The Newborn and the Family – PT 3
Samantha H. Bishop, RN, BSN
Instructor of Nursing
Gordon College
Identify the at risk Newborn!
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Maternal Factors
Birth Weight
Gestational Age
Multiple Births
Neonatal Mortality
Neonatal Morbidity
SGA
• 2 standard deviations below population norm OR
• < 3rd %
• ↑ risk of asphyxia, perinatal mortality, polycythemia, and hypoglycemia
• Complications
Asphyxia
Aspiration syndrome
Hypothermia
Hypoglycemia
polycythemia
IUGR
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Definition
Common causes:
Maternal Factors
Maternal Disease
Environmental Factors
Placental Factors
Fetal Factors
Symmetric & Asymmetric IUGR
Congenital malformations
Intrauterine infections
Continued growth difficulties
Cognitive difficulties
Nursing Care
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Assessment
Prevent hypoglycemia
Prevent hypothermia
Community Care
LGA
• > 90%
• Maternal Diabetes
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Genetic disposition
Multiparity
Male vs. female
Erythroblastosis fetalis, Beckwith-Wiedemann, transposition of great vessels
Complications – Birth trauma d/t CPD, ↑ C/S, hypoglycemia, polycythemia, hyperviscosity
Nursing Care - LGA
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Identification
Monitoring VS
Screening for polycythemia & hypoglycemia
Assessment for birth trauma
IDM
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Hypoglycemia
High levels of insulin
Incidence 30-50%
S&S
Hypocalcemia
Tremors
Mothers = ↓Mg secondary to ↑ urinary Ca secretion = secondary hypoparathyroidism
Hyperbilirubinemia
IDM
• Birth Trauma
• Polycythemia
Fetal hyperglycemia + hyperinsulinism = ↑ oxygen consumption = fetal hypoxia = ↑
erythropoietin production
• Respiratory Distress Syndrome (RDS)
Insulin antagonizes cortisol stim of lecithin synthesis AND ↓ phospholipid
phosphatidylglycerol (PG) production (stabilizes surfactant)
• Congenital Birth Defects
IDM – Nursing Care
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Prenatal management
Blood glucose monitoring
Early PO feedings
IV Fluids
Monitor for polycythemia, RDS, and hyperbilirubinemia
Postterm Infant
• > 42 weeks gestation
• Complications
CPD
Shoulder dystocia
• Postmaturity syndrome
↓ placental function
• Common disorders:
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Hypoglycemia
MAS
Polycythemia
Congenital anomalies
Seizure activity
Cold stress
Postterm infant – Nursing Care
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Monitor hypoglycemia
Monitor polycythemia
Oxygen for respiratory distress
Maintain NTE
Assessment
Premature Infant
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<37 weeks gestation
Immaturity of all systems
Respiratory
Cardiac
Thermoregulation
Gastrointestinal
renal
Respiratory/Cardiac
Surfactant
DA remains open
Thermoregulation
Glycogen in liver and availability of brown fat
↑ ration of body surface to body weight
↓ SQ fat
Thinner/ more permeable skin
Posture
Decreased ability to vasoconstrict
Gastrointestinal
Poorly developed gag reflex = aspiration
Incompetent esophageal cardiac sphincter
Poor suck/swallow reflex
Small stomach capacity
Can not handle ↑ osmolarity of formula
Difficulty absorbing saturated fats
Difficulty w/ lactose ingestion
Ca and Ph deficient (deposited in last trimester)
↑ BMR and ↑ oxygen consumption
Feeding intolerance and ↑ risk of NEC
Renal Immaturity
↓ GFR
Limited ability to concentrate urine
Limited ability to excrete excess fluid
↓ buffering capacity = metabolic acidosis
Drug excretion time longer
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Nursing Care –
Premature Neonate
• Maintain Respiratory Function
• Maintain NTE
• Nutrition & Fluid requirements
• Methods of Feeding
– Bottle
– Breast
– Gavage
– TPN
• Prevent Infection
• Developmental Care
Maintain Respiratory Function
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Suctioning
Positioning
C/R Monitors
Monitor for S&S of Respiratory Distress
Administer oxygen PRN
Pulse Oximeter
Consider prior to feeding
Maintain NTE
Decreases oxygen consumption
• Skin to skin contact
• Warm and humidify oxygen
• Double wall incubator
• Humidity
• Keep skin dry and use
cap on head
• Skin probe to monitor temp
• Warm formula before feeding
• Reflector patch
• Wean to OC (1500 grams)
Nutrition & Fluid requirements
• 95 to 130 kcal/kg/d OR 80-100 mL/kg/dol #1, 100-120 mL/kg/dol #2, 120-150 mL/kg/dol #3,
can be as high as 200 mL/kg/d
• Requires ↑ protein
• Slow gradual introduction
• TPN – Total Parenteral Nutrition
• Supplemental Vitamins & minerals
Vitamin E
Vitamin D
Amino Acids
Medium-chain tryglycerides (MCT)
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Methods of Feeding
• Bottle feeding
34-36 weeks
Special nipples, burping, timing, technique
Progression from gavage feeds
Monitor respirations
• Breastfeeding
When?
