OB- High risk newborn

What criteria classifies Micropreemie?

Born before 26 weeks or less than 0.8 kg

What criteria classifies Preterm (Preemie)?

36 6/7 weeks

What criteria classifies Late Preterm?

34-36 6/7 weeks

What classifies as Post term?

greater than 42 weeks

What classifies Very Small Gestational Age (VSGA)?

Below 3rd percentile

What is typically seen in a Large for gestational age infant?

• Macrosomia (weight above 4 kg)

• Infant of a Diabetic mother

• Large body, normal H/C

What are some potential problems for LGA infants?

• Hypoglycemia, hyperinsulinemia

• Birth trauma- shoulder dystocia, CNS injury

• Polycythemia

• Hyperbilirubinemia

• Poor feeding

• Thermal instability

What are some factors concerning an infant of a Diabetic mother?

• Insulin does not cross placenta

• Glucose does cross

• Fetus increases insulin production in response to mother’s high glucose levels

• Hypoglycemia may occur at birth

  • Baby keeps making insulin but glucose is shut off after birth, hypoglycemia

What symptoms will you see in an infant of a Diabetic mother?

1-2 hour post delivery

• tremors/jittery

• cyanosis

• apnea

• temp instability

• poor feeding

• hypotonic

• seizures

What are some interventions for infants of diabetic mothers?

• Control Maternal glucose

• Monitor for signs of hypoglycemia

• Early feeding

• IV if unable to PO, D10W

• Glucose monitoring q 30-60 minutes until stable, then q 24 hrs and before each feeding

• Monitor electrolytes

• Assess for congenital anomalies

What classifies Small for gestational age infant?

• Below the 10th percentile in weight or IUGR

• Can apply to preterm, term, or post-term

How will a small for gestational age infant appear?

• wasting

• decreased fat stores

• loose dry skin

• poor muscle tone

• wide skull sutures

What are some potential problems for a SGA infant?

• Increased respiratory effort

• hypoglycemia

• polycythemia

• cold stress

What can you see in a Preterm infant before 37 weeks?

• Immature CNS and other systems

• Thermoregulation problems

• Hypoglycemia

• Feeding problems

• Posture lacks flexion

• Decreased muscle tone (Hypotonia)

• Skin thin and transparent

• Lanugo

• Respirations: rapid, periodic breathing

• Abdomen: soft, slightly rounded to scaphoid

• Eyes: fused until b/w 25.5- 26.5 weeks

• Ears: Pinna flat w/out cartilage, folded

What can you see with an infant born after 42 weeks?

• Can be SGA or LGA

• Deep creases over soles of feet

• thick ear cartilage

• no lanugo

• Increased risk for meconium aspiration

• Uteroplacental insufficiency

• Increased mortality risk

What is Intraventricular Hemorrhage?

bleeding into the fluid-filled areas, or ventricles, surrounded by the brain (Google)

• Primarily related to prematurity

• 90% occurs w/in first 72 hours of life

• Can cause long term developmental delay

What are the clinical manifestations of Intraventricular hemorrhage?

• possibly none

• hypotonia

• increased HR

• low BP

What is Hypoxic Ischemic encephalopathy?

a type of brain injury caused by a lack of oxygen and blood flow, often occurring before, during, or after birth (Google)

What are the possible causes of Hypoxic Ischemic Encephalopathy?

Inutero abruption, Cord issue, resuscitation at birth

• newborn is limp, cyanotic, bradycardia, and apnic upon initial assessment

How to you treat Hypoxic Ischemic Encephalopathy?

head and body cooling

What is Menigocele?

Protrusion of sac from spine that contains meninges and spinal fluid

What is Myelomeningocele?

Sac like cyst that contains meninges, spinal fluid and a portion of spinal cord and nerves

What nursing measures are needed with Menigocele/Myelomeningocele?

