complications of the neonate and nursing care

level I to level IV nicks

• Level 1 - Nursery care

• Level 2 - Level 1 plus premature care (usually cut off age), give oxygen by cannula, CPAP, vent occasionally, IV therapy

• Level 3 - Level 1 & 2 plus higher level ventilators, more prematurity, oscillators, PICC lines, surgical patients

• Level 4 - All things plus ECMO

assessment of preterm infants

• 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

what is the gold standard for BP for infants

indwelling arterial catheter (umbilical)

BP infant key fx

• Blood pressure cuffs need to be the correct size

• Measure the newborn’s extremity circumference, cuff should be half the circumference

• MAP should be at or slightly above gestational age***

• The difference between the systolic and diastolic pressures (pulse pressure) should not be too close together (narrow) or too far apart (wide). Arms and legs should be no more than 20 mmHg apart. Usually a bit higher in lower extremitie

IV feedings

• Via PIVs or central lines

• UAC or UVC

• PICC line

• Total Parenteral Nutrition (TPN)

• Lipids

enteral feedings

• NG or OG tube -> until showing cues to start eating by mouth

• Start low and go slow

bottle and breastfeeding

• Breastmilk is gold standard - <34 wks they get donor breastmilk

• Support mom! - want moms to breastfeed for 72 hours consecutively before introducing bottle

• Nonnutritive Sucking (NNS) - as OG or NG feeding is going, place pacifier in mouth -> teaches them to suck as get full

strict I&O

skin care for infants

• Skin breakdown occurs where tubes touch the skin -> rotate leads often and switch pulse ox to other foot every 6 hours 

• Risk for nosocomial infection

• Bathing every three days

• Protective tape or barrier is used

developmental care for infants

• Noise

• Sleep

• Lighting - isolets are covered so it is filtered light similar to in utero

• Handling 

• Positioning -> turned q3hrs to ensure head is developed properly

what is respiratory distress syndrome (RDS)

• Underdeveloped lungs and surfactant deficiency

• Lack of surfactant cause alveoli to collapse

• Almost all infants born before 28 weeks develop RDS

s/s of RDS

• Grunting

• retractions,

• cyanosis,

• tachypnea,

• labored breathing,

• decreased breath sounds,

• respiratory/mixed acidosis,

• periods of apnea

what can you give if you are impending preterm delivery to help prevent RDS

2 doses of IM betamethasone

nursing care for RDS

• Administer surfactant (curosurf) -> weight-based -> can have 3 doses through ET tube -> use bag to blow into lungs -> infant can stay on ventilator or can be an in-and-out procedure

• Adverse Effect: Pulmonary hemorrhage -> most HCP don’t like to give all 3 doses

what is bronchopulmonary dysplasia

• Chronic lung disease due to long-term mechanical ventilation

• Diagnosis - Newborn becomes dependent on oxygen therapy past 36 weeks’ gestation

• These are the newborns that are discharged home on oxygen via nasal cannula

• Parents need education on home oxygen therapy

what is apnea of prematurity

• Very commonly seen in the NICU

• Also called “A&B Spells” or “Spells”

• Apnea longer than 20 seconds accompanied with cyanosis, abrupt pallor, hypotonia, bradycardia, and oxygen desaturation

interventions for apnea of prematurity

• Monitors set to alarm for apnea, O2 desaturation and bradycardia

• stimulation of infant

  • Minimal stimulation -> opening doors to isolets

  • Moderate stimulation -> touching infant (rubbing foot, touching hand)

  • Vigorous stimulation -> bag/mask

tx/prev of apnea of prematurity

• Caffeine -> tells brain to keep breathing -> loading and maintenance dose given daily IV or PO.

• Infant has to be spell-free for 5 days before they can be d/c

what is patent ductus arteriosus

• opening persists between the aorta and pulmonary artery -> supposed to close w/in 1st 3 days -> if doesn’t, then dx w/ PDA

• Continuous machinery like murmur

• Major complication is CHF (rare)

tx of PDA

• Indomethacone - a prostaglandin inhibitor & NSAID that promotes ductal constriction -> increase risk for NEC -> HCP often prefer ibuprofen because there is less rx for NEC

• cardiac cath or surgery

what are the two types of acute intracranial hemorrhage

• intraventricular hemorrhage

• periventricular leukomalacia

what is intraventricular hemorrhage

rupture of fragile vessels in brain from extensive hypoxia, rapid changes in BP, or from rapid volume expansion

what is periventricular leukomalacia

more severe than IVH

key fx of acute intracranial hemorrhage

• Most bleeds occur within 72 hours of life - First 72 hrs, have to slide diaper underneath (do not lift legs up), do not suction, keep head midline

