OB test # 2 - Neonate

1. Appear frail, weak, and less muscle tone 2. Extremities are limp 3. Head appears large compared to body 4. Thin skin makes them appear red and translucent with blood vessels visible 5. Nipples and areola may be barely perceptible 6. Plantar creases are absent in infants of less than 32 weeks gestation 7. Vernix caseosa and lanugo may be abundant 8. Pinna of the ear is soft, flat, and contains little cartilage. 9. In the female infant, the clitoris and labia minora appear large and are not covered by the small, separated labia majora. 10. Male infant may have undescended testes with a small, smooth scrotal sac.

Characteristics of preterm infants - appearance

Varies according to gestational age. In general, infants have less energy for maintaing muscle tone. Easily exhausted from noise and routine activities. Responses are varied, including lowered oxygenation levels and stress-related behavior changes. The cry may be weak.

Characteristics of preterm infants - behavior

because of most hemorrhages occur during the first week, ultrasonography is often performed at 7 days of age on preterm infants at risk. Treatment is supportive and focuses on maintaining respiratory function and dealing with other complications. hydrocephalus may develop from blockage of cerebrospinal fluid flow. A ventriculoperitoneal shunt may be necessary to drain the fluid.

IVH - management

Infants may have no signs or may show lethargy, poor muscle tone, deterioration of respiratory status with cyanosis or apnea, drop in hematocrit level, acidosis, hyperglycemia, decreased reflexes, tense fontanel, and seizures.

IVH - manifestations

The nurse must avoid situations that may increase the risk of IVH and be alert for early signs (mechanical ventilation, suctioning, excessive handling, and crying). Nursing care includes daily measurement of the head circumference and observation for changes in neurologic status, which may be subtle. Pain and stress are reduced as much as possible. Parents need assistance to cope with the diagnosis and their concerns regarding long-term implications. They should learn how to assess for sings of IICP from hydrocephalus and understand that follow-up care may include periodic ultrasound exams.

IVH - nursing considerations

also called periventricular-intraventricular hemorrhage or germinal matrix hemorrhage. It is bleeding around and into the ventricles of the brain.

Intraventricular hemorrhage

Signs include feeding intolerance increased abdominal girth caused by distention increased gastric residuals decreased bowel sounds visible loops of bowel vomiting abdominal tenderness erythema of the intestinal wall blood in the stools signs of infection Respiratory difficulty may occur because of pressure from the distended abdomen on the diaphragm Apnea, bradycardia, temperature instability, lethargy, hypotension, and shock may also be present. Thrombocytopenia, increased or decreased leukocytes, and metabolic acidosis may occur. The presence of air within the intestinal wall on a radiographic is a diagnostic of the condition. Free air in the peritoneum indicates that perforation has occurred.

NEC - manifestations

although the cause is unknown, immaturity of the intestines is a major factor. Previous ischemia of the intestines is another cause. Feedings and organisms can be risk factors for NEC. Eventually necrosis, perforation, and peritonitis may occur. Breast milk, which contains immunoglobins, leukocytes, and antibacterial agents may have a positive preventive effect.

NEC - pathophysiology

serious inflammatory condition of the intestinal tract that may lead to necrosis of the intestinal mucosa. The ileum and proximal colon are the areas most often affected.

Necrotizing Enterocolitis (NEC)

is a condition caused by insufficient surfactant in the lungs. Occurs in asphyxia, cesarean delivery, multiple births, male infants, cold stress, and maternal diabetes Occurs less often in heroin addiction, maternal hypertension, prolonged rupture of membranes, and antenatal cortiocosteriods.

Respiratory distress syndrome (RDS)

Are born before the beginning of the 38th week of gestation. Preventing preterm birth is best accomplished by providing adequate prenatal care. Treat risk factors early Teach women to recognize signs of preterm labor

Premature infants - preterm

Preterm infants are born without surfactant, which causes respiratory distress. Preterm infants also have a poorly developed cough reflex and narrow respiratory passage.

Preterm infants - problems with respiration

Need to be assessed constantly. Differentiate between periodic breathing from apneic spells. Periodic breathing - cessation of breathing for 5 to 10 seconds without other changes. May be followed by rapid respirations for 5 to 10 secs. Apneic spells - are a lack of breathing lasting more than 20 seconds, or accompanied by cyanosis, pallor, bradycardia, or hypotonia. These are common in preterm infants and improve with gestational age. May require gentle tactile stimulation, medications, or CPAP. Nurse observes the effort required for breathing, location and severity of retractions. Grunting may be an early sign of RDS.

