Nursing care of Premature Newborn
Definition:
The premature newborn is a baby born before completion of 37
weeks of gestation.
Gestational Age:
The course of time from day one of menstrual cycle in which
conception occurred till birth.
Methods used in Determination of Gestational Age:
1. Physical and neurological examinations.
2. L.M.P.
3. Obstetric history.
Classification of Newborn:
Classification of newborn at birth by both gestational age and
weight provides a more satisfactory method for predicting
mortality risk and providing guidelines for management of
neonates.
In using gestational age, neonates can be classified as:
Preterm: The neonate is born before term i.e. completion of 37
weeks of gestation.
Term: The neonate is born between 38-42 weeks of gestation.
Post term: The neonate is born after 42 weeks of gestation.
Newborn by Birth Weight and Gestational Age
When using gestational age and birth weight, newborn can be
classified as:
 Small for gestational age (SGA): when plotted on
intrauterine growth chart, they lie below 10 th percentile.
 Appropriate for gestational age (AGA): When plotted on
intrauterine growth chart, they lie between 10th and 90th
percentile.
 Large for gestational age (LGA): When plotted on
intrauterine growth chart, they lie above 90th percentile.
According to size:
1. Low – birth – weight (LBW) infant:
An infant whose birth weight is less than 2500 gm
regardless of gestational age.
2. Very-low-Birth weight (VLBW):
An infant whose birth weight is less than 1500 gm.
3. Very-very-Low-Birth-weight (VVLBW) or extremely low
(ELBW):
An infant whose birth weight is less than 1000 gm.
1. Assessment of Clinical Gestational Age:
The frequently used method of determining gestational age
is the simplified assessment of gestation age by Ballard. It
assesses six external physical and six neuromuscular signs.
Physical signs: skin, lanugo, planter surface, breast eye/ear
and genitals (male), genitals (female).
Neuromuscular signs as posture, square window (wrist), arm
recoil, popliteal angle, scarf sign and heal to ear sign. Each
sign has a number score, and the cumulative score correlates
with a maturity rating for 26-44
The new Ballard and Scale, a revision of the original scale,
can be used with newborns as young as 20 weeks of
gestation. The tool has the same physical and
neuromuscular sections but includes -1 and -2 scores that
reflect signs of extremely premature infants such as fused
eye lids, imperceptible breast tissue , sticky friable
transparent skin , no lanugo and square – window (flexion
of wrist) angle of greater than 90 degrees The total
numerical, score for both external physical and
neuromuscular criteria is plotted on maturity rating graph
and the estimated gestational age obtained.
Characteristics of Premature Newborns:
- Premature newborn is small with large head in proportion to
the whole body.
- Hair is fine, fuzzy on the head.
- Subcutaneous tissue is deficient.
- Skin is thin, wrinkled, red, and smooth and clearly visible
blood vessels.
- Excessive lanugo and no or/ little vernix caseosa.
- Eyes are prominent and the ear cartilage is soft and easily
folded.
- Thorax is less firm.
- Breast tissue is minimal (less than 10 mm in diameter),
nipple flat and barely seen.
- Abdomen is protruded.
- Extremities and muscles are thin and small.
- Small genitalia, as male newborn have few scrotal rugae and
tests are undescended.
- Female newborn has separated labia majora and labia
minora are protruding.
- Soles and palms have minimal creases.
- Short and soft finger nails and toenails.
- Premature newborn is inactive and has a weak cry with
extremities extended.
Etiology
The cause of prematurity is unknown in most cases
Predisposing Factors of Prematurity
 Maternal age less than 17 years or over 35 years.
 Toxaemia of pregency.
 Multiple births.
 Premature rupture of membrane.
 Cardiac disease and hypertension of the mother.
 Maternal diabetes mellitus.
 Acute or chronic infection.
 Inadequate antenatal care.
 Abnormality of the pelvis.
 Exposure to radiation during pregnancy.
 Fetal abnormality.
 Low socioeconomic background
Physiological Reasons for Maladaptation in a premature Newborn:
Prematurity accounts for the largest number of admission to an
NICU. The premature newborn is at risk because of immaturity of
organ system and lack of reserves.
1. Respiratory function: There are a numerous deficits in the
respiratory system.
- Decreased number of alveoli.
- Deficient surfactant levels.
- Smaller lumen in the respiratory system.
- Greater collapsibility in the lungs.
- Immature and friable capillaries in the lungs.
2. Cardiovascular function:
The persistence of fetal circulatory pattern can lead to
problems in premature infants
3. Central nervous system function:
- Birth trauma with damage to immature structures.
- Bleeding from fragile capillaries.
- Impaired coagulation process, including prolonged
prothrombin time.
- Recurrent anoxic episodes.
- Predisposition to hypoglycemia.
4. Renal function:
The premature newborn immature renal function is unable:
- To adequately excrete metabolites.
- To concentrate the urine.
- To maintain the balance in acid-base, fluids, or
electrolytes.
5. Hematologic status:
The premature hematologic problems raised are a result of the
following factors:
- Increased capillary friability.
