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High Risk Newborn: Part II
Resuscitation Asphyxia leads to tissue damage
Oxygen saturation 93-97% Airway -- establish patent airway
Suction mouth and nose Prone in sniffing position
Breathing – Rate of 40-60 bpm Initiate breathing Tactile stimulation while drying Mask fits over nose and mouth 100% oxygen
Resuscitation Circulation
Assess pulse by palpating umbilical cord or auscultate apical pulse
If pulse < 60 bpm, begin compressions Drugs – administer medications
Initiate IV of 10% dextrose (D10W) Epinephrine for bradycardia Naloxone Hydrochloride (Narcan) to
reverse narcotic depression
Respiratory Distress Assessment
Tachypnea Retractions Expiratory grunt Nasal flaring Cyanosis Decreased
breath sounds
Breath sounds wet
Decreased pH, decreased pO2, increased pCO2
Causes Cold stress Sepsis Respiratory
distress syndrome
Respiratory Distress Interventions
Monitor color, rate, and effort of breathing
Monitor oxygenation Airway clearance Support respirations as prescribed
O2 at lowest concentration needed Nasal cannula or Oxyhood Positive pressure or High frequency
ventilator Liquid ventilation or Nitric oxide
Transient Tachypnea of the Newborn Begins after birth and lasts about 2 days Delayed absorption of fetal lung fluid
Common in babies from cesarean delivery
Smoking during pregnancy Neonates of diabetic mothers Small for gestational age Percipitous delivery – no thoracic
squeeze
Transient Tachypnea of the Newborn Assessment – respiratory distress Intervention
Oxygen administration Monitor oxygen level Neutral thermal environment Maintenance of acid-base balance Nutrition
Respiratory Distress Syndrome Deficiency in surfactant production
resulting in atelectasis, hypoxia, and acidosis With atelectasis, lungs are less compliant Leads to vasoconstriction and increased
pulmonary vascular resistance Decreases blood flow to lungs Leads to hypoxia and increased CO2 Leads to acidosis Leads to increased vasoconstriction Which further impairs surfactant production
Respiratory Distress Syndrome (cont)
Alveoli can become necrotic and capillaries are damaged
Ischemia allows fluid to leak into the interstitial and alveolar space
Forms a hyaline membrane Hyaline membrane hinders respiratory
function by decreasing lung compliance Poor lung compliance leads to right to left
shunting of blood through foramen ovale and ductus arteriosus
Associated with high risk of long-term respiratory and neurologic complications
Respiratory Distress Syndrome Assessment
Tachypnea Labored breathing Retractions and nasal flaring Crackles Cyanosis Expiratory grunting Hypoxemia, hypercapnia, aciodosis X-ray has diffuse granular pattern
Respiratory Distress Syndrome Intervention
Administer surfactant replacement Administer glucocorticosteroids Thermoregulation Oxygen and mechanical ventilation Monitor blood oxygen level Correct acidosis Parenteral feedings Decrease stresss
Persistent Pulmonary Hypertension (PPHN) High pulmonary vascular resistance
Unoxygenated blood shunting through ductus arterosa
Assessment Respiratory distress and tachycardia Murmur Fluctuating PO2 levels
Interventions Administer O2 and nitric oxide Decrease stress
Bronchopulmonary Displasia Chronic disease as complication of RDS
Ventilator - alveoli over inflate and rupture Inflammatory changes lead to scarring
Assessment Abnormal alveoli on x-ray Signs of respiratory distress
Interventions Low ventilator pressure to maintain O2 level Theophylline to increase lung compliance Diuretics to decrease interstitial fluid Long hospitalization and maybe home on O2
Meconium Aspiration Syndrome
Fetal hypoxia, relaxing anal sphincter, passes meconium in amniotic fluid
Meconium inhaled into lungs while in utero or with first breaths Adheres to airway and alveoli Meconium creates ball-valve effect Hyperinflation, hypoxemia, and acidosis
causes increased peripheral vascular resistance
Meconium Aspiration Syndrome
Assessment Dark green staining of amniotic fluid Green staining of vernix, skin, and nails Respiratory distress with course
crackles Interventions
Suction airway before shoulders are delivered and before first breath taken
Suction trachea until clear Administer oxygen and ventilation Extracorporeal membrane oxygenation
Thermoregulation:Cold stress
Maintain neutral thermal environment to ensure metabolic homeostasis Temperature at which the infant’s
metabolic rate and oxygen consumption is at a minimum
Influencing factors Characteristics of baby Environment: sources of heat loss Stimulation of non-shivering
thermogenisis
Thermoregulation:Cold stress
Signs of cold stress Decreased skin temperature Mottling, acrocyansis, and pallor Respiratory distress Lethargy, decreased muscle tone,
poor feeding Decreased oxygen to tissues Hypoglycemia Acidosis
Thermoregulation:Cold stress
