nursing care of the newborn with special needs (preterm and post-term)

postterm newborn

• inability of placenta to provide adequate oxygen and nutrients to fetus after 42 weeks

• nursing assessment: typical characteristics

  • dry, cracked, wrinkled skin; possible meconium stained

  • long, thin extremities; long nails; creases cover entire soles of feet

  • wide-eyed, alert expression

  • abundant hair on scalp

  • thin umbilical cord

  • limited vernix and lanugo

perinatal asphyxia - postterm

• living in hypoxic environment prior to birth due to placental insufficiency, leaving little to no oxygen reserves available to withstand stress of labor

• poor tolerance to stress of labor, frequently leading to acidosis

• placental deprivation or oligohydraminios, leading to cord compression and subsequent reduction in perfusion to fetus

complications associated with postterm newborn

• perinatal asphyxia (caused by placental aging or o

• oligohydraminios)

• hypoglycemia (caused by acute episodes of hypoxia related to cord compression which exhausts carbohydrate reserves)

• hypothermia (caused by loss of subcutaneous fat)

• polycythemia (caused by an increased production of rbcs to compensate for a reduced oxygen environment)

hypogylcemia - postterm

• hypoxia secondary to depleted glycogen reserves

• placental insufficiency secondary to placental aging contributing to chronic fetal nutritional deficiency further depleting glycogen stores

hypothermia - postterm

• associated with depleted glycogen stores, poor subcutaneous fat stores, and disturbances in cns thermoregulation due to hypoxia

• increased risk for acidosis and hypoglycemia secondary to metabolic stress

• loss of subcutaneous fat secondary to placental insufficiency

• use of stored nutrients for nutrition due to lost ability of placenta to nourish fetus

• subsequent wasting of subcutaneous fat, muscle, or both

• loss of natural insulation (subcutaneous fat) important in temperature regulation

nursing implications for hypothermia - postterm

• maintain a neutral thermal environment to promote stabilization of newborn’s temperature

• assess skin temperature and respiration characteristics

• monitor abgs and blood glucose levels

• eliminate sources of heat loss

  • dry newborn thoroughly

  • wrap in warmed blanket with stockinette cap on head

  • use radiant heat source

nursing implications for hypothermia

• monitor blood glucose levels, initially on arrival to nursery and hourly thereafter

• maintain fluid and electrolyte balance

• watch for subtle changes

• initiate early oral feedings if possible; if not, administer iv infusion with 10% dextrose in water

polycythemia - postterm

• intrauterine hypoxia triggers increased rbc production to compensate for lower oxygen levels

nursing implications for polycythemia

• ensure adequate hydration (orally or iv)

• monitor hematocrit levels (goal is 60%)

• administer partial exchange transfusion, albumin, or normal saline iv to reduce rbc volume and increase fluid volume (controversial)

meconium aspiration - postterm

• commonly associated with chronic intrauterine hypoxia

• struggling by fetus makes respiratory efforts and bearing down with abdominal muscles, leading to expulsion of meconium into amniotic fluid

• normal sucking and swallowing by fetus elads to meconium filling airways

nursing implications for meconium aspiration - postterm

• initiate resuscitation measures as necessary

• suction airways and support ventilation

hypoglycemia overview

• with the loss of placenta at birth, the newborn now must assume control of glucose homeostasis through intermittent oral feedings

• initiate breastfeeding as soon as possible; otherwise, formula feed the infant on demand

• if oral feedings are not accepted, a buccal dextrose gel or an iv infusion with 10% dextrose in water may be needed to maintain the glucose level above 40 mg/dL

polycythemia overview

• hyperviscosity results from the increased number of rbcs

• poor perfusion to organs occurs with hyperviscosity and is associated with long-term motor and cognitive neurodevelopmental disorders

• observe for clinical signs of polycythemia

  • ruddy skin

  • abdominal distention, vomiting, and poor feeding

  • cyanosis and tachycardia (less common)

  • tachypnea, weak suck reflex, jaundice, lethargy, hypotonia, irritability, jittery

• monitor hematocrit as ordered

• newborns with symptoms and with a hematocrit of 70% or less may simply be supported with adequate fluid intake, close observation, and a repeat hematocrit level in 12 hours

• if the newborn shows symptoms, a partial plasma exchange transfusion may be needed to decrease the viscosity of blood and relieve symptoms

signs and symptoms of hypoglycemia

• lethargy

• tachycardia

• respiratory distress

• poor feeding

• diaphoresis

• hypothermia

• weak cry

• hypotonia

preterm newborn

• body system immaturity affecting transition to extrauterine life, increasing risk for complication

