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HIGH RISK NEWBORN Maybelle Tipon-Beltran RN.,MD
Newborn Priorities in 1st days of Life: 1. Resp Respir irat atio ion n 2. Circ Circul ulat atio ion n 3. Temp Temper erat atur ure e 4. Nour Nouris ishm hmen entt 5. Elim Elimin inat atio ion n 6. Preve Preventi ntion on of Infe Infecti ction on 7. Infant Infant-Pa -Paren rentt Relati Relations onship hip 8. Devel Develop opmen mental tal Care Care
I.
Respiration
a. Most death deaths s during during 48 hrs after after birth birth b. (+) Difficulty and survives Neurologic Neurologic dysfunction due to cerebral hypoxia c. (+) Respiratory acidosis Inadequate defense mechanisms A. Re Resus suscit citati ation on a. Factors Predisposing Predisposing Respiratory Respiratory Difficulty Difficulty i. LBW ii. Mater ternal nal DM iii. PROM iv. Maternal Maternal use of Barbi Barbitura turates tes or or Narcot Narcotics ics v. Meco Meconi nium um stai staini ning ng vi. vi. Irreg Irregula ularit rities ies in in fetal fetal monit monitor or vii. vii. Cord Cord prol prolap apse se viii viii.. Low Low Apg Apgar ar <7 ix. Post matur ture x. SGA (Small for Gestational Age) xi. Breech xii. xii. Mult Multip iple le bir birth th xiii. xiii. Chest, Chest, heart heart or respir respirator atory y tract tract anomal anomalies ies b. Ineffective Breathing (+) PDA Increase left side heart pressure L to R shunting Ineffective heart pumping c. (+) Struggle Decrease glucose quickly Hypoglycemia d. Proc Proces ess: s: i. Estab Establis lish h and and maint maintain ain AW ii. Exp Expand Lung Lungs s iii. iii. Initia Initiate te and maint maintain ain venti ventilat latio ion n e. (+) Respiratory depression Heart fails f. Incl Includ ude e card cardia iac c mas massa sage ge B. Airw Airway ay a. Bulb Bulb syri syringe nge sucti suction on st b. (-) 1 breath suction mouth and nose, rub the back c. Prevent chilling d. (+) Meconium stained: Do not stimulate
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e. f. g. h.
i. j. j. k. l. m.
n.
i. Give Give O2 O2 by mask mask with without out pre pressur ssure e ii. Insert laryngoscope laryngoscope suction give O2 under pressure Place Place head head in in neutral neutral position position Slid Slide e a cat cathe hete terr (8F (8F – 12F 12F)) Do not not suct suctio ion n >10 >10 secs secs (-) Spontaneous respiration respiration Laryngoscope Deep tracheal suctioning ET tube Give O2 by (+) pressure bag and mask with 100% O2 at 40-60 bpm Primary ap apnea Seco Second ndar ary y apne apnea a Laryng Laryngosc oscop opes es and and ET tube tube Lary Laryng ngos osco cope pe siz size: e: 0 – 1 (NB (NB)) ET tube: <1000 g 2.5 mm, >3000 g 4.0 mm Gentle Gentle care care during during inserti insertion on is cruci crucial al
C. Lung Lung Expan Expansio sion n a. (+) Crying Lung expansion is good b. Mask should cover mouth and nose 100%, 40-60 bpm c. Warmed Warmed (32-34 (32-34C) C) and humidifi humidified ed (60-80 (60-80%) %) d. Pressure Pressure to open open lung lung alveoli alveoli:: 40 cmH2O cmH2O e. 15-20 cmH2O continuous inflation f. Monito Monitorr with with pulse pulse oxime oximeter ter g. Ausc Auscul ulta tate te h. Insert Insert OGT and and leave leave distal distal end open open D. Drug Drug Therap Therapy y a. Naloxone (Narcan): Narcotic antagonist; injected into into umbilical umbilical vessel or IM thigh; i. 0.01 0.01 – 0.1 0.1 mg/ mg/kg kg/B /BW W b. Atropine: Decreases bronchial secretions, decreases vagus nerve nerve effects effects c. CaCl CaCl:: Incr Increa ease ses s HR d. Dopamine: Dopamine: Increases BP Increases perfusion e. Epin Epinep ephr hrin ine: e: i. Strengt Strengthens hens or or initiate initiates s cardiac cardiac contract contractions ions ii. ii. Incr Increa ease ses s HR HR and and BP f. Lidocain Lidocaine: e: Count Counterac eracts ts ventr ventricul icular ar arrhy arrhythmi thmias as g. NaHCO3: NaHCO3: Corre Corrects cts metabol metabolic ic acidosi acidosis s h. Surfactan Surfactant: t: Preven Prevents ts RDS RDS in <1,500 <1,500 g i. NO: NO: Pot Poten entt vas vasod odil ilat ator or E. Ventilat Ventilation ion Maintena Maintenance nce a. ↑RR 1st sign of obstruction obstruction undress the chest b. Place Place under under warme warmerr c. Elevat Elevate e head head 15 15 degr degrees ees d. Suctio Suction n secr secreti etion ons s e. “Bag” “Bag” infant infant for 1 min befor before e sunctioni sunctioning ng f. Monito Monitorr with with pulse pulse oxime oximeter ter
look for retractions
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II.