- Increased tendency to bleed.
- Slow production of red blood cells (because of rapid
decrease in erythropoiessis after birth).
- Loss of blood from frequent laboratory tests.
- Decreased red blood cell survival related to relatively
larger size of the RBC and increased permeability to
sodium and potassium.
General Nursing Management:
Nursing Diagnoses:
 Ineffective breathing pattern related to pulmonary and
neuromuscular immaturity, decreased energy, and fatigue.
 Ineffective thermo-regulation related to immature
temperature control and decreased subcutaneous body fat.
 High risk for infection related to deficit immunologic
defenses.
 Altered nutrition: less than body requirement related to
inability to ingest nutrients because of immaturity or illness.
 High risk for fluid volume deficit or excess related to
immature physiologic characteristics of preterm infant.
 High risk for impaired skin integrity related to immature
skin structure. Immobility decreased nutrition state,
invasive procedures.
 High risk for injury from increased intra-cranial pressure
related to immature central nervous system and physiologic
stress response.
 Pain related to procedure, diagnoses and treatment.
 Altered growth and development related to preterm birth,
unnatural neonatal intensive care unit (NICU) environment,
and separation from parents.
 Altered family process related to situational crisis,
knowledge deficit, and interruption of parental attachment
process.
Planning:
The following are basic goals for care of all high-risk infants.
1. Exhibit adequate oxygenation.
2. Maintain stable body temperature.
3. Protect the infant from nosocomial infection.
4. Receive adequate hydration and nutrition.
5. Maintain skin integrity.
6. Experience no pain.
7. Receive appropriate development care.
8. Receive appropriate family support, including, preparation
for home care.
Implementation:
1. Respiratory support
Assess for deviations of respiratory function, observe for signs
of distress, grunting, cyanosis, nasal flaring and apnea many
infants require supplemental oxygen and assisted ventilation.
Nursing Intervention:
 Position for optimum air exchange (place prone when
feasible or side lying) since this position results in
improved oxygenation and is better tolerated.
 Suction to remove accumulated mucus from nasopharynx,
trachea.
 Carry out regimen prescribed for oxygen therapy
 Apply and manage monitoring equipment and ventilatory
support correctly.
 Observe and assess infant’s response to ventilation and
oxygenation therapy.
 Observe any deviation.
 Avoid routine suction as it may cause bronchospasm,
bradycardia and increased intracranial pressure
 Maintain neutral thermal environment to conserve
utilization of oxygen
2. Thermoregulation:
After the establishment of respiration, the most crucial need of
premature infant is the application of external warmth, to delay or
prevent the effects of cold stress; infants are placed in a heated
environment immediately after birth. This is especially important
for the pre-term infant, whose very high skin surface relative to
body mass promotes heat loss.
Nursing intervention:
 Place infant in incubator, radiant warmer or warmly
clothed in open crib.
 Regulate servo controlled unit or air temperature
control as needed.
 Monitor for signs of hyperthermia-redness, flushing.
 Check temperature of infant in relation to temperature
of heating unit.
 Avoid situation that might predispose infant to heat
loss such as exposure to cool air drafts, bathing or cold
scales.
 Monitor for signs of hypothermia cold extremities,
cyanosis
 Use plastic heat shield, bubble wraps to reduce heat
and water loss
 Use kangaroo care as appropriate
4. Protection from infection:
High-risk neonates are particularly susceptible to infection. The
source of infection rise in direct relationship to the number of
person and pieces of equipment coming in contact with the infant.
Nursing intervention:
 Ensure that all caregivers wash hands before and after
handling the infant.
 Ensure that all equipments in contacts with infant are
clean or sterile.
 Ensure strict asepsis or sterility with invasive
procedures.
 Prevent persons with upper respiratory tract or
communicable infections from coming into direct
contact with infant.
 Isolate infants who have infections.
 Emphasize health care workers and parents to
administer antibiotics as ordered.
 Ensure that the incubator must be clean and sterilized
to combat infections
3. Nutrition:
Optimum nutrition is critical in the management of LBW preterm
infants, but there are difficulties in providing their nutritional
needs. An infant’s need for rapid growth and daily maintenance
must be met in the presence of several anatomic and physiologic
disabilities.
Nursing Intervention;
 Encourage breast-feeding if strong sucking,
swallowing, and gag reflexes.
 Use Gavage feeding if infant tires easily or has weak
sucking, gag or swallowing reflexes.
 Assist mothers with expressing, breast milk to
establish and maintain lactation until infant can be
breast-fed.
 Administer parenteral fluid or total parenteral
nutrition therapy as ordered.
 Monitor for signs of intolerance to protein and glucose.
 Follow until protocol for advancing volume and
concentration of formula.
4. Hydration:
Adequate hydration is important in preterm infants because their
extracellular water content is higher, their body surface is larger,
and the capacity for osmotic dieresis is limited in preterm infant’s
underdeveloped kidneys, Therefore, these infants are highly
vulnerable to water depletion.
Nursing intervention:
 Monitor fluid and electrolytes closely with therapies
that increase insensible water loss (IWL) e.g.
phototherapy, radiant warmer.
