NUR 413 Exam 2

Respiratory distress syndrome

Leading cause of morbidity and mortality among premature neonates Disease mostly related to immaturity of lung tissue and lack of surfactant Incidence and severity increases with lower GA Other risk factors Maternal diabetes mellitus, male infant, caucasian race, stress during delivery that produces acidosis in neonate Causes Prematurity Surfactant deficiency Provides alveolar instability Decreases surface tension and collapse Alteration in quantity, composition, fxn, or production Causes atelectasis Consequences Mild Tachypneic With, or without, need for O2 for sx Moderate Cyanotic on room air Sx of respiratory distress Severe Struggles to breath Difficulty maintaining O2 sat despite supplemental O2 Abnormal blood gases CNS alteration: hypotonia or minimal response to stimulation Pathophysiology Poor gas exchange and ventilatory failure Lack of surfactant in lungs leads to Atelectasis, labored breathing, respiratory acidosis, hypoxemia Worsening atelectasis Increased pulmonary vascular resistance Decreased blood flow to lungs Low oxygen levels perpetuates fetal circulation by keeping foramen ovale and ductus arteriosus patent Alveoli become necrotic, capillaries are damaged Ischemia allows fluid to leak into interstitial and alveolar spaces and hyaline membrane forms; hindering respiratory function by lowering compliance of lungs Radiographic findings Alveolar atelectasis Shown by diffuse granular pattern fields Assessment and treatment of RDS Assessment Skin color Pallor, mottling, cyanosis RR >60 sustained Apnea (>20 sec) Chest movement Nasal flaring, asymmetric, retractions, grunting, diminished breath sounds HR: murmur (PDA) Hypothermia Poor muscle tone Treatment/Consequences for premature infant Ventilation, correction of acidosis, surfactant administration, thermoregulation, glucose stabilization Consequences Pneumothorax Retinopathy of prematurity Injury to the retina, visual impairment, hyperoxemia

Neonatal resuscitation

1. BreathingApnea >20sec → positive pressure ventilation 2. CirculationHR<100 → positive pressure ventilationHR<60 → compressionsHR persistent <60 → epinephrine 3. Perfusion-Acrocyanosis- ok -Central cyanosis → mucous membranes, free flow 02 at 100%

Nursing care for phototherapy

1. Protection-Retina: eye pads-Skin: lotions/emollients to prevent burns, skin may be dry-Maintain thermo neutral environment 2.Promote family interaction: rooming-in 3. Monitor feedings/intake-Observe for signs of effective breastfeeding-Breastfed infants are slower to recover-Fluid volume, longer periods away from light unless using blanket, components in milk 4. Monitor output and Sx of dehydration-Bili excreted in stool-Risk for insensible water loss thru loose, watery stools

Methods of heat loss

Convection: from cool air currents Radiation: indirect contact with cold items Evaporation: from being wet Conduction: direct contact with cold items

Meconium aspiration syndrome

Fetal asphyxia Presents with difficult transition to extrauterine life Depressed RR, HR 100 Impairs alveolar function Mechanical obstruction, chemical pneumonitis: pneumonias, inactivation of surfactant Persistent pulmonary hypertension of the newborn (PPHN)-Persistent fetal circulation treatment: tracheal suctioning

Intrauterine growth restriction (IUGR)

First trimester: teratogens, infection, chromosomal abnormalities, extrinsic conditions Results in symmetric IUGR (intrauterine growth restriction) Growth restriction 2nd and 3rd trimester: infants have potential for normal growth and development Results in asymmetric IUGR Causes of IUGR Placental insufficiency, abnormal placentation, chronic maternal disease, genetic disorders

Gastroschisis vs Omphalocele

Gastroschisis (no sac) Omphalocele (sac) (For both): Protrusion of abdominal contents through abdominal wall at junction of the umbilical cord and abdominal wall Usually herniated intestines but can include liver and stomach May be revealed by elevated AFP, maternal AFP Action may be done to protect the exposed organs

APGAR scoring

A: appearance (skin color) P: pulse (HR) G: grimace (reflex irritability) A: activity (muscle tone) R: respiration (respiratory effort) Score given at 1 minute and 5 minutes after birth; if there are problems an additional score is given at 10 minutes A score of 7-10 is considered normal4-7 might require some resuscitative measures A baby with Apgars of 3 and below requires immediate resuscitation

Diaphragmatic hernia

Abnormal opening in the diaphragm allowing a portion of the intestines in the thoracic cavity (left) Shift in apical pulse

