraventricular hemorrhage treatment?
HOB elevated
Prevent hydrocephaly
Lumbar taps done periodically for pressure removal and
V/P shunt to drain the fluid
160
Pharm ways to prevent pain
morphine
| fantayl
161
Nonpharm ways to prevent pain
swaddle, cuddle, rock
music, oral
sucrose and pacifiers
162
Why do premature infants need reduced light , less noise, and quiet?
How should you space care?
what position should infant be swaddled in?
Bc they can't handle heavy stimuli
clustered care
flexed positioning
163
T/F
| an infant will never lose sucking ability
false they definitely can
164
Signs of overstimulation
Cross sign
mottling
bradycardia