• Can be minimal or extensive - Grade I is less severe, Grade IV is most severe 

• Occurs most commonly in newborns less than 32 weeks gestation at birth

prev of acute intracranial hemorrhage

• Give O2, all meds and fluids are put on pump

• minimal stimulation (anything that is going to raise BP = do not do)

what is necrotizing enterocolitis (NEC)

• Serious inflammatory condition of bowel mucosa -> can lead to ischemia 

s/s of necrotizing enterocolitis

• feeding intolerance (spit-up after feeding),

• vomiting (bright-green),

• abdominal distention (late sign),

• visible bowel loops,

• bloody stools,

• signs of infection (apnea, HOTN, temperature instability),

• irritability,

• lethargy

interventions for necrotizing enterocolitis

• Colostrum/breast milk have protective properties & easily digested

• Need to hold feeds (bowel rest → TPN) -> if severe, then surgery and ostomy (temporary)

what is retinopathy of prematurity

in mid-20th century → high concentration of oxygen in incubators → caused blindness

rx factors of retinopathy of prematurity 

premature babies & babies with RDS

prev of retinopathy of prematurity

• wean infant off oxygen as soon as possible,

• avoid high concentrations of oxygen unless necessary,

• dim lights and decrease environmental stimuli,

• stay at constant oxygen level (do not increase and decrease)

assessment of the postterm newborn

• May or may not be LGA

• May have lost weight in utero because of declining placental ability to transport nutrients and oxygen

what are the conditions of preterm newborn

• respiratory distress syndrome

• bronchopulmonary dysplasia

• apnea of prematurity

• PDA

• acute intracranial hemorrhage

• necrotizing enterocolitis

• retinopathy of prematurity 

characteristics of postterm newborn 

• Meconium-stained cord or skin

• Peeling of the skin

• Parchment-like skin that is often cracked on abdomen and extremities

• Fingers appear long, often peeling

• General muscle wasting may be evident

what is meconium aspiration syndrome

• Compromised fetus passes meconium in utero due to hypoxia and aspirates

• Respiratory symptoms get progressively worse over the first 12 to 24 hours

• Treatment and Care: Chest PT, CPAP and oxygen

s/s of meconium aspiration syndrome

• Meconium-stained skin, nails, cord,

• initial respiratory distress and cyanosis,

• barrel-shaped chest (air-trapping)

comp of meconium aspiration syndrome

Respiratory distress, pneumothorax, surfactant deficiency, PPHN

what is Persistent Pulmonary Hypertension of the Newborn (PPHN)

• Resistance in the pulmonary system from most commonly MAS, caused the ductus arteriosus and foramen ovale to stay patent and shunt blood away from the lungs -> pressure in lungs is really high from meconium, so shunts can’t close

tx of PPHN

• sedation,

• aggressive respiratory and BP management,

•  environmental modifications

• inhaled nitric oxide

• HFOV

s/s of persistent pulmonary HTN

The newborn usually demonstrates brief respiratory distress at birth and then responds normally. By 12 hours after birth, the signs and symptoms of PPHN are displayed and include:

• Central cyanosis and tachypnea

• Grunting and retractions

• Possible audible murmur because of tricuspid insufficiency

• Blood pressure usually remains normal

what is inhaled nitric oxide

ventilator and bag/mask need to be hooked up to this

• A potent vasodilator

• Dilates the pulmonary vessels to decrease pulmonary pressure

what is high frequency oscillating ventilation (HFOV)

• 600 to 900 breaths per minute

• Nursing Assessment: make sure there is a chest wiggle

• Use ear muffs for hearing protection on the baby

what is ECMO (extracorporeal membrane)

• MAS, PPHN, congenital Oxygenation diaphragmatic hernia, congenital heart defects, and severe pneumonia

• An ECMO machine is a machine that takes blood from the body, oxygenates it using an artificial lung and pumps it back into the body using an artificial heart.

• Used as a last resort for newborns that are not responding to conventional ventilation or HFOV 

• 80% success rate

what newborns are not candidates for ECMO

Newborns less than 34 weeks or 2000 grams because of the need for heparin, which could cause cerebral hemorrhage

what is IUGR

part of SGA

Asymmetrical vs. Symmetrical - Asymmetrical is when head and length are normal, weight is low. Symmetrical is when everything is below 10% -> it causes long-term complication

rx factors for SGA

Genetic, chromosomal deformities, infection, drugs

characteristics of SGA newborn

Wasting of muscle mass, large eyes, long finger-nails, meconium stained cord

conditions affecting SGA newborn

Cold stress, temperature instability, higher response to pain, hypoglycemia

what is weight for LGA

>4100 g

causative factors for LGA

• Maternal diabetes mellitus (IDM)