Circulation a. (-) HR or HR <80 bpm b. 1 or 2 cm depth, 30x
c. d. e. f. g.
III.
closed chest massage
Lung ventilation at 30x/min Continue monitoring with pulse oximeter (-) HR: Epinephrine 0.1 – 0.3 ml/kg (1: 10,000) thru ET tube Transfer to high risk nursery Fluid and Electrolyte Balance: i. Hypoglycemia, dehydration ii. LR or D5W + Electrolytes (Na or K+) and glucose iii. (+) Warmer requires more fluid iv. Monitor UO and urine specific gravity v. UO: <2ml/kg/hr or sp gravity >1.015-1.020 Dehydration vi. ↓BP Give Dopamine vii. (+) Hypovolemia NSS or LR viii. Control rate to prevent heart failure, PDA or Intracranial hemorrhage
Temperature a. Keep NB in neutral temperature with environment b. (+) Chills ↑metabolism ↑O2 demand hypoxic vasoconstriction ↓pulmonary perfusion ↓pO2, ↑pCO2 open fetal R-L shunts ↓Surfactant c. Anaerobic glycolysis acidosis Kernicterus d. Maintain axillary temperature at 36.5C e. Radiant Heat Source: i. Radiant Warmer 1. (+) Servocontrol probes continually monitors temperature 2. abdominal skin temperature: (35.5 – 36.5C) ↓ alarm 3. Tape the probe between umbilicus and xiphoid 4. Place plastic bridge or shield to preserve heat ii. Incubators 1. (+) Servocontrol probes 2. Portholes must remain closed 3. (+) Improve weaning until room temperature is reached iii. Kangaroo Care 1. Skin to skin contact 2. Infant is undressed except diaper 3. parent child interaction
IV.
Nutritional Intake a. b. c. d.
V.
(+) Asphyxia, (-) NEC IVF ↑RR, (-) NEC Gavage feeding Preterm breastfeed, or may use breast pump Gavage fed infants needs oral stimulation
Waste Elimination
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a. Document voiding: Proof that hyotension is improving
VI.
Preventing Infection a. Prenatal: CMV and toxoplamosis
Congenital anomalies b. Perinatal: Group B strep, Candida, Herpes c. Postnatal: Health care personnel NB
