High-Risk Newborns and Child during illness and hospitalization - Pediatric Nursing

Marcelo Q. Buenavista Jr.Marcelo Q. Buenavista Jr.

HIGH RISK NEWBORNHIGH RISK NEWBORN

High Risk NeonatesHigh Risk Neonates a newborn a newborn regardless of gestational age or birth regardless of gestational age or birth weight, who has a greater-than-average weight, who has a greater-than-average chance of morbidity or mortality because chance of morbidity or mortality because of conditions or circumstances of conditions or circumstances superimposed on the normal course of superimposed on the normal course of events associated with birth and the events associated with birth and the adjustment to extrauterine existence.adjustment to extrauterine existence.

HIGH RISK NEWBORNSHIGH RISK NEWBORNS

Encompasses human growth and development Encompasses human growth and development from the time of viability – 28 days following birth from the time of viability – 28 days following birth and includes threat to life and health that occur and includes threat to life and health that occur during the prenatal, perinatal, and postnatal during the prenatal, perinatal, and postnatal periods.periods.

Viability – gestational age at which survival Viability – gestational age at which survival outside the uterus is believed to be possible, or outside the uterus is believed to be possible, or as early as 23 weeks of gestation.as early as 23 weeks of gestation.

CLASSIFICATION OF HIGH-RISK CLASSIFICATION OF HIGH-RISK NEWBORNNEWBORN

Birth WeightBirth WeightGestational AgeGestational Age – preterm/post term – preterm/post termPredominant Physiologic FactorsPredominant Physiologic Factors – –

associated with state of maturity; chemical associated with state of maturity; chemical disturbances (hypoglycemia, disturbances (hypoglycemia, hypocalcemia); consequences of hypocalcemia); consequences of immature organ systems (hypothermia, immature organ systems (hypothermia, Respiratory Distress Syndrome, Respiratory Distress Syndrome,

CLASSIFICATION ACCORDING CLASSIFICATION ACCORDING TO SIZETO SIZE

Low Birth WeightLow Birth Weight – less than 2500g – less than 2500g regardless of gestational ageregardless of gestational age

Moderately Low Birth WeightModerately Low Birth Weight – birth – birth weight is between 1501g to 2500g.weight is between 1501g to 2500g.

Very Low Birth WeightVery Low Birth Weight – birth weight is – birth weight is less than 1500g.less than 1500g.

Extremely Low Birth WeightExtremely Low Birth Weight – