The High-Risk Newborn: Acquired and Congenital Conditions Flashcards
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A lack of oxygen and increase of CO2 in the blood
> Can occur in utero, at birth, or later (neonatal life)
Lack of oxygen → anaerobic metabolism → production of lactic acid
Metabolic acidosis and respiratory acidosis can occur
At birth this can happen because of fetal lung immaturity that doesn’t allow proper gas exchange to occur
Asphyxia
Metabolic acidosis
* Due to buildup of acids and not enough bicarbonate buffer
Could see a mixed acidosis where there is a buildup of acids and CO2
- Immediately after birth we may see rapid respirations followed by a cessation of respiration (what we call primary apnea)
- Resolved with stimulation or O2
- If asphyxia continues, secondary O2 needed (must protect neurological status of newborn)
- Narcotic administration close to delivery can cause asphyxia; may have to give Narcan
Respiratory acidosis
* Buildup of CO2 in the blood
Neonatal Resuscitation (NRP)
* ALL personnel involved in deliveries should know how to perform resuscitative measures of the newborn
* Equipment should be readily available and functioning properly to prevent delays in response
Preparing for Delivery
Prepare treatment area
> Prewarm the radiant warmer
> Turn on oxygen and suction to proper settings and ensure functionality
> Have intubation equipment nearby
If suspecting asphyxia before birth, also have…
> Neonatologist and special care/NICU nursery staff present
> Code cart in room
> Additional staff
Initial Measures of NRP
FIRST 30 SECONDS
* Dry and stimulate the infant (baby placed on the maternal abdomen); remove any wet linens
* Place infant in “sniffing” position
* Suction the mouth and then the nares
IF NO RESPONSE
* Evaluate need for immediate resuscitation: respirations, heart rate, tone, color
* Central cyanosis [in trunk; don’t confuse with acrocyanosis which is normal] but infant is breathing and pulse greater than 100 - supplemental O2
- Fails to breathe spontaneously, gasping respirations, a heart rate less than 100, or remains cyanotic with supplemental O2 - initiate positive pressure ventilation (PPV) at 21% O2
- Heart rate and oxygen saturation do not improve, breath sounds are not heard, chest does not move… what do you do? → move to endotracheal intubation
- If PPV is necessary for more than a few minutes, endotracheal tube should be placed
* Assess every 30 seconds
* IF THE HEART RATE DROPS BELOW 60 INITIATE CHEST COMPRESSIONS AND CALL A NEONATAL CODE
> 110-160 = normal
p. 646-647 - Resuscitation directions
- Understand normal compression and ventilation rate
- Ventilate at 40-60 breaths/min and compressions at over 100 (closer to 120)
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Rapid respirations soon after birth due to inadequate absorption of fetal lung fluid (presents similar to respiratory distress syndrome)
See this in cesarean and rapid labor babies
Resolves within 24-72 hours
Infants at risk: cesarean birth; precipitous delivery; males; perinatal asphyxia; maternal diabetes; maternal asthma
Transient Tachypnea of the Newborn (TTN)
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Caused by obstruction, air trapping, and chemical pneumonitis from meconium in the infant’s lungs
Highest risk in post-term and small for gestational age (SGA) infants [more at risk for hypoxic events which is thought to trigger that passage of meconium] and those who had compromise before birth (placental insufficiency, cord compression, etc.)
