High Risk Newborn (21 questions on final)

Transient tachypnea of the newborn (TTN)

"Wet lung" Baby develops rapid respirations soon after birth. Delayed absorption of fetal lung fluid by pulmonary capillaries and lymph vessels. Can't get air out of lungs because of the fluid in the lungs.

Myelomeningocele: Paralysis

Depends on where myelomeningocele is located. Monitor lower extremities Look for dribbling of urine or stool Monitor for ICP

Meconium aspiration syndrome (MAS)

Develops when meconium in amniotic fluid enters lungs during fetal life or at birth Occurs most often in asphyxia and term/post term infants who are SGA and have decreased amniotic fluid Results in obstruction of airways. Alveoli can't expand well, so the air can get in but can't get out (like in TTN) "air trapping/barrel chest". Alveoli become overdistended and can burst = pneumothorax,

Neonatal Abstinence Syndrome (NAS)

Disorder in which drug-exposed neonates demonstrate signs of drug withdrawal

Hyperbilirubinemia (Pathologic jaundice)

Excessive amount of bilirubin (byproduct of breakdown of RBC) in blood

ECMO

ExtraCorporeal Membrane Oxygenation -*Last resort* -heart/lung bypass machine -Veno-arterial: blood is drained from the venous system, oxygenated outside the body, and returned to the ARTERIAL system. -Veno-venous: blood is drained from the venous system, oxygenated outside the body, and returned to the VENOUS system. Carotid Artery: at risk for stroke in the future since it's plugged off.

Sepsis neonatorum

GBS #1 Cause. Early onset - s/s by 24 hours of life acquired during birth. Mortality 5-20% Late onset - develops after first week of life acquired during or after birth, before or after hospital discharge. Mortality rate 5%.

Gastroschisis Management

Gastric decompression IV nutrition Antibiotics Surgical emergency, when stable Infection prevention Injury prevention

Ballard Tool

Gestational age assessment tool with Physical and Neurological criteria. The scoring relies on the intra-uterine changes that the fetus undergoes during its maturation. *Neurological criteria* depends mainly upon muscle tone *Physical criteria* rely on anatomical changes Skin (in premi: mottling) Ear/Eye (eyes fused = negative #) Lanugo Hair (premi will have more) Plantar Surface Breast bud Genitals Each range from a score of 0-5. Will give us an estimate starting at 26 weeks. *This is from wikipedia.. Refer to lecture for picture and her description

S/S of Respiratory distress

Grunting Nasal flaring Tachypnea Retractions Central cyanosis Seesaw respirations

Apnea of Prematurity (AOP)

Having so many apneic spells and we don't know why. No other evident problems. Will see a drop in HR and stop breathing. Cause is unknown. Baby usually grows out of this.

ROP Risk Factors

High levels of oxygen Prolonged ventilation Sepsis (Exact cause is unknown)

Bilirubin Serum Levels & Non-Phys Jaundice

High risk zone: Bilirubin between 15-20 mg/dL. chart on p 454 in book

Congenital Diaphragmatic Hernia (CDH)

Hole in diaphgram. Diaphragm fails to fuse during gestation Large or small part of abdominal contents moves into the chest cavity, usually on left side

MAS Risk factors

At Risk: Postterm babies - Poop because they're stressed bc of lack of oxygen (hypoxia or asphyxia) and placenta isn't nourishing them anymore. Hypoxic event causes increased peristalsis and relaxes the anal sphincter. SGA

Why is maternal diabetes a risk factor for RDS?

Because insulin blocks the effect of cortisol, which is involved in surfactant production. So because of their increase in insulin, they have reduced surfactant.

Conjugated vs. Unconjugated bilirubin

Bilirubin is yellow and is a product of the breakdown of hemoglobin, which is the protein inside red blood cells. If bilirubin cannot leave the body, it accumulates and discolors other tissues. Unconjugated/Indirect: Toxic to the body. Fat soluble breakdown of RBC. Combines with albumin and is carried to the liver, where it is then conjugated. Conjugated/Direct: Water soluble, so it can be excreted through the kidneys.

Cold stress

Can be deadly to a premi. Trying to keep themselves so warm, they're metabolizing brown fat as much as they can. Need to increase oxygen and glucose use, so if they need that oxygen to breathe, they can't, because they're using it for heat production. Will need to give them oxygen support and ventilation. They're glucose is also dropping.

