WKU OB Exam 2

what are the different levels of NICUs

- level 1: nursery care

- level 2: Level 1 plus premature care (usually cut off age), give O2 by cannula, CPAP, vent occasionally, IV therapy

- level 3: Level 1 & 2 plus higher level ventilators, more prematurity, oscillators, PICC lines, surgical pts, peds specialists

- level 4: all things below plus ECMO

what is important to know when it comes to the circulatory system of a NICU pt

- shunts: important to high risk newborn nursing

- want to know if valves/ openings are closed or not

what is the thing you should worry about w/ the respiratory system of a NICU pt

surfactant: most important factor for lung maturity (not fully developed until around 36 wks)

what is important to know when it comes to the neurological system of a NICU pt

term babies have immature neurological systems and the earlier one is born the worse it is

the NICU RN provides general care measures and interventions tailored to

specific conditions, and holistic and developmental care as well as ensuring a safe nurturing environment

what are some interventions that are done in the NICU

- VS measured constantly

- thorough physical assessment

- temp probe on belly

- involve parents in care

what do you need to do w/ the NICU environment

- reduce stimuli

- decrease visitors

- cluster care to promote sleep/ rest

- provide for circadian rhythm

- decrease infection: hand hygiene

what do you need to do w/ NICU parents

teach and prepare them for what they are going see

what should you teach parents of NICU pts about touching their baby

use firm touch and do skin to skin

what is the most common population of pts in the NICU

preterm (before 37 wks)

what are some assessment findings that are common in preterm infants

- smaller size, no subq fat

- translucent, thin red skin, blood vessels: clearly visible

- limp posture; poor muscle tone

- weak/ absent suck

- abundant vernix & lanugo

- immature ears and genitalia

- little energy and decreased ability to cope w/ stressors

- may have periodic apnea/ bradycardia episodes

what is the gold standard machine that needs to be used for getting BP in a NICU pt

indwelling arterial catheter/ umbilical arterial catheter (UAC)

how do you choose the correct size for a newborn BP cuff

measure the newborn's extremity circumference: cuff should be half the circumference

what should the MAP be for a newborn

equivalent to gestational age (25 wks = 25 MAP)

what are some considerations for newborns BP

- 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 (coarcation of aorta)

- usually a bit higher in lower extremities

what are the different lines a newborn can get feedings

- PIVs or central lines

- UAC/ UVC

- PICC line

what does TPN look like

clear fluid and made of dextrose

what do lipids look like

white and fatty

what are the considerations for giving enteral feedings

- via NG/ OG tube

- start low and go slow

what type of milk is best for a newborn

breast milk

what should you do for moms who are breastfeeding

support them

what are some things you need to do/ look out for when assessing the nutrition of a NICU pt

- strict i/o

- weigh diapers, count feedings,

- babies show interest in bottle feeding around 34 wks

- look out for nonnutritive sucking (NNS): makes them feel full but no nutrition

how does skin breakdown occur in NICU pts

from tubes touching the skin

what is a NICU pt at risk for if they have skin breakdown

nosocomial infection

how do you prevent skin breakdown in NICU pts

- bathing every 3 days

- protective tape or barrier is used under standard tape

how do you promote development in NICU pts

- reduce noise

- promote sleep

- decrease lighting at night/ during naps and increase during day

- limit the amount of times you handle them (cares usually every 3 hours or 6 for high acuity babies)

- positioning: turn q3hr

almost all infants born before __ wks develop RDS

28

what causes RDS

- underdeveloped lungs and surfactant deficiency

- lack of surfactant cause alveoli to collapse

what are the s/s of RDS

- grunting

- nasal flaring

- retractions

- cyanosis

- tachypnea, decreased breath sounds

- respiratory or mixed acidosis

- apnea

if a mom has impending preterm delivery, what can you give them to help prevent the baby from getting RDS

