UNIT 2 COMPLICATIONS OF THE NEWBORN Flashcards
What are some nonmodifiable risk factors that put a newborn at risk?
- Previous preterm delievery
- Multiple abortions
- Race/Ethnic group
- Uterine/cervical anomaly: Cervix trying to dialate to quickly
- Multple gestation
- pregnancy induced hypertenion- terminating pregnancy is the only way to resolve.
- Short interval between pregnancies
- Bleeding in the 1st trimester
What are some modifiable factors that put newborns at risk?
- Age at pregnancy <17 or >34 years of age
- Unplanned pregnancy: prenantal care not in place
- Domestic violence: Stress and trauma to mom and baby
- Low pre-pregnancy weight: Malnutrition can play a factor on unborn baby
- Obesity: can lead to type 2 DM
- Infection: Mom and/or baby
- Substance abuse/alcohol abuse: Mom and baby connected so anything mom ingest baby gets
- Cigarette smoking: Causes babies to be smaller
- Late or no prenatal care
Define a very premature baby?
Neonates born at less than 32 weeks gestation
Define a premature baby?
Neonates born between 32-34 weeks gestation
Define a late premature baby?
Neonates born between 34-37 weeks
In our assessment of a preterm baby what might there color be like?
Usually pink or ruddy; may be acrocyanotic– Not as common in preterm babbies.
In our assessment of a preterm baby what might their skin look like?
- Reddened, translucent, blood vessels apparent; lack of subq fat.
- 23-24 weeks old skin is very thin and delicate
How does lanugo on a preterm babies present?
Plentiful, widley distrubuted
How does the head of a preterm baby present?
Appears large in relation to the body
How does the skull present in a preterm baby?
Bones pliable, fontanels smooth and flat, sutures approximated and overriding
How do ears present on our assessment on a preterm baby?
Minimal cartilage, pliable, folded over
Important during care to reshape the ear
On assessment of a preterm baby what might there nails look like?
Soft; short
On assessment of a preterm babys genitals what might we see?
Males: nonrugated, small scrotum; testes may or may not be descended.
Females: prominent clitoris and labia minora, not as much psudomenstration
On assessment of a preterm baby what might we notice about their posture.
- Flaccid, froglike position
On assessment what might we notice about a preterm babies cry?
Weak, Feeble
On assessment of a preterm baby what might reflexes look like?
Poor suck, swallow and gag making them poor eaters
Not able to safely eat before 34 weeks
On assessment of a preterm baby what might we notice about their activity?
Jerky, generalized movements
True or false: Determining gestational age in preterm newborns requires knowledge and experience in adminstering gestational assessment tools?
True
What physiologic data might we monitor in a preterm infant?
- Hr
- Respirations
- Pulse ox
- Bp if they have an arterial line
Nursing care for the high-risk newborn includes?
1.Establish and maintain respiration
2.Apply external warmth
- Radiant warmers… not able to thermoregulate on their own.. brain can only do so much at a time..
- 1800G is when we might start weaning off of external warmth.
3.Administer fluids and meds
4.Enteral feeding (nipple, breast, gavage)
- under 34 weeks we gavage feed
5. Skin Care
- Do not give baths right away due to issues with thermoregulations might do spot baths.
6. Developmental and family-centered care.
Whar are 5 physiologic and anatomic factors that increase heat loss in the preterm infant?
- Preterm baby has a high ratio of body surface to body weight
- Preterm baby has very little Sub Q fat
- Preterm baby has thinner, more permeable skin
- The posture of the preterm baby influences heat loss
- The preterm baby has a decreased ability to vasoconstrict superficial blood vessels and conserve heat in the body core (they cant shiver)
True or False: Providing a neutral thermal environment minimizes the oxygen consumption required to maintain a normal core temp; it also prevents cold stress and facilitates growth by minimizing caloric expenditure to maintain body temp.
True
What are some nursing interventions to minimize heat loss?
- Allow skin to skin between mother and newborn
- Moms have a natural hormanal response when they fill baby and will warm up to meet babies needs.
- Warm and humidify oxygen to minimize evaporative heat loss and decrease oxygen consumption
- Place baby in double-walled incubator; use plexiglass heat shield over preemie in single-walled incubator; use radiant warmer and pipe in humidity
- Avoid placing infant on cold surfaces. Use warmers during procedures; pre-warm mattresses; warm hands and stethoscopes
What are special characteristics of the preterm renal system?