Neonatal herpes treatment and care

Acquired from mother with an active, possibly unapparent herpes infection at the time of birth. Aggressive treatment with antiviral medication is required, but may not be effective in the case of systemic herpes. Risk of transmission of HSV with true primary infection at the time of vaginal delivery to her infant is approximately 50%. Nursing care: Contact precautions, Acyclovir, Hand washing, Rooming in, Promote parental bonding

SIDS prevention

Always place baby on back every sleep time Always use a firm sleep surface. Car seats and other sitting devices are not recommended for routine sleep The baby should sleep in the same room as the parents, but not in the same bed (room sharing without bed sharing) Keep soft objects or loose bedding out of the crib. This includes pillows, blankets, and bumper pads Keep environment smoke free Breastfeeding is recommended Offer a pacifier at nap time and bedtime once breastfeeding is established Avoid covering the infant's head or overheating Infants should receive all recommended vaccinations Supervised, awake tummy time is recommended daily to facilitate development and minimize the occurrence of positional plagiocephaly (flat heads (AAP, 2011)

Phototherapy

Blue spectrum light-Converts bilirubin to water soluble form that is easily excreted Fluorescent lighting over open bassinet, 10cm Fiberoptic blankets, 24/7 Goal: decrease TSB

caput succedaneum vs cephalohematoma

Caput succedaneum Swelling and a collection of serous fluid in the scalp due to birth trauma. The swelling often crosses the suture lines Cephalhematoma A collection of blood between the surface of the cranial bone and the periosteal membrane due to birth trauma. Swelling confined to 1 cranial bone and does not cross the suture lines

Car seat safety

Car seat challenge test Preterm infants with hx of respiratory distress may experience distress in a car seat so try it in the unit before discharging the infant home Placement Use a rear facing position in the back seat until baby is 18-20 lbs New guidelines rear facing until 2 Never place a rear facing car seat in the front seat Passenger airbag could seriously injury or kill if bag deploys Center back seat is safest spot in the car

Risks for hypothermia

Common problem due to:-Blood vessels closer to surface of skin -less adipose tissue and subcutaneous fat -newborns have large body surface to body weight ratios

Thermoregulation

Conserve heat: assume position of flexion, constrict peripheral blood vesselsGenerate heat: increase muscle activity, non-shivering thermogenesisBrown fat: rapidly depleted w/ cold stress, less mature infants have less fat, reserves of brown fat present for several weeks, metabolism generates high heat and warms blood

Rh/ABO incompatibility

Hemolytic disease occurs when blood groups of mother and newborn are different Maternal antibodies of IgG class cross placenta, causing hemolysis of fetal RBCs Fetal anemia, neonatal jaundice, hyperbilirubinemia Rh incompatibility (isoimmunization) Only Rh-positive offspring of Rh negative mother is at risk If fetus is Rh positive and mother is Rh negative, mother forms antibodies against fetal blood cells Fetal hydrops: one example of complication from isoimmunization

Signs and risk factors for hyperbilirubinemia

High Jaundice in 1st 24 hours Bili in high risk zone GA 35-36 wk Sibling received phototherapy Exclusive BF, w/difficulty Rh or ABO incompatibility Hemolytic disease G6PD deficiency Cephalohematoma Asian race Moderate Jaundice before discharge Bili in high/intermediate risk zone GA 37-38 wk Sibling with jaundice Exclusive BF Macrosomic infant of diabetic mother Maternal age > or = to 25 Male

Umbilical cord care

Identify vessels 2 arteries, 1 vein No nerve endings No discomfort Clamp removed before discharge 24 hrs Changes color Yellowish green, brown, to black Dries out Falls off, usually within 10 days Keep clean and dry Expose the stump to air, fold down diaper, swab with alcohol PRN, after cord falls off, small pink granulating area is left, observe for s/sx of infection, omphalitis: redness and drainage

Gavage feeding

Implications Prematurity, RDS Warm the milk/formula to promote effective thermoregulation Offer holding whenever possible Right side lying reduces risk of aspiration of emesis Pour milk into syringe w/o plunger Raise 6-8 inches above NB Allow milk to flow by gravity Finish feed by clear clearing tubing w/ 2-3 mL air Gavage tube placement Measure Nose to earlobe Earlobe to the midpoint between the xiphoid and umbilicus Insert Swaddle Lubricate tube with sterile water Can be in place for 30 days Tape to secure Check placement Aspirate gastric contents and return Check pH pH <6

Assessing, symptoms, treating NAS

Infants with neonatal abstinence syndrome are at a significantly higher risk for sudden infant death syndrome (SIDS) when the mother used heroin, cocaine, or opiates. The infant should sleep in a supine position, and home apnea monitoring should be implemented. Perform NAS scoring per hospital protocol-Monitor for temp for hyperthermia Monitor carefully pulse and respirations q 15 minutes and pulse ox until stable Provide S&F feedings Positioning on the right side-lying or semi-fowler's to prevent aspiration Monitor weight gain Administer oral morphine elixir, methadone, sedations such as phenobarbital Monitor frequency of V/D