VII. Parent-Infant Bonding a. b. c. d. e.
Tour women to NICU Inform parent about what is happening during resuscitation Parents should be able to visit the special receiving unit Urge parents to spend time with infant as infant improves (+) Infant dies: Parents need to see the infant without being covered
VIII. Developmental Needs a. Anticipatory guidance i. Follow-up at home 1. Before discharge: Safety of home should be evaluated 2. Transporting: Blanket, head support ii. High risk Infants and Child Abuse: Due to separation of child from family at birth ALTERED GESTATIONAL AGE OR BIRTH WEIGHT Term: 38 – 42 wks Preterm: <37 wks Postterm: >43 wks AGA: 10th and 90th percentile of weight regardless of gestational age SGA: Below 10th percentile of weight LBW: <2,500g Very LBW: 1000-1,500g Extremely very LBW: 500-1000g • • • • • • • •
1)SGA a) Preterm, term, postterm b) (+) IUGR or failed to grow at expected rate c) Causes: i) ↓Mother’s nutrition (Adolescents) ii) Placental anomaly (1)Developmental defect (2)Placental damage iii) Systemic disease (DM) iv) Smokers or use of narcotics v) Intrauterine infection vi) Chromosomal abnormality d) Assessment: i) Perinatal assessment (1) ↓FH than expected
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(2)Ultrasound: small size (3) BPP: Poor placental perfusion CS (a)NST (b)Placental grading (c) AF amount (d)Ultrasound exam ii) Appearance (1)Small liver (2)Poor skin turgor (3)Large head (4)Widely separated skull sutures (5) Hair is dull and lusterless (6)Sunken abdomen (7)Cord appears dry and stained yellow (8)Better developed neurological responses, sole creases, ear cartilage (9)Skull may be firmer (10) Alert and active iii) Lab. Findings (1) ↑hct >65 – 70% exchange transfusion (2) ↑RBC blood viscosity acrocyanosis (3)Hypoglycemia (<40 mg/dl) •
Nursing Diagnoses: o Ineffective breathing pattern r/t underdeveloped body systems Resuscitation Observe RR and character o Risk for Ineffective thermoregulation r/t lack of SC fat Control environment o Risk for Impaired Parenting r/t Child’s High Risk Status and Possible Cognitive or Neuro. Impairment from lack of Nutrition in Utero Discuss to parents ways to promote infants development Provide toys suitable for age •
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LGA (Macrosomia) a) Causes: i) Overproduction of GH in utero ii) DM mothers iii) Multiparous women iv) Conditions associated with LGA (1)Transposition of Great Vessels (2)Beckwith syndrome (3)Ompahocele b) Assessment: i) Uterus is unusually large for the date of pregnancy ii) Sonogram Confirm iii) NST assess placental perfusion iv) Assess lung maturity by Amniocentesis v) (-) Descent
6 vi) CPD, Shoulder dystocia
CS
vii) Appearance: (1)Immature reflexes (2)Extensive bruising or birth injury (a)Ecchymosis, jaundice, erythema (b)Clavicle or cervical nerve injuries (c) Asymmetry of anterior chest (d)Unresponsive or dilated pupils (e)Seizure (3) Prominent caput succedaneum, cephalhematoma or Molding (4)CV Dysfunction (a)Polycythemia (b)(+) Stress on the heart (c) (+) Cyanosis Transposition of Great Vessels (5)Hypoglycemia (a) ↓glucose to sustain the weight (b) (+) DM mother ↑glucose in utero ↑insulin production continues up to 24 hrs of life Rebound hypoglycemia •
Nursing Diagnoses: o Ineffective Breathing Pattern r/t Possible Birth trauma CS o Risk for Imbalanced Nutrition Less than body requirements r/t additional nutrition needed to maintain weight and prevent hypoglycemia Breastfeed immediately Supplemental formula feedings o Risk for Impaired Parenting r/t High risk status Needs the same developmental care Encourage parents to treat their baby as a fragile NB
3)Preterm a) b) c) d)
<37 wks AOG Weight <2,500 g (5 lb 8 oz) at birth Lack of surfactant Difference between SGA and Preterm i) Characteristics SGA Preterm ii) Gestational age 22-44 wk <37 wks th iii) BW <10 percentile Normal for age iv) Cong. Malformations Strong possibility Possibility v) Pulmo. Problems Meconium aspiration, RDS Hemorrhage, penumothorax vi) Hyperbilirubinemia Possibility Very strong vii) Hypoglycemia Very strong Possible viii) IC hemorrhage strong possibility Possible ix) Apnea episodes Possible Possible
