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Lecture 5

NUR 323 Lecture 5: Chapter 19

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Quinnipiac University
NUR 323

Chapter 19: caring for the new born at risk Anatomy and Physiology review • Respiratory system - Fetal lung maturity is determined by the L/S ratio (lecithin to sphingomyelin) and PG (phosphatidylglyerol) values • Circulatory system - At birth, the three fetal shunts (ductus arteriosus, foramen ovale, and ductus venosus) close and circulation converts to adult circulation to accommodate oxygen intake by the lungs • Neurological system - The neurological system, including the central and peripheral nervous systems and the parasympathetic nervous system, are underdeveloped at brith Classification of the High-risk newborn • Gestational age(GA): length of time in utero - Preterm (delivered at or before the completion of 37 weeks) - Term (delivered any time from 38 to 41 completed weeks) - Posterm (newborn delivered on or after 42 weeks) • Birth weight th - Small for gestational age (weight ,10 percentile for GA) - Appropriate for gestational age (weight between 10 and 90 percentile for GA) - Large for gestational age (weigth >90 percentile GA) - Low birth weight (<2,500 g) - Very low birth weight (<1,500) - Extremely low birth weight (<1000g) • IUGR - Intrauterine growth restriction o Term used to denote a lack of intrauterine fetal growth o Usually results in a SGA newborn Small for gestational age • Asymmetrical - Brain sparing, appropriate sized head - Usually deficit occurred after 20 weeks of gestation • Symmetrical - Non brain sparing, small head circumference - Usually deficit occurred in first trimester • Characteristics - Wasted muscle tissue - Lack of brown fat - Abdomen is often scaphoid (sunken in) - Eyes appearing large, with a “wise old man” look - Fingernails are often long - Meconium-stained thin cord is often present • Conditions affecting the SGA newborn - Cold stress: a consequence of prolonged hypothermia - Pain: high risk newborns undergo lifesaving interventions, many of which can produce pain - Hypoglycemia o Often preterm newborns or high risk newborns are considered hypoglycemic when blood glucose levels fall below 50 to 60 mg/dl o Signs: jitters, hypothermia, lethargy, poor feeding - Polycythemia o Venous hematocrit >65% o Ruddy appearance, delayed capillary refill, hematuria Large for Gestational age th • Infants born >90 percentile • Two reasons - Can be genetically large - More commonly, exposed to imbalance of nutrients in utero • Conditions affecting LGA newborns - Newborns with a diabetic mother: chronic hyperglycemic state in utero due to elevated maternal glucose levels o Glucose passess through placenta; insulin does no; fetus produces more insulin (hyperinsulinemia) o When cord is cut, glucose stopped but newborn pancrease continues to produce more insulin = hypoglycemia - Transient tachypnea of the newborn (TTN): delayed clearance of fetal lung fluid - Hypocalcemia: calcium levels should be >7.5mg/dl in preterm newborns and 8mg/dl in term newborns. Low calcium levels can produce seizures in the newborn and may be present along with hypoglycemia - Hypomagnesemia: present when magnesium levels are <1.5mg/dl (normal range = 1.5 -2.8 mg/dl) - Birth injuries: one of two types: neurological injuries or bone fractures o Brachial plexus injuries (BPI): occur when the nerves are stretched and leave the arm without function ▪ Lack of movement of arm, elbow, wirst or hand, lack of moro reflex on affected side o Fractures: ▪ Usually involve the clavicle – most common birth fracture (crepitus detected on palpation of the bone) ▪ Less commonly in long bones of the humerus or femur The premature Newborn • Prematurity classified by week of gestation - Severe (23-26 weeks) - Moderate (26 to 34) - Late (34 to 37) • Risk factors for preterm birth - Maternal smoking, AMA or younger than 20 years, drug abuse, multiple gestations, uterine abnormalities, fetal anomalies, African American descent, history of previous preterm birth Physical assessment of the high risk newborn • Skin, head, chest ,cardiac, abdomen, musculoskeletal, genitalia, neurolocgical/sensory Respiratory distress syndrome • Developmental respiratory disorder - Lack of surfactant - Underdeveloped alveolar saccules • Affects preterm newborns • Due to lack of lung surfactant - Diffuse atelectasis( parts of lung are not expanded) - Congestion - Edema - Decreased lung compliance (adds to infants work of breathing) • Signs and symptoms - Expiratory grunting - Nasal flaring - Cyanosis in room air - Rapid