Asphyxia treatment/mngmnt

Close monitoring Parental support Brain/Body cooling: cold mattress with cold cap over head to decrease temperature & metabolic rate to save whatever brain is left. Can't take away injury, but trying to prevent further damage.

Omphalocele

Congenital defect in abdominal wall where the intestines *protrude into the base of the umbilical cord * Associated with other anomalies (Trisomies) Management - Similar to gastroschisis

Gastroschisis

Congenital defect to the side of the abdomen, next to and not involving the cord Intestines protrude through defect and float freely in amniotic fluid

Respiratory Distress Syndrome (RDS)

(Different from respiratory distress) -Lung disorder affecting mostly preterm infants -Insufficient production of surfactant -Signs usually appear at birth or within 6 hours

NAS Management

- NAS scoring (see handout) If baby reaches a score of 24, will start meds. - 50-60% need medications for withdrawal symptoms: *oral morphine*, tincture of opium, methadone, and phenobarbital; tapering dose

Infection

-Acquire infection before, during, or after birth -10% infected during first month of life -Incidence in preterm infants 3-10x that of full term infants -Major cause of death during neonatal period -Group B Streptococci: can cause severe meningitis -Sepsis Neonatorum

Pathologic/Abnormal Jaundice Complications

-Acute: bilirubin encephalopathy -Chronic: kernicterus

Periventricular-Intraventricular Hemorrhage (PIVH)

-Bleeding around and into the ventricles of the brain due to rupture of fragile blood vessels in the germinal matrix -Occurs most commonly within first 72 hours of life -*Most often associated with hypoxic injury to the vessels, increased or decreased blood pressure, and increased or fluctuating cerebral blood flow*

Hypoglycemia

-Can cause brain damage (glucose is the brain's fuel/energy.) -No consensus on exact level for hypoglycemia; however, optimal glucose level approx. 50 mg/dL -Glucose levels reach the lowest point at 1-3 hours after birth and begin to improve by 4-6 hours

Thermoregulation manifestations/problems

-Changes in feeding behavior -Lethargy/Irritability -s/s respiratory difficulty and/or hypoglycemia -Mottled or pale -Causes of thermal instability

If premi's temperature is low, what do we do?

-Check sugar -Check RR -Make sure they're not having any respiratory distress -Make sure they're not grunting *(early sign of resp distress)* -Make sure there are no retractions -May need to give oxygen -Maybe skin probe came off -FIND CAUSE!

Complications from heat loss

-Cold stress -Hypoglycemia (due to depleted glycogen stores) -Respiratory problems -Metabolic acidosis (secondary to anaerobic metabolism used for heat production, which results in lactic acid production) -Pulmonary HTN (secondary to pulmonary vasoconstriction) (p. 449)

Infants of diabetic mothers Management

-Controlling maternal diabetes -Glucose monitoring/early feeds -Monitor for complications

PIVH Nursing care

-Daily head circumference -Observe for changes in neurologic status -Elevate head 30°

NAS Nursing Considerations

-Encouraging feeding -Cluster tasks-/cares -Swaddling, prevent over stimulation -Injury prevention: excoriations from itching and on butt from stools. -Enhancing parental attachment

Problems with Respirations Nursing Interventions

-Gentle stimulation -Airway clearance (suction with bulb syringe) -Bag and mask ventilation -Correct underlying problem (is it due to thermoregulation? low blood sugar? infection?) -Supportive care - O2/ventilation support

Hyperbilirubinemia Risk Factors

-Hemolytic disorders are #1 cause (Rh incompatibility) -Infection -Hypoxia -Infant of diabetic mothers: Polycythemia bc they need more oxygen. They have so many fetal RBC that have to die off.

PIVH Complications

-Hydrocephalus: Bleeding in brain causes blood clots in drainage areas for CSF, so the CSF starts to increase, causing hydrocephalus bc the blood clots are blocking drainage. May need to get a shunt. -Life-long neurological deficits, specifically cerebral palsy -Developmental delay -Seizures

RDS Risk factors

-Hypoxia -Aphyxia -Stress -Infections -Male gender -<28 week premis -C Sections -Infants of diabetic mothers

Etiology of the High Risk Infant

-Ill mother: sepsis, diabetes -Young (teen) mother -Multiple births -Substance abuse during pregnancy -Smoking during pregnancy -Maturity of fetus -Perinatal events -Neonatal course -Maintenance of newborn's initial breath and subsequent breaths -Unknown