• Sensory motor function depends on location

• Latex allergy

• Possible loss of movement/sensation in lower extremities

• Nerogenic bladder/Constant dribble of stool

• Clubbed feet is common

• Repaired w/in 24-48 hrs

• May develop Hydrocephalus after surgical repair, monitor H/C

What is the clinical presentation of Hydrocephalus?

Large head

• widened sutres

• full/fontanelles

• sun setting eyes

• vomiting, lethargy, irritablilty

• Visible scalp veins

• ING can cause post-hemorrhagic hydrocephalus

• Could be after myelo closure

How do you treat Hydrocephalus?

• EVT (endoscopic third ventriculostomy)

• VAD (Ventricular access device)

• VP shunt (Ventricular peritoneal shunt)

Educate families of shunt malfunctions and infections

• irritability, vomiting, increased H/C, lethargy, change in feeding

What is seen w/ Transient Tachypnea of the Newborn?

• Most common in LGA, Post term, c-section infants

• RR >60 up to 80-100

• Shorty after birth: grunting, nasal flaring, retractions, cyanosis

• Improves in 12-72 hrs

What interventions are done for Transient Tachypnea of the Newborn?

Supportive treatment including IV fluids and supplemental O2

What is Meconium Aspiration Syndrome (MAS)?

occurs when a newborn breathes in a mixture of meconium (first stool) and amniotic fluid into their lungs, usually around the time of delivery

What are the risk factors for Meconium Aspiration Syndrome (MAS)?

• Post-term newborns

• long labor

• Maternal Smoking/diabetic/chronic CV disease or hypertension

• IUGR

What is the clinical presentation of Meconium Aspriation Syndrome?

• Pachypneic w/ rales

• grunting, flaring, retracting, lower apgars

• Barrel shaped chest

• Meconium stained skin, nails, umbilical cord

What interventions are needed for Meconium Aspiration Syndrome?

If distressed:

• Resuscitation w/ 100% O2

• Direct tracheal suctioning (decompression)

• Mechanical ventilation

• High frequency oscillation

• Surfactant

• Antibiotics for infection

• Maintain pulmonary blood flow w/ volume expanders and vasopressors

• PPHN (persistent pulmonary hypertension of newborn): Nitric Oxide, ECMO

What is the cause of Respiratory Distress Syndrome (RDS) in the Newborn?

• surfactant deficiency

• structural immaturity

What are the clinical presentations of Respiratory Distress Syndrome?

• Tachypnea, grunting, flaring, retractions

• Poor lung compliance

• Hypotension

• Altered electrolytes

What are some interventions for Respiratory Distress Syndrome?

• Monitoring

• Cardiorespiratory monitoring

• Pox

• Co2

• Correct acidemia, reduce hypoxemia

• Antenatal corticosteroids

• Supplemental oxygen and ventilation

• Exogenous surfactant

• Administered intra-tracheal via ETT

• Monitor for pneumothorax and airway obstruction

• Wean oxygen and ventilation as indicated

• Remember to involve and inform family: mother may still be receiving medical care

How would you give Surfactant/Curosurf?

• Infant may be intubated: Surfactant is given via ETT

• Position infant flat and midline

• pre-oxygenate and suction

• Initial dose given in 2 aliguots

• Rapidly admin half the total dose (one aliquot)

• Immediately manual bag patient for 1 minute

• Repeat w/ second aliquot

• immediately manually bag pt for 1 minute

• do not rotate pt side to side, keep pt flat and midline

• do not suction pt for at least 1 hr after dose is given

What is the acceptable oxygenation level for a preemie <28 6/7 weeks gestation?

83-93%

What is the acceptable oxygenation level for an infant of 29-33 6/7 weeks gestation?

85%-95%

What is Bronchopulmonary Displasia (BPD)?

Chronic lung disease of prematurity

What causes Bronchopulmonary dysplasia?

• chronic lung disease following neonatal lung injury

• barotrauma

• RDS, PPHN

What physical manifestations can be seen with Bronchopulmonary dysplasia?