- The preterm infants kidneys are limited in their ability to concentrate urine or to excrete exccess amounts of fluid
- Renal immaturity affects ability to excrete drugs.
Why might we see dosages for our preterm babies being under the theraputic dose range?
Due to their immature kidney.. they are going to have a harder time excreting.
True or false: Strict I&O are not as important in preterm as it is newborns
False. Just as important
What should we keep in mind with a preterm infants liver?
- Immaturity of the preterm newborn’s liver predisposes the infant to several problems
- At birth, glycogen stores in liver are rapidly used for energy, so preterm infants are at higher risk for hypoglycemia
- Iron is stored in liver, especially in 3rd trimester so preterm has low iron stores
- conjugation of bilirubin is impaired in preterm
Why must we be careful when taking blood from a preterm infant?
Preterm babies aren’t able to restore blood supply so we have to be careful with how much we take. This information is vital during report… so that we can determin our care for the day… We send the minimum amount of blood as we can.
What should we keep in mind about a preterm babies immune system?
1.** Because most IgG immunity is acquired in the last trimester, the preterm infant has few antibodies at birth**
2. IgA is found in breast milk and because of preterms infant inablility to feed-they do not get sufficient IgA
3. Preterm skin is easily excoriated and this, coupled with multiple inavasive procedures places the infant at great risk for nosocomial infection
How can we prevent infections in preterm babies?
- Nurse is responsible for minimizing preterm’s exposure to pathogenic organisms
- Strict hand washing
- Use separate quipment for each infant
- Most nurseries have adopted the standard percautions recommended by CDCC of isolating every baby
- Most nurseries have adopted the JCAHO requirement that all staff members have short-trimmed nails are no artifical nails
- Wear gloves
- Staff members are required to do a 2 to 3 min scrub using antimicrobial solutions
What are methods of feeding preterm babies?
- Total parenteral nutrition (TPN)
- Used when feeding is contraindicated though GI tract
- TPN provides complete nutrtion for metabolic requirements and growth to the infant intravenously
- A percutaneous central venous catheter (PCVC/PICC) is often used with LBW infant to deliever higher concentration of glucose
- Serum glucose levels and chemistries should be carefully monitored during infusion
LIPIDS are kept seperately
What should we know about gavage feeding?
- Syringe or tube feeding
- Used with preterm infants who lack or have a poorly coordinted suck-swallow-breathing pattern, are ill or ventilator dependant
- May be used as an adjunct to nipple feeding
- Administered by intermittent or continous drip methpd
- Early initation of MEN (minimal enteral nutrition) via gavage is now advocated in the preterm as a supplement to parentral nutrition
When might we remove the oral tube and replace with an NG tube for feedings?
When the baby starts trying to use a bottle
What are some benefits of gavage feedings?
- Preterm newborns who are ill or fatigue easily are usually fed by favage
- Infant is passive with these methods.
- Conserves energy and calories
As baby matures, gavage feeds are replaced with …..
nipple or bottle feedings
What are signs of rediness that a preterm baby is ready to move from gavage feedings to nipple feeds?
- Strong gag reflex
- Presence of non-nutritive sucking
- Rooting bhavior
What 3 things do preterm babies need to be doing in order to go home?
- Eating
- Off the warmer
- Gaining weight
What should we know about bottle feeding?
1.Need suck-swallow breathing coordination
2.Readiness to feed behaviors include: remain engaged in feeding, able to organize oral-motor function, can maintain physiologic stability
3.Infant fed in semi-sitting position and burped after each 15ML
4.Feeding should take no longer than 15-30 mins
5.Start with one session a day and increase slowly until infant can tolerate all bottle feedings
We never want to feed a baby when there are?
Stressed or fatigued… limit feeding to 30 mins anything more gavage feed.
True or false: We want to give them a paci during NG or OG feeding because it is pracice for them
True
What should we know about breastfeeding?
- Should be put to breast as soon as there is a coordinated suck-swallow-breath coordination consistent weight gain, and control body temperature without heat source.
