Chapter 30: High Risk Newborn: Acquired and Congenital Conditions Flashcards Preview

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Flashcards in Chapter 30: High Risk Newborn: Acquired and Congenital Conditions Deck (57)
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asphyxia in the newborn

  • insufficient O2 and excess CO2 in the blood and tissue
    • can occur in utero, at birth, or after birth
  • many causes:
    • maternal: HTN, infection drug use
    • placental conditions: placenta previa, abruption, or postmaturity
    • fetal causes: cord problems, infection, prematurity, multifetal gestation
  • lack of O2 to the cells-->lactic acid production and metabolic acidosis develops when inadequate bicarb available
    • results in ischemia to major organs
  • quick intervention is needed to prevent brain damage and death


what are problems that may occur as a result of asphyxia?

  • asphyxia leads to ischemia of major organs; therefore, pulmonary ischemia occurs which results in the inability to produce surfactant-->inc risk of RDS, 
  • intrauterine stress may cause passage of meconium and meconium aspiration syndrome
  • hypoglycemia
  • feeding and thermoregulation problems
  • seizures
  • hypoTN
  • pulmonary HTN
  • metabolic acidosis
  • renal problems
  • fluid and electrolyte imbalances


manifestations of asphyxia

  • rapid respirations followed by cessation of respirations and a rapid fall in HR
    • stimulation (alone or with O2) may restart respirations
  • if no intervention, gasping respirations may resume until the infant enters a period of secondary apnea
    • in secondary apnea, O2 levels continue to dec, infant loses consiousness, and stimulation is ineffective
  • resuscitative measures must be started immediately


infants at risk for asphyxia

  • if complications occurred during pregnancy, labor, or birth
  • if mother received narcotics for analgesia, may depress infant's CNS 
    • if infant has a normal color and HR but depressed respirations, and the mother received opiates w/in 4 hours of birth, given naloxone


neonatal resuscitation

  • ABC's and prevent heat loss
  • ventilate over nose and mouth at 40-60/min
  • do compressions if HR<60 at 90/min
  • maintain thermoregulation
    • warm infant slowly over 2-4 hours as rapid warming can cause apnea
  • umbilical line
  • administer sodium bicarb (to help with acidosis) and epinephrine as ordered
  • use the lowest O2 concentration possible


transient tachypnea of the newborn (TTN)

  • infants develop rapid respirations soon after birth from inadequate absorption of fetal lung fluid
    • usually resolves in 24-48 hours
  • risk factors: C/S, macrosomia, multiple gestation, excessive maternal sedation, prolonged or precipitous labor, male gender, maternal diabetes or asthma
  • cause unknown: possibly delay in absorption of fetal lung fluid which means decreased lung compliance and air trapping


manifestation of TTN

  • tachypnea w/in 6 hours of birth
  • grunting
  • retractions
  • nasal flaring
  • mild cyanosis
  • CXR: shows hyperinflation, perihilar streaking


TTN: management and nursing considerations

  • oxygen
  • gavage feeding when RR is high in order to prevent aspiration and conserve energy
  • watch for signs of sepsis and RDS


meconium aspiration syndrome (MAS)

  • condition in which there is obstruction, chemical pneumonitis, and air trapping caused by meconium in the lungs
  • risk factors: asphyxia, post-term, SGA, being compromised with placental insufficiency with decreased amniotic fluid and cord compression
  • causes: MAS occur when hypoxia causes inc peristalsis of the intestines and relaxation of the anal sphincter, so meconium is passed and it is aspirated into the lungs
    • airways can be complete or partially blocked and the obstruction may occur in utero or at birth


severe MAS

  • when meconium is below the vocal cords which results in respiratory distress


complications of MAS

  • atelectasis: if small airways are completely blocked
  • pneumothorax or pneumomediastinum: occurs when overdistended alveoli (due to air being inhaled but being blocked from exhalation by meconium in the airway) have a leak
  • inhibition of surfactant production-->resp distress
  • chemical pneumonitis
  • persistent pulmonary HTN


manifestations of MAS

  • respiratory distress can be mild to severe:
    • tachypnea
    • cyanosis
    • retractions
    • nasal flaring
    • grunting
    • rales
    • barrel shaped chest r/t hyperinflation
  • radiography: patchy infiltrates, atelectasis, consolidation, hyperexpansion
  • yellow green nails, skin, umbilical cord


