week 3 Chapter17 high risk neonatal nursing care Flashcards
(126 cards)
Two most important predictors of an infants health and survival
Period of gestation and birth weight
prematurity and low birth weight are second leading causes of infant death
Prematurity classifications
Prematurity is classified as:
● Very premature: Neonates born at less than 32 weeks’ gestation (Fig. 17–1).
● Premature: Neonates born between 32 and 34 weeks’ gestation.
● Late premature: Neonates born between 34 and 37 weeks’ gestation.
The percentage of premature births based on mother’s race are:
● Non-Hispanic black: 13.4%.
● American Indian or Alaska Native: 10.5%.
● Hispanic: 9.1%.
● Non-Hispanic white: 8.9%.
● Asian or Pacific Islander: 8.6% (Martin et al., 2017).
Classifications of birth weight
Prematurity is a primary reason for low birth weight. Classification of birth weight (regardless of gestational age) is as follows:
● Low birth weight: Less than 2,500 g at birth
● Very low birth weight: Less than 1,500 g at birth
● Extremely low birth weight: Less than 1,000 grams at birth
Common complications related to prematurity
Common complications related to prematurity are respiratory distress syndrome, retinopathy of prematurity, bronchopulmonary dysplasia, patent ductus arteriosus, periventricular-intraventricular hemorrhage, and necrotizing enterocolitis.
Assessment findings:
Prematurity
● Gestational age by Ballard score is at or below 37 weeks.
● Physical characteristics vary based on gestational age (Fig. 17–2).
● Tone and flexion increase with greater gestational age. Early in gestation, resting tone and posture are hypotonic and extended.
● The skin is translucent, transparent, and red.
● Subcutaneous fat is decreased.
● Lanugo is present between 20 and 28 weeks’ gestation. At 28 weeks’ gestation, lanugo begins to disappear on the face and the front of the trunk.
● Creases on the anterior part of the foot are not present until 28 to 30 weeks. As gestation increases, plantar creases increase and spread toward the heel of the foot.
● Eyelids are fused in very preterm neonates. Eyelids open between 26 and 30 weeks’ gestation.
● Overriding sutures are common among premature, low-birth-weight neonates.
● The pinna of the ear is thin, soft, flat, and folded.
● The testes are not descended and are found in the inguinal canal.
● Tremors and jittery movement may be noted.
● The cry is weak.
● Reflexes may be diminished or absent.
● Immature suck, swallow, and breathing patterns are observed in very premature infants. These neonates may not be able to take adequate oral feedings.
● Apnea (cessation of breathing for 20 seconds or longer) or a shorter pause accompanied by bradycardia (heart rate less than 100 beats per minute [bpm]) are commonly observed (Eichenwald, 2016).
● Hypotension may occur among extremely low-birth-weight infants.
● Heart murmur may be present related to patent ductus arteriosus.
● Anemia is common, especially among very-low-birth-weight babies.
Non-modifiable risk factors for preterm labor and birth
Previous preterm birth Multiple abortions Race/ethnic group Uterine/cervical anomaly Multiple gestation Polyhydramnios Oligohydramnios Pregnancy induced hypertension Placenta previa (after 22 weeks) Diethystilbestrol exposure Short interval between pregnancies abruptio placenta Parity(0 or greater than 4) Premature rupture of membranes Bleeding in first trimester
Treatable/modifiable risk factors for preterm labor and birth
Age at pregnancy younger than 17 or older than 34 unplanned pregnancy single Low education level poverty, unsafe environment Domestic violence Life stress Number of implanted embryos in assisted reproduction low pre-pregnancy weight Obesity Health problems that can be treated:hypertension, diabetes, clotting problems, anemia Incompetent cervix Genitourinary infection Infection Periodontal disease Substance/alcohol use Cigarette smoking long hours of employment/standing Late or no prenatal care Air pollution
Medical management-
Lung maturity
● Lung maturity is determined with lecithin/sphingomyelin (L/S) ratio or phosphatidylglycerol (PG) before elective induction or cesarean birth and for women in preterm labor.
● Corticosteroids, betamethasone or dexamethasone, are administered to the pregnant woman if the woman presents in preterm labor or if preterm birth is anticipated. Evidence suggests that corticosteroid administration results in reduced mortality rates as well as neonatal morbidities such as respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), and intraventricular hemorrhage (IVH). Corticosteroid administration also reduces the need for respiratory support and the length of stay in the neonatal intensive care unit (NICU)
Monitoring of
● Cardiorespiratory, oxygen saturation, blood gas, and end CO2 monitoring
Respiratory support
● Respiratory support
● Nasal continuous positive airway pressure (NCPAP) or intubation
Lab tests
● Bilirubin level
● Blood cultures based on risk factors
● Complete blood count with manual differential
● Electrolytes
● Blood glucose
● Liver function tests
Medications
● Sodium bicarbonate to treat metabolic acidosis if present
● Dopamine or dobutamine for treatment of hypotension
● Erythropoietin (EPO) administration to stimulate production of red blood cells (RBCs) if indicated
● The use of EPO reduces the need for RBC transfusions, but there is an increased risk for retinopathy of prematurity.
● Antibiotic therapy as indicated to decrease risk of infection or treatment of infection
● Opioids to treat pain associated with procedures that cause moderate to severe pain, such as with surgical procedures
Other medical interventions
● Blood transfusion if the neonate is anemic or to replace blood loss due to laboratory tests or blood loss during birth (Sherman, 2015a)
● Intravenous fluids as indicated
● Parenteral (intravenous) nutrition if indicated by the neonate’s gestational age and/or clinical condition
● Central line if long-term parenteral nutrition is required
● Umbilical artery and umbilical vein catheters
● Information about the neonate’s condition, treatment plan, and follow-up care is provided to the parents
Nursing actions-assess
● Review prenatal, intrapartal, and neonatal histories for any known risk factors that would potentially impact the neonate.
● Participate in resuscitation of the neonate as indicated.
● The NICU nurse, neonatologist, and/or neonatal nurse practitioner should be present at high-risk births.
● Stabilize and transfer the neonate to the NICU for ongoing specialized care.
● Perform gestational assessment to determine age of neonate if gestational age is unknown or unreliable.
● Protocols of care differ with gestational age.
● Perform a physical assessment, evaluating for problems associated with prematurity.
● Nursing care includes the immediate recognition and prioritization of problems to decrease neonatal morbidity and mortality.
● Assess for signs of respiratory distress:
● Grunting
● Flaring
● Retracting
● Cyanosis
Provide respiratory support
● Provide respiratory support.
● Maintain a patent airway.
● Administer oxygen to maintain oxygen saturation within ordered parameters.
● Oxygen administration may be given using low- or high-flow nasal cannulas, NCPAP, or ventilator.
● Oxygen is humidified and warmed to prevent drying of mucous membranes and dropping of body temperature. A decrease in body temperature increases body metabolism, which increases the risk for hypoglycemia and respiratory distress.
● Suction airway as needed to remove secretions, as neonates have a smaller airway diameter, which increases the risk of obstruction.
Maintain thermal environment
● Maintain neutral thermal environment by:
● Drying the infant gently immediately after birth to prevent heat loss from evaporation.
● Keeping the head covered to prevent heat loss due to radiation and convection.
● Using plastic barriers made of polyethylene to cover preterm neonates after birth to prevent heat loss and transepidermal water loss
● Using a chemical warming mattress during resuscitation and transport to the NICU
● Extremely-low-birth-weight neonates are at high risk for cold stress during the period immediately after birth. Neonates placed in plastic barriers and/or on chemical mattresses immediately after birth have higher admission temperatures upon admission to the NICU (Sharma, 2016).
● Prewarming radiant warmers, incubators, and linens
● Controlling environmental temperature with the use of servo control. A temperature-control probe should be placed on the neonate’s abdomen to assist in maintaining the neonate’s temperature within the normal range (axillary 36.3°C to 36.9°C [97.4°F to 98.4°F]) for premature neonates.
● Placing the neonate in a double-walled incubator to prevent transepidermal water loss and heat loss
● Encouraging kangaroo care (skin-to-skin care) in stable neonates
● Weaning infants gradually from incubator to an open crib
Assessment and support for cardiovascular system
● Assess cardiovascular system.
● Murmurs
● Pulses
● Capillary refill
● Provide cardiovascular support.
● Monitor blood pressure, oxygen saturation, and blood gases.
● Obtain and monitor hemoglobin and hematocrit as per order.
● Administer blood transfusion as per order.
● Assess responses to interventions. These responses may be changes in breathing, oxygen saturation, vital signs, and neonatal behavior.
Maintain fluid and electrolyte balance
● Maintain fluid and electrolyte balance.
● Monitor input and output by:
● Weighing diapers to determine output.
● Assessing frequency, color, amount, and specific gravity of urine to determine hydration status.
● Recording fluid intake and output (I&O) from IV fluids, feedings, chest tubes, urinary catheters, stomas.
● Restrict fluid intake as per order.
● Fluid restriction is commonly ordered for neonates with bronchopulmonary dysplasia (BPD) and patent ductus arteriosus (PDA) or other complications that can lead to pulmonary edema.
● Monitor electrolyte levels as per order.
● Hyperkalemia (elevated potassium levels), hyponatremia (low sodium level), and hypernatremia (high sodium level) may occur among low-birth-weight infants (Sherman, 2015a).
● Administer intravenous fluids as per order.
