Chapter 17: Complications of the Neonate and Nursing Care

care of the high risk newborn

- nurse provides general care measures, interventions tailored to specific conditions, and holistic and dev care as well as ensuring a safe and nurturing environment

- thorough physical assessment is completed, vital signs monitored frequently

- vitals: temp, pulse, bp, pulse ox, pain assessment

nicu environment

- dim light

- decrease noise/quiet

- cluster care (sleep and rest periods)

- care time q3hrs, premature q6hrs

- work w other teams for care times

nicu parents

- preparation

- education

- orientation to nicu

nicu rules

- visiting rules (may allow parents, visitors list)

- cluster care

touch in the nicu

premature: dont like to be stroked, firm touch, skin to skin/kangaroo care

assessment of preterm infants

<37 wks

• Smaller size, no subcutaneous fat

• Translucent, thin red skin, blood vessels clearly visible

• Limp posture; poor muscle tone

• Weak or absent suck

• Abundant vernix & lanugo

• Immature ears, genitalia

• Little energy, decreased ability to cope with stressors

• May have periodic apnea/bradycardia episodes

key fx blood pressure preterm
gold standard?

- gold standard: umbilical arterial cath

- bp cuffs need to be correct size: measure newborns extremity circumference, cuff should be half the circumference

map in preterm

- should be at or slightly above gestational age, ex: 27wks map of 27

- difference between systolic and diastolic (pulse pressure) should not be too narrow or too wide

- arms and legs should be no more than 20 apart

- usually a bit higher in lower extremities

iv feedings preterm

- via pivs or central lines

- uac or uvc

- picc line

- tpn: dextrose, vitamins, minerals

- lipids: fats

enteral feedings preterm

- ng or og tube

- < 34 wks uncoordinated suck reflex

- start low and go slow

bottle and breastfeeding preterm

- breast milk gold standard: donor breast milk is given until 34 weeks

- breastfeed for first 72 hours

- support mom w breastfeeding

- nonnutritive sucking (NNS): put baby on breast or give pacifier while they are getting food, belly gets full when sucking

- strict i and o

skin care preterm

- skin breakdown occurs where tubes touch the skin

- risk for nosocomial infection

- bathing q3 days

- protective tape or barrier is used under standard tape

- rotate leads and pulse ox often and switch feet pulse ox q6hrs

dev care preterm

- noise

- sleep (lights off at night - keep isolets covered)

- lighting (dim)

- handling

- positioning: turn q3hrs, makes sure head dev correctly, supine, side, prone

resp distress syndrome in preterm

- underdev lungs and surfactant def < 36wks

- lack of surfactant cause alveoli to collapse

- almost all infants born before 28 wks dev RDS

s/s rds

- grunting

- retractions

- cyanosis

- tachypnea

- labored breathing

- decreased breath sounds

- resp acidosis or mixed acidosis, apnea > 20 sec

what to do if impending preterm delivery

- give 2 betamethasone IM injections to mom

administering surfactant
adverse effect

 can have up to 3 doses in ET tube

- pulmonary hemorrhage: most hcp dont like doing all 3 doses

bronchopulmonary dysplasia

- chronic lung disease r/t mechanical ventilation

- newborn becomes dependent on o2 therapy past 36 wks

- newborns d/c home on o2 nasal cannula

- parents need education on home o2 therapy

apnea in preterm

- commonly seen in nicu

- AKA a & b spells

- monitor set to alarm for apnea, o2 desats and bradycardia

s/s apnea

apnea > 20 sec accompanied w cyanosis, abrupt pallor, hypotonia, bradycardia, o2 desat

interventions apnea
stimulation?
tx/prevention?

- minimal stim: opening door to isolet

- moderate stim: putting hands on baby/rubbing down/flicking foot

- vigorous stimulation: bag mask positive pressure

- give loading dose caffeine and maintenance dose daily to prev episodes

- need to be spell free for 5 days before they can be d/c

patent ductus arteriosus
major comp?