MAS: management and nursing considerations

  • if good APGARs, routine care
  • if poor APGARs, warmed O2, endotracheal tube to remove meconium, ventilation
  • may have to use ECMO if severe MAS which oxygenates blood while bypassing the lungs ot allow the infant's lungs to rest
  • nurse should notify physician during labor is meconium in fluid
    • NICU RN/neonatologist may be needed for birth
    • be sure O2 and suction are working before birth
  • monitor baby for infection and monitor thermoregulation


Persistent Pulmonary HTN of the Newborn (PPHN)

  • condition in which pulmonary vasoconstriction occurs after birth and elevates vascular resistance of the lungs, so it causes a rise in pressure on the right side of the heart-->R to L shunt of unoxygenated blood that flows thru foramen ovale-->aorta: so this blood bypasses lungs and metabolic acidosis occurs which makes for more pulmonary vasoconstriction
    • causes changes to neonatal circulation
    • develops w/in 12 hours
  • causes: 
    • most often in term or preterm infants
    • abnormal lung development, maternal use of NSAIDs or SSRIs
    • also assoc with hypoxemia and acidosis from asphyxia, MAS, sepsis, polycythemia, hernia, RDS


PPHN: manifestations

  • tachypnea
  • respiratory distress
  • progressive cyanosis that becomes worse with handling/stimulation
  • O2 sats are dec, PaCO2 is inc, acidosis is present
  • echocardiogram indicates R to L shunting of the blood


PPHN: management and nursing considerations

  • tx underlying cause of poor oxygenation and relieve vasoconstriction
    • sedation, ventilation, surfactant therapy
    • can use inhaled NO to dilate vessels
    • ECMO
  • maintain thermoregulation to prevent cold stress which will require  need for more O2
  • keep handling and noise to a minimum to prevent inc hypoxia
  • assess for hypoglycemia, anemia, acidosis


what is hyperbilirubinemia (pathologic)?

  • when total serum bilirubin is >5-6, then jaundice appears
    • it is considered abnormal when the TSB rises more rapidly or to a higher level than expected or remains elevated
  • usually seen during 1st 24 hours
  • may lead to bilirubin encephalopathy which can lead to kernicterus (brain damage from bilirubin toxicity)
    • more likely in infants who have had hypoxemia, resp acidosis, infection, dehydration


causes of hyperbilirubinemia

  • hemolytic dz of the newborn is more common cause: caused by Rh or ABO incompatibility of the mom and baby
    • erythroblastosis fetalis: occurs when Rh incompatibility causes the Rh antibodies the mom has formed to cross the placenta, attach to the fetal RBCs, and hemolyze them-->causes severe anemia
      • hydrops fetalis: can result from this if too many RBCs destroyed, causes HF and edema
  • infection
  • hypothyroidism
  • polycythemia
  • G6PD deficiency


therapeutic management of hyperbilirubinemia

  • need to prevent bilirubin encephalopathy and kernicterus
  • Rh negative mother has indirect Coombs test to check for antibodies against fetal blood
  • if an infant is jaundiced, a direct coombs test is done using cord blood
    • if positive, this means mother's antibodies have attached to infant's RBCs
  • TC bilirubinometers are used to screen the TC bili level--noninvasive
  • frequent feedings--every 2-3 hours
  • phototherapy (infant wears only diaper and covers over the eyes, monitor hydration and temp)
  • exchange transfusions


what are side effects of phototherapy?

