high risk newborn - preterm infant

full term infant

39 0/7- 40 6/7

preterm infant

<37 weeks

late preterm: still at risk for complications
-34-36.6 weeks
-physical characteristics
-physiologically and metabolically immature
-interventions and nsg care

very perterm: 28-32 weeks

extremely preterm: <28 weeks

post term

42+ weeks

chronological age

how old based on delivery date

corrected age

how old should be based on EDD

28 weeks at 6 months old, so 12 weeks = 3 months

birth weight

classification based on gestational age

SGA: small for gestational age; <10%

LGA: large for gestational age; >90%

AGA: appropriate for gestational age

low birth weight (LBW): <2500grams

very low birth weight (VLBW): <1500grams

extremely low birth weight (ELBW): <1000grams

smaller they are, more at risk for complications

intrauterine growth restriction (IUGR)

failure to grow normally while in uterus

vascular impairment, decreased placental perfusion, decreases supply of glucose and oxygen to fetus

symmetric IURG: long-term exposure so more detrimental ; early in pregnancy.

asymmetric IUGR: occurs later in pregnancy, head continues to grow

preterm characteristics

poor muscle tone

large head compared to rest of body

minimal subcutaneous/white fat; at risk for skin tears; shift weight

thin red and translucent skin

nipples and areola barely noticeable

vernix abundant

lanugo none in extremely preterm then to abundant

plantar creases absent in less than 32 weeks

pinnae of ears soft and flat with recoil, lack cartilage

female/male not developed

skin: protectants

physiologic immaturity

adaptation struggles

increased complications; decrease surfactant = compromised respiratory

bathing consideration; could stress them out

position considerations; skin breakdown

erythema toxicum; normal newborn rash. newborns don’t get this so if have a rash = infection

preterm infant - pain

signs for pain in preterm infants; VS changes, color change, may cry, grimace, furrow brow but depends on what baby can do

consequences of pain; brain hemorrhage

nsg considerations: holding, skin to skin, suck, give meds

preterm infant - stress

lack ability to select, control, and properly process stimuli

easily exhausted by environment stimuli; lights, touch

easily exhausted by routine activities

overstimulation

short term effects: apnea, increased O2 consumption, alterations in O2 sat, HR variability, altered nutrition, altered growth, sleep disturbances, increased ICP (brain hemorrhages)

long term effects: montor development, coordination of movement, and adaptive behaviors

stress limiting interventions

schedule care: follow infant cues, cluster care

reduce stimuli: ear muffs, private rooms/cover incubators, low voice tone, low lights

promote rest

promote motor development: nesting to promote flexed positioning, position changes

NIDCAP: newborn individualized developmental care and assessment program: promote individualized relationship-based care involving family members to decrease stress

preterm infant - thermoregulation

increased risk of cold stress
5-6 times more likely to lose body heat than an adult; less subcutaneous fat, less flexion of extremities, thinner skin, blood vessels closer to surface, decreased ability to vasoconstrict

cold stress is fatal to preterm infants

artificial means of thermoregulation: kangaroo care (skin to skin), radiant warmer, incubator

preterm infant - immune system

preterm infants increased risk for infection
-decreased IgG from mother
-decreased IgA from breast milk (limited intake)
-thin skin and easily damaged

management of sepsis in preterm infant; same as full term

preterm infant - cardiac

preterm infants are at an increased risk for delay of fetal shunts closing

PDA: increased pulmonary blood flow, pulmonary edema, decreased lung compliance, left sided volume overload, left side enlargement

treatment: medications (indomethacin or ibuprofen); surgical closure

preterm infant - respiratory

preterm infant at risk
-immature lungs; can give mom steroids if know is going to happen; 7 days prior to delivery
-lack surfactant; can give artificial surfactant
-poor cough reflex
-narrow airway passages
-weak respiratory muscles

assessment: resp rate, tachy/bradycardia, periods of apnea (stop breathing 20 sec or more), retractions, labored, accessory muscle use, see-saw breathing, nasal flaring, grunting, lung sounds

blood gases; most accurate way to assess oxygenation

pulse oximetry

chest xray: atelectasis? something else?

respiratory support

nasal canula

oxygen hood

continuous positive airway pressure (CPAP): deliver constant PEEP, keep alveoli open and prevent collapsing

high frequency ventilation: decrease volume and pressure → decreases damage and trauma to lungs. 300-400 breaths/min