- when opening persists between aorta and pulm artery after 3 days

- continuous machinery like murmu

- major comp is CHF

tx pda

- indomethacin, a prostaglandin inhibitor and nsaid that promotes ductal constriction

- cardiac cath or surgery

comp indomethacin and nsaids

increases risk for bowel prob, necrotizing enterocolitis, use w caution or only use ibuprofen

types of acute intracranial hemorrhage in preterm
from?

- intraventricular: rupture of fragile blood vessels in their brain. Can happen from rapid volume expansion, big change in their BP, or low oxygen

- preventricular leukomalacia: more severe

key fx acute intracranial hemorrhage preterm
occur at what time in life?

- most bleeds occur w in 72 hrs of life

- can be minimal or extensive

- occurs most comm in newborns <32 wks

**prevention acute intracranial hemorrhage

- give everything though an iv pump even if can push

- keep o2 levels good

- slide diaper underneath/ dont raise legs

- head needs to stay midline

- minimal stim so BP doesn’t rise: don’t suction them unless absolutely necessary

grading intracranial hemorrhage

- g1 less severe, can reabsorb and go away

- g4 most severe, cp, seizures, learning disabilities

necrotizing enterocolitis

• Serious inflam condition of bowel mucosa (can lead to ischemia)

• Premature babies are more at risk. Start low and go slow.

s/s necrotizing enterocolitis

- feeding intolerance (spitting up when haven't before)

- bright green vomiting

- abd distention (late sign - measure every 6 hours)

- visible bowel loops

- bloody stool

- signs of infection (apnea, temperature instability, hypotension)

- irritability

- lethargy

first thing to do if s/s nec

- hold feedings

- bowel rest (TPN/lipids)

- severe cases: surgery and ostomy

what can help nec

colostrum/breastmilk have protective properties and are easily digested

retinopathy in premature - historically

in mid 20th century, common practice in nicu was high concentration of o2 in incubators (100% all the time) which was leading cause of blindness in children during this period

r/f retinopathy of prematurity

- prematurity

- RDS

prev retinopathy

- wean infant off o2 as soon as possible

- no 100% o2

- avoid high concentrations of o2 unless necessary

- dim lights and decrease environmental stimuli

- stay at constant o2 level

- get eye exam before d/c

key fx post term newborn

- > 41 wks

- may or may no be lga

- may have lost weight in utero bc of declining placental ability to transport nutrients and o2

characteristics of post term neonate

- meconium stained cord

- peeling of skin/wrinkly

- parchment like skin that is often cracked on abdomen and extremities

- fingers appear long, often peeling

- general muscle wasting may be evident

meconium aspiration syndrome

compromised fetus passes meconium in utero due to hypoxia and aspirates (ingested through amniotic fluid)

s/s and comp MAS

- s/s: stained skin/nail/cord, initial respiratory distress/cyanosis, barrel chest, hyperinflation and air trapping

- comp: resp distress, pneuomothorax, surfactant def, pphn

- resp s/s get progressively worse over first 12-24hrs

prev MAS

- amnioinfusion, suctioning at delivery

tx mas

- chest pt

- cpap

- o2

what is persistent pulm HTN of the newborn

resistance in pulm system from most commonly MAS, causes ductus arteriosis and foramen ovale to stay patent and shunt blood away from lungs

s/s pphn

- brief resp distress at birth and then responds normally

- by 12 hrs after birth s/s: central cyanosis and tachypnea, grunting and retractions, possible audible murmur from tricuspid insuff, bp remains normal

tx pphn

- sedation (babies are very irritable)

- aggressive resp and bp management (ventilator, inhaled nitric oxide or HFOV)

- environmental modifications

- ecmo

what is inhaled nitric oxide

- potent vasodilator

- dilates pulm vessels

- bed & bag and mask are both hooked up to this instead of oxygen

high freq oscillating ventillation

- 600-900 breaths per min

- make sure chest wiggles, if not, prob extubated

- use ear muffs for hearing protection on the baby

common needs for ecmo

mas, pphn, congenital diaphragmatic hernia, congenital heart defects, severe pneuomina

what is ecmo
candidates?