2 IM injections of betamethasone (helps mature babies lungs)

what are some nursing actions you can do for a NICU pt w/ RDS

- humidified O2 through different types of respiratory support

- give surfactant (curosurf): give up to 3 doses

what are the adverse effects of surfactant (curosurf)

pulmonary hemorrhage after 3 dose

how do tx pulmonary hemorrhage due to surfactant (curosurf)

epi

what is bronchopulmonary dysplasia (BPD)

chronic lung disease d/t mechanical ventilation for a long time

how do you dx BPD/ Bronchopulmonary Dysplasia

newborn becomes dependent on O2 therapy past 36 wks gestation

what should you teach parents about their NICU babies w/ BPD

- DC home w/ O2 nasal cannula: teach how to work

- babies usually come off of O2 w/in the year

what are apnea of prematurity/ apnea and bradycardia spells s/s

apnea longer than 20 s accompanied w/ cyanosis, abrupt pallor, hypotonia, bradycardia, and O2 desats

what should you set monitor to alarm for when it comes to apnea of prematurity

- apnea

- O2 desaturation

- bradycardia

how many different grades are there of apnea of prematurity

4 (1-4)

what are the interventions for apnea of prematurity based on

amount of stimulation needed based on what grade or if alarms are going off: assess baby and try and do the minimum to see if baby can breathe on their own

how do you tx/ prevent apnea of prematurity

- caffeine w/ a loading dose and a maintenance dose every day (IV or PO)

- spell count down to see if they can go home (need to be 5 days free from a spell before they leave)

what is PDA

opening persists between the aorta and pulmonary artery

what type of murmur is heard in PDA

continuous machinery like murmur

what is the tx for PDA

- endomethasone: a prostaglandin inhibitor & NSAID that promotes ductal constriction (increased risk for necrotizing entercolitis)

- cardiac cath or sx

when does acute intracranial hemorrhage usually occur

newborns <32 wks gestation at birth: must be placed on an IVH protocol

what are the 2 types of acute intracranial hemorrhage

- intraventricular hemorrhage (IVH): graded 1 to 4 and need a head CT

- periventricular leukomalacia (PVL)

when do most bleeds occur in acute intracranial hemorrhage

w/in 72 hrs of life

how do you prevent acute intracranial hemorrhage

Keep oxygen levels good

Give everything through a pump

Slide the new diaper underneath them - don’t lift their legs up

Don’t suction them unless absolutely necessary

Keep head midline

Minimal stimulation so their BP doesn’t raise

what is necrotizing enterocolitis (NEC)

serious inflammatory condition of bowel mucosa and can become ischemic

what are the s/s of NEC/ Necrotizing Enterocolitis

- feeding intolerance

- vomiting (bright green)

- abdominal distention (late sign - measure Q6h)

- visible bowel loops

- bloody stools

- signs of infection (hypotension, temp instability, periods of apnea)

- irritability, lethargy

if any s/s of NEC are noticed, what needs to happen

- hold feedings (get TPN and lipids, need NG or OG tube for bowel decompression via suction)

- may need sx (ostomy) which is later removed later on in life

what can you give to a baby with NEC to help protect the intestines and is easily digestable

colostrum/ breast milk

what is the mortality rate of NEC

30%

what are the long term complications of NEC

short gut syndrome

what causes retinopathy of prematurity (ROP)

in the mid-20th century, a common practice in the NICU was the high concentration of O2 in incubators, which was the leading cause of blindness in children during this period

what are the risk factors of ROP

- RDS

- premature babies

- high intensity lighting

how can you prevent ROP

- wean infant off O2 ASAP

- avoid high concentrations of O2 unless necessary

- dim lights and decrease environmental stimuli

- need an eye exam

what does a post term baby look like

- may or may not be large for gestational age

- may have lost weight in utero because of declining placental ability to transport nutrients and O2

- general muscle wasting may be evident

- meconium stained cord

- peeling of the skin

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

- fingers appear long, often peeling

what cause meconium aspiration syndrome (MAS)

compromised fetus passes meconium in utero due to hypoxia/ stress and aspirates

what are the s/s of MAS

stained skin/nail/cord

initial respiratory distress/cyanosis

barrel chest

what condition gets progressively worse over what _____ of time

MAS
first 12-24 hrs

what are the complications of MAS

- RDS

- pneumothorax

- surfactant deficiency

- PPHN (persistent pulmonary HTN in newborns)

what is the tx for MAS

- chest PT

- CPAP

- O2

what is the goal of tx for MAS

prevention of worsening condition (amnioinfusion, suctioning at delivery)

what causes persistent pulmonary HTN 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

what is another name for PPHN

persistent fetal circulation

what are the s/s of PPHN

Brief respiratory distress at birth and then responds normally. By 12 hours after birth:

- central cyanosis and tachypnea

- grunting and retractions

- possible audible murmur because of tricuspid insufficiency

- BP usually remains normal

what is the tx for PPHN

- sedation

- aggressive respiratory and BP management

- environmental modifications

- inhaled nitric oxide

- ECMO

what is inhaled nitric oxide (iNO)

a potent vasodilator

when should iNO be used

- dilates the pulmonary vessels

- if baby needs to be hooked up to bag and mask, hook it up to this

what is high frequency oscillating ventilation (HFOV) used for

used for PPHN but also prematurity (surfactant deficiency)

what frequency amount if used in HFOV

600-900 breaths per min

what are some nursing considerations for HFOV

- make sure there is a chest wiggle

- use earmuffs for hearing protection on the baby

what is an ECMO machine

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

when is ECMO used

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

- for certain conditions: MAS, PPHN, congenital diaphragmatic hernia, congenital heart defects, and severe pneumonia

what is the success rate of ECMO

80%

what are the contraindications for ECMO

newborns <34 wks or 2000 g because of the need for heparin during the process, which could cause cerebral hemorrhage

what are some criteria for a high risk newborn classification

- preterm or postterm

- small for gestational age (SGA)

- large for gestational age (LGA)

- low birth weight (LBW)

- very low birth weight (VLBW)

- extremely low birth weight (ELBW)

what causes SGA

IUGR

what are the different types of IUGR

- asymmetrical/ headsparing (head and length is normal but wieght is low; appear wasted; caused by uteroplacental diminishment or poor nutrition)

- symmetrical (weight, head, and length are below the 10th percentile; caused by congenital or infections or drugs and have more long term complications)

what are the s/s of SGA

- wasted muscle tissue

- lack of brown fat

- scaphoid abdomen

- long finger nails

- meconium stained cord

what conditions affect SGA in newborns

temperature instability

higher response to pain

at risk for hypoglycemia

how do you dx LGA

- weight is above 90th percentile: protocol is initiated if baby is above 4000 g (8 lbs 14 oz)

- US

what causes LGA

- maternal IDM

- maternal obesity

- multiparity

- heredity/ ethnicity

- certain congenital anomalies

what are the complications of LGA

Birth trauma related to CPD & 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 is the leading cause of litigation and malpractice suits in OB

birth injuries

what do birth injuries cause

increase neonatal morbidity/ mortality

why are most birth injuries avoidable

conditions can be diagnosed and prevented via c section

what do you tx birth injuries

most resolve w/ or w/out tx: few are fatal

what are the different types of birth injuries

- skeletal fractures: skull, clavicle, humerus, femur

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

- neurologic injury: intracranial hemorrhage (prematurity increases risk)

what is brachial plexus injury (BPI)

nerve injury

what are the s/s of BPI

- erb's palsy in the face

- shoulder dystocia or difficult birth

- affected limb is limp at side and hand abducted and rotated internally

how do you tx BPI

- lasts 3 to 6 mths

- OT/PT consult

- supportive swaddling

- baby sling

what is a common cause of a clavicle fracture

shoulder dystocia

what are the s/s of clavicle fracture

- limp arm

- asymmetrical moro reflex

- crepitus

how do you handle/ tx clavicle fractures

- supportive care w/ gentle handling

- swaddling in blanket

- baby sling

what are some risk groups for transient tachypnea of the newborn (TTN)

LGA

infants of a diabetic mother (IDM)

late preterm infants (born between 34-36 wks)

what causes TTN

delayed clearance of fetal lung fluid and causes air trapping/ hypoxia

what are the s/s of TTN

- RR of 60 to 120 per min (tachypnea)

- grunting, retracting, nasal flaring

- cyanosis may be present

how do you dx TTN

blood gas showing respiratory acidosis and CXR showing residual fetal lung fluid