Ch. 24- High-Risk Newborns: Gestational Age (10)

Topics to Review

Preterm Infant

infant born before completing 37 weeks Gestation

Low Birth Weight

Infant weighs under 5 lbs 8 oz

Small for Gestational Age (SGA)

Can be pre-, post-, or full-term

Falls below the 10th percentile in size on growth charts

SGA

• Causes

Congenital Malformation, Chromosomal Abnormalities

Fetal Infection, Maternal Illness

Poor Placental Functioning

Maternal Malnutrition

SGA

• Characteristics

Growth Variation affects Weight, Length, and Head Size

Sympathetic Growth Restriction of entire body

SGA

• Asymmetric Growth Restriction

Due to Preeclampsia in the 3rd Trimester

• head is normal but seems large for body

• Brain, Heart, Length are normal

• Weight in Low 10th Percentile

• Low abdominal Circumference bc little organs

• Dry loose skin and sunken abdomin

• thin cord

SGA

• Therapeutic Management

Prevention!!

• Screen to treat problems early (US, Biophysical Profile)

• Good prenatal care

SGA

• Nursing Considerations

Hypoglycemia!

• Caloric Care

• Early adn frequent feedings

• Temperature Regulation

Respiratory Support

OBSERVE FOR JAUNDICE

SGA Nursing Considerations

• Respiratory Support

Immature Lungs are Forced to breathe in Outside Environment

• inadequate surfactant→ Respiratory Distress Syndrome

• Apneic Spells (>20 seconds)

  • Stimulate!

  • Equipment

  • Position→ Prone-Side lying

SGA/ preterm Nursing Consideration

• Thermoregulation

SUPER thin skin, sometimes jelly looking (ew!) and blood vessels are like right at surface and little fat

• they are not all flexed so that also impedes warmth

All Causes issues with Hypoglycemia, Resp., Acidosis, etc

Hypo- and Hyperthermia are bad!

Manifestations of Hypothermia

• Poor Feeding/ Intolerance

• irritability

• lethargy

• poor muscle tone

• cool mottled skin

SGA/ Pre-term Infants

• Pain

they have to experience more procedures→ more pain obv

• Extended or repeated pain may not show behavioral signs of pain

• EDU parents on how to recognize pain signs and encourage them in relief measures

minimize handling before procedures, Do Containment

SGA/ Preterm

• Overstimulation

causes increased energy spending

interruption in sleep

→ interferes with growth and development

Touch Aversion

Signs of Overstimulation in Preterm Infants

Oxygen Changes

• BP, HR, RR

• Cyanosis, Pallor, Mottling

• Work of Breath stuff

• Dec O2 sats

Behavior Changes

• Stiff, Extended limbs

• fisting or extended hands

• arching

• alert worried expression

• Gaze Aversion

• Regurg, gagging, and hiccupping

• yawn

Gavage Tube Placement

Small catheter inserted through nose or mouth into stomach

Intermittent bolus simulates normal feeding (slowly, over 30-60minutes)

Continuous for Short Bowel Syndrome, Congenital heart Disease, Recovering from NEC