● Monitor the site of intravenous access for signs of infection, skin breakdown, and infiltration.
● Add humidity to the neonate’s environment to decrease water loss that can occur through the neonate’s immature skin, known as transepidermal water loss (TEWL).
● Humidity added to the environment prevents heat loss, improves skin integrity, decreases TEWL, and promotes electrolyte balance
Meet neonates nutrition requirements
● Meet the neonate’s nutrition requirements.
● Obtain and monitor blood glucose levels as per order.
● Administer parenteral nutrition (intravenous) if the neonate is unable to receive enteral feedings (via gastrointestinal tract) or is advancing slowly on feeding volumes.
● Administer trophic feedings (small volume enteral feedings) as per order. They are often given while neonates are receiving parenteral feedings to ease the transition to full enteral feedings and enhance gastrointestinal functioning
Feeding for neonates less than 2500g
● Low-birth-weight neonates (less than 2,500 g) and neonates less than 32 weeks’ gestation:
● May lack the ability to digest and absorb feedings.
● May have an inability to suck, swallow, and breathe.
● Will most likely require parenteral nutrition
Enteral feedings
● Administer enteral feedings orally or by gastric tube (gavage feedings), depending on the infant’s gestational age and clinical condition. Most neonates who are older than 34 weeks’ gestation usually receive oral feedings soon after birth.
● Human milk reduces the risk of necrotizing enterocolitis (NEC) and is preferred for enteral feedings (Herrmann & Carroll, 2014).
● Human milk requires fortification because it does not provide the calories, protein, fat, carbohydrate, potassium, calcium, sodium, and phosphorus that the premature infant needs (Ditzenberger, 2015).
● Formulas developed specifically for preterm infants are available. These formulas are modified to promote absorption and digestion for babies with immature gastrointestinal functioning and contain the extra calories, protein, minerals, and vitamins required by preterm babies
● Use proper technique for gavage feedings (NG tube)
● When feedings are initiated and before each feeding, assess for signs of feeding tolerance as follows (Ditzenberger, 2015):
● Check for the presence of bowel sounds.
● Assess the abdomen for bowel loops and discoloration.
● Measure abdominal girth.
● Check for gastric residuals by aspirating stomach contents with the syringe. Note the amount, color, and consistency of the contents.
● Assess for emesis.
● Check stools for occult blood as per order.
● Check stools for reducing substances as per order.
● Assess stools for consistency, amount, and frequency.
● Use nonnutritive sucking with a pacifier during gavage feedings. Nonnutritive sucking eases the transition from gavage feeding to bottle feeding and results in decreased length of hospital stay for preterm neonates (Foster, Psaila, & Patterson, 2016).
● Monitor weight daily. Weight gain of 10 to 20 g per kg/day indicates appropriate growth and caloric intake for a preterm neonate (Ditzenberger, 2015).
● Monitor length and head circumference weekly.
● Calculate and monitor intake of fluids, calories, and protein daily (Ditzenberger, 2015). Preterm infants require between 105 and 130 kcal/kg/day.
Transitioning from tube feedings to oral feedings
● Transition the neonate from tube feedings to oral feedings.
● Transitioning to oral feedings occurs when the neonate:
● Has cardiorespiratory regulation.
● Demonstrates a coordinated suck, swallow, and breathe.
● Demonstrates hunger cues such as bringing hand to the mouth, sucking on fingers.
● Maintains a quiet alert state.
● Properly position the neonate for bottle feeding by holding the swaddled baby in a semi-upright or upright position.
● Observe the neonate for respiratory status, apnea, bradycardia, oxygenation, and feeding tolerance.
● Pace feeding and allow for breathing breaks since preterm neonates may become fatigued during feedings.
Support breastfeeding
● Support breastfeeding.
● Evidence suggests that breast milk decreases the incidence of NEC (Herrmann & Carroll, 2014).
● When the neonate is unable to breastfeed, instruct the mother in the use of a breast pump and storage of breast milk.
● Encourage the mother to bring breast milk to the NICU so that it can be used for enteral feedings for her infant.
● Teach the mother about feeding cues, breastfeeding positions, correct latch, and evaluating the feeding.
● Encourage breastfeeding as frequently as possible to establish successful latching. Infants who successfully breastfeed in the NICU are more likely to continue breastfeeding after discharge (Briere, McGrath, Xiaomei, Brownell, & Cusson, 2016).
● Weigh the neonate before and after breastfeeding to monitor intake.
● Many mothers are hesitant to breastfeed their premature or ill neonate because they are afraid the volume will not be adequate. Weighing the neonate before and after breastfeeding can be an accurate way to demonstrate successful breastfeeding and positive mother–infant bonding (Rankin et al., 2016).
● See Appendix A for additional nursing actions.