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x) Feeding problems Hypoglycemia Small stomach, poor suck xi) Wt gain in nursery Rapid Slow th xii) Future restricted growth Possible under 10 percentile “Catch up growth” e) Incidence: i) Watch for specific problem of prematurity ii) RDS, hypoglycemia, Intracranial hemorrhage f) Causes: i) Low socio economic level ix) Order of birth ii) Poor nutritional status x) Closely spaced pregnancies iii) Lack of prenatal care xi) Abnormalities of the mother’s iv) Multiple pregnancy reproductive system v) Previous early birth xii) Infections vi) Race xiii) OB complications vii) Cigarette smoking xiv) Early induction of labor viii) Age of the mother xv) Elective CS g) Assessment: i) History: (1)Pregnancy history (2)Do not convey disapproval of reported pregnancy behaviors ii) Appearance: (1)Appears small and underdeveloped (2)Head is disproportionately large (3 cm or > chest) (3)Skin is unusually ruddy (4)Veins are easily noticeable (5)Acrocyanosis (6)Covered with vernix caseosa (7)Lanugo is usually extensive (8)Few or no creases on soles of feet (9)Eyes are small (10) Myopia (11) Immature ear cartilage, pinna falls forward (12) Ears appears large in relation to head (13) <33 weeks: (a)(-) Sucking and swallowing reflex (b)(-) Achilles tendon reflex (14) Less active, rarely cries (15) (+) Cry; weak and high pitched iii) Laboratory Findings: iv) Potential Complications: (1)Anemia (a)Normochromic, normocytic anemia (b) ↓Reticulocyte count (c) Pale,lethargic and anorectic (d)Keep a record of the amount of blood drawn (e)Give DNA recombinant erythropoietin (f) BT, Vit. E and iron (2)Kernicterus
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(a)Acidosis (b) ↓albumin ↓bind to indirect bilirubin (c) (+) Jaundice phototherapy or exchange transfusion (3)Persistent PDA (a) ↓surfactant ↓blood from pulmonary artery to lungs Pulmonary artery HPN PDA (b)Hydrate (c) Give Indomethacin or Ibuprofen (i) Complication of Indomethacin: Oliguria monitor UO closely (4)Periventricular/ Intraventricular Bleeding (a) (+) Fragile capillaries and immature cerebral vascular development (b) (+) Rapid change in cerebral BP capillaries rupture (i) Hypoxia (ii) IV infusion (iii) Ventilator (iv) Pneumothorax © Bleeding clotting and obstruction Hydrocephalus (d) (+) Ultrasound (5)Other Potential Complications: (a)RDS (b)Apnea (c) Retinopathy (d)NEC •
Nursing Diagnoses: o Impaired Gas Exchange R/T Immature Pulmonary Function <32 weeks: Periodic respiration, (-) Bradycardia True apnea: >20 secs ↓surfactant alveolar collapse (+) Breech expel meconium into AF aspiration inflammation or pneumonia (+) CS retained lung fluid Give mother O2 ↓Maternal analgesia and anesthesia Preterm must be resuscitated within 2 mins after birth Keep infant warm Carry out all procedures gently 100% O2: 2 Dangers: Pulmonary edema Retinopathy of prematurity o Risk for Deficient Fluid Volume R/T Insensible Water Loss at birth and small stomach capacity Normal glucose: 40-60 mg/100 ml Specific gravity: 1.003 – 1.030 UO: 1 ml/kg/hr IVF 160-200 ml/kg/BW umbilical venous catheter Monitor weight, UO and specific gravity and electrolytes • •
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Measure UO by weighing diapers Preterm: 40-100 ml/kg x 24 hrs ; 1.012 Term: 10-20 ml/kg x 24 hrs ; 1.030 Test urine for glucose and ketones Keep a record of all blood drawn Check for blood in stool Determine possible cause of hypovolemia Risk for Imbalanced Nutrition Less than Body Requirements R/T Additional Nutrients Needed for Maintenance of rapid growth, possible sucking difficulty and small stomach Feeding Schedule IVF feeding may be delayed TPN Breast, gavage or bottle feeding Get CXR before feeding (+) Air in stomach Small, frequent feeding (1-2 ml every 2-3 hrs) o Preterm: 115 – 140 cal/kg/ BW o Term: 100 – 110 cal Gavage Feeding (+) Gag reflex 32 weeks 32-34 weeks, ill, (+) RDS Gavage feeding Bottle feeding or breast feeding is gradually introduced Give softer nipple Observe preterm infant closely Offer pacifier Aspirate stomach secretions measure replace >2 ml not allowed (-) Digestion NEC Formula: 24 cal/oz preterm 20cal/oz term Vit. K 0.5 ml Give Vit. E prevent hemolytic anemia Breastmilk: Prevents NEC Ineffective Thermoregulations R/T Immaturity PE should be delayed Keep NB warm during transportation Heat shield or plastic wrap Risk for Infection Linen and equipment must not be shared Staff members must be free of infection Hand washing and gowning Risk for Impaired Parenting