Preterm infants - respiratory assessment

preterm infants lose fluid very easily. The ability of the kidneys to concentrate or dilute urine is poor, causing fragile balance between dehydration and over hydration. The fluid needs of preterm infants vary according to size, gestational age, insensible water loss, and medical needs. Normal urinary output is 2 to 5 ml/kg per hour for preterm infants. After 24 hours of life 0.5 ml/kg per hour is oliguria. Kidneys regulation of electrolytes is a problem. They need higher intakes of sodium because the kidneys do not reabsorb it well. If they receive too much sodium they cannot excrete is adequately and is susceptible to sodium overload.

Problems with fluid and electrolyte balance

Monitoring intake and output of fluids is important in determining fluid balance. Parenteral, feeding tube, medication, and oral fluids are included when measuring intake. Output from regurgitation, drainage tubes, stools, and urine should be measured. The nurse must also keep track of the amount of blood taken.

Problems with fluid and electrolyte balance - assessment

The nurse must carefully monitor IV fluids using infusion control devices that administer fluid with a precision of 0.1 ml/hr to help prevent fluid volume overload. IV medications should be diluted in as little fluid as is consistent with safe administration of drug and should be included in intake. IV sites should be assessed at least every hour for signs of infiltration. Many infants have central venous catheters or umbilical lines that must be assessed for infection and position changes. Small blood transfusion may be necessary to replace blood drawn frequently.

Problems with fluid and electrolyte balance - nursing interventions

Dehydration 1. urine output less than 2 ml/kg/hr 2. Urine specific gravity greater than 1.01 3. Weight loss greater than expected 4. Dry skin and mucous membranes 5. Sunken anterior fontanel 6. Poor tissue turgor 7. Blood: elevated sodium, protein, and hematocrit levels Overhydration 1. Urine output greater than 5 ml/kg/hr 2. Urine specific gravity less than 1.002 3. Edema 4. Weight gain greater than expected 5. Bulging fontanels 6. Moist breath sounds 7. Difficulty breathing 8. Blood: decreased sodium, protein, and hematocrit levels

Problems with fluid and electrolyte balance - signs of dehydration or over hydration

Plastic bags that adhere to the perineum are not suitable for preterm infants because they may damage the fragile skin. Weighing diapers is less invasive. The weight of dry diapers is subtracted from the weight of wet diapers. One gram = 1 ml of urine. Humidification and warmers can affect the amount of urine. Specific gravity should be checked. Urine is collected by placing cotton balls at the perineum. The specific gravity should range between 1.002 and 1.01.

Problems with fluid and electrolyte balance - urinary output

changes in the infants weight can give an indication of fluid gain or loss, especially if the changes are sudden and greater than would be expected. The undressed infant should be weighed at the same time each day with the same scale. they may be weight two to three times a day to monitor their fluid status more closely.

Problems with fluid and electrolyte balance - weight

The incidence of infection is 3 to 10 times greater in a preterm infant. Many preterm infants have one or more episodes of sepsis during their hospital stays. Factors that contribute to the high rate of infection include exposure to maternal infection, lack of transfer of immunoglobin from the mother during the third trimester, and immature immune response to infection. Preterm infants are often exposed to situations that can cause infection.

Problems with infection

The nurse should be alert for signs of sepsis at all times General signs 1. temperature instability 2. nurse's feeling that infants is not doing well Respiratory signs 1. tachypnea 2. respiratory distress - nasal flaring, retractions, grunting. 3. apnea Cardiovascular signs 1. color changes - cyanosis, pallor 2. tachycardia 3. hypotension 4. decreased peripheral perfusion 5. edema Gastrointestinal signs 1. poor feeding 2. vomiting 3. increased gastric residuals 4. diarrhea 5. abdominal distension 6. hypoglycemia or hyperglycemia Central nervous system signs 1. decreased or increased muscle tone 2. lethargy 3. irritability 4. full fontanel 5. high-pitched cry Signs that may indicate advanced infection 1. jaundice 2. evidence of hemorrhage - petechia, purpura, pulmonary bleeding 3. anemia 4. enlarged liver and spleen 5. respiratory failure 6. shock 7. seizures

Problems with infection - assessment

Hand hygiene is the most important factor in preventing nosocomial infections. Nursing care involves cleanliness and maintaining the infant's skin integrity. Even normal flora on the hands of caretakers can cause sepsis. Caretakers and parents should thoroughly wash hands and arms before handling the infant. Exposure to family or staff members who have contagious diseases should be prevented. Early signs of infections should be identified and reported so that treatment can begin immediately. The nurse should note the response to treatment because some organisms become resistant to antibiotics.