Can be drawn into lungs in utero during asphyxia and acidosis, then inhaled deeper upon the first breath
Chest x-ray shows atelectasis, consolidation, and hyperexpansion
For treatment, may have to suction out from the lungs some of the meconium
Meconium Aspiration Syndrome (MAS)
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Prevents the changes in neonatal circulation that need to occur; also termed persistent fetal circulation (the shunts that needed to close did not close)
Caused by inadequate oxygenation triggering vasoconstriction of the pulmonary artery and pulmonary vessels, forcing a right-to-left shunt of unoxygenated blood [we end up reopening the ductus arteriosus and foramen ovale]; worsens in the setting of metabolic acidosis
Symptoms can include tachypnea, respiratory distress, progressive cyanosis, decreased oxygen saturation
Treat the underlying cause of pulmonary vasoconstriction ⇒ improving oxygenation leads to vasodilation
Persistent Pulmonary Hypertension of the Newborn (PPHN)
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Nonphysiologic/Pathologic Jaundice
> Total serum bilirubin reaches ___-___ mg/dL, jaundice occurs
> Can lead to ___, caused by bilirubin toxicity
> Mortality and morbidity of infants with ___ and/or ___ is high (cerebral palsy)
> Most common cause = ___ [an incompatability between mother and fetal blood types; Rh incompatability or ABO incompatability]
- Erythroblastosis fetalis
- Hydrops fetalis
Hyperbilirubinemia
5-6 mg/dL
bilirubin encephalopathy
bilirubin encephalopathy; kernicterus
hemolytic disease of the newborn
Hyperbilirubinemia
* Any condition that causes destruction of erythrocytes or impairment of the liver can result in elevated bilirubin levels
* Main nursing focus is prevention of bilirubin encephalopathy and kernicterus
* Coombs Test: Indirect/Direct [is done on the cord blood sample]
* Transcutaneous Bilirubinometers - noninvasive, can screen on the surface of the skin
> Can be inaccurate in preterm infants and those undergoing phototherapy
* Monitor serum bilirubin levels through a heelstick
Phototherapy
* Most common treatment of jaundice
* Bilirubin in the skin absorbs the light, turning into water-soluble products, which excrete in bile and urine
* Side effects: frequent, loose green stools; insensible water loss; “bronze baby syndrome”; macular skin rash
* We want maximum skin exposure but protect the infant eyes
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* Performed when phototherapy cannot reduce dangerous total serum bilirubin (TSB) levels
* Removes sensitized red blood cells, maternal antibodies, and unconjugated bilirubin
* Corrects severe anemias
* At the end, 85% of the infants red blood cells are replaced and the bilirubin level drops by 50%
* Bilirubin pulls from tissues into plasma - rebound elevations occur
Exchange Transfusions
Review Common Infections in the Newborn
* Cytomegalovirus (CMV)
* Hepatitis B (HepB)
* Herpes
* Human Immunodeficiency Virus (HIV)
* Rubella
* Varicella-Zoster Virus (VZV)
* Group B Streptococcal Infection (GBS)
* Gonorrhea
* Chlamydial Infections
* Toxoplasmosis
* Syphilis
Up to 10% of neonates develop infections within the 1st month of life and all these above are the most common culprits
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Systemic infection from bacteria in the bloodstream
Newborns at higher risk - why?
> Because of immature immune systems
> Have slower responses to infectious pathogens
> Have fewer antibodies (especially if they’re a preterm infant)
> Are unable to localize infection
> There is a less effective blood-brain barrier
Sepsis Neonatorum
Nursing’s Role in Newborn Infection
* Assessment
> Risk factors for sepsis: preterm; low birth weight; prolonged rupture of membranes (>18 hrs); prolonged or precipitous labor; maternal infection; chorioamnionitis
> Infants in the NICU are at risk of healthcare-associated infections (HAI) [e.g. pneumonias]
> Know the signs of infection and sepsis (p. 655)
* Interventions
> Implement measures to prevent infection; good hand hygiene
> Administer antibiotics as prescribed
> Supportive care to the newborn and the family
The Macrosomic Infant
* Hypertrophy of the heart, liver, and spleen
* Face is round, body is “obese”, skin may be plethoric (red)
* Poor muscle tone at rest; irritability and tremors
* Risk of respiratory issues, including respiratory depression syndrome
* Risk of injury: fractures (shoulder dystocia = nerve injury), cephalohematoma (may be a baby delivered through an operative vaginal delivery), nerve injury
* High risk of hypoglycemic events
- Rapid respirations, low temperature, poor muscle tone
- Occasionally jittery/tremors