breathing - Labored breathing (retractions) - Decreased breath sounds, often with rales - Beractant: lowers minimum surface tension and increases pulmonary compliance and oxygenation in preterm newborns - Silverman and index evaluation of respiratory status • RDS Nursing care - Airway maintenance and oxygenation are the priority intervention for the newborn with RDS (O2>92) - Types of oxygen therapy o Humidified oxygen o Continuous postivie airway pressure (CPAP) o Conventional mechanical ventilation o Bilevel ventilators o High frequency oscillating ventilation o High frequency jet ventilation o Nitric oxide (for patients with subsequent PPHN) o Extracorporeal membrane oxygenation (ECMO) Apnea of Prematurity • Apnea: - Spontaneous pasue in breathing - Common occurance in preterm newborns - Apnea sleeps or episodes >20 seconds are significant; often accompanied by: o Abrupt pallor o Hypotonia o Cyanosis o Bradycardia o Oxygen desaturation • Nursing care - Cardiorespiratory monitor: set to alarm if newborn fails to breath spontaneously for 20 seconds, respiratory rate falls below a certain rate (usually 20), or the heart rate drops below a certain rate (80-100) - Continuous O2 sat >92 - Apneic, bradycardia, or desaturation episode requires immediate attention - Initially theophylline or aminophylline is used to stimulate respirations but caffine is the most widely used medication for long term treatment Bronchopulmonary Dysplasia • Condition in which the newborn becomes oxygen dependent past 36 weeks gestation • Sign/symptoms: inability to wean off oxygen completely • Nursing care: - Prevention: use lowest amount of oxygen possible - Wean newborns from oxygen as soon as possible - Prevent erratic oxygen levels during delivery; maintaining at a constant level of oxygen delivery • Education/discharge instructions • Parents taught to care for oxygen dependent newborns - How to secure oxygen supply for the home - Newborn positioning - Care of oxygen prongs and equipment - Receive cardiorespiratory monitoring training Jaundice • Hyperbilirubinemia - Occurs because newborns immature liver cannot conjugate bilitubin as quickly as needed - s/s: yellowish discoloration is seen at a level of 5mg/dl within first 24 hours of birth - diagnosis: level is rising faster than 5mg/dl - direct bilirubin >2mg/dl would be lower than that of a full term neonate; level of concern varies with gestational age and postnatal age in hours - prevention: frequent and early feedings - nursing care o in high risk zone undergo phototherapy o new borns eyes must be shielded o cover genitals o hydrate with electrolyte solution Anemia of prematurity • due to - many blood serum evaluations - rapid growth in a short period of time - erythropoietin release (usually at 34-36 weeks) • s/s - fatigue, respiratory distress, pale skin • diagnosis - drop in hemoglobin below the average HCT values 35-45 is a definitive sign of anemia • nursing care - assess HCT levels - administer blood transfusions - administer recombinant erythropoietin subcutaneously to stimulate erythropoiesis Necrotizing enterocolitis • caused by ischemic bowel episode • s/s - lack of bowel movemtn - abdominal distension - increased abdominal circumference of 1-2 cm since feed - irritability - lethargy • nursing care - measure and record abdominal circumference - bowel sounds before every feeding - before gastric feeding, check for aspirates of undigested formula or milk - record bowel movements for amount, consistency and frequency - hematest stools for oculat (noninvasinve) - post op care • educate on ostomy care GERD • the lower esophageal sphincter does not close properly or spontaneously opens, which results in retrograde flow of gastric contents into esophagus • s/s - frequent spiting up - irritability when feeding - refusing to eat - only eats small amounts - arching the back while feeding - regurgitation - hiccups or cough - frequent waking during sleep - respiratory problems • nursing care - assess apriates from nasogastric or orogastric tubes for amount and color prior to each feeding - used thickend formula or breast milk - place newborn with head of bed 30 for sleeping - feed infant slowly in upright position - a proton pump inhibitor is used to neutralize stomach acidity or prokinetic agents are used to increase gastric emptying retinopathy of prematurity • result of immature retinal vasculature followed by hypoxia • extent of retinal damage in preterm newborn dependent on three criteria - gestational age - length of exposure to oxygen - arterial pressure - damage is
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