Presentation on theme: "Nancy Pares, RN, MSN Metro Community College"— Presentation transcript:
1Nancy Pares, RN, MSN Metro Community College NURS Unit 4Nancy Pares, RN, MSNMetro Community College
2Objective 1Discuss pathophysiology and nursing process for high risk newborn
3Identification of At-risk Newborn Low socioeconomic level of the motherLimited or no prenatal careExposure to environmental dangersPreexisting maternal conditionsMaternal factors such as age or parityMedical conditions related to pregnancyPregnancy complications
4Feeding GuidelinesTable 32–1 Suggested feeding guidelines for the preterm infant.
5Early Feeding Skills (EFS) Table 32–2 Examples of efs items within each section.
6Preterm Infant: Respiratory Alterations Inadequate surfactant productionMuscular coat of pulmonary blood vessels is not completely developedGreater risk for the ductus arteriosis to remain open
7Fetal/Neonatal Risk Factors for Resuscitation Nonreassuring fetal heart rate patternDifficult birthFetal scalp/capillary blood sample-acidosis pH<7.20Meconium in amniotic fluidPrematurityMacrosomia or SGA
11Fetal/Neonatal Risk Factors for Resuscitation (continued) Male infantSignificant intrapartum bleedingStructural lung abnormality or oligohydramniosCongenital heart diseaseMaternal infectionNarcotic use in labor
12Fetal/Neonatal Risk Factors for Resuscitation (continued) An infant of a diabetic motherArrhythmiasCardiomyopathyFetal anemia
13Respiratory Distress Syndrome (RDS) Deficiency or absence of surfactantAtelectasisHypoxemia, hypercarbia, academiaMay be due to prematurity or surfactant deficiency
14Figure 33–5 RDS chest x-ray Figure 33–5 RDS chest x-ray. Chest radiograph of respiratory distress syndrome characterized by a reticulogranular pattern with areas of microatelectasis of uniform opacity and air bronchograms. SOURCE: Courtesy of Carol Harrigan, RNC, MSN, NNP.
15RDS: Nursing Care Maintain adequate respiratory status Maintain adequate nutritional statusMaintain adequate hydrationEducation and support of family
16Figure 33–9 Premature infant under oxygen hood Figure 33–9 Premature infant under oxygen hood. Infant is nested and has a nonnutritive sucking pacifier. SOURCE: Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.
17Transient Tachypnea of the Newborn (TTN) Failure to clear lung fluid, mucus, debrisExhibit signs of distress shortly after birthSymptomsExpiratory grunting and nasal flaringSubcostal retractionsSlight cyanosis
18TTN: Nursing Care Maintain adequate respiratory status Maintain adequate nutritional statusMaintain adequate hydrationSupport and educate family
19Meconium Aspiration Syndrome (MAS) Mechanical obstruction of the airwaysChemical pneumonitisVasoconstriction of the pulmonary vesselsInactivation of natural surfactant
20MAS: Nursing Care Assess for complications related to MAS Maintain adequate respiratory statusMaintain adequate nutritional statusMaintain adequate hydration
21Persistent Pulmonary Hypertension (PPHN) Blood shunted away from lungsIncreased pulmonary vascular resistance (PVR)PrimaryPulmonary vascular changes before birth resulting in PVRSecondaryPulmonary vascular changes after birth resulting in PVR
22PPHN: Nursing Care Minimize stimulation Maintain adequate respiratory statusObserve for signs of pneumothoraxMaintain adequate nutritional statusMaintain adequate hydration statusSupport and educate family
23Figure 33–10 Chest x-ray of a left-sided pneumothorax Figure 33–10 Chest x-ray of a left-sided pneumothorax. A rupture of the alveoli sacs allows air to leak through the pleura, forming collections of air outside the lung (air shows on x-ray as dark area over lung). SOURCE: Courtesy of Carol Harrigan, RNC, MSN, NNP.
24Genetic disordersThis information will be discussed in greater detail later in the course.For the purposes of this unit, know that certain disorders are genetic
25Congenital AnomaliesTable 32–3 Congenital anomalies: identification and care in newborn period.
26Congenital AnomaliesTable 32–3 (continued) Congenital anomalies: identification and care in newborn period.
27Congenital AnomaliesTable 32–3 (continued) Congenital anomalies: identification and care in newborn period.
28Congenital AnomaliesTable 32–3 (continued) Congenital anomalies: identification and care in newborn period.
29Congenital AnomaliesTable 32–3 (continued) Congenital anomalies: identification and care in newborn period.
30Congenital AnomaliesTable 32–3 (continued) Congenital anomalies: identification and care in newborn period.
31Congenital AnomaliesTable 32–3 (continued) Congenital anomalies: identification and care in newborn period.
32Congenital AnomaliesTable 32–3 (continued) Congenital anomalies: identification and care in newborn period.
33Cardiac DefectsTable 32–7 Cardiac defects of the early newborn period.
34Cardiac DefectsTable 32–7 (continued) Cardiac defects of the early newborn period.
35Cardiac DefectsTable 32–7 (continued) Cardiac defects of the early newborn period.