• hypoxia

• hypercarbia

• growth failure

• pulmonary hypertension

• Cor pulmonale and right sided HF

What are some Bronchopulmonary dysplasia complications?

• Increased mortality

• Chronic Respiratory infections

• Home O2

• PPHN

• Features and rickets

• Neordevelopmental sequelae

How do you manage Bronchopulmonary dysplasia?

• Prevent development of BPD

• Prevent & manage hypoxia/hypercarbia

• Lowest oxygen and ventilator settings tolerated

• corticosteroids

• chronchodilators

• CPT, positioning, suctioning

• Nutrition

• Increased caloric intake

• Co-existing conditions

• GE reflux, emesis, fatigue, oral aversions

• EMOTIONAL SUPPORT, home care, respite care

What is Persistent Pulmonary Hypertension (PPHN)?

Persistent fetal circulation

• right to left shunt away from lungs and through ductus and PFO, bypasses lungs

• Causes hypoxemia and acidosis stimulating pulmonary vasoconstriction and increased PVR

• Common etiology: hypoxia, asphyxia, bacterial sepsis

How do you treat Presistent Pulmonary Hypertension?

• oxygenation

• ventilation

• niric oxide (pulmonary vasodilator)

• Volume expanders

• vasopressors

• after load reducers

• hemodynamic support

• ECMO

What are some nursing considerations with a UAC (umbilical Artery catheter)?

• Draw frequent blood samples/ ABGs

• Continuously monitor BP

• Monitor Cap refill of fingers, toes, and bottom- alert provider and prepare to pull if change occurs

What are some nursing considerations with a UVC (umbilical Venous catheter)

• goes into vein of umbilical cord

• IV fluids, nutrition, medications, gtts

What are the symptoms of an infant w/ a patent ductus arteriosus?

• unstable BP, widened pulse pressure, bounding PP, murmurs

• Increased O2 requirements, singing SpO2, metabolic acidosis

What are some interventions for Patent ductus arteriosus?

• Fluid restrictions

• Diuretics

• Respiratory support

Close the PDA

Prostaglandin Synthetase Inhibitors

• Indomethacin or Ibuprofen

• Tylenol

• Surgical ligation

What are the symptoms of Feeding Intolerance?

• Emesis

• Distension

• Bowel loops

• Decreased bowel sounds

• Irritability/lethargy

What are some indications of Feeding Intolerance?

• Necrotizing enterocolitis

• Sepsis

• Acidosis

What is typically the cause of Necrotizing Enterocolitis?

• Ischemia, bacterial colonization of bowel, enteral feedings

• Most common < 29 weeks gestation

• Hypoxia, Necrosis

• 90% of cases occur in Preterm infants

What are the s/s of Necrotizing Enterocolitis?

• Abdominal Distention/shiny discoloration

• Bilious Emesis

• Bloody stools

• Decreased bowel sounds

• Temp instability

• Poor perfusion

• Metabolic acidosis/respiratory distress

• Hypotension

What are some Necrotizing Entercolitis interventions?

• Emergency

• Stop feedings immediately

• Decompress Abdomen

• Frequent CBC/CMP

• Respiratory support

• Abdominal exam frequently

• Septic work up and antibiotics (Possible perforation)

• Surgical resection or drain placement

What is Acute Bilirubin Encephalopathy?

Bilirubin is deposited in the brain, can result in permanent damage

What is Kernicterus?

Irreversible, bilirubin toxicity, develops severe cognitive impairments, hypotonia, and quadriplegia

What are some risk factors of hyperbilirubinemia?

• Increased RBC production or breakdown

• Rh or ABO incompatibility

• Decreased liver function

• Prematurity

• TSB at 12 hrs <9.0

What are the physical manifestations of Hyperbilirubinemia?

• yellow skin, scleria, mucosa membranes

• Bilirubin labs- elevated serum bilirubin

• hypoxia, hypothermia, hypoglycemia

What interventions are needed for hyperbilirubinemia?