Hypothermia (HIE treatment)

Initiate within 6 hours of incident Passively: undress/remove heat source Place on pre-cooled hypothermia blanket All care will be on the bed/blanket x 72hrs Baseline rectal temp and VS Goal 33.5 C UAC/UVC access NPO Reposition q6hrs (supine, left, right) After 72 hrs, rewarm Rate of 0.5C q2hrs Goal 36.5C

Birth trauma

Injury sustained during labor and birth Birth injuries may be avoidable Careful assessment of risk factors and appropriate planning of birth Ultrasonography Macrosomia, hydrocephalus, and unusual presentations Elective cesarean birth Prevent significant birth injury Soft tissue Abrasions, erythema petechia, ecchymosis, lacerations Skull caput succedaneum, cephalhematoma, linear fractures Face Subconjunctival hemorrhage, retinal hemorrhage Musculoskeletal injuries Clavicular fractures, fractures of long bones, sternocleidomastoid injury

Erythromycin eye ointment

Instill ASAP after delivery, <24 hr Wait for 1st feed at breast Thumb and forefinger are used to open the eye Medication is placed in the lower conjunctiva from the inner (nasal) to the outer (temporal) canthus. Prevents opthalmia neonatorum Federal law: infants born in US are given prophylactic eye treatment

Newborn intake and output

Intake Stomach size 20 mL avg Formula Every 3-4 hours, start 10-15 mL/feed, double volume each day until 2-3 oz Breastmilk Every 2-3 hours, on demand, avg 6 in 1st 24 hrs of life, avg 8-12, 5-50 minutes, first milk called colostrum (thick and viscous, clear-dark yellow, aka liquid gold, coats and protects gut) Output Voids Day 1= 1 wet diaper Day 2=2 Day 3=3 Day 4= 4 (uric acid a problem) Day 5= 5 Day 6= 6-8 Stools Day 1= meconium Day 2=2 Day 3= 3 transition Day 4=3-4

Nursing interventions for preventing heat loss

Keep infant dry and remove wet blanket or clothing-place baby on mother's skin, put cap on infant's head-keep room free of drafts, don't place cold items next to baby, use radiant warmer if necessaryKeep axillary temp between 98=99 (36.6-37.2), Cold stress increases oxygen consumption, metabolic acidosis and respiratory distress, Hyperthermia (>37.5) can cause cerebral damage

Large for gestational age (LGA)

LGA (large for gestational age)Infant weighing more than or equal to 4000g (8lb 13oz) at birth Weight above 90th percentileFetopelvic disproportion Birth trauma: breech or shoulder presentation, asphyxia or CNS injury

Risk factors and s/sx of hypoglycemia

LGA, SGA, IUGR Limited stores Increased needs Maternal diabetes (I, II, or Gestational) Fetal BS are 80% of maternal Insulin production in high response Preterm Multifactorial Stressed (physically, emotionally) S/sx BS <40 in the first 4 hrs <45 after 4 hrs of life Jittery, exaggerated reflexes (moro), seizures Cyanosis, apnea, unstable temp Lethargic, decreased muscle tone, poor feeding behaviors Long term consequences Damage to CNS

Maternal HIV and management for newborns at delivery

Measures to reduce mother to infant transmission Antiretroviral drugs starting at 14-16 wks gestation Transmission is high if mother has high viral load Scheduled C/S Avoid breastfeeding, in the USA Care management All infants will receive AZT asap after delivery Term 2mg/kg PO q6hr Preterm 2 mg/kg PO q12hr Serum blood draw to determine in utero transmission Standard precautions: first bath, diaper changes

Transient tachypnea of the newborn

Mild respiratory problem: birth-3 days Delayed absorption of fetal lung fluid after birth Neonate breathes harder, faster for adequate O2 Common in infants delivered without adequate thoracic squeeze C/S Precipitous vaginal delivery Dx: chest x ray reveals streaking which correlates with lymphatic engorgement of retained retinal fluid Tx: oxygen, IV fluids, gavage feeds, close monitoring for pulmonary hypertension, pneumonia Antibiotics for suspected infection Neutral thermal environment Low stimulation (lights, sounds, cluster care) Usually resolves within 72 hrs

Patent ductus arteriosus (PDA)