Problems with infection - nursing interventions

Infants in the NICU undergo many painful procedures each day. Pain stimuli cause physiologic and behavioral changes in infants Pain can increase ICP causing hemorrhage. Other risks include hypoxia, changes in metabolic rate, and adverse effects on growth and wound healing. Nurse should routinely assess pain, minimize painful procedures, and use environmental and pharmacologic interventions to prevent, reduce, or eliminate pain in neonates.

Problems with pain

the nurse should perform pain assessment whenever vital signs are taken. The nurse must assess the infant's response to painful stimuli and to pharmacologic and nonpharmacologic interventions. The premature infant pain profile (PIPP) can be used to determine pain rating. It uses gestational age, behavior states, heart rate, oxygen sat, brow bulge, eye squeeze, and nasolabial furrow (lines from the edge of the nose to beyond the corners of the mouth) to assign a pain score. Physiologic changes may be unpredictable and cannot be used alone to assess pain. Behavioral responses must also be assessed which include high-pitched, intense, harsh crying infants who are intubated or too weak to cry have a cry face a facial expression of crying without the sound of a cry. Lack of response to painful stimulation should not be perceived as an absence of pain. Family should be involved in helping to assess infants pain.

Problems with pain - assessment

increased or decreased heart rate and respirations, apnea decreased oxygen saturation increased BP high-pitched, intense, harsh cry whimpering, moaning cry face eyes squeezed shut grimacing bulging of the brow tense, rigid muscles or flaccid muscle tone rigidity or flailing of extremities sleep-wake pattern changes

Problems with pain - common signs of pain in infants

An oxygen hood is usually used for infants who can breathe alone but need extra oxygen. Oxygen may also be given by nasal cannula. After discharge many infants continue to receive oxygen therapy at home. Oxygen must be humidified to prevent insensible water loss and drying of the mucous membranes. It is also warmed to maintain body temperature. CPAP may be necessary to keep the alveoli open and improve expansion of the lungs. It can be delivered with nasal prongs, a mask, or endotracheal tube. Infant may need mechanical ventilation when respiratory failure, severe apnea, or bradycardia are present. Because too little or too much oxygen can cause problems, the level of oxygen in the infants blood must be monitored. (arterial blood, or pulse ox). Handling, feeding, and linen changes may increase oxygen need. Changes in settings on equipment may be needed during such activities.

Respiration interventions - working with respiratory equipment

nurses should prepare infants for potentially painful procedures by waking them slowly and gently and using containment. Containment stimulates the enclosed space of the uterus and is comforting to infants. It involves keeping the extremities in a flexed position and midline by swaddling, positioning devices, or the nurse's hands. at least one of the infants hands should be near the mouth for sucking. The infant should be allowed to rest before and after procedures. The infant is often hypersensitive after a painful stimulus and may perceive other activities painful. Comfort measures help the infant cope with short-term, mild pain and reduce agitation. they include using a pacifier for mild pain and reduce agitation. Sucrose placed on the pacifier or given by mouth 2 to 3 minutes before a painful stimulus increased pain relief. Talking softly, holding, rocking, or prone position are other methods of pain relief. Comfort measures alone are not enough. Opioids, such as morphine and fentanyl can be used or acetaminophen. Topical anesthesia can be used to reduce pain during some procedures. Sedatives are effective for agitation but not effective for pain. The nurse should give pain medications before painful procedures and when the infant demonstrates signs of pain. the infants response is assessed frequently to determine the need to increase or decrease the dosage. analgesics may be given continuously or on an ass-needed basis.

Problems with pain - nursing interventions

Adequate hydration is essential to keep secretions thin so that they can be removed by drainage or suction. If infants become dehydrated, secretions will become thick and viscous and could obstruct tiny air passages. Fluid intake should be increased.

Problems with respiration - maintaining hydration

The side-lying and prone positions facilitate drainage of respiratory secretions and regurgitated feedings. These positions are NOT recommended for normal newborns they are associated with SIDS. Prone positions in the preterm infant increases oxygenation, enhances respiratory control, improves lung mechanics and volume, and reduces energy expenditure. supine positioning for sleep is begun when the infant can tolerate and before discharge so the infant can become accustomed to sleeping on the back before going home. Before discharge the parents should be taught the importance of the supine position for sleep to prevent SIDS.