NEC s/s

-Increased abdominal girth -Increased gastric residuals -Decreased or absent bowel sounds -*Visual bowel loops* (bc food and air is trapped in the bowel. Can see on X-Ray) -Bilious vomiting -Occult blood in stools -Signs of infection -Respiratory difficulty

Asphyxia possible causes

-Insufficient surfactant -Maternal factors: HTN, drug abuse, infection -Placental factors: previa, abruption -Fetal factors: chromosomal abnormalities, cord compression, multiple births (one baby is hogging nutrients), infection

NAS Characteristics

-Irritability, jittery -Muscular rigidity/increased tone -Restless -Exaggerated Moro reflex -Prolonged high pitched cry -Poor sleeping patterns -NVD, Weight loss -Tachypnea, tachycardia -Retractions -Uncoordinated sucking/swallowing

Hypoglycemia Early signs

-Jitteriness/Tremors -Irritability -Respiratory difficulty -Decrease in temperature -Poor muscle tone -Poor feeding

PIVH S/S

-Lethargy -Poor muscle tone -Deterioration of respiratory status with cyanosis or apnea -Decreased reflexes -Full or bulging fontanel -Seizures (late sign)

Infection Characteristics

-Low temperature is first sign bc baby is using up glucose and oxygen and other things to try and keep themselves warm while fighting infection and it's not working. -Hypothermia -Hypotension -Respiratory problems -Tachycardia -Glucose intolerance -Lethargy -Feeding problems

CDH Management

-Mechanical ventilation -Gastric decompression: so that it's not putting pressure on lungs & heart -Surgery when stable -ExtraCorporeal Membrane Oxygenation (ECMO)- -Position infant on *affected side* to allow unaffected lung to expand -Elevate head to decrease pressure on heart and lungs -Monitor respiratory status

Myelomeningocele

-Most common form of spina bifida cystica -Protrusion of a membrane-covered sac through the spina bifida (incomplete closure of spine) -Sac contains meninges, nerve roots, spinal cord and spinal fluid -Increased alpha-fetoprotein

Care of high risk newborns

-Multidisciplinary approach: Residents, neonatologists, pastoral, nurses, social workers, etc. -Case management: Will receive pt from admission to discharge for smooth transmission home -Clinical pathways: Protocols on things such as how to feed a baby, hypoglycemia monitoring, hyperbilirubinemia, etc.

Infants of diabetic mothers

-Neonatal mortality rate 5x that of non- diabetic mothers -Congenital anomalies 3x more likely -4x more likely to be admitted to NICU

Infection Risk Factors

-Prematurity -Low birth weight -Rupture of membranes longer than 18 hours -Maternal infection; known maternal group B streptococci -Foul-smelling amniotic fluid

Infants of diabetic mothers complications

-Prematurity -Hypoglycemia -Asphyxia -Hypothermia/cold stress -Respiratory distress -Birth trauma -Hyperbilirubinemia -Meconium aspiration

Hypoglycemia Risk Factors

-Prematurity/Late Preterm -Infant/Postmaturity -IUGR -LGA/SGA -Asphyxia -Cold stress -Maternal diabetes (baby comes out with a lot of insulin on board, and now have low blood sugar)

Hypothermia treatment/prevention

-Radiant warmers -Incubators -Warm blankets, clothes, hats (tell parents to dress babies in one more layer than we would for adults) -Kangaroo Care (skin to skin)

Asphyxia s/s

-Rapid respirations after birth followed by cessation of respirations and rapid fall of HR -Gasping -Loss of consciousness Resuscitation may be required

CHD Characteristics

-Small left lung because it didn't have room to grow. -Bowel sounds in chest, breath sounds in right -Barrel chest -Scaphoid (concave) abdomen -Mild to severe respiratory distress

Common Nursing Diagnosesfor Preterm Infants

Activity Intolerance Ineffective Airway Clearance Ineffective Infant Feeding Pattern Ineffective Thermoregulation Risk for Disorganized Infant Behavior Risk for Impaired Parent-Infant Attachment

MAS Therapeutic Management

Airway clearance: Tracheal suctioning Supportive care -Oxygen/ventilation support -Extracorporeal membrane oxygenation (ECMO) -Nitric oxide gas to dilate pulmonary vessels -Monitor for infection: damaged lungs are good reservoir for bacteria