  • frequent, loose, green stools that result from inc bile flow and peristalsis-->more rapid excretion of bilirubin, but damaging to the skin and causes rapid fluid loss
    • so need to inc fluids in infant by 25% during therapy
  • macular skin rash
  • bronze baby syndrome: grayish brown discoloration of skin and urine
  • rebound TSB of 1-2 when phototherapy ends, but monitor for 24 hours and should not inc more


explain exchange transfusions to treat hyperbilirubinemia

  • used when phototherapy cannot reduce bili levels enough quickly
  • this tx removes maternal Abs, unconjugated bilirubin, and antibody coated (sensitized) RBCs
  • provides fresh albumin with binding sites for bilirubin and helps correct severe anemia
  • if Rh incompatibility: use type O, Rh negative blood
  • if ABO incompatibility: use type AB blood, so that there are not A/B antibodes to destroy RBCs
  • complications: electrolytes and acid base imbalance, infection, dysrhythmias, NEC, bleeding, thrombosis, thrombocytopenia, air embolism
  • nurse: prepare equipment, assess infant: cardiac monitor/temperature/etc., teach parents


signs of bilirubin encephalopathy

  • lethargy
  • inc or dec muscle tone
  • poor feeding
  • dec or absent Moro reflex
  • high pitched cry
  • opisthotonos
  • seizures


infection in newborns

  • can be acquired before, during, and after birth
    • during pregnancy: rubella, CMV, syphilis, HIV, and toxoplasmosis can pass across placenta
      • type of vertical infection
    • during labor: GBS, herpes, hepatitis 
      • type of vertical infection
    • after birth: from hospital staff or contaminated equipment, family, visitors
      • type of horizontal infection
      • ie. MRSA


sepsis neonatorum

  • infection that occurs during or after birth may result in this systemic infection from bacteria in the bloodstream
  • newborns have immature immune systems that react more slowly to invaders
    • they have fewer Abs and are less able to localized infection, so the organism can spread easily from one organ to the next
    • BBB is less effective in preventing entrance of organisms-->CNS infection


common causes of sepsis neonatorum

  • GBS
  • E. coli
  • coagulase negative Staphylococcus
  • Staph aureus
  • Haemophilus influenze
  • fungi like Candida albicans


early vs. late onset of sepsis neonatorum

  • early:
    • acquired during birth: from complications of labor like prolonged ROM, prolonged labor, or chorioamnionitis
    • show signs during 1st hours after birth, 90% in 24 hours
    • rapidly progressive, multisystem, high mortality
    • pneumonia and meningitis are often present
  • late:
    • occurs from 8-90 days after birth in healthy term infants or after 72 hours of life in VLBW infants
    • acquired during or after birth
    • usually localed infection such as meningitis
    • serious long term effects


diagnosit testing of sepsis neonatorum

  • CBC count: will show inc immature neutrophils, sudden change in number of leukocytes
    • elevated IgM
  • cross reactive protein: sign of inflammatory process
    • can check rise and fall as infection improves
  • CXR: differentiate b/w sepsis and RDS
  • glucose levels: unstable with sepsis


treatment of sepsis neonatorum

  • if GBS +, women receive abx during labor
  • if develop signs of infection, then treat with IV broad spectrum abx
    • and do a culture and sensitivity test in order to determine how to better treat the specific organism
    • commonly use: ampicillin, aminoglycoside, cephalosporin, vancomycin
  • oxygen
  • fluid maintenance
  • monitor glucose


complications of sepsis neonatorum

  • shock 
  • hypo/hyperglycemia
  • electrolyte imbalances
  • problems with thermoregulation


risk factors for sepsis neonatorum

  • prematurity and low birth weight: MOST IMPORTANT
  • prolonged ROM or labor
  • chorioamnionitis
  • foul smelling amniotic fluid
  • being in the NICU
    • risk of infection in as gestational age and birth weight decrease