Skin-to-skin
Cup feeding
• Gavage Feeding
NG/OG
“priming” the intestinal tract
• TPN
Day 2-3 of life
Intralipids
Compatibility
Central Line
Nursing Care R/T Nutrition
• NG/OG tube insertion
• Measurement of abdominal girth
• Auscultate for bowel sounds
• Assessment for feeding intolerance
• Residual
• Nonnutritive sucking
• Daily weights
• Strict I&O
• Positioning after feedings
Prevent Infection
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HANDWASHING
Equipment cleaning
Reverse isolation
2-3 minute scrub
Changing incubators weekly
Skin care
Developmental Care
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Decrease Noise
Turn down lights
Grouping nursing care
Containment
“nesting”
Nonnutritive sucking
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Kangaroo care
Parent-infant Bonding
Prematurity –
Common Complications
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Apnea of Prematurity
Patent Ductus Arteriosus
Respiratory Distress Syndrome (RDS)
Intraventricular Hemorrhage
Anemia of Prematurity
Prematurity - Long Term Needs
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Retinopathy of Prematurity (ROP)
Bronchopulmonary Dysplasia (BPD)
Speech Defects
Neurologic Defects
Auditory Defects
Other?
Substance Abuse
• Fetal Alcohol Syndrome
Cognitive difficulties
Facial/structural abnormalities
NO determined SAFE amount
Exhibit – sleeplessness, excessive arousal states, inconsolable crying, abnormal reflexes,
jitteriness, abdominal distention
Physiologic vs. psychologic (dependence vs. addiction)
• Nursing Care
Environment
Feeding difficulties
Consistent staff
Referrals
Breastfeeding?
Observe VS closely
Monitor for resp distress and/or seizure activity
Substance Abuse
• Drug Dependency
Greatest Risks:
Intrauterine asphyxia
Intrauterine infection
Alterations in birth wt
Low apgar scores
Narcan NO-NO!!!!!
Complications:
Resp distress
Jaundice
Congenital anomalies & IUGR
Behavioral Abnormalities
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Withdrawal
• Nursing Care
Methadone maintenance programs
Test for syphillis, HIV, Hep B
Urine drug screen
Social Service Referral
NTE
Monitor VS
Feeding vs. IVF’s
Positioning
Medications to prevent withdrawal
Swaddling
Environment
HIV/AIDS
• Placenta / Breast Milk / Blood
• Transmission rates 13 – 40%
• Decreased vertical transmission = zidovudine during gestation
• Early ID (ELISA & Western Blot not accurate until > 15mths of age)
• Preferred testing = HIV DNA Polymerase chain reaction (PCR)
– Results within 24hrs
– Perform before 48hrs of age
– Repeat @ 1-2 mths and 4-6mths
– R/O HIV = 3 negative PCR tests, neg ELISA @ > 18mths
HIV/AIDS – Nursing Care
• Standard Precautions
• Provide for Comfort
• Protect from Infection
• Good Skin Care
• Facilitate G&D
• Bath before injections?
• Treatment w/ zidovudine BEFORE 8-12hrs of life and continue for 6 weeks
• Exposure to Varicella
• Live vaccines
Congenital Anomalies
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Refer to chart in book!