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4.5 or 5.5 lb (“magic” weight) parents are called Rocking, singing and talking and gentle holding Kangaroo care Encourage the mother to express breastmilk Encourage mother to come to the hospital and hold the baby before and after gavage or bottle feeding Photograph of baby Notes to convey messages from the baby to them can be taped to the incubator Sibling should not visit if they have colds or fever, (+) immunization, (-) exposure to communicable diseases Deficient Diversional Activity (Lack of stimulation) Organize procedures Shield from noise and light Pain should be kept into minimum Look directly at an infant in the straight forward position Provide some “talk time” Gentle stroke an infant’s back Risk for disorganized infant behavior Modify environment; reduce stimuli Dim the lights; cover the incubator, turn infant to the side, contain body with rolled towels Offer non-nutritive sucking Maintain “quiet hour” Parental health-seeking behaviors Overprotection is not necessary Basic immunization
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4)Post term a) >42 weeks b) Placenta functions effectively for only 40 weeks c) (+) Postterm syndrome: SGA characteristics i) Dry ii) Cracked (leather like) iii) (-) Vernix d) Light weight e) ↓AF, meconium stained f) Fingernails have grown well g) Alertness = 2 weeks old h) BPP is done i) CS may be indicated j) (+) Difficulty establishing respiration k) Hypoglycemia l) ↓SC tissue temperature regulation difficult m) Polycythemia, ↑hct n) ↓nutrition and O2 (+) Neurologic symptoms
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ILLNESS IN THE NEWBORN:
1) Respiratory Distress Syndrome (Hyaline Membrane Disease) a) Due to ↓blood perfusion of lungs; ↓surfactant b) (+) Hyaline like (fibrosis) membrane formed from an exudate of infants blood
lines terminal bronchioles, alveolar ducts and alveoli prevents exchange of O2 and CO2 c) Pathophysiology: i) ↓surfactant (+) areas of hypoinflation pulmonary resistance blood shunts to foramen ovale and ductus arteriosus lung perfusion ↓↓surfactant ii) (+) Hypoxia, ↑Co2 (+) Lactic acid acidosis vasoconstriction ↓pulmonary perfusion ↓↓surfactant production alveoli collapse with expiration d) Assessment: i) Lowbody temperature ii) Nasal flaring iii) Retractions iv) Tachypnea (>60) v) Cyanosis vi) Expiratory grunting vii)↑distress (1)Seesaw respiration (2) Heart failure (3)Pale, gray skin (4)Periods of apnea (5)Bradycardia (6) Pneumothorax viii) CXR: Diffuse pattern of radiopaque areas “ground glass” (haziness) ix) Blood gas: Respiratory acidosis x) C/S: R/O β-hemolytic group B strep (1)May start Penicillin or Ampicillin + Gentamycin or Kanamycin e) Management: i) Surfactant replacement (1)Sprayed into lungs by syringe or catheter by ET tube (2)Head held upright and tilted downward (3)AW should not be suctioned (4) (+) Ventilator needs close observation ii) O2 administration (1) Continuous Positive Pressure (CPAP) or Assisted Ventilation with Positive End Expiratory Pressure (PEEP) Keep alveoli from collaping (2)Cx: Retinopathy of prematurity iii) Ventilation (1)Normal I/E ratio: 1:2 (2)Infant ventilators: 2:1 (3)Complications: (a)Pneumothorax (b)Impaired CO (c) ↑ICP and arterial pressure