Problems with respiration - positioning the infant

Nurse checks suctioning equipment at the beginning of each shift to ensure it is available and functioning properly at all times. The infant is suctioned only as necessary when the need becomes apparent. Suction should be gentle to avoid traumatizing the mucous membranes. Suction should be applied for only 5 to 10 seconds at a time, and increasing oxygen should be provided before and after each suction attempt. The mouth is suctioned before the nose. Rest periods should be provided after suctioning.

Problems with respiration - suctioning secretions

Preterm infants have fragile, permeable, easily damaged skin. They often have endotracheal tubes, IV lines, electrodes, and other equipment that must be maintained in place, but standard adhesive tape can be very damaging to the skin. Preparations used to disinfect the skin before invasive procedures can be harmful to fragile skin and may be absorbed.

Problems with skin

The nurse should frequently assess the condition of the infant's skin and record any changes. The infants response to products used for cleaning and disinfection should be noted.

Problems with skin - assessment

Adhesives should be used as little as possible. Commercial devices are available to secure tubes and catheters. Backing tape with cotton, waiting more than 24 hours to remove it, and using gauze wraps instead of tape decreased skin damage. Hydrogel or silicone-based adhesive products, and barrier films are less traumatic to the skin and may be used to attach devices. Hydrogel and hydrocolloid dressings may be used if skin breakdown or wounds occur. These substances promote moist healing and need no adhesive. All disinfectants have potential risks when used on neonates. Providone-iodine injure the skin and may have toxic effects on the thyroid in premature infants. All disinfectants should be removed with sterile water or saline. Alcohol should not be used. Cleansers with a pH of 5.5 to 7 may be used for bathing infants. Infants should not be bathed more than every other day. Warm water without soap should be used for infants less than 32 weeks of gestational age for the first week after birth. Sterile water is not necessary unless there are concerns about the safety of tap water or there is a break in skin integrity. Infants and their equipment should be positioned to avoid undue pressure on the skin. Frequent position changes are important but should be based on the infants ability to tolerate changes.

Problems with skin - nursing interventions

Thin skin with blood vessels near the surface and little subcutaneous fat for insulation cause problems with thermoregulation. Their extended extremities increase exposure to the air for heat loss. The temperature control center of the brain is less mature. Complications of heat loss include hypoglycemia, metabolic acidosis, pulmonary vasoconstriction, impaired surfactant production, and hyperbilirubinemia. It also uses calories that can be used for growth and weight gain.

Problems with thermoregulation

Infants temperature is monitored continuously by a skin prove on the abdomen. They need to be under a heat control mechanism (radiant warmer or incubator). The abdominal skin temperature is usually maintained at 96.8 to 97.7. Infants temperature should be recorded every 30 to 60 minutes and then 1 to 3 hours once infant is stable. The axillary temperature should be compared with the heat control reading to ensure that the equipment is functioning properly. Axillary temperature should remain before 97.3 to 98.4. Indications of inadequate thermoregulation include poor feeding or intolerance to feeding in an infant who previously had little difficulty. Lethargy, irritability, poor muscle tone, cool skin temperature and mottled skin. Hypoglycemia and respiratory distress may be the first sign that the temperate is low. Because temperature instability may be an early sign of infection, the nurse should assess for other evidence of infection.

Problems with thermoregulation - assessment

The delivery room should be warmed to decrease heat loss at birth. The infant is dried and placed on the mother's abdomen or a pre warmed radiant warmer for care. Infants less than 29 weeks should be placed in a polyethylene bag or wrap that covers the body from the shoulders down before the infant is dried. This prevents heat loss by evaporation during initial care and transfer to the NICU and is used until the infant is stabilized. Radiant warmers or incubators are used until infants can maintain normal body temperature alone. Doors near the warmer should be closed and traffic kept to a minimum to decrease convective heat loss. Infant should receive only warmed oxygen. Equipment or caregivers should not come between the infant and the heat source. Transparent blanket over the infant is sometimes used. If infant is in a incubator humidity may be added to decrease evaporator heat loss and insensible water loss. Incubators should be placed away from air conditioning ducts or windows that may affect the temperature. Nurses should keep portholes and doors closed as much as possible. When infant is removed form the incubator the infant should be wrapped in heated blankets and a hat applied. The incubator doors should be closed while the infant is outside to maintain heat inside. Overheating can occur when heating devices are set too high or a skin probe is accidentally removed. Overheating leads to an increase in metabolic rate, with increased oxygen and glucose needs, and insensible water losses. Alarms to detect high and low temperature should be turned on at all times.