 Ensure adequate parenteral/oral fluid intake.
 Assess state of hydration (e.g. skin turgor, edema,
weight, mucous membrane, urine specific gravity,
electrolytes, fontanel).
 Regulate parenteral fluid closely to avoid dehydration
over hydration or extravasation.
 Avoid administering hypertonic fluid (e.g. undiluted
medication, concentrated glucose infusions) to prevent
excess solute load on immature kidneys and fragile
veins.
 Monitor urinary output and laboratory values for
evidence of dehydration or over hydration (adequate
urinary output), strict measurement of urine output is
indicated.
5. Skin Care:
Assess skin for any discoloration redness, signs of irritation
and skin turgor because the skin of infant is very delicate.
Nursing intervention:
 Clean skin with plain water.
 Provide daily cleaning of eye, oral, cord and diaper
area, and any areas of skin breakdown (for infant who
are not feeding, wipe the mouth and tongue with
Nystatin daily using a cotton piece until they are
advancing to feeds).
 Use minimal tape/adhesive.
 Use a protective skin barrier between skin and all tape/
adhesive especially premature babies
 Clean the skin with sterile water after application of
alcohol or betadine
 Avoid using alkaline based soap
6. Minimize Stress:
Preterm infants are subject to stress just as other human beings.
They are biologically deficient in their capacity to cope with or
adapt to environmental stresses. Stress affects hypothalamus
function, causing adverse effects on growth, heat production, and
neurologic mechanisms.
Nursing intervention:
 Decrease environmental stimulation because of stress
responses especially increased blood pressure, increase
risk of elevated ICP.
 Establish a routine that provides undisturbed
sleep/rest periods.
 Use minimal handling.
 Organize care during waking hours.
 Close and open drapes and dim lights to allow for
day/night schedule.
 Remain calm, limit number of visitors and staff near
infant at one time.
 Keep equipment’s noise to minimum.
 Maintain adequate oxygenation because hypoxia
increases cerebral blood flow.
7. Neonatal Pain:
Both preterm and full term perceives and react to pain in much
the same manner as children and adult. The responses of neonate
to pain is evidenced by cardio respiratory changes, increase in
heart rate and blood pressure, and decrease PO2 or oxygen
saturation, sweating. Crying associated with pain is more intense.
Facial features include eye squeeze, brow bulge, open mouth.
Nursing Intervention:
 Recognize that infants, regardless of gestational age
feel pain.
 Use non-pharmacologic pain measure appropriate to
infant’s age and condition as touch, music, cuddling
and rocking.
 Encourage parents to provide comfort measure.
 Use nonnutritive sucking
 Administer analgesics as ordered.
 Monitor for side effects of opioids, especially
respiratory depressants.
 Assess effectiveness of non-pharmacologic and
pharmacologic pain measures.
8. Promotion of Growth and Development:
Much attention had been focused on the effects of early
intervention or its lack on both normal and preterm infants.
Findings indicate that infants are able to respond to a greater
variety of stimuli. The atmosphere and activities of the NICU are
over stimulating.
Nursing Intervention:
 Provide optimum nutrition to ensure steady weight
gain and brain growth
 Provide regular periods of undisturbed rest to decrease
unnecessary O2 use and caloric expenditure.
 Provide age-appropriate development intervention
simulate all the sense of infant and observe their
response e.g. visual, tactile, auditory, olfactory and
taste.
 Promote parent-infant interaction since it is essential
for normal growth and development.
9. Family Support and Involvement:
The birth of a preterm infant is an unexpected and stressful event
for which families are emotionally unprepared.
Nursing Intervention:
 Give information to help parents understand most
important aspects of care.
 Encourage parents to ask questions about child’s
status.
 Be honest; respond to questions with correct answer to
establish trust.
 Encourage mother and father to visit the infant so that
attachment process in initiated.
 Help parents by demonstrating infant care and offer
support.
 Encourage siblings to visit infant.
 Explain to family members the infant condition and
why he cannot come home soon.
Discharge Planning and Home Care:
 Assess readiness of family to care for infant in home
sitting to facilities parents’ transition to home with
infant.
 Teach necessary infant care techniques and
observation.
 Reinforce medical follow up.
 Refer to appropriate agencies or services so that
needed assistance are provided.
Evaluation:
The effectiveness of nursing intervention is determined by
continuous reassessment and evaluation of care based on the
following observational guidelines and expected outcomes:
 Take vital signs and perform respiratory assessments
at time intervals based on infant,s condition and needs.
Observe infant’s respiratory efforts and response to
therapy.
 Measure abdominal, skin and axillary temperature at
specified intervals.
 Observe infant’s behavior and appearance for evidence
of sepsis.
 Assess for hydration: assess and measure fluid intake,
observe infant during feeding, measuring amount of
formula or parental intake, weigh daily.
 Observe infant’s response to pain and pain relief
interventions.
 Observe infant’s response to developmental care.
Observe parental interaction with infant, interview family
regarding their feeling and readiness for taking care of infant