High Risk Conditions

Hypothermia Respiratory complications Periventricular/intraventricular hemorrhage Necrotizing enterocolitis (NEC) Hypoglycemia Hyperbilirubinemia Sepsis Infants of Diabetic Mothers Neonatal Abstinence Syndrome (NAS) Congenital Anomalies

Premis & thermoregulation

Hypothermia: Axillary temp < 36.3° C (< 97.3° F) Methods of heat loss (p 447) -Greater surface area because limbs are extended and not flexed -No brown fat (starts to accumulate around 28 weeks) -Immature CNS (doesn't regulate thermoregulation as well as full term) -Skin is thin so blood vessels are close to skin and get cold very quickly.

RDS Treatment/Prevention

Incidence and severity reduced by giving mother corticosteroids (*BETAMETHASONE*) before birth Artificial surfactant: intubate them and administer. This will increase the surfactant production and increase their survival rate

BPD S/S

Increased need for or an inability to be weaned from respiratory support and oxygen Tachycardia Respiratory acidosis Will be in and out of hospital for the first 2 years of life with resp infections bc of the damage done.

Bronchopulmonary Dysplasia (BPD)

Injury to bronchial epithelium and interferes with alveolar development

Retinopathy of Prematurity (ROP)

Injury to the blood vessels in the eye bc they're not fully formed yet. Can cause a leak, rupture, hemorrhage, scarring, and even detachment of the retina, causing visual impairment or blindness. Can resolve on it's own most of the time.

Bilirubin Serum Levels & Phys Jaundice

Jaundice becomes visible when bilirubin reaches 5-7 mg/dL. If physiologic (normal) jaundice, bilirubin will begin to decline to <2 mg/dL by 5-7 days and then to the normal adult level of 1 mg/dL by 10-14 days.

Asphyxia

Lack of oxygen and *increase of carbon dioxide in blood* Results in ischemia to major organs (bc all oxygen is just going to heart and brain)

TTN Risk Factors

Male gender Cesarean birth without labor; prolonged or precipitous labor Asphyxia Macrosomia Maternal diabetes or asthma Multiple gestation Excessive maternal sedation

Nonshivering thermogenesis

Metabolizing brown fat bc it has a lot of vasculature to it that produces a lot of heat, producing heat for the baby. Premis that are very immature didn't have a chance to start to develop brown fat. Also use a lot of oxygen and glucose to metabolize brown fat, which can cause further problems if they already have respiratory distress.

Respiratory Equipment: Oxygen/ventilation support

Nasal cannula Oxyhood Continuous positive airway pressure (CPAP) Ventilator (Intubation) --Conventional --High frequency (Oscillator or Jet: 200-900 breaths per minute to keep lungs expanding all the time)

Physiologic jaundice

Normal phenomenon bc babies will lose their *fetal* RBC. Occurs >24 hours after birth. a build-up of bilirubin due to the normal hemolyisis of red blood cells that were needed for fetal circulation before birth and discarded afterward

Pathologic/Non-physiologic/Abnormal jaundice

Occurs WITHIN 24 hrs after birth. Related to a condition other than normal newborn bilirubin being processed slowly by an immature liver. Such conditions include an incompatibility between the baby's and the mother's blood types, incompatibility of additional blood factors, or liver problems. There is actual pathology involved that might require more aggressive and lengthier intervention than physiological bilirubin problems. Total serum bilirubin rises more rapidly and to a higher level than is expected and/or stays elevated for longer than normal.

AOP Treatment

Oral caffeine. Sometimes may receive IV, but usually PO. This stimulates respiratory center in the brain.

TTN therapeutic management

Oxygen if cyanosis present Gavage or IV feeding Do not feed until supported on their own and RR < 60 !!!

Periodic breathing vs. apneic spells

Periodic breathing: Baby goes through regular patterns of breathing for 5-10secs, then they stop breathing for a little bit, then continue to breathe. As long as it doesn't last longer than 20 seconds, and they're not experiencing cyanosis or drop in desaturation. Apneic spells: Baby stops breathing for more than 20 secs and if there is cyanosis and drop in desaturation.