NAVA: mutually assisted ventilatory assistance. NG tube/catheter placed into stomach that has signal that picks up signal from diaphragm and tells when to breathe

respiratory - nsg interventions

positioning: HOB up, prone, side lying

suction when necessary
-small air passages; edema caused from suctioning can cause further narrowing
-weak/absent cough reflex
-as needed suctioning and gentle
-can cause trauma and edema

preterm infant complication - apnea of prematurity

apnea of prematurity: “spontaneous pausing in breathing”, typically last longer than 20 seconds

why? immature inspiratory center in brain, immature chemoreceptors and neuroregulators

s/s oxygen destaturation, bradycardia

treatment: maintain neutral thermal environment (NTE), monitor O2 sats; maintain >92%, monitor HR, RR all the time, tactile stimulation, artificial ventilation, medications (caffeine citrate)

long-term: 37-38 weeks corrected age

respiratory distress syndrome (RDS)

caused by insufficient surfactant
-alveoli collapse on expiration, decreasing lung function
-surgactant deficiency → atelectasis → hypoxia → acidosis

incidence increases with decreasing gestational age

risk factors: prematurity, perinatal asphyxia, c section without labor, multiple births, male, cold stress, maternal diabetes

antenatal steroids: decrease risk

surfactant

decreases surface tension and makes breathing easier

keeps alveoli open on expiration

RDS s/s

tachypnea, nasal flaring, cyanosis, retractions, accessory muscle use, grunting, diminshed breath sounds, crackles, acidosis, elevated CO2 in and decreased O2

diagnositic tests: diagnosis supported by chest xray (see atelectasis, decrease lung volumes), ABGs (decreased pH, decrease PaO2, increase PaCO2)

RDS nsg considerations

monitor vital signs (RR, HR, BP, O2 sats)

monitor blood glucose

assess and report changes in infant status

monitor for complications; PDA and BPD

monitor blood gases; acid-base balance

provide NTE

provide nutrition

O2 sats:
full term: >95%
preterm: 85-90%

RDS treatment and management

pulmonary surfactant administration

lucinactant: first FDA approved artificial surfactant

poractant alfa (curosurf)

calfactant (infasurf)

reduces morbidity and mortality

decreases risk of BPD

ventilation/oxygenation supportive treatment; CPAP most common

sodium bicarb; changes pH from acidic → alkalotic

IV fluids

antibiotics

pulmonary surfactant - poractant alfa

artificial lung surfactant

action: reduces the surface tension, and improvement in lung compliance and respiratory gas exchange

dosage: intratracheally, weight-based dosage

adverse reactions: bradycardia, hypotension, endotracheal tube blockage, and oxygen desaturation

nsg considerations: assist, monitor, and collaborate with respiratory therapy

bronchopulmonary dysplasia (BPD)

aka chronic lung disease; need for supplemental O2 at 36 weeks

RDS can lead to BPD

patho: immature lungs; result of lung injury caused by mechanical ventilation and O2, acidosis, inflammation. leads to decreased lung compliance, inflammation, and oxygen dependency, barotrauma/volutrauma

babies on high frequency ventilation have lower chance than mechanical ventilation

easier gestation at birth → high pressure from ventilator to get aveoli to expand → more damage to bronchioles and cilia → inflammation, atelectasis, edema, airway hyperreactivity

BPD risk factors

extreme prematurity and need long term ventilation or increased O2 concentration

<32 weeks

1/3 of VLBW infants

prolonged mechanical ventilation

high oxygen concentrations

infection/inflammation

BPD s/s

persistent oxygen requirement

inability to wean off respiratory support and O2

respiratory distress

wheezing

respiratory acidosis due to CO2 retention

increased secretions

bronchospasms

possible pulmonary edema

BPD diagnosis

clinical signs and symptoms

chest X-rays: show serous fluid with generalized hyperinflation, atelectasis, interstitial thickening, cardiomegaly

28 days on O2 support; with inability to wean off

BPD management

prevention steroids to mom

assessment: VS, respiratory status, fluid status (strict I&O, daily weight)

chest physiotherapy (CPT)

suction as needed

positioning; prone to open space

supportive treatments

possible discharge on O2; weaning off

increased risk for respiratory infections into childhood

preterm infant - fluid and electrolytes

preterm infants at higher risk of imbalances because:
-immature kidney function
-increased water loss through skin and lungs
-physiologic diuresis

nutritional needs based on gestational age but also individualized
-fluid overload; edema, weight gain
-fluid deficit; dehydration s/s
-lab draw; increased concentration

preterm infant - nutrition

preterm infants have immature ingestion, digestion, and absorption

feeding difficulties include: immature suck/swallow reflexes, lack of coordination, weak suck, low tone, fatigue/exhaustion can’t complete oral feedings, lack of muscle development, bradycardia/desats

digestion difficulties include: decreased GI motility, immature gut colonization, prolonged gastric emptying, difficulty absorbing saturated fats and lactose, lack gastric acids needed for digesting products

feeding progression of a preterm infant

NPO at birth

clear IV fluids

TPN/intralipids for long term
-includes glucose, amino acids, lipids, electrolytes
-start as soon as possible
-effects of long term use: infections

gavage feedings (NG or OG): enteral feeds started ASAP

oral feeding (bottle/breast)

preterm infant feeding considerations

dietary needs

goal: simulate a growth pattern similar to what would have occurred in utero

weight gain: goal is 15 grams/day

monitor caloric intake and volume intake

feeding readiness: determined by behavioral state; gag present, rooting, alert state for 10+ minutes, tolerate handling

feeding tolerance

gastric aspirates if gavage feeding

regurgitation

vomiting

abdominal assessment: palpate(non tender, soft), auscultate(normoactive), distention, loops, measure abdominal girth every feed