  • respiratory system

  • cardiovascular system

  • gi system

  • renal system

  • immune system

  • central nervous system

effect of prematurity on body systems

• cns

  • hypothermia due to a relatively larger body surface area and heat production instability

  • unable to shiver

  • lack flexion and muscle tone

  • flaccid

• immune system

  • deficiencies in igg

  • impaired ability to develop antibodies

  • thin and fragile skin

  • weak blood vessels

  • immature immune system

  • infection

• glucose abnormalities

• retinopathy of prematurity related to immature retinal vascularization

• respiratory

  • respiratory issues due to surfactant deficiency

  • apnea as a consequence of immature respiratory control

• cardiovascular

  • patent ductus arteriosis

  • hypotension

  • intraventricular hemorrhage related to the preterm infant’s fragile germinal matrix

  • anemia (preterm infants have lower levels of circulating hemoglobin at birth as compared with term infants)

• gastrointestinal

  • blood is shunted to brain and heart which can lead to gastrointestinal ischemia and damage to intestines

  • small stomach capacity, limited absorption in the gut

  • feeding difficulties, lack the ability to suck and swallow

  • necrotizing enterocolitis

  • slow growth

• renal

  • less able to concentrate urine

  • slow gfr

  • retain fluid

  • risk for electrolyte imbalance

  • increased risk for drug toxicitity

preterm characteristics

• weight < 5.5 lb

• scrawny appearance

• poor muscle tone

• minimal subq fat

• undescended testes

• plentiful lanugo

• poorly formed ear pinna

• fused eyelids

• soft spongy skull bones

• matted scalp hair

• absent to few creases in soles and palms

• minimal scrotal rugae; prominent labia and clitoris

• thin transparent skin

• abundant vernix

promoting oxygenation in the preterm infant

• preterm infant lacks surfactant which lowers surface tension in the alveoli and stabilizes them to prevent their collapse

• inability to initiate and establish respirations leads to hypoxemia, acidosis, and hypercapnia

• failure to initiate extrauterine breathing or failure to breathe well after birth leads to hypoxia

  • the heart rate falls, cyanosis develops, temperature decreases, blood pressure decreases, and respirations are altered (apnea, tachycardia, retractions, grunting, and nasal flaring)

• if the newborn does to not respond to tactile stimulation with effective respirations or vigorous crying, position and clear the airway, then immediately provide positive-pressure ventilation

promoting optimal nutrition

• obtain blood glucose measurements upon admission to the nursery and every 1 to 2 hours to evaluate for changes

• initiate early oral feedings or gavage feedings

• if oral or gavage feedings aren’t tolerated, initiate an iv glucose infusion

• assess skin for pallor and sweating

• assess neurologic status for tremors, seizures, jitterness, and lethargy

• monitor weight daily

• maintain temperature using warmed blankets, radiant warmer, or warmed isolette

• monitor temperature

• cluster care and provide rest periods

maintaining thermal regulation

• frequently assess temperature every hour

• encourage immediate skin-to-skin contact after birth

• observe for signs of cold stress: respiratory distress, central cyanosis, weak cry, abdominal distention, apnea, bradycardia, and acidosis

clinical manifestations of infection

• increase in apnea

• respiratory distress

• increased need for respiratory support

• hypotonia

• lethargy

• poor feeding

• temperature instability

• hypotension

• tachycardia

interventions to prevent infection

• monitor for changes in vital signs such as temperature instability, tachycardia, tachypnea, or decreased oxygen saturation

• assess for feeding intolerance, which can be an early sign

• encourage skin-to-skin contact

• avoid using tape

• use equipment that can be discarded

• adhere to standard precautions

• use sterile gloves in invasive procedures

• avoid coming to work ill

• remove all jewelry on your hands prior to washing

manifestations of pain in the newborn

• sudden high-pitched cry

• facial grimace with furrowing of brow and quivering chin

• increased muscle tone

• oxygen desaturation

• increase in heart rate

• body posturing, such as kicking, squirming, and arching

• limb withdrawal and thrashing movements

• increase in heart rate, blood pressure, pulse, and respirations

• fussiness and irritability

cries tool

• evaluates cry, oxygen requirement, increased vital signs, expression, and sleeplessness

non-pharmcological techniques for pain

• gentle handling, rocking, caressing, cuddling, and massaging

• rest periods before and after painful procedure

• kangaroo care (skin to skin) during procedure

• breastfeeding

• use of a facilitated tuck (holding arms and legs in a flexed position)

• application of topical anesthetics prior to venipuncture or lumbar puncture

• nonnutritive sucking (pacifier dipped in sucrose) prior to procedure

• minimal use of tape with gentle removal

• warm blankets for wrapping

• reduction of environmental stimuli

• distractions such as with colored objects or mobiles

meconium aspiration syndrome

• serious condition that occurs when newborn inhales particulate meconium mixed with amniotic fluid into the lungs while still in utero or when taking the first birth after birth

