PHINMA EDUCATION - CARE OF A FAMILY WITH A HIGH-RISK NEWBORN PART 2

LESSON TITLE

  • Care of a Family with a High-Risk Newborn Part 2

LEARNING TARGETS

At the end of the module, students will be able to:

  1. Define the common classifications of high-risk newborns and describe common illnesses that occur in these classifications of newborns.

  2. Integrate the knowledge of the common classifications of high-risk newborns to formulate a nursing care plan aimed at delivering quality maternal and child health nursing care.

MATERIALS

  • Pen

  • Paper

  • Index card

  • Book

  • Class List

REFERENCES

  • Pilliteri, Adele and Silbert-Flagg, JoAnne (2018) "Maternal and Child Health Nursing, 8th Edition." USA: Lippincott Williams and Wilkins

A. LESSON PREVIEW/REVIEW

Instruction: Enumerate the newborn priorities in the first days of life.

B. MAIN LESSON

ILLNESSES THAT OCCUR IN NEWBORNS
RESPIRATORY DISTRESS SYNDROME (RDS)

  • Formerly known as Hyaline Membrane Disease.

  • Common in:

    • Preterm infants

    • Infants born to diabetic mothers

    • Infants delivered via cesarean section

    • Infants with meconium aspiration.

PATHOLOGIC FEATURE

  • Formation of a hyaline-like (fibrous) membrane from an exudate of the infant's blood.

THERAPEUTIC MANAGEMENT

  1. Surfactant Replacement

    • Administered immediately after birth via the endotracheal tube using a syringe or catheter (lung lavage).

    • Position: Infants should be tipped to an upright position to facilitate lung capacity.

    • Adjust ventilator settings to improve lung function.

  2. Oxygen Administration

    • Maintains correct PO2 and pH levels following surfactant administration.

    • Methods of administration:

      • Oxygen Cannula

      • Mask

      • Continuous Positive Airway Pressure (CPAP)

      • Assisted Ventilation with PEEP (Positive End-Expiratory Pressure).

CAUSE

  • Largely due to the lack of surfactant, which begins to form around the 34th week of gestation.

PATHOPHYSIOLOGY

  • Initial breaths require 40 to 70 cm H2O, maintenance of quiet respirations only requires 15 to 20 cm H2O.

  • Alveoli collapse leads to increased pulmonary resistance, causing blood to shunt through the foramen ovale and ductus arteriosus.

  • Lack of oxygen exchange results in tissue hypoxia and acidosis.

  • Acidosis leads to vasoconstriction and decreased pulmonary perfusion, reducing surfactant production, creating a repeating cycle of inadequate gas exchange and reliance on ventilator support.

ASSESSMENT OF RDS

  • Difficulties initiating respiration at birth.

  • Low body temperature.

  • Nasal flaring and sternocostal retractions.

  • Tachypnea (greater than 60 respirations per minute).

  • Cyanotic mucous membranes; periods of apnea and bradycardia.

  • Signs of pneumothorax, expiratory grunting (closure of the glottis), fine rales, diminished breath sounds, and seesaw respirations.

  • Symptoms of heart failure like decreased urine output and extremities edema; pale gray skin.

DIAGNOSIS

  • Clinical signs: grunting, cyanosis in room air, tachypnea, nasal flaring, retractions, shock.

  • Chest X-ray: Diffuse pattern resembling ground-glass haze.

  • Blood gas: Generally reveals respiratory acidosis.

  • Blood cultures to rule out B-hemolytic streptococcal infection, exhibiting RDS-like symptoms.

ADDITIONAL THERAPY FOR RDS

  1. Nitric Oxide

    • Causes pulmonary vasodilation, ensuring systemic vascular tone is not affected by dilating pulmonary arterioles.

  2. Extracorporeal Membrane Oxygenation (ECMO)

    • A process in which blood is removed from the heart, oxygenated, and then reintroduced, assisting severe hypoxemia from various causes (e.g., meconium aspiration, RDS, pneumonia, diaphragmatic hernia).

PREVENTION OF RDS

  • Continuous monitoring of the Lechithin/Sphingomyelin (L/S) ratio during pregnancy (normal is 2:1).

  • Avoid premature labor and delivery (using tocolytic agents).

  • Administer Betamethasone to mothers at 12 and 24 hours, especially effective between the 24 to 34 weeks of pregnancy.

  • Consider liquid ventilation for alveolar distention and oxygenation.

  • Ensure warmth for the infant’s environment to prevent acidosis and metabolic stress.

II. TRANSIENT TACHYPNEA OF THE NEWBORN

  • At birth, respiratory rate (RR) peaks at 80 bpm, dropping to 30 to 60 cpm after 1 hour.

  • In some cases, the RR remains elevated (80-120 cpm).