Gavage Tube Placement

• Continuous Feeding Issues/ Intervention

Higher Risk for Aspiration

germ growth

oral aversion from intubation, suction, tubes in general

• gradual increase

• pacifier use to help comfort and feeling of fullness

Macrosomia

Weighs more than 8 lbs 3oz- 9lbs 15oz

Large for Gestational Age

Commonly Born at Term, maybe pre/post

Above the 90th percentile for gestational age on Intrauterine growth charts

LGE

• Causes

Maternal Obesity/ Diabetes

LGA

• Scope of the Problem

Longer Labor

Suffer more injuries from birth

• Dystocia, Fractures, Facial Nerve Injuries

• Cephalohematoma, Subdural Hematoma

• Bruising

• Congenital head defect

• high Mortality rate

LGA

• Therapeutic Management

ID the increased size during pregnancy by measuring fundal height and US

• use vacuum, forceps, or C-section

LGA

• Nursing Consideration

Assess for Injuries, Hypoglycemia, Polycythemia

Intraventricular Hemorrhage

bleeding into and around the ventricles of the brain

• most likely in first few days of life in preemies under 3lbs 5oz

• bc

  • high or low BP

  • asphyxia

  • Respiratory Distress w/ mechanical ventilation

  • inc. or fluctuating brain flow

  • Rapid blood volume expansion

  • Hypercarbia, Anemia, Hypoglycemia

Intraventricular Hemorrhage

• Grading

1→ very small

4→ there’s ventricular dilation in brain tissue

Intraventricular Hemorrhage

• Manifestations

Lethargy

Poor Muscle Tone

Bradycardia

Deterioration of Respiratory Status

• Cyanosis or Apnea

Drop in H&H

Acidosis

Hyperglycemia

Tense Fontanel

Seizures

Intraventricular Hemorrhage

• Diagnosis

Cranial US through anterior fontanel

Intraventricular Hemorrhage

• Therapeutic Management

Series of Ultrasounds to determine progression of the problem

TX: supportive and focused on maintaining Respiratory Function and dealing with Complications

Intraventricular Hemorrhage

• Nursing Consideration

Avoid Situations that may increase the risk

• minimize handling, Stimuli, Pain,

Daily head circumference measurements

Monitor Change in Neurological status

Retinopathy of Prematurity

injury to the blood vessels in the eye leads to growth of new blood vessels that may result in visual impairment or blindness

Retinopathy of Prematurity

• Risk Factors

• Premature (under 32 weeks, under 1500g)

• High O2 supplement in blood

  • USE A PULSE OX WHEN INFANT ON O2 Supp

Retinopathy of Prematurity

• Therapeutic management

Frequency of repeated examination determined by results of screening

TX: Laser surgery to destroy abnormal blood vessels

• also, Cryosurgery or reattachment of the retina

Retinopathy of Prematurity

• Nursing Considerations

• Check Pulse Ox frequently for infant getting O2

  • O2 titrated to keep Sats within prescribed level

  • AVOID Extreme High and Lows

• Eye exams can be stressful

  • Swaddle and rest periods

  • Mydriatic Eye drops to dilate

    • Bradycardia, HTN, Apnea

• Surgery

  • assess drainage

  • ice packs

  • pain meds

Necrotizing Enterocolitis (NEC)

Serious inflammatory condition of the intestinal tract causing cellular death in areas of intestinal mucosa

Necrotizing Enterocolitis

• Risk Factors

Immaturity of Intestines

Hypoxia of intestines

Feeding too early or increased too fast

Breastmilk Can Prevent

Necrotizing Enterocolitis

• Manifestations

Things are just Rotting in there, so…

• Abdominal Girth Causing Distention

• Increased gastric residuals

• decreased or absent bowel sounds

• loops of bowel seen through abdominal wall (EW)

• Vomiting, bile-stained residuals or emesis

• abdominal tenderness and discoloration

• Blood in Stool

• Respiratory difficulties

  • apnea, bradycardia, temp. instability

  • lethargy

  • hypotension

• Signs of Infection

Necrotizing Enterocolitis

• Therapeutic Management

• ABX

• D/c Oral Feedings

• Continuous or Intermittent suction

• Parenteral Nutrition to Rest the Bowel

• Surgery if perforation or necrotic area removed

  • Ostomy

  • Short Bowel Syndrome

Necrotizing Enterocolitis

• Nursing Considerations

Early Signs like Abdominal Distention

→ HOLD Next Feeding and NOTIFY PROVIDER

IVF

Parental Feedings

I&Os

SIDE-LYING to minimize pressure on Diaphragm

Scar Tissue may cause blockages

Short Bowel Syndrome

condition caused by a bowel that is shorter than normal

• Congenital

• Surgical

Decreased mucosal SA causes inadequate absorption of Fluids, Electrolytes, and Nutrients

• 50% or more lost can result in malabsorption or deficiencies

Short Bowel Syndrome

• Manifestations

• Malabsorption

• Diarrhea

• Failure to Thrive

Short Bowel Syndrome

• Therapeutic Management

Preserve as much bowel as possible

Fluids and Electrolyte Balance Must Be Restored

TPN will be the primary source of nutrition while recovering

Enteral Feedings given ASAP to allow Intestines to Adapt to Food

Short Bowel Syndrome

• Nursing Considerations

• Manage TPN

• Enteral Feedings advanced SLOWLY while adjusting TPN; a give and take

• Careful assessment and documentation

  • feeding tolerance

  • Electrolyte imbalances

  • dehydration signs

  • nutritional deficits

  • non-nutritive sucking