BPD Prevention/Treatment

Prevention -Maternal steroids (BETAMETHAZONE) -Minimizing exposure to oxygen and pressure with ventilation Treatment - supportive -Antibiotics and bronchodilators as necessary -Gradual decreases in amount of oxygen

PIVH Prevention/Treatment

Prevention: Betamethazone Management -Screening of at risk preemies (ultrasound of anterior fontanel) -Supportive: maintain respiratory function

NEC Prevention/Treatment

Prevention: Betamethazone and breast milk Treatment: -Antibiotics -*Discontinuation of oral feedings* -Continuous or intermittent gastric suction -Parenteral (IV) nutrition -Surgery may be necessary with possible ostomy

Myelomeningocele Prevention/Management

Prevention: Maternal folic acid Mngmnt: -Surgery to correct defect as soon as possible -Antibiotics -Long-term follow up -Prevent injury -Monitor for signs of infection -Monitor for increased intracranial pressure

Hypoglycemia Prevention/Correction

Preventive measures include glucose monitoring and *early feeds* --Screening every hour for 4 hours after birth and then every 4 hours twice or until the results are normal --Glucose levels of less than 40-45 mg/dL measured with a bedside glucometer should be reported and verified by lab analysis Correction: If hypoglycemia persists despite PO feeding, correction is with IV glucose infusion

Respiratory Equipment Complications

Retinopathy of Prematurity (ROP): Broncho-pulmonary Dysplasia (BPD)

Hypoglycemia Late signs

Respiratory distress Seizures Coma

Hyperbilirubinemia Management

Promote excretion of bilirubin: frequent feedings! Provide more protein to conjugate bilirubin. Prevent dehydration (via frequent feedings). Phototherapy: Helps convert billirubin. Can be drying to baby, keep baby hydrated. Be sure to cover eyes to prevent retina damage. Draw labs frequently. Exchange transfusions: Umbilical line to pull off unconjugated bilirubin and mom's maternal antibodies that are connected to RBCs, then give baby more blood and albumin.

Difference between RDS and TTN

RDS: insufficient surfactant, start to retain CO2 TTN: fluid in the lungs. give them time and oxygen support to get fluid out of the lungs.

TTN S/S

Rapid respirations Grunting Retractions Nasal flaring Mild cyanosis

Characteristics of preterm infants

Refer to Ballard Tool

Coombs Test

Rh compatibility. Positive: Maternal antibodies are attacking the baby's fetal hgb. Rh negative mom + Rh positive baby.

ROP Treatment/Prevention

Screenings to detect changes in the eye until retina is mature (about a month or so) Can do laser treatment to prevent retina damage.

Necrotizing Enterocolitis (NEC)

Serious, acute inflammatory condition of intestinal tract that may lead to cellular death of areas of intestinal mucosa Can be due to: hypoxia and the bacteria that has been growing inside the intestine from the damage. Area is dead now and aren't able to eat. Belly blows up, becomes tender, and may require immediate surgery bc it can rupture/perforate, which would be deadly. Occurs in 1%-5% of infants admitted to NICUs Often fatal (25%-35%) Exact cause unknown

Gastroschisis Surgery

Surgeons put mesh over organs, and each day they roll it down to squeeze intestines back into stomach. In a few days, baby has normal belly with bandage. Umbilical cord is not involved. TPN after surgery until you know intestines are working correctly.

MAS s/s

Tachypnea Cyanosis Skin stained yellow-green Limp Retractions Nasal flaring Grunting Barrel-shaped chest

Acute bilirubin encephalopathy

The *acute* manifestation of bilirubin toxicity. Blood-brain barrier has been impaired and unconjugated bilirubin has stained areas in brain.

Kernicterus

The *chronic* and permanent result of bilirubin toxicity. In this condition, unconjugated/free bilirubin deposits causing yellowish staining of the brain. Mortality rate is 50%. "Never Event" If baby gets discharged and then comes back for hyperbilirubinemia = BAD!! Probably kernicterus.

Infection Treatment/Prevention

Treatment -IV antibiotics -Supportive care Prevention -Infection control -Handwashing

Asphyxia complications

metabolic acidosis (with anaerobic metabolism-producing lactic acid) Hypoglycemia hypothermia hypotension feeding problems seizures F/E imbalances

Methods of Heat Loss

p. 447 1. Evaporation: Can occur during birth or bathing from moisture on skin as a result of wet linens or clothes, and from insensible water loss. 2. Conduction: occurs when the infant comes in contact with cold objects or surfaces (scale, hands, stethescope) 3. Convection: occurs when drafts come from open doors, A/C, people walking by. 4. Radiation: when infant is near cold surfaces.