  • Symptoms: Mild retractions, no significant cyanosis, and slight hypoxia.

  • Elevated RR may interfere with feeding; often observed in cesarean delivered infants.

  • May require oxygen administration and typically resolves within 72 hours post-birth.

III. SUDDEN INFANT DEATH SYNDROME (SIDS)

  • Defined as a sudden unexplained death in infancy with uncertain causes.

  • Risk Factors include:

    • Adolescent mothers, closely spaced pregnancies, underweight and preterm infants, twins, and infants with respiratory ailments, certain ethnic backgrounds (e.g., Alaskans, Native Americans).

ASSESSMENT OF SIDS

  • Blood-flecked sputum or vomitus present.

  • Autopsy may reveal petechiae in the lungs and mild inflammation of the respiratory tract.

MANAGEMENT OF SIDS

  • Apnea: A respiratory pause > 20 seconds with supporting bradycardia and cyanosis; frequent in preterm infants.

  • Prevention involves sleep positioning; education for parents on CPR and proper sleeping positions for infants is crucial.

  • Monitoring devices may be sent home for infants exhibiting apnea episodes.

IV. HYPERBILIRUBINEMIA

  • Defined as elevated bilirubin levels in the blood often due to hemolysis of red blood cells.

HEMOLYTIC DISEASE OF THE NEWBORN

  1. Rh Incompatibility:

    • Occurs when an Rh-negative mother is sensitized by Rh-positive fetal blood leading to antibody formation and subsequent fetal RBC destruction.

    • Management can involve intrauterine blood transfusions or phenobarbital.

  2. ABO Incompatibility:

    • When maternal blood type is O and fetal type A or B; notable problems generally arise in the first pregnancy.

  • Assessment for Hyperbilirubinemia: Rise in anti-Rh titer, positive Direct Coombs’ test.

  • Emergency interventions can involve phototherapy or exchange transfusions depending on bilirubin levels and clinical status.

V. HEMORRHAGIC DISEASE OF THE NEWBORN

  • Caused by Vitamin K deficiency leading to inadequate prothrombin factors, manifesting as petechiae and potential hemorrhage into various tissues.

  • Preventative measure includes Vitamin K IM administration to all newborns immediately after birth.

VI. APPARENT LIFE-THREATENING EVENT (ALTE)

  • Episodes of limp, cyanotic infant requiring resuscitation; apnea monitoring recommended for risk infants.

  • CPR training recommended for parents before discharge.

VII. PERIVENTRICULAR LEUKOMALACIA (PVL)

  • Abnormal brain white matter formation due to ischemic events; commonly seen in preterm infants.

  • Diagnosis through ultrasound demonstrating areas of necrosis.

VIII. TWIN-TO-TWIN TRANSFUSION SYNDROME

  • Typically affects identical twins sharing the same placental blood supply, leading to anemia in one twin and polycythemia in another.

IX. NECROTIZING ENTEROCOLITIS (NEC)

  • A serious intestinal condition affecting mainly premature infants characterized by necrotic patches in the bowel.

X. RETINOPATHY OF PREMATURITY

  • Ocular disease in preterm infants leading to potential blindness due to immature retinal vessel development triggered by elevated oxygen levels.

XI. MATERNAL INFECTION OR ILLNESS IN NEWBORN

  • Conditions may include:

  1. Ophthalmia Neonatorum: A severe eye infection due to Chlamydia or Neisseria gonorrhea; treated prophylactically with erythromycin.

  2. HIV/AIDS: Significant risk for infants born to untreated mothers; management includes antiviral medications and avoidance of breastfeeding unless safe.

  3. HERPES SIMPLEX INFECTION: Can be congenital; requires isolating infant and treating with Acyclovir.

XII. INFANTS BORN TO DIABETIC MOTHERS

  • Diabetes control pre-delivery critical; infants often larger with risks for hypoglycemia and congenital defects.

XIII. INFANT OF A DRUG-DEPENDENT MOTHER

  • Symptoms include irritability and withdrawal patterns; management includes ensuring F&E balance and minimizing stimulation.

XIV. INFANT WITH FETAL ALCOHOL SYNDROME

  • Symptoms manifest frequently in the newborn period and include CNS impairment, facial dysmorphisms; supportive care is essential.

CHECK FOR UNDERSTANDING

  1. Common in preterm, infants of diabetic moms, cesarean birth, meconium aspiration due to hyaline-like (fibrous) membrane formed from an exudate of the infant's blood:

    • A: Transient Tachypnea of the Newborn

    • B: Sudden Infant Death Syndrome (SIDS)

    • C: Apnea

    • D: Hyperbilirubinemia

    • E: Respiratory Distress Syndrome (RDS)

Answer: E