Norepinephrine & Thyroxine
Metabolism of brown fat
Hypoxia Hypoglycemia
Respiratory distress
Respiratory Metabolic acidosis acidosis
Thermoregulation:Cold stress
Intervention Reduce heat loss -- Conduction,
convection, radiation, evaporation Gradually warm baby Monitor vital signs Monitor for and treat hypoglycemia Monitor for and treat hypoxemia Evaluate for underlying problems
Sepsis Assessment
Behavioral changes
Temperature instability
Changes in feeding
Apnea Mottling, pallor,
and cyanosis
Hyperbilirubinemia
Abdominal distention
Intervention Obtain cultures Antibiotics Neutral thermal
environment Supportive care
Hypoglycemia Factors
Decreased availability of glucose and fat
Increased utilization of glucose Signs
Jittery and twitching - Poor suck Unstable temperature - Seizures Apnea - Hypotonia Lethargy - Weak cry Hypoglycemia: < 40 mg/dl
Hypoglycemia Interventions
Monitor at-risk population Decrease glucose requirements Provide glucose
Entera: Oral and Gavage Parenteral: IV
Pain Relief Pain medications Sucrose elevates the pain threshold
through an opioid release in the CNS Use for heel sticks, suctioning,
venipuncture, circumcision 0.5 to 2 ml via syringe or nipple Monitor for hyperglycemia
Hyperbilirubinemia Bilirubin - red blood cells are broken
down Unconjugated cannot be excreted Liver enzymes transform into
conjugated Conjugated bilirubin excreted in stools
and kidneys Jaundice - yellow pigment in tissue Kernicterus - Serum level over 20 mg/dL
Unconjugated bilirubin is toxic and crosses blood-brain barrier
Results in permanent neurological damage
Hyperbilirubinemia Intervention
Phototherapy Florescent light alters structure of
bilirubin to water soluble for excretion Expose as much skin as possible Shield eyes Monitor temperature and increase
fluids Fiberoptic blanket Home phototherapy
Frequent feeding for hydration and excretion
Administer albumin and phenobarbital
Hyperbilirubinemia: Pathologic jaundice or hemolytic disease
Rh and ABO blood type incompatibility Antigens from baby’s blood enter mom’s
bloodstream Antibodies are formed by mom Future pregnancies the antibodies cross
the placenta Antibodies hemolize fetal RBCs
ABO more common but less threatening than Rh ABO - Type O mom with Type A or B fetus Rh – negative moms with positive baby
Hyperbilirubinemia: Pathologic jaundice or hemolytic disease
Assessment Hyperbilirubinemia rapidly after birth Edema and anemia
Intervention Exchange transfusion after birth or
intrauterine Indicated for positive direct Coombs’ and
elevated bilirubin levels Removes sensitized RBC and treats
anemia Rho(D) immune globulin (RhoGAM) within 72
hours of delivery or procedures
Neonatal Developmental Care Decrease noxious stimulation
Lights and noise Read the baby’s behavioral cues
Stress Self-comforting
Care techniques Containment Nesting Kangaroo care Co-bedding
Psychosocial Needs:Facilitate family coping
Explain equipment simply and slowly No technical jargon Focus on the baby not on the equipment
Don’t make promises you cannot keep Do not give unrealistic reassurance or
take away all their hope Allow parents to touch and talk to baby
Don’t insist that they touch if they are uncomfortable
Show how baby is responding to them
Psychosocial Needs:Facilitate family coping
Refer to child by name Parents need to understand and be
understood Allow to voice concerns and feelings Allow to help with THEIR child’s care Allow to voice concerns and feelings
Keep communication open. Telephone calls.
“You must be wondering what caused this” “Are you wondering how you are going to manage?”
Anticipatory Grief Attachment
Parents go home without baby (loneliness), bring in toys and pictures, marital problems
Loss of the perfect child Guilt (what did I do wrong?), may withdraw
physically or emotionally, be realistic and honest with child’s outcome, must grieve for loss of perfect child before attaching to this one, demands from abnormal child inhibit grief recovery
Neonatal death Pictures, lock of hair, foot prints, hold baby
ECMO Extra Corporeal Membrane Oxygenation
References Hogan, M.A., & Glazebrook, R.S. (2003).
Maternal-newborn nursing: Reviews & rationales. Upper Saddle River, NJ: Prentice Hall.
Ladewig, P.A, London, M.L., & Davidson, M.R. (2006). Contempary maternal-newborn nursing care (6th ed.). Upper Saddle River, NJ: Prentice Hall.
Littleton, L.Y., & Engebretson, J.C. (2005). Maternity nursing care. Clifton Park, NY: Thomson Delmar Learning.
Olds, S.B., London, M.L., Ladewig, P.A., & Davidson, M.R. ( 2004). Maternal-newborn nursing & women’s health care (7th ed.). Upper Saddle River, NJ: Prentice Hall.
Silvestri, L.A. (2002). Saunders comprehensive review for NCLEX-RN (2nd ed.). Philadelphia: W.B. Sanders.
Straight A’s in maternal-neonatal nursing. (2004). Philadelphia: Lippincott Williams & Wilkins.