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(d)Hemorrahge (4) Limit fluid intake ↓pulmonary artery pressure (5) Indomethacin or Ibuprofen closure of PDA (a)Complications: (i) ↓Renal function (ii) ↓platelet function (iii) Gastric irritation iv) Additional Therapy (1)Muscle relaxants (a) Pancuronium (Pavulon) IV ↓spontaneous respiratory function (i) ↓Pressure mechanical ventilation (ii) ↓Pneumothorax 1. Needs critical observation 2. Frequent ABG (iii) Atropine and Prostigmine should be available (2)Extracorporeal Membrane Oxygenation (ECMO) (a) Blood removed from baby by gravity advanced to RA (i) ECMO machine reoxygenated and warmed carotid artery aortic arch (ii) Used for 4-7 days (iii) Cx: Intracranial hemorrhage (3)Liquid Ventilation (a)Use of Perflourocarbons (b) (+) O2 Perflourocarbons pick up and carry O2 distends the lungs exchange of O2 (c) Can be used to deliver O2 (4)Nitric Oxide (a)Cause of pulmonary vasodilation v) Prevention: (1)Sonogram (2)Document: Lecithin should exceed Sphingomyelin (2:1) (3) MgSO4 or Terbutaline prevent preterm birth (4) Steroids ↑Lecithin (a)Betamethasone 12-24 hrs; 24-34 wks AOG (takes effects before 2448 hrs)
2) Transient Tachypnea of the NB a) b) c) d) e) f)
g) h)
i)
Birth: 80bpm when crying; 80-120 bpm, 1 hr: 30-60 bpm Mild retractions, (-) cyanosis Mild hypoxia and hypercapnia Feeding is difficult CXR: (+) Fluid in the central lung, (+) adequate aeration Cause: Slow absorption of lung fluid, ↓phosphatidyl-glycerol (mature surfactant) Common in CS and preterm infants ↑↑RR 1st sign of obstruction Peaks at 36 hrs of life, 72 hrs fades
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Meconium Aspiration Syndrome a) (+) Meconium at 10 weeks AOG b) (+) Breech expel meconium in amniotic fluid c) (+) Hypoxia (+) Vagal reflex relaxation of rectal sphincter d) Appearance; Green to greenish black e) May be aspirated in utero or with 1 st breath f) (+) Respiratory distress: i) (+) Inflammation of bronchioles ii) Mechanical plugging iii) ↓surfactant production g) Hypoxemia, ↑CO2, (+) shunting h) (+) secondary infection Pneumonia i) Assessment: i) ↓Apgar score ii) Tachypnea, retractions, cyanosis iii) Suction with bulb syringe or catheter while at the perineum iv) Do not administer O2 under pressure v) Enlargement of AP diameter (barrel chest) vi) ABG: ↓pO2, ↑pCO2 vii) CXR: Bilateral coarse infiltrates in the lungs, (+) spaces of hyperaeration (honeycomb effect) viii) Diaphragm pushed downward j) Management: i) Amniotransfusion ii) CS birth iii) Tracheal suction, O2, assist ventilation iv) Antibiotic therapy v) Observe closely for signs of trapping air in the alveoli vi) Observe for signs of heart failure due to shunting of blood from pulmonary artery to aorta ( ↑HR, respiratory distress) vii) Maintain a temperature neutral environment viii) Chest physiotherapy ix) ECMO
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Apnea a) Pause in respiration longer than 20 secs, (+) Bradycardia b) (+) Beginning cyanosis c) Causes: i) Preterm: Fatigue or immature respiratory mechanism ii) Secondary stress: infection, hyperbilirubinemia, hypoglycemia or hypothermia d) Gently shake infant or flicking the sole of the foot e) Resuscitation is necessary f) May be placed on ventilator g) Maintain neutral thermal environment h) Gentle handling i) Always suction gently
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j) NGT k) Observe infant carefully after feeding l) Careful burping m) Never take rectal temperature bradycardia apnea n) Theophylline or Caffeine Sodium Benzoate stimulate respiration ↑sensitivity to CO2 o) High risk of SIDS
5)SIDS a) Unexplained death in infancy b) Commons among: i) Infants of adolescent mother ii) Closely spaced pregnancy iii) Underweight and preterm infants iv) Bronchopulmonary dysplasia v) Twins vi) Narcotic dependents c) Peak age: 2-4 mos. d) Contributory Factors: i) Prolonged, unexplained apnea ii) Viral respiratory or botulism iii) Pulmonary edema iv) Brainstem abnormality v) Neurotransmitter deficiency vi) HR abnormalities vii) Distorted familial breathing patterns viii) ↓arousal response ix) ↓ surfactant x) Sleeping prone e) Infants are well nourished f) Slight head cold g) Dies with laryngospasm h) Blood flecked sputum or vomitus in mouth or on bed clothes i) Autopsy: i) Petechiae in the lungs ii) Mild inflammation and congestion in respiratory tract j) Inform parents that the death was unexplained k) Give assurance that SIDS is a disease of infants
6) Apparent Life threatening Event a) (+) Cyanosis, limp, survived mouth to mouth resuscitation b) Apnea monitoring alarms (apnea 20 secs, HR <80)
c) Parents should be taught CPR