• induces airway obstruction, surfactant dysfunction, hypoxia, and chemical pneumonia with inflammation of pulmonary tissues

nursing assessment for meconium aspiration syndrome

• assess the amniotic fluid for meconium staining when the maternal membranes rupture

• green-stained amniotic fluid suggests the presence of meconium in the amniotic fluid and should be reported immediately

• after birth, note any yellowish-green staining of the umbilical cord, nails, and skin

  • this staining indicates meconium has been present for some time

• symptoms

  • barrel-shaped chest

  • progressive respiratory distress including cyanosis

  • marked tachypnea which progresses to significant respiratory distress

  • intercostal and subxiphoid retractions

  • end-expiratory grunting

  • coarse crackles and rhonchi

meconium aspiration syndrome diagnostic findings

• chest x-ray shows streaky linear densities progressing to patchy infiltrates with a flattened diaphragm and marked hyperaeration

• metabolic acidosis

• atelectasis

nursing management for meconium aspiration

• suctioning at birth

• supplemental oxygen to maintain 95% to 98%

• neutral thermal environment

• ensure adequate nutrition and fluid balance

• provide continuous reassurance and support to the parents

hyperbilirubemia

• a total serum bilirubin level above 5 mg/dL resulting in jaundice

• jaundice is a yellowish discoloration of the skin and sclera of the eyes caused by the deposition of bilirubin in those areas when increased levels of unconjugated bilirubin exist in the newborn’s circulation

• newborns produce large quantities of bilirubin which is a byproduct of the breakdown of rbcs

• processed in the liver and normally excreted out of the body in the urine and stools

physiologic jaundice

• bilirubin levels reach a high enough level after 24 hours of age to manifest as jaundice, peaking on the third to fourth day life

• early onset breast feeding jaundice

  • not breastfeeding enough

• late onset breast feeding jaundice

  • related to changes in composition of breast milk, may need to supplement with formula

• early frequent feedings can provide the newborn with adequate calories and fluid volume (via colostrum) to stimulate peristalsis and passage of meconium to eliminate bilirubin

pathologic jaundice

• refers to the development of jaundice within the first 24 hours of life, regardless of gestational age

• hemolysis due to rh isoimmunization or abo incompatibility, metabolic or respiratory acidosis, and congenital inherited defects of enzyme

• kernicterus results when free bilirubin crosses the blood brain barrier adn binds to brain tissue, resulting in selective brain damage

  • chronic bilirubin encephalopathy

nursing assessment for jaundice

• neonatal jaundice first becomes visible in the face and forehead, identified by gentle pressure on the skin, since blanching reveals the underlying color

• spreads in a cephalocaudal manner

nursing management for jaundice

• documentation of the timing of onset of jaundice is essential to differentiate between benign (later than 24 hours) and significant (earlier than 24 hours) hyperbilirubemia

• ensure newborn feeding (breast milk or formula) occur every 2 to 3 hours to prompt emptying of bilirubin from the bowel

• encourage breastfeeding (at least eight feedings per day)

• check for at least six wet diapers daily and a transition to at least four yellow, seedy stools

phototherapy

• cover the newborn’s genitals and shield the eyes

• turn every two hours

• remove for feedings

• assess temperature every FOUR hours

• monitor fluid intake and intake/output

• encourage breast or bottle feeding every 2-3 hours

• check skin turgor for evidence of dehydration

• monitor stool for consistency and frequency

providing parent teaching about jaundice

• seek treatment

  • lethargy, sleepiness, poor muscle tone, floppiness

  • poor sucking, lack of interest in feeding

  • high-pitched cry

teaching guidelines - caring for a newborn with phototherapy

• inspect nb’s skin, eyes, and mucous membranes

• home health nurse will come to set up light system

• keep the lights about 12-30 in above newborn

• cover your newborn’s eyes with patches or cotton balls and gauze

• keep the newborn undressed, except for the diaper area; fold the diaper down below the newborn’s navel in the front and as far as possible in the back

• turn every two hours

• remove for feedings

• remove the eye patches during feedings

• record temperature, weight, and fluid intake daily

• document frequency, color, and consistency of all stools; should be loose and green as the bilirubin is broken down

• keep the skin clean and dry

risk factors for jaundice

• bruising at birth

• prematurity

• history of a sibling with jaundice

• inadequate breastfeeding

• hemolytic disease

• birth injury such as cephalohematoma

• polycythemia

• down syndrome

• family history of hemolytic disorder

• maternal diabetes

• male sex