necrotizing enterocolitis (NEC)

inflammation of intestinal tract that may lead to cellular death of intestinal mucosa

cellular death/ischemia → peristalsis stops → food/gas builds up → localized bacterial infection → septicemia

mortality 40%

contributing factors: prematurity, history of hypoxia, feedings

necrosis, perforation, peritonitis

prevention: breast milk is benefit, feeding slowly, minimize hypoxia

NEC s/s

GI symptoms/feeding intolerance
-abdominal distention
-increased gastric residuals
-decreased bowel sounds
-bowel loops
-vomiting
-bile stained residuals/emesis
-tender abdomen
-discolored abdomen
-occult blood

activity changes
-apnea
-bradycardia
-irritability
-lethargy

temperature intability

hypotension

shock

suspicion of NEC

abdominal xray: dilation of bowel, free air (perforation)

laboratory findings: leukopenia, metabolic acidosis, anemia, electrolyte imbalances

NEC treatment/management

prevention: probiotics, breastmilk, slow increase in feeding volume and calorie concentration

treatment/management:
-based on severity
-medical management: bowel rest, gastric decompression, antibiotics, parenteral nutrition
-surgical intervention; bowel resection

NEC nsg consideration

encourage mothers to provide breastmilk

monitor s/s; early subtle signs

measure abdominal girth

administer IV fluids

parenteral nutrition

monitor I&O; risk for third spacing

position infant on the side

monitor for feeding intolerance when recovering and feeds restarted

preterm infant - neurologic

nervous system underdeveloped

fragile blood vessels

immature regulation of cerebral blood flow

short-term and long-term neurologic deficits: intellectual and learning disabilities, cerebral palsy

magnesium sulfate administration antenatal reduces risk of cerebral palsy in preterm infants

intracranial hemorrhage

intraventricular hemorrhage (IVH), periventricular hemorrhage, germinal matrix hermorrhage

antenatal steroid administration linked to prevention of IVH

most occur in first 72 hours

30% of infants <1500 grams

intracranial hemorrhage increased risk

rapid changes in BP (high or low); from IV fluids, position changes (keep head midline, move slowly)

asphyxia

respiratory distress requiring mechanical

elevated of fluctuating cerebral blood

rapid blood volume expansion

hypercarbia

anemia

hypoglycemia

IVH

grade 1-4

diagnosis: cranial US
American academy of neurology recommend that all infants born <30 weeks receive US at DOL 7-14. repeat screening at 36-40 weeks corrected age

s/s are variable: lethargy, poor muscle tone, bradycardia, weak suck/feeding difficulties, uneven posture/reflexes/movements, deterioratoin of respiratory status, apnea, drop in hematocrit bc bleeding, hyperglycemia, tense fontanel, seizures

IVH outcomes

can depend; may not have outcomes. long term outcomes: seizures, intellectual disabilities, cerebral palsy

nsg considerations:
-avoid situations that cause changes in cerebral blood flow
-minimize handling, reduce environmental stimuli, minimize pain
-minimize deep suctioning
-developmental care
-monitor for s/s of IVH
-daily head circumference
-monitor Neuro status
-family support
-provide supportive care
-administer medications for seizures if warranted

periventricular leukomalacia (PVL)

cause:
-lack of oxygen or inflammation in the periventricular area of brain
-white matter damage
-cysts develop in damaged area

s/s: generally none

outcomes: motor disorders, delayed mental development, coordination problems, vision impairments, cerebral palsy

retinopathy of prematurity (ROP)

injury to blood vessels in eye leading to growth of new blood vessels that develop abnormally

67% of infants <1250 grams

contributing factors
-high levels of O2 administration; allows blood vessels to grow rapidly → grows incorrectly
-prolonged ventilation
-acidosis
-sepsis
-shock
-IVH
-fluctuating blood oxygen levels

ROP screening

screening:
<1500 grams
<32 weeks
>32 weeks with unstable clinical course
1st exam at 4-6 weeks old

exam: dilated eye and look at vessels behind eyes

treatment: laser surgery, anti-vascular endothelial growth factor (anti-VEGF) injection into eye that stops blood vessel growth, cryosurgery or reattachment of retina

RPO nsg considerations

oxygen administration decreases

parent education about follow up

swaddling during exam

mydriatic eye drops: dilate eyes

preterm infant - discharge planning

often go home before due date

education early on: normal vs abnormals to look for, med admin, feeding

“rooming in”: parents stay and take care day and night at hospital

consistent weight gain

maintaining temperature in open crib

feeding without cardiopulmonary compromise

stable cardiopulmonary function

required testing prior to discharge

carseat evaluation; monitor status for 90 mins

immunizations given

metabolic screening completed

hearing screen

eye exam as needed

nutritional risks performed

appropriate treatment plans completed

2 individuals who can feed and car for infant demonstration
CPR education
medication administration education
operate needed equipment

home evaluation

social work/family evaluation

primary care follow up

other follow up appointment