- Preterm infants tolerate breastfeeding with better transcutaneous maintenance than with a bottle feeding
- Nurse should coordinate flexible feeding schedule
- Mothers can pump and milk be given by gavage
- May introduce bottle first that we can observe suck then the breast.
How do we record I&O when breastfeeding?
- Note the time the baby starts and ends
- Weight gain
- staying asleep until next feeding?
- Diapers
- Somtimes we allow them to breast feed and then offer a bottle at the end to ensure they are satisfied if we have concerns
How can we promote successful parent-infant attachement?
- Nurse should promote positive parental feelings toward infant
- Involve the parents early in care and decsions
- Nurse can point out infant’s patterns of behavior and unique characteristics and reposnses
- Nurse can teach parents about their infant’s sleep/wake states and optimal times for interacting with infants
- Teach care giving skills and assist to understand premature infant behavioral characteristics
- Daily participation in care is encouraged
- Nurse provides opportunities for parents to touch, hold, talk to and care for their baby
- Skin-to-skin holding (kangaroo care) helps parents feel close to their infants
- Parental involvement in difficult decisions is essential
- Rooming in can provide another opportunity for infant and parents to get acquinted
How can we provide developmentally supportive care?
- Facilitate handling by using containment measures when turning or moving the infant or doing procedures such as suctioning.
- Touch infant gently and avoid sudden postural changes
- Promote self-consoling or soothing activities to provide “nesting”
- Swaddle infant to maintain extremitites in flexed position while ensuring that the hands can reach the face
- Stimulate the kinesthetic advantages of the intrauterine environment by using soft or fleece-like blanks and gel beds
What are signs of stress or fatigue in neonates?
- Physiologic instability
- Fluctuating tone
- Lack of control over movement
- Disorganized
- Closed eyes and sleeplike withdrawal.
What is cold stress?
- Cold stress occurs when there is a decrease in environmental temperature and a decrease in body temperature causing an increased heart and respiratory rate which increases oxygen consumption, depletion of glucose and decrease surfactant which can lead to resp distress
In short excessive heat loss that leads to hypothermia.
What are risk factors for cold stress?
- Prematurity
- Hypoglycemic baby
- becuase they dont have that extra fuel to help boost the temp
- Small baby for gestational age
- Likely to have less subq tissue.
What are s/s of cold stress?
- Increased hr
- Increased RR
- Increased oxygen consumption
- Gruting
- Nasal flaring
- Flaccid tone
- Temp below 36.5
- lethargic
- Cold to touch
- pale
- Weak suck
What is surfactant?
It is what coats the lungs and helps the lungs open and close more easily
What are our nursing actions to help with cold stress?
- Actions to decrease risk
- Actions when neonate displays signs of cold
- Dry baby at birth
- keep room warm
- place baby on mom
- stocking cap and socks
- delay bath
- warm blankets
- may need be under a radiant warmer
What should we need know about placing a baby under a radiant warmer?
1.Baby needs to be in diaper only since we want the heat to hit the skin.
2.Can wear hat
3.Monitor every 30 mins until the temperature rises about 36.5
What does our care consistent of for the post mature newborn?
- Post mature newborn- any newborn orn after 42 weeks gestation
- Occurs in approximately 4 to 14% of all pregnancies
- Many classified as postterm are thought to be a result of inaccurate estimated date of birth EDB
- More common in greek, Italian, and aboriginal people of australia
- Most are of normal size and health
- Some over 4kg at birth
What are common complications of a post-mature infant?
- Postmaturity syndrome
- Decreased placental function
- Prone to hypoglyemia and hypoxemia
- Increased risk for cold stress because the fat layers are non-existent
What are physical characteristics of a post-mature infant?
- Dry cracking, parchment-like skin.
- Long fingernails
- Absence of lunugo, vernex is gone
- Appears long and thin, fat layers are non existent, frequently meconium stained (due to stress)
What normally happens in a healthy baby to prevent jaundice
- RBC that die at the end of their lifetime are borken down by the body
- One of the waste product is bilirubin, a yellow piagment bilrubin is not soluable in water
- Bilirubin is processed in the liver to make it soulable in water
- The soluable product leaves the body, mostly in stools
What are our interventions for a post-mature baby?
- monitor for hypoglycemia
- Monitor thermoregulation
- Monitor respiratory
What happens when a baby has jaundice?