You will see more in NURS 2903
Congenital Heart Defect
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Contributing factors
Maternal infections
Anticonvulsants
Pesticides
Maternal PKU
Chromosomal factors
Genetic predisposition
Classification
– Acyanotic vs. cyanotic
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Congenital Heart Defect - Nursing Care
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ID #1
3 most common manifestations
Parent Education
Emotional Support
Inborn Errors of Metabolism
• Hereditary disorder involving mutated gene
• Detected through newborn screening programs
• Types
– PKU
– MSUD
– Homocystinurua
– Galactosemia
– Congenital hypothyroidism
Neonatal Resuscitation
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Inability to transition
hypoxia
Metabolic acidosis
Respiratory acidosis
Protective mechanisms
Apneic @ birth = immediate resuscitation
Asphyxia
• Assess immediately @ time of birth
• APGAR scores
• ABC’s
• Stimulation
• PPV w/ 100% FiO2
• Endotracheal Intubation
• HR <60 bpm after PPV for 30” = Cardiac compressions
• HR <60 bpm after 30” of PPV and compressions = MEDS
Epinephrine
Narcan
Volume replacement
Blood products
Respiratory Distress
• Failure to synthesize surfactant
• Increased atelectasis, hypoxia, acidosis
• Confirmed on CXR – “white out” lungs
• Nursing Care
– Surfactant replacement
– Ventilation therapy
– Blood gas monitoring
– Maintain NTE
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ANALGESIA & SEDATION
Monitor VS
Monitor for S&S of Resp Distress
Maintain IVF’s
Transient Tachypnea of the Newborn (TTN)
• Resembles RDS
• Inability to clear lungs of fluid
• > in C/S infants
• Little/No difficulty initially
• Shortly thereafter → grunting, nasal flaring, mild cyanosis
• Tachypnea by 6hrs of age
• Nursing Care:
Oxygen via hood or nasal cannula
VS, IVF’s
PO feedings contraindicated
Clinical course = 72hrs
Meconium Aspiration Syndrome (MAS)
• Indicates asphyxial insult (except breech babies)
• S&S of resp distress present @ BIRTH
• Severity = extent of aspiration
• Resulting effects:
Metabolic acidosis
Respiratory acidosis
Extreme hypoxia
Persistent Pulmonary Hypertension (PPHN)
• Mortality is VERY high!
MAS Clinical Therapy
• Prevention
Sx oro/nasopharynx before shoulders and chest exit birth canal
If infant vigorous = NO special resuscitation
If infant w/ absent resp, HR <100, and/or poor muscle tone = direct tracheal suctioning until
clear – AVOID STIMULATION OF INFANT
• Administer high levels of O2 and high pressure ventilation
• Surfactant
• Maintain B/P and pulmonary blood flow
• Nitric Oxide or ECMO
• CPT
• IV antibiotic
• Monitor for pulmonary air leaks
• NTE
• IVF’s
Cold Stress
• Preterm & SGA infants at risk
• Inability to respond to cold stress w/ NST caused by:
Hypoxemia
Intracranial hemorrhage / CNS abnormality
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Hypoglycemia
Maternal Meds (i.e. Demerol)
• Nursing Care
NTE
Temp assessments
Monitor for hypoglycemia
Warm slowly
Block heat loss
Hypoglycemia
• 40mg/dL
• At risk → IDM, SGA, twins, infants w/ mothers w/ preeclampsia, male infants, and preterm
AGA infants
• Untreated → Brain damage
• Management
Early identification
Routine screening
Performing Heelsticks (diagram in text!)
Blood samples that sit in lab will be inaccurate!
Early feeding – formula, breast, glucose
D25/D50 IVP contraindicated!
IVF’s
NTE
Hyperbilirubunemia
• Jaundice
• Physiologic jaundice – normal process, appears after 24hrs of life, peaks @ 3-5 DOL,
resolves by DOL 10
• Hyperbilirubunemia – decreased serum albumin binding sites d/t certain conditions
• Kernicterus – deposition of unconjugated bilirubin in the basal ganglia
• Primary causes
hemolytic disease of the newborn
Erythroblastosis fetalis
Hydrops fetalis
• Diagnosis – Jaundice before 24hrs, need for phototx, S&S of underlying illness, persistent
jaundice
• Coombs Test
Hyperbilirubinemia –
Clinical Therapy
• Phototherapy
Expose entire skin surface
Monitor serum bilirubin levels
Eye patches
• Exchange transfusion
• Infusion of albumin
• Tx depends on serum bilirubin level, birth weight, and age in hours
• Nursing Care
Careful assessment for jaundice
“Bilicheck”
Early feeds, IVF’s
Assess Stools
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Anemia
• Most common causes:
Blood loss
Hemolysis (G6pd)
Impaired RBC production (physiologic anemia)
• Nursing Care:
Monitor for S&S
Labs
C/R Monitor
Blood transfusions vs. Fe supplements
Erythropoietin (Epogen) – Anemia of prematurity
Neonatal Sepsis
• Immature immunologic system
• Protection before birth
Maternal screening
Intrapartally sterile technique used
C/S when indicated
Antibiotic Opthalmic ointment after birth
Prohylactic abx for +GBS women
• Septic Work up – abx tx prior to results
• Nursing Care
ID of S&S
Prevention – hand washing
Collection of specimens
Equipment cleaning
Abx therapy
NTE
Resp Support
Cardiovascular support
Nutritional support
Monitor wt, I&O
Monitor lab results
Care of the Family
• Parental responses
• Assessment of
• Documentation
• Provide Support & Ed
• Facilitate attachment
• Promote touching & parental care giving
• Developmental consequences r/t Outcomes
The End!
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