• monitor vitals

• Phototherapy-maintain eye mask, keep undressed, avoid lotions

• Observe for effects of phototherapy- Dehydration, rash, bronze coloration, elevated temp

• Maintain/monitor fluid status

• Encourage parent bonding, explain phototherapy, and reason for loose greenish stool

• Possible exchange transfusion

What is retinopathy of Prematurity

• Abnormal vascularization of retina

  • too much oxygen

  • damage causes overgrowth or regrowth

• Generally LBW Preterm infants

• Outcomes: blindness

How do you prevent Retinopathy of prematurity?

Cautious use of oxygen

How do you treat Retinopathy of prematurity?

Laser photocoagulation or avastin

What is Apnea of Prematurity?

• Apnea in newborn <37 weeks

• 20 seconds or longer or for less than 20 seconds assoc w/ cyanosis, pallor, or bradycardia

• Immature CNS

• Incidence decreases w/ gestational age

What interventions are needed for Apnea of Prematurity?

• Assessment/Close monitoring

• Prone positioning

• Gentle stimulation back or front

Document:

• duration, HR, O2 sat

Interventions:

• caffeine, theophylline

• Respiratory support

• Family support/community care

What can cause Neonatal Sepsis?

• Birth to 28 days

• Immature immune systems

• Inability to localize

• Poor inflammatory response

• Ineffective phagocytosis

• Lack of IgM immunoglobin

What physical manifestations might be seen w/ Neonatal Sepsis?

• May rapidly deteriorate in first 12 hrs post-delivery

• Subtle behavioral changes

• Lethargy/irritability

• Color change: pallor/dusky/cyanosis/mottling

• Skin cool and clammy

• temp instability

• hypothermia, rarely hyperthermia

• tachycarida

• later apnea/bradycarida

• Feeding intolerance

• vomiting, diarrhea, abd distention

• poor suck, disinterest

• hyperbilirubinemia

What interventions are needed for Neonatal Sepsis?

• Broadspectrum antibiodic therapy as soon as cultures are obtained

  • Ampicillin

  • Cefotaxim (Claforan)

  • Zosyn

  • Meripenum

• Supportive

  • Respiratory

  • Hemodynamics

  • Nutrition

  • Metabolic

How do you prevent Neonatal Sepsis?

• Strict handwashing

• Use of isolette

• Visitation restriction to unnecessary personnel

• Clean equipment and incubators weekly

• Aseptic technique

• Supportive Care

• Neutral Thermal Environment

• Respiratory

• Cardiac (anemia, hyperbilirubinemia, HR, BP)

• Nutrition

• Fluid and electrolyte

What are the signs of Hyperthermia?

• Elevated temp

• Tachycardia

• Tachypnea

• Ruddy skin color

• Increased metabolism

• Always check temp before calling provider

What are the signs of Cold stress related to hypothermia?

• pale, acrocyanosis, cyanosis, mottling

• Respiratory Distress (nasal flaring)

• Apnea and/or bradycardia

• Lethargic/hypotonic

• Feeble cry

• Poor feeding

What interventions are needed for hypothermia/Cold stress?

Neutral Thermal Environment (isolette)

• Servo control skin probe

• Radiant warmer

• Double walled Isolette

• Humidity

Other interventions

• Use warm blankets/swaddling

• Allow skin to skin care when possible

• Keep skin dry and cover head w/ cap

• Cover baby w/ plastic/Polyethylene wrap

• Warm and humidify oxygen

• Use a skin probe to regulate temp

What are some stress cues?

• hiccupping, yawnings, sneezing, frowning

• looking away, squirming, frantic, disorganized activity

• arms and legs pushing away

• arms and legs limp and floppy

• skin color changes

How would you properly position an infant?

• Neutral head position (prevent misshapened head/torticollis)

• Rounded shoulders

• Hips and knees flexed

• Toes pointed stright

• Hands to mouth

• Boundaries provided appropriately

• Mimic the fetal position (lacing in Preterm)