Think Patho
- RBC die off in large numbers at birth
- Alot of biliruben is created
- Because the liver is not yet mature, it processes biliruben very slowly
- Verly little bilirubin leaves the body
- The excess, unprocessed biliruben builds up everywhere inthe body. It colors the skin and eyes yellow
What is hemolytic disease or pathological jaundice?
1.Hyperbilirubinemia within the 1st 24 hours is most often the result of hemolytic disease of the newborn.
What can cause hemolytic disease or pathological jaundice?
- ABO incompatibility
- Mother has blood type o and a newborn with A or B blood
- RH incompatilbility (most common)
- Develops when an Rh negative conceives a RH postive infant
Due to this baby starts seeing blood from mom as a foriegn which leads to an increase breakdown of blood. Since the liver is still so immature it increases biliruben too quickly which can lead to permenant brain damage which is why we must report it!
What is physiologic jaundice?
If you have a baby who is jaundice within the 1st 24 hours what are we going to look for?
- Baby and moms blood type
- Rule out RH factor
When mom has a baby with a postive RH what must the mom get?
Shots… 1 before and 1 after birth to help prevent body from attacking next baby
What is physiologic jaundice?
- Not associated with any pathologic process
- Immature hepatic function
- Increased biliruben load due to RBC heolysis
- Onset after 24 hours typically peaks around 3-4 days
When does physiologic jaundice peak?
3-4 days
What are the interventions for physiologic jaundice?
Place the baby under light therapy
How do we confirm that a baby has hypervilirubinemia?
- Diagnostic evaluation
- Nursing assessment is usually how it starts… remember that jaundice normally starts in the eyes, works its way day and then resloves backwards.
- Transcantanous bili or lab draw
What should we know about a transcutaneous bili?
It is a the thermometer like instrument that you place on the infants head 3x and it will tell you what the bili is… if it abnormal then you get blood levels… if normal keep monitoring… if baby is already under bili light make sure to turn off when doing your blood draw. Or when you are doing care.
What do we need to know about phototherapy for tx of jaundice in infants?
- Keep googles on
- Change position everyday
What is the prognosis for hyperbilirubinemia?
Good as long as it caught early and no damage to brain occurs…
How do babies get septic?
- Prenatally aquired
- During Labor
- Prolonged rupture of membranes
- group b streptococtus… which is a naturally occuring flora some women but if babies ingest it sepsis is a risk.. moms are usally tested around 34-36 weeks this helps guide delievery and care.
True or false: Babies with birth trauma are at higher risk of hyperbiliremia?
1.True
Early sepsis occurs when?
1 to 3 days of age usually prenatal or labor aquired.
If mom is showing signs of infection baby becomes at risk for….
infection
Late sepsis occurs in infants when?
1 to 3 weeks of age usually hospital aquaired during this time. so IV, intubation staff, e.coli…
What should we keep in mind with sepsis of a newborn?
- Nurse may be first to identify subtle clinical signs
- Subtle behavior changes
- Increased episodes of apnea and brady cardia
- Color changes (greenish gray color)
- Temperature instability
- may become hypothermic since they are increasing work to fight off infection baby may forget to stay warm
- Feeding intolerance; vomiting, diarrhea, abdominal distention
- Nurses should immediately inform clinican of changes and implement ordered treatment plan
Diagnostic evaluations of infections for infants include?
- Cultures of blood, urine, cerebrospinal fluid
- CBC, hemoglobin, hematocrit
- CRP- good in identifying late onset sepsis… it shows inflammatory responses
What is our therapeutic management of neonatal sepsis?
- Vigorous antibiotic therapy: blood cultures 1st
- Start on broad specturum antibiotic… on day 3 if they are better and culture is negative we can stop the antibiotic… however if they are negative and still sick we will ocntinue for 7-10 days
- Supportive therapy: oxygen theapy and blood transfusions
What is the prognosis of sepsis in infants?
Depends on how fast it is caught and treated
Infants of diabetic mothers (IDMs) are considered at high risk and require close observation for how long?
First few hours to days of their lives
What does IDDM stand for?
Insulin dependant diabetic mother
Typically IDM (infants of diabetic mothers) are caused by what?
when diabetes is poorly controlled or gestational is LGA (large for gestational age)
What are characteristics of IDM?