36Cardiac DefectsTable 32–7 (continued) Cardiac defects of the early newborn period.
37Cardiac DefectsTable 32–7 (continued) Cardiac defects of the early newborn period.
38Infants at Risk for HIV/AIDS Table 32–6 Issues for caregivers of infants at risk for HIV/AIDS.
39Infants Born to HIV/AIDS Infected Mothers: Consequences PrematuritySGAFailure to thriveEnlarged spleen and liverSwollen glands
40Infants Born to HIV/AIDS Infected Mothers: Consequences Recurrent respiratory infectionRhinorrheaRecurrent GI problemsPersistent or recurrent candidiasis
41Nursing Care of the Infant Born to HIV/AIDS Infected Mothers Provide comfortKeep the newborn well nourishedKeep the infant protected from infectionsFacilitate growth, development, and attachment
42SepsisRisk factorsMaternal infection (group B streptococcus most common)Long labor, prolonged rupture of the membranesMaternal fever, chorioamnionitisFetal distress, aspiration
55Nursing Care of the Drug-Exposed Newborn Neonatal abstinence scoringMonitoring VS and pulse oximetry until stableSmall frequent feedingsIV therapy if neededPositioning on the right side-lying or semi- Fowler’sMonitoring frequency of diarrhea and vomiting
56Nursing Care of the Drug-Exposed Newborn Weigh infant every 8 hours during withdrawalSwaddle infantProtect face and extremities from excoriationPlace infant in quiet, dimly lighted area of the nurseryAdministration of medications
57Newborn WithdrawalTable 32–4 Clinical manifestations of newborn withdrawal.
60Figure 33–14 Potential sites for heel sticks Figure 33–14 Potential sites for heel sticks. Avoid shaded areas to prevent injury to arteries and nerves in the foot and the important longitudinally oriented fat pad of the heel, which in later years could impede walking.
61Figure 33–15 Heel stick. With a quick, piercing motion, puncture the lateral heel with a microlance. Be careful not to puncture too deeply.
62Postmaturity Syndrome HypoglycemiaMeconium aspiration and oligohydramniosPolycythemiaCongenital anomaliesSeizuresCold stress
63Care of the Premature Infant Delivery prior to 37 weeks’ gestationFactorsMultiple gestation, PROM, incompetent cervix
64Assessment of the Preterm Newborn Physical characteristicsGestational ageMaternal prenatal risk factorsDelivery risk factorsPhysical assessmentFamily assessment
65The Premature Infant (continued) AssessmentGestational age assessmentNeurologic assessmentPhysical characteristicsThin skin, soft cartilage, absent plantar creasesAbundant lanugo and vernixGenitalia characteristic of prematurity
66Review of Systems and Potential Complications CardiovascularPatent ductus arteriosisHypotensionCentral nervous systemIntraventricular hemorrhagePosthemorrhagic hydrocephalusHematologic systemAnemiaPolycythemiaHepatic systemHyperbilirubinemiaPhototherapy
67Review of Systems (continued) Gastrointestinal systemDysmotilityNecrotizing enterocolitisGastroesophageal refluxImmune systemInfectionIntegumentary systemEpidermal strippingAbsorption of chemical agentsCrib with head elevated for reflux
68Review of Systems (continued) Ophthalmologic systemRetinopathy of prematurityRenal systemOliguriaGlycosuriaRespiratory systemRespiratory distress syndromeBronchopulmonary dysplasiaApnea of prematurityPneumoniaPreterm infant inan oxygen hood
69Preterm Infant: GI Alterations Poorly developed gag reflexIncompetent esophageal cardiac sphincterPoor sucking and swallowing reflexesDifficulty meeting caloric needs for growthInability to handle the increased osmolarity of formula proteinDifficulty with absorbing saturated fats
70Preterm Infant: GI Alterations (continued) Difficulty with lactose digestionDeficiency of calcium and phosphorousIncreased basal metabolic rate and increased oxygen requirementsFeeding intolerancePotential for the development of necrotizing enterocolitis (NEC)
71Preterm Infant: Alterations in Thermogenesis Unavailability of glycogen and brown fatInability to increase oxygen consumptionHigh ratio of body surface area to body weightExtended position increases body surface areaDecreased ability to vasoconstrict superficial blood vessels
72Preterm Infant: Kidney Alterations Lower glomerular filtration rate (GFR)Limited ability to concentrate urine or excrete large amounts of fluidExcrete glucose at a lower serum glucose levelBuffering capacity is reducedExcretion time of drugs is longer
73Preterm Infants: Liver Alterations Glycogen stores are used rapidlyGlycogen stores are affected by asphyxia and cold stressLow iron storesConjugation is impaired
74Preterm Infants: Other Alterations ImmunologicLack of passive IgG antibodiesSkin is easily excoriatedNeurologicIncreased risk for IVH & ICHDelayed or absent reactivity
75Hydrocephalus: Nursing Assessments Occipital-frontal baseline measurementsDaily head circumferencesSkin integritySigns and symptoms of infectionSigns of widening of suture lines
76Hydrocephalus: Nursing Interventions Assist with head ultrasounds and transilluminationChange position frequentlyClean skin creasesKeeping a sheepskin under the headPostoperatively position head off the operative site