7) Periventricular Leukomalacia (PVL) a) Abnormal formation of white matter b) Cause: Ischemic episode ↓circulation to brain c) Phagocytes and macrophages invade area
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d) e) f) g) h)
Sonogram: (+) Hollow space Common in preterm infants No therapy (+) Learning disabilities Prevention: i) Reduce environmental stimuli ii) Avoid rapid fluid infusion iii) Avoid sudden noises
8) Hyperbilirubinemia a) Hemolytic Disease of the NB i) Rh incompatibility (1)Mother: Rh (-) (2)Fetus: Rh (+) (a)Sensitization: Mother begins producing antibodies against D antigen (72 hrs) (b) 2nd pregnancy: ↑D antibody destroy fetal RBC (3)Requires intrauterine transfusions (4)May induce preterm labor (5) Administer Phenobarbital to women speeds liver maturity ii) ABO Incompatibility (1)Mother: Type O (2)Fetus: Type A or B or AB (3)Not born anemic (4)Hemolysis begins with birth; may continue up to 2 wks (5)Preterm: Not affected (6)Increase reticulocyte count Assessment: o Percutaneous umbilical blood sampling ↑anti-Rh titer (Indirect Coomb’s test) Mother (+) Abs Fetal erythrocytes o (-) Pale o Enlarged liver and spleen o (+) Edema o Severe anemia Heart failure (Hydrops Fetalis) o (+) Progressive jaundice o (+) Preterm: (+) Hemolysis Liver cannot convert indirect to direct bilirubin o (+) Breastfeeding: (+) Prenanediol ↓Progesterone interferes with conjugation of indirect bilirubin o Normal bilirubin: 0-3 mg/100ml o >20mg/dl or 12 mg/dl in preterm Kernicterus o Hypoglycemia ↓Hgb o Management: o Early feeding ↑peristalsis Bilirubin incorporated into feces •
•
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Phototherapy Specialized light: Quartz halogen, cool white day light or special blue fluorescent light 12-30 inches above the bassinet or incubator Infant is undressed except for diaper Term NB: Bilirubin 15 mg/dl; Preterm: 10-12 mg/dl Eyes must always be covered Stool: Bright green, loose, irritating to skin; Urine: Dark colored Assess skin turgor, I/O DHN Monitor axillary temperature Infant should be removed for feeding Exchange Transfusion Aspirate stomach Umbilical vein is catheterized Draw small amounts of blood (2-10 ml) replace with equal amounts of donor blood Blood is exchanged slowly 1-3 hrs (automatic pumps) End: hct, bilirubin, Ca+, glucose, culture Repeat exchange transfusion Done for hyperbilirubinemia or polycythemia, blood incompatibility, ↓heart failure Keep NB warm Blood should be given at room temperature Use only commercial blood warmers Albumin may be administered 1-2 hrs before Monitor rate of flow of albumin Blood type used: O Monitor HR, RR and BP Blood contain acid-citrate-dextrose (ACD) as anticoagulant ↓Ca acidosis Ca gluconate is given every 100 ml of blood Citrate-Phosphate Dextrose (preservative) hyperglycemia ↑insulin hypoglycemia Heparinized blood interferes with clotting ↓glucose hypoglycemia Give Protamine sulfate Observe infant for umbilical vessel bleeding (+) Redness or inflammation (+) infection Report changes with V/S Take and record glucose 1 hr after Monitor bilirubin 2 or 3 days after May administer erythropoietin • •
9) Hemorrhagic Disease of the NB a) ↓Vit K ↓formation of prothrombin by the liver
↓blood coagulation
17 b) Babies born from mothers receiving anticonvulsive meds
↓Vit K
c) Administer Vit K to mother before birth IM d) ↓Vit K: i) (+) Petechiae on skin ii) Conjunctival, mucous membrane or retinal hemorrhage iii) Vomit fresh blood, black, tarry stools e) Dip stick guaiac test f) Vit K deficiency bleeding: 2-5 days of life g) PT prolonged, CT prolonged or normal h) Prevention: 1 mg Vit K IM immediately after birth i) Handle infant extremely gently j) (+) Subdural hemorrhage may occur
10) Twin to twin transfusion a) Monozygotic (identical; sharing same placenta) or with abnormal AV shunts b) Donor twin: anemia, SGA, hypoglycemia, pale c) Receiving twin: Polycythemia Hyperbilirubinemia d) Identified in sonogram e) Hgb determination at birth: Difference of >5.0g/100 ml f) Donor: Transfusion g) Recipient: Exchange transfusion
11) Necrotizing Enterocolitis (NEC) a) Infants in NICU b) (+) Necrotic patches ↓digestion paralytic ileus c) (+) Perforation and peritonitis d) May be a complication of exchange transfusion