- extracorporeal membrane ox

- takes blood from body, oxygenated it using an artificial lung and pumps it back into the body using an artificial heart

- used as last resort for newborns that are responding to conventional ventilation or hfov (didn't respond to ventilator or oscilator)

- 80 % success rate

- newborns < 34 wks or 2000 grams not good candidates because of need for heparin, which could cause cerebral hemorrhage

sga newborn

- result of intrauterine growth restriction (iugr)

- IUGR:  Asymmetrical (head circumference and length are normal but weight is low) vs. Symmetrical (all below 10%; risk long term comp)

characteristics of sga

- waste of muscle tissue

- scaphoid abdomen (sunken)

- no brown fat

- eyes look big

- long fingernails

- may have meconium stained cord

conditions affecting sga newborn

- cold stress (no brown fat), temp instability, higher response to pain

- risk for hypoglycemia

what is considered lga

- > 4000g, 8 lbs 15 oz

causative fx lga

- maternal dm

- maternal obesity

- multiparity: 2+ babies

- heredity or ethnicity

- certain congenital anomalies

comp lga

birth trauma r/t cephalopelvic disproportion and shoulder dystocia: clavicle fracture

brachial nerve damage, facial nerve damage

increased c-section

breech presentation

TTN (resp distress for term babies)

hypoglycemia, poor feeding, jaundice

birth injuries often occur from

- forceps delivery

- vacuum extraction delivery

key fx birth injuries

- most are avoidable

- increase neonatal morbidity/mortality

- most resolve w or w out tx, few are fatal

- leading cause of litigation and malpractice suits in ob

types of birth injuries

- skeletal fractures: skull, clavicle, humerus, femur

- peripheral nervous system injury: damage by stretching, pulling, torsion, forceps

- neurologic injury: prematurity increases risk, intracranial hemorrhage

key fx brachial plexus injury

- can cause erbs palsy: affects nerve controlling arm and shoulder

- caused by shoulder dystocia or difficult birth

- nerve stretches and damage occurs

s/s brachial plexus injury

*arm abducted and rotated internally

tx BPI

- supportive/gentle handling

- baby sling

- supportive swaddling

key fx clavicle fracture

clavicle fracture not uncommon when shoulder dystocia occurs

s/s clavicle fracture

- crepitus

- limp arm

- asymmetrical moro reflex

tx clavicle fracture

- supportive

- baby sling

- gentle handline

- swaddling

what is transient tachypnea of the newborn
common in?

- delayed clearance of fetal lung fluid in term baby

- common in lga, infants of diabetic mother, late preterm infants (34-36 wks)

s/s TTN

- rr 60-120 per min

- grunting, retracting, nasal flaring = resp distress

- cyanosis

dx TTN

- blood gas showing resp acidosis and cxr showing residual fetal lung fluid

tx TTN

- freq resp assessments

- nasal cpap

- can transition

- no long term comp

physiologic jaundice

- occurs after 24hrs of age

- delayed elimination of bilirubin (released w rbc lysis)

- levels rise slowly and peak at lower levels

s/s physiologic jaundice

- decreased i and o due to poor feeding

- difficulty breastfeeding (very sleepy)

tx physiologic jaundice

- usually resolves w out tx, sit by window or outside

- interventions based on causative fx

what is pathologic jaundice

- occurs w in first 24hrs

- more severe

- increased bilirubin production

- levels rise rapidly w normal compensatory mechanisms overwhelmed

causes pathologic jaundice

- hemolytic disease of newborn (rh incompatability)

- infection

- idm

- congenital liver/metabolic disorders

tx pathologic jaundice

- requires intensive therapy to prevent acute bilirubin encephalopathy and kernicterus (brain damage and long term probs)

- phototherapy

nursing care for infant receiving phototherapy

- protect eyes

- remove eye protection for feedings to assess eyes

- monitor vs (esp temp), i and o

- assist w feedings, bonding

- maximize skin exposure to light source, turn q2hrs

- macular rash common, do NOT use lotion

risk fx hypoxic ischemic encephalopathy

- prematurity/low birth weight

- operative vaginal delivery (forceps or vacuum), shoulder dystocia

- resuscitation

comp hypoxic ischemia encephalopathy

- cp

- hydrocephalus

- seizure d/o

- blindness

- learning d/o

tx hypoxic ischemia encephalopathy

- prevention

- supportive to reduce severity of neuro damage

dx hypoxic ischemia encephalopathy

- based on clinical presentation

- brain imaging

- eeg

therapeutic/neuroprotective hypothermia criteria

- started w in 6 hrs of birth

- >= 36 wks

- weigh >= 1800 g

- ph <7

what is therapeutic neuroprotective hypothermia

- body cooling

- good outcomes

- body temp of 33.5 degrees c for 72 hrs

- after 72 hrs slowly rewarm the infant to normal body temp: rewarming is when effects of the neurologic injury can show up

risk for hypoglycemia

- sga

- lga

- gdm

why does hypoglycemia occur in infants

glucose crosses placenta but insulin doesnt

s/s hypoglycemia

- asymptomatic

- lethargy

- jittery

- poor feeds

- s/s transient tachypnea

- cyanosis

- seizures if rly low

prev hypoglycemia

maintaining normal glucose levels in mom during pregnancy, feeding newborn as soon as possible after delivery, and making sure they feed q3hrs around the clock

blood sugar checks infant

- done via heel stick

- follow policy for freq

tx hypoglycemia in infant

- supplementing w formula if breastfeeding

- sugar gel 3 times then have to go to nicu for iv d10w

normal blood sugar level infant

- >40

risk neonatal infection

- maternal: low ses, poor prenatal care

- intrapartum: prom, pprom, maternal fever, uto, fse/iupc

- neonatal: premature/low bieth weight, invasive procedures, prolonged hospitalization

transplacental infections

- torch

- toxoplasmosis

- other: hep b, hiv, zika, chickenpox, syphillus

- rubella: blueberry muffin

- cytalomegalovirus

- herpes simplex virus

vertical congenital infections

- chlamydia

- gonorrhea

- group b streptococcus

what is group b streptococcus
when is mom tested

- bacteria that can live in vag and normal flora

- transmission rate low but infected neonate carries high morbitity/mortality

- mom tested at 35-37 wks

tx group b streptococcus

- gbs+ intrapartum (during labor) antibiotic prophylaxis

signs of sepsis in neonate

- resp: tachypnea, resp distress, apnea

- cv: color changes, decreased perfusion

- gi: poor feeding, vomiting/diarrhea, abd distention

- cns: lethargy, irritability, changes in muscle tone, high pitched cry, temp instability

- advanced infection: jaundice, hemorrhage, resp failure, shock, seizures

nursing considerations septic neonate

- assessment of risk fx

- monitoring for signs of sepsis

- prev of infection

- admin of antibiotics

- providing supportive care

- teaching and supporting parents

dx septic neonate

- cbc w differential, crp, blood culture, csf, urine, cxr

tx septic neonate

- broad spectrum antibiotics after the culture is obtained

prenatal drug exposure

- tobacco

- alcohol (fetal alc syndrome)

- neonatal abstinence syndrome= drug w drawl from exposure to maternal drugs in utero

- caffeine

risk prenatal drug exposure

- poverty

- limitied or no prenatal care

- hx of drug abuse/tx

- co morbidities of mother

- obstetric comp (preterm labor, placental abruption)

s/s prenatal drug exposure

- begin 24-72 hrs but may take up to 4 wks, persist for months

nas scoring

- cns

- autonomic nervous system

- resp system

- gi system

- all high, very irritated