77Intrauterine growth restriction Small for gestational ageLarge for gestational agePost term infant
78Intrauterine Growth Restriction Infants <10th percentile for weight at birthMay be symmetric or asymmetricFactors may be fetal, maternal, or placentalComplicationsHypoxia, hypothermia, hypoglycemia, polycythemia, hyperbilirubinemia, meconium aspiration
79Intrauterine Growth Restriction (continued) Nursing implicationsPrevent heat lossMonitor blood glucose, feed earlyMonitor for respiratory complicationsManagement of hyperbilirubinemia
82Large for Gestational Age Infant Infants >90th percentile for weight at birthFactorsMaternal diabetes, parental obesityComplicationsDifficult delivery, birth trauma, hypoglycemiaNursing implicationsAssess for birth injuryMonitor for hypoglycemia
83Impact of Maternal Diabetes Mellitus (DM) on the Newborn LGASGAHypoglycemiaHypocalcemiaHyperbilirubinemia
84Impact of Maternal Diabetes Mellitus (DM) on the Newborn Birth traumaPolycythemiaRDSCongenital malformations
94Management of Hyperbilirubinemia Encourage frequent feedingsExposure to sunlightPhototherapyShield infant’s eyesMonitor body temperatureMonitor weightMonitor fluid intakeWeigh diapersNote frequency of stools
95Physiologic Hyperbilirubinemia Appears after first 24 hours of lifeDisappears within 14 daysDue to an increase in red cell mass
96Pathologic Hyperbilirubinemia Appears within first 24 hours of lifeSerum bilirubin concentration rises by more than 0.2 mg/dL per hourBilirubin concentrations exceed the 95th percentileConjugated bilirubin concentrations are greater than 2 mg/dLClinical jaundice persists for more than 2 weeks in a term newborn
97Causes of Pathologic Hyperbilirubinemia Hemolytic disease of the newbornErythroblastosis fetalisHydrops fetalisABO incompatibility
98Treatment of Pathologic Hyperbilirubinemia Resolving anemiaRemoving maternal antibodies and sensitized erythrocytesIncreasing serum albumin levelsReducing serum bilirubin levelsMinimizing the consequences of hyperbilirubinemia
99Phototherapy: Nursing Care Maximize exposure of the skin surface to the lightPeriodic assessment of serum bilirubin levelsProtect the newborn’s eyes with patchesMeasure irradiance levels with a photometerGood skin care and reposition infant at least every 2 hoursMaintain an NTE and adequate hydration and nutrition
100Figure 33–18 Infant receiving phototherapy Figure 33–18 Infant receiving phototherapy. The phototherapy light is positioned over the incubator. Bilateral eye patches are always used during photo light therapy to protect the baby’s eyes. SOURCE: Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.
101Nutrition and Fluid Management FluidsStrict I&O, weigh diapersElectrolyte managementManagement of sodium and potassium levelsGlucose homeostasisFeedingGavage or nipple methodTypes: formula or breast milkGavage feeding tube
102Developmental Care of the Preterm Infant LightSoundTemperaturePositioning and containment strategiesHandling and touchingNonnutritive sucking
103Cold Stress Increase in oxygen requirements Increase in utilization of glucoseAcids are released in the bloodstreamSurfactant production decreases
104Figure 33–13 Cold stress chain of events Figure 33–13 Cold stress chain of events. The hypothermic, or cold-stressed, newborn attempts to compensate by conserving heat and increasing heat production. These physiologic compensatory mechanisms initiate a series of metabolic events that result in hypoxemia and altered surfactant production, metabolic acidosis, hypoglycemia, and hyperbilirubinemia.
105Cold Stress: Nursing Care Observe for signs of cold stressMaintain NTEWarm baby slowlyFrequent monitoring of skin temperatureWarming IV fluidsTreat accompanying hypoglycemia
106Objective 2Explain the assessment and nursing interventions associated with birth injuries
107Trauma and Birth Injuries FracturesClavicle, long bones, skull most commonRisksLarge infant, breech, difficult laborAssessmentImpaired mobilityManagementImmobilization, traction, casting
108Trauma and Birth Injuries (continued) Facial PalsyUsually related to use of forcepsBrachial PalsyUsually related to difficult delivery such as shoulder dystociaAssessmentImpaired mobility of armParalysis may be temporary or permanent
109Needs of Parents of At-risk Infants Realistically perceiving the infant’s medical condition and needsAdapting to the infant’s hospital environmentAssuming primary caretaking roleAssuming total responsibility for the infant upon dischargePossibly coping with the death of the infant if it occurs
110Facilitating Parental Attachment Facilitating family visitsAllowing the family to hold and touch the babyGiving the family a picture of the babyLiberal visiting hoursEncouraging the family to get involved in the care
111Figure 33–20 Mother of a 26 weeks’ gestational age infant with respiratory distress syndrome on a ventilator is getting acquainted with her baby. Physical contact is vital to the bonding process and should be encouraged whenever possible. SOURCE: Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.