- Macrosomia (large), ruddy in color
- Has excess adipose tissue
- Umbilical cord thick, placenta large
- Decreased total body water, particulary in extracellular spaces
- Excessive weight due to increased weight of visceral organs, cardiomegaly (hypertrophy) and increased body fat
Why do poorly controlled diabetic mothers pose such a risk to babies health?
It exposes baby to surgar so baby starts producing insulin to regulate thier sugar. Once cord is cut the sugar supply from mom is gone and insulin is still being produced and so babys blood surgar will get really low.
What is the only organ not affected by the increase of sugar in babies bloodstream?
The brain
What are some common complications of the IDM?
- Hypoglycemia
- Hypocalcemia: because of the issues diabetics mom may not have a mg… baby may also have tremors
- Hyperbilirubinemia
- Birth Trauma
- Polycythemia- extra insulin baby has been producing
- Respiratory distress syndrome (inhibited serfactin production) So babys dont breath like they should
- Congenital malformations- Cardiac/renal defects
What is the nursing management of IDM?
- Early detection and ongoing monitoring for hypoglycemia, polycythemia, resp. distress and hyperbilirubinemia
- Blood glucose hoursly during x4 the q 4 hours during first 48 hours (or by agency protocol)
- IDMs who have hypoglycemia should have early feeding.
- If normal glucose cannot be maintained with oral feedings, an IV infusion of glucose will be necessary (d10W at 6-8mg/kg/min)— and a trip to NICU
- Assess for signs of birth trauma and congenital anomalies
True or false: Babies are not born dependant?
True
What is neonatal abstinence syndrome?
A physiologic dependance that we must help them through
What drug might a mother be put on if she finds out that she is pregnant and did not plan for the baby and has been actively using drugs…
Mom should not stop using drugs cold turkey due to increased risk of harming the baby
Methadone
What might we find during our assessment of baby suffering from substance abuse?
- Signs of neonatal withdrawl
- Fetal alcohol syndrome (FAS)
- Alcohol-related birth defects (ARBD)
- Alcohol-related neurodevelopmental disorders (ARND)
- Medical management
- Nursing actions
- test the umbilical cord or meconium, urine or hair
True or false and why: The more term a baby is the more we will see neonatal abstinence syndrome?
True: they have had longer exposure to the drug through the umbilical cord.
What neurologic signs may a baby suffering from neonatal abstinence syndrome present with?
- Irritability
- seizures
- hyperactivity
- High-pitched cry
- tremors
- exaggerated moro reflex
- Hypertonicity of muscles
What are gastrointestinal signs may a baby suffering from neonatal abstinence sydnrome present with?
- Poor feeding
- diarrhea
- dehydration
- vomiting
- Frantic, uncoordincated suck
- Gastric residuals
What autonomic signs may a baby suffering from neonatal abstinence syndrome present with?
- Diaphoresis
- fever
- Molttled skin
- Nasal stuffiness
What miscellaneous symptoms may a baby who is suffering from neonatal abstinence syndrome present with?
- Disrupted sleep patterns
- Diaphoresis
- Tachypenia (>60)
- Excoriations
- Temp instability
What is failure to thrive?
R/O neglect
FTT (failure to thrive) may be a result of:
1.Physical problems
2. Psychosocial issues
3. Poverty
4. Health beliefs
5. Family stress
6. Feeding issues
What is a indicator of FTT?
Weight being lower than the 5th percentile for age
1. Look for a pattern of consistenent deviation in growth pattern
2. FTT usually the result of mixed causes
What are potential causes of FTT
- Inadequate calorie intake
- Incorrect formula prep, neglect, fad foods, poverty, behavioral problems affecting eating, CNS issues
- Inadequate absorption
- Cystic fibrosis, celiac disease, bilary atresia
- Increased metabolism
- Hyperthyroidism, congenital heart defects
- Defective utilization
- Genetic anomaly
How can we identify FTT?
- History
- Parent height
- Physcial
- Assessment of meal time rituals, behaviors
- Parent child interaction
- R/O lead toxicity, anemia, ova & Parasites, etc.
What is our nursing management of FTT babies?
- Provide a positive feeding environemnt
- Document child’s feeding bheaior and the patient-child interaction during feedign
- Provide primary core of nurses
- Avoid distractions
- Introduce new foods slowly