12) Retinopathy of Prematurity (ROP) a) Acquired ocular disease
b) c)
d) e)
f)
partial or total blindness Due to vasoconstriction of immature retinal blood vessels Endothelial cells in the periphery of retina proliferate retinal detachment blindness Monitor blood pO2 by pulse oximeter or blood gas >100mmHg ↑risk Management: Cryosurgery or laser therapy
NEWBORN AT RISK BECAUSE OF MATERNAL INFECTIONS OR ILLNESS:
1) Beta hemolytic, group B streptococcus infection (GBS) a) Normal flora b) Give ampicillin IV at 28 weeks and during laor c) Assessment: i) PROM blood culture ii) Early onset: (1)Pneumonia, apnea (2) Shock (↓UO, paleness, hypotonia) (3)CXR: Ground glass (RDS) iii) Late onset: (2-4 weeks) Meningitis
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(1)Lethargy, fever, loss of appetite (2)Bulging fontanelles d) Management: i) Gentamycin, Ampicillin, Penicillin
2) Ophthalmia neonatorum a) N.gonorrhea and C. trachomatis b) Extremely serious form of conjunctivitis corneal ulceration opacity of cornea severe vision impairment c) Assessment: i) Generally bilateral ii) Fiery red, thick pus iii) Eyelids edematous d) Prevention: Erythromycin ointment e) Management: i) (+) Gonococci: IV Ceftriaxone (Rocephin), Penicillin ii) (+) Chlamydia: Erythromycin ophthalmic solution iii) Irrigate with sterile saline solution by using sterile medicine dropper or bulb syringe and use barrier protection (goggles) (1)Room temperature (2)Direct it laterally iv) Treat mother for Gonorrhea or Chlamydia v) Sexual contact should be treated also
3) Hepatitis B virus a) 70-90% become chronic carriers
Liver cancer
b) Vaccinate at birth c) Mother (+) HBsAg Give HBIg within 12 hrs of birth d) Bathe ASAP e) Gentle suctioning f) Mother may breastfeed
4) Herpes Virus a) HSV2 can cross placenta b) Assessment: i) During pregnancy: (1)(+) Vesicles covering skin (2)Neurologic damage ii) Birth: (1)Loss of appetite, low grade fever lethargy (2)Stomatitis or few vesicles on skin (3)Vesicles are clustered, pin point, surrounded by reddened base (4)Dyspnea, jaundice, purpura, convulsion and shock (5)Death may occur within hours or days c) Diagnosis: i) Culture d) Management: i) Acyclovir (Zovirax)
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ii) CS iii) Separate infant with other infants iv) Women with lesions on face should not feed or hold their NB
5) Infant with DM mother a) (+) Macrosomia b) (+) Congenital anomaly (cardiac) c) Hyperglycemia teratogenic d) Caudal regression syndrome (hypoplasia of lower extremities) e) Cushingoid appearance f) Lethergic and limp g) (+) GH, ↑insulin extra fat Macrosomia h) Immature i) (+) RDS: ↑insulin ↓glucose (-) cortisol release (-) formation of Lecithin (-) Lung maturity j) “Fragile giant” k) Complications: i) Birth injury CS ii) Birth: ↓glucose ↑insulin severe hypoglycemia iii) Hyperbilirubinemia iv) Hypocalcemia due to ↓PTH v) Hypoglycemia: Glucose <40 mg/dl l) Management: i) Early feeding with formula ii) Continuous infusion of glucose iii) May not be given bolus rebound hyperglycemia iv) Smaller left colon limited oral feeding (1)Vomiting (2)Abdominal distention (3)Monitor normal bowel movement
6) Drug Dependent Mother a) SGA b) (+) Withdrawal symptoms (neonatal abstinence syndrome) i) Irritability, constant movements, disturbed sleep pattern ii) Frequent sneezing iii) Hyperreflexia and clonus iv) Tachypnea alkalosis v) Tremors vi) Shrill, high pitched cry, convulsions vii) Vomiting and diarrhea c) Avoid excessive stimuli d) Darkened room e) F/E balance, IVF f) Antidotes: i) Phenobarbital ii) Methadone iii) Chlorpromazine
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g) h) i) j)
iv) Diazepam Treat mother for withdrawal symptoms Follow up care for infant Determine whether environment is safe for infant at home May have neurologic problem
7) Fetal Alcohol Syndrome a) b) c) d) e) f) g) h) i) j) k)
Alcohol crosses the placenta (+) Pre and post natal growth restriction Cognitive challenge Microcephaly Cerebral palsy Short palpebral fissure Thin upper lip Tremulous, fidgety and irritable Weak sucking reflex Sleep disturbance (always awake or always asleep) Mother needs follow up