Problems with thermoregulation - maintaining a neutral thermal environment

Preparation of infants for moving to open cribs should begin early. Infants who weigh about 3 lbs and 5 oz, have a consistent weight gain for 5 days, have no medical complications, and are tolerating enteral feedings can begin gradual weaning from external heat. Each NICU has its own protocol for the weaning process. The incubator temperature is usually decreased gradual. It is increased if the infants temperature falls below the desired range. If the temperate remains stable, the process can continue. When the infant is ready for transfer to an open crib, double-wrapping with warm blankets at first helps insulate body heat. The temperature is assessed at gradually increasing intervals until the infant is on a routine schedule. A blanket can be added fora low temperature, but if the temperature does not rise to normal the infant is returned to the incubator.

Problems with thermoregulation - weaning to an open crib

surfactant replacement therapy may be instilled into the infants trachea immediately after birth or as soon as signs of RDS become apparent. Doses are repeated if necessary. Other supportive treatments includes oxygen, CPAP or mechanical ventilation, inhaled nitric oxide therapy, correction of acidosis, IV fluids, and care of other compilations. Maintenance of thermoregulation is essential .

RDS - management

tachypnea nasal flaring retractions cyanosis grunting breath sounds may be decreased rales may be present acidosis develops as a result of hypoxia blood gases show increased carbon dioxide levels and decreased oxygen chest radiographs show the ground glass appearance on the lungs Signs become worse and peak within 3 days, then begin to improve gradually.

RDS - manifestations

The nurse observes for signs of developing RDS at birth and during the early hours after birth. Changes in infants condition is constantly assessed. Ventilator settings may need to be adjusted. Observe for signs of complications, such as patent ductus arteriosus and bronchopulmonary dysplasia. The nurse must monitor the results of laboratory tests for abnormalities in blood gases and acid-base balance. Early signs of sepsis must be identified and reported.

RDS - nursing considerations

without surfactant the lungs and thorax become non compliant or stiff and resist expansion. the alveoli cannot open properly and it causes atelectasis, hypoxia, and hypercapnia. Those changes causes pulmonary vasoconstriction and decreases blood flow to the lungs.

RDS - pathophysiology

preterm infants should be assessed for changes of the eyes 4 weeks after birth or 31 weeks gestation. Laser surgery to destroy abnormal blood vessels is the current treatment of choice. Cryosurgery or reattachment of a detached retina also may be necessary.

ROP - management

Nurse should check pulse ox readings frequently for any infant receiving oxygen. Patients should be informed about ophthalmologic tests and receive an explanation of the results. Eye exams can be very stressful for the infant, and swaddling and rest periods should be provided as appropriate. If surgery is performed the eye is assessed for drainage and pain medication should be given. Support parents.

ROP - nursing consideration

may result in visual impairment or blindness in preterm infants. It occurs most often in preterm infants weighting less than 1000 g and less than 29 weeks of gestation.

Retinopathy of prematurity

IVH results from rupture of the fragile blood vessel sin the germinal matrix, located around the ventricles of the brain. It is associated with increased or decreased blood pressure, asphyxia, or respiratory distress requiring mechanical ventilation, and increased or fluctuating cerebral blood flow. Rapid blood volume expansion, hypercarbia acidosis, and hypoglycemia are other causes. Hemorrhage is graded 1 through 3, according to the amount of bleeding. Grade 1 is a very small bleed at the germinal matrix, producing few if any clinical changes. Grade 2 hemorrhage extends into the lateral ventricles, and grade 3 causes distention of ventricles. The condition is diagnosed by cranial ultrasound.

intraventricular hemorrhage - pathophysiology

ROP results from injury to retinal blood vessels. The exact cause is unknown, but one risk factor is high levels of oxygen. Prolonged ventilation, acidosis, sepsis, shock, IVH, hyperglycemia, and fluctuating blood oxygen levels have all been associated with ROP. In ROP, immature blood vessels in the eye constrict and are obliterated. Then new vessels proliferate throughout the retina and into the vitreous humor in some infants. Fluid leakage and hemorrhages may cause scarring, traction on the retina, and retinal detachment. The pathophysiology stops in more than 90 percent of infants, and these is little or no visual loss.

retinopathy of prematurity - pathophysiology