Most common Right to left shunting Oxygenated blood recirculates to the lungs and heart Evident by day 2 or 3 Harsh grade murmur (2-3/6) Risks Respiratory distress, prematurity, female, maternal rubella infections Due to lowered oxygen associated with respiratory impairment Decreased pulmonary flow, low O2, CHF Treatment Fluid regulation, respiratory support, administration of indomethacin (indocin), surgical ligation if neonate does not respond to other interventions

New Ballard Score

New Ballard Scale Examine 6 neuromuscular maturity features Posture, wrist, arm recoil, popliteal angle, scarf sign, heel to ear Examine 6 external physical maturity features Skin, lanugo, plantar surface, breast, eye/ear, genitals Score gives gestational age, accuracy to +- 2 wks Assessment on NB between 2-12 hrs after birth New Ballard assessment Skin Dry vs gelatinous Term is more dry The top flakes off shortly after birth Plenty of dry, peeling skin Eucerin cream, thin film, may be awake Lanugo Small vs large amount Covered by fine, downy hair at birth Back, shoulder, forehead, temples, ears or in other spots Ears texture/appearance Gestational age, development Skin tags may indicate other anomalies Renal, notify MD Plantar surface Wrinkles: term Smooth: early Breast buds and genitalia Mother's hormones pass through the baby's system at birth causes swelling of Breast buds Boys and girls Could even produce a bit of milk Labia: girls Light vaginal discharge May be blood-tinged (pseudo menses) Swelling typically disappears within two to four weeks Vaginal discharge may only last several days Scrotum: boys Descent of testes

Circumcision procedural information

Parental decision: cultural, MD obtains consent NPO 1hr prior (may not be necessary if BF) Observe for bleeding -Dime size or more, droplets: apply pressure, gel foamApply wound dressing: vaseline gauze Care of Circumcision: No soap! Rinse with warm water, good hand washing, frequent diaper changes, loose diaper, tylenol for pain Complications Minor: bleeding (controlled w/compression), infection of the surgical site Rare: accidental amputation of glans, life threatening infection

Developmental care

Promotes thermoregulation Promotes appropriate posture, flexed positioning Promotes comfort, non nutritive sucking Minimizes stress Dim lighting, quiet, minimal interruption (cluster care), parents present

Neurological newborn assessment

Reflexes: observable- Tonic neck reflex-grasp reflex-step reflex-crawl reflex-moro reflex Muscle tone: flexed Behavioral states:Crying, light sleep, deep sleep, quiet alert, active alert

Small for gestational age (SGA)

SGA (small for gestational age/ IUGR)Weight below the 10th percentile expected at term

Causes, effects, S/S, and treatment of infection and newborn sepsis

Sepsis: Significant cause of neonatal morbidity & mortality Bacterial, viral, fungal, parasitic Bacterial infections: E. coli, Group B streptococcus Since screening & tx in mothers, neonatal sepsis declined drastically ABX- tx IV during labor -Penicillin at least 1 dose, 4hr prior to delivery -Preferably 2 -Clindamycin if risk of anaphylaxis w/ PCN Challenge q6-8hr dosing Untreated or insufficient tx-Observation x48hr for s&sx of infections

Kangaroo care

Skin to skin contact Ventral to ventral, flexed (like a frog), head to the side, blanket to lower ear, face visible, neck straight, 30-80 degrees reclined Stabilizes VS, BS, promotes feeding behaviors, and maternal milk supply

Assessment of fontanelles

Soft spots on head Bony plates that make up the skull, not yet fused Allows for growth of brain during 1st year of life Should be flat and open May see a pulse or bulge w/crying Bulging: increased intracranial pressure (hydrocephaly) Depressed: dehydration Overriding in premature infants Anterior Diamond shaped Closes by 18-24 months Posterior Triangular shaped Closes between 1-2 months

Normal V.S. for newborn - what signs would need immediate intervention.

T: 36.5-37.5, RR: 30-60 HR: 110-160, HR: 80-100 → Bradycardia, administer oxygen HR: 60 → begin compression

Normal bilirubin and blood sugar levels at birth

Total Serum Bilirubin (TSB) Normal is 2-5mg/dLAbnormal: >5mg/dL increase per day Blood glucose >45 after first 4 hrs of life anything below could indicate hypoglycemia

myelomeningocele

Under the umbrella of spina bifida Most serious form Incomplete formation of the spine 90% have hydrocephalus Bulging fontanelles Fragile spinal cord is exposed higher= more complications Complications vary Paralysis Urinary complications Prone positioning Cover with protective plastic Meticulous diaper care Surgical repair

Swaddle bathing

Water temp: <104 F Limited time: 10 min Maintain contact with the newborn Use hands for washing Preterm infants Warm blankets for drying Skin to skin with parent Rationale Better thermoregulation Soothing for infant Less stressful for infant and parents Promotes confidence in parent