• Maternal obesity

• Multiparity

• Heredity or ethnicity

• Certain congenital anomalies

comp of LGA

• Birth trauma related to cephalo-pelvic disproportion & shoulder dystocia: Clavicle fracture, Brachial nerve damage, Facial nerve damage

• Increased risk for C-section

• Increased tendency for breech presentation

• TTN (Respiratory distress)

• Hypoglycemia, poor feeding, jaundice

what are birth injuries

• Most are avoidable

• Increase neonatal morbidity/mortality

• Most resolve with/without treatment; 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

what is brachial plexus injury 

• Erb’s palsy - Face has reaction from nerve being pulled on

• Shoulder dystocia or difficult birth - excessive force or positioning of arm/neck

• Signs and Symptoms: Limp arm that is rotated 

• Treatment: Supportive -> swaddling, baby sling -> resolves in 3-6 mos

what are skeletal fractures

• clavicle, humerus, femur, skull

• Clavicle fx not uncommon when shoulder dystocia has occurred

• S/S of clavicle fracture: Limp arm, crepitus, asymmetrical moro reflex

• Care supportive - gentle handling, swaddling in blanket, baby sling

what is transient tachypnea of the newborn

• Common in LGA or infants of a diabetic mother (IDM) and Late preterm infants (born between 34 and 36 weeks)

• What causes it - brain is still immature -> delayed clearance of fetal lung fluid

• Diagnosed by blood gas showing respiratory acidosis and CXR showing residual fetal lung fluid

s/s of transient tachypnea of newborn

• RR of 60-120 per minute

• Grunting, retracting, nasal flaring

• Cyanosis may be present

what Is tx of transient tachypnea of the newborn

Frequent respiratory assessments, nasal CPAP -> can transition back to mom’s room -> only in NICU for about 6 hrs

what are the two types of hyperbilirubinemia 

• physiologic jaundice

• pathologic jaundice

what is physiologic jaundice

• Occurs after 24 hours of age

• Delayed elimination of bilirubin

• Decreased I&O (esp stools) due to poor feeding, difficulty breastfeeding -> jaundice makes them extremely lethargy

• Levels rise slowly and peak at lower levels

• Usually resolves without treatment

• Interventions based on causative factors

what is pathologic jaundice

• Occurs within first 24 hours

• Increased bilirubin production

• Hemolytic disease of newborn, infection, IDM, congenital liver/metabolic disorders

• Levels rise rapidly with normal compensatory mechanisms overwhelmed

• Requires intensive therapy to prevent acute bilirubin encephalopathy and kernicterus

nursing care of infant receiving phototherapy 

• Protect eyes

• Remove eye protection for feedings to assess eyes

• Monitor VS (especially temp bc only in diaper), I&O

• Assist with feedings, bonding

• Maximize skin exposure to light source; turn every 2 hrs

• Macular rash common -> do NOT use lotion

rx factors of hypoxic-ischemic encephalopathy

prematurity/low birth weight, operative vaginal delivery (forceps or vacuum extractor), shoulder dystocia)

key fx hypoxic-ischemic encephalopathy

• Can result in CP, hydrocephalus, seizure disorders, blindness, learning disorders

• Prevention crucial

• Diagnosis based on clinical presentation, brain imaging, EEG

• Treatment supportive to reduce severity of neuro damage

what is therapeutic hypothermia 

• Body Cooling 

• Good outcomes

• Criteria: Started w/in 6 hrs of birth,  >36 wks, >1800 grams, pH <7

• Body temperature of 33.5 degrees C for 72 hours

• After 72 hours, we slowly rewarm the infant to normal body temperature

• Rewarming is when effects of the neurologic injury can show up 

rx factors of hypoglycemia

: SGA, LGA, mothers w/ pre-existing DM or gestational DM

s/s hypoglycemia

Asymptomatic, lethargic, jittery, poor feeding, s/s resp distress

prev hypoglycemia 

• maintaining normal glucose levels in mom during pregnancy,

• feeding the newborn as soon as possible after delivery,

• making sure they feed every 3 hours around the clock.

where are glucose checks done in infants

heel stickst

tx hypoglycemia

feeding (supplementing with formula if breastfeeding) and IV therapy (D10W)

rx factors of neonatal infection 

• Maternal - Low SES, poor prenatal care

• Intrapartum - PROM, PPROM, maternal fever, UTI, FSE fetal scalp electrode)/IUPC (intrauterine pressure catheter)

• Neonatal - Premature/low birth wt, invasive procedures, prolonged hospitalization

what are vertical infection

• Chlamydia

• Gonorrhea

• Group B Streptococcus (GBS)

group B strep key fx

• Transmission rate low, but infected neonate carries high morbidity/mortality

• Mom tested at 35-37 weeks

• GBS + : intrapartum antibiotic prophylaxis 

signs of sepsis in neonate: respiratory 

Tachypnea, respiratory distress, apnea

signs of sepsis: CV

Color changes, decreased perfusion

signs of sepsis: GI

Poor feeding, vomiting/diarrhea, abdominal distention

signs of sepsis: CNS

Lethargy, irritability, changes in muscle tone, high-pitched cry, temperature instability

signs of sepsis: advanced infection

Jaundice, hemorrhage, respiratory failure, shock, seizures

nursing considerations care of septic neonate

• Assessment of Risk factors

• Monitoring for signs of sepsis

• Prevention of infection

• Administration of antibiotics

• Providing supportive care

• Teaching & supporting parents

therapeutic management of septic neonate

• Diagnostic Testing - CBC w/ differential, CRP, Blood culture, CSF, urine, CXR

• Treatment - Broad-spectrum antibiotics before the culture is obtained

rx factors of prenatal drug exposure

• Poverty

• Limited or no prenatal care

• History of drug abuse/treatment

• Co-morbidities of mother

• Obstetric complications (preterm labor, placental abruption) 

neonatal abstinence syndrome (NAS) key fx

• Infant signs usually begin in 24-72 hrs but may take up to 4 wks

• Symptoms may persist for months

• All systems are irritated -> everything high (high pitch cry, irritable, hyperactive reflex, hypertonia, fever, sweat, tachypnea, excessive sucking, diarrhea, vomiting)

• 3 scores of >8 or 2 scores of >12 land them in NICU -> need tx with morphine 

NAS nonpharm tx

• Holding/Comforting

• Music

• MamaRoos and other swings

• Dark, quiet environment

• Breastfeeding (if allowed)

NAS pharm tx

• Morphine - 1st line PO

• Clonidine - if s/s are uncontrolled and baby maxed out on morphine -> sedative

• Phenobarbital - third med if s/s still uncontrolled -> CNS

• Some hospitals are testing the use of methadone to treat these infants

what is eat sleep console

• Encourages parents to participate in much of the care

• This tool has 3 components that are scored on every 3-4 hours

  • Eat: Can the infant take 1 to 1.5 oz of formula or breastfeed effectively?

  • Sleep: Can the infant sleep for 1 hour (either independently or while being held by the caregiver?

  • Console: Can the infant be consoled within 10 to 20 minutes?

what are the neuro conditions

• Anencephaly

• Encephalocele

• Microcephaly

how to prev neuro conditions

folic acid***

what is congenital diaphragmatic hernia (CDH)***

• Diaphragm is not developmentally complete

• Survival rate is 50%

• No prevention

• Early detection can improve outcomes

s/s congenital diaphragmatic hernia 

• bowel sounds in the thoracic cavity,

• cyanosis, bradycardia,

• barrel chest, s

• caphoid abdomen (sunken in because bowels are in chest)

what is priority in congenital diaphragmatic hernia

• maintain newborn’s airway and oxygenation,

• NG tube to decrease bowel distention (helps get air out to prevent compression on heart)

surg repair of congenital diaphragmatic hernia

go in and put bowels where they are supposed to be and repair diaphragm

what is cleft lip/palate

• Can be unilateral or bilateral

• May be found on ultrasound

• Cleft palate needs to be assessed by the nurse on admission to newborn nursery or NICU

• They can successfully breastfeed and bottlefeed

how to feed with cleft lip/palate

• Haberman feeder - can control flow of milk that comes out

• Fed in an upright position

surg repair of cleft lip/palate

• Cleft lip: typically done at 3 months of age

• Cleft palate: repaired before 18 months

what is gastroschisis***

• Usually diagnosed with ultrasound

• The stomach and intestine herniate through the abdominal wall 

what is omphalocele

• a congenital condition in which the intestines protrude into the umbilical cord region of the abdominal wall (similar to gastrhcisis)

• It is often associated with trisomy 13 and 18 and urinary tract anomalies.

nursing interventions of gastroschisis

• Nurse should keep the abdominal contents sterile by wrapping in sterile bowel bag with sterile water to keep moist

• Fluids replaced at 1.5 times the normal maintenance volume

tx of gastroschisis

• The intestines will be placed in a silo above the level of the defect

• Is reduced back into the abdomen over several days

• If repair can be accomplished in one stage, surgical repair

key fx transporting high-risk newborn

• From a lower level of care to a higher level of care

• The Transport Team

• S.T.A.B.L.E

what is STABLE

Sugar, Temp, Airway, Blood pressure, Labs, Emotional Support -> renewed every two years -> for newborn nurses at any level nursery or NICU to learn critical stabilization of neonate

key fx NICU discharge planning 

• Begins on admission

• Encourage parental involvement in neonate care

• Readiness for Discharge - Stable Condition

• Exams/Screenings completed

• Car Seat trial

• Family readiness

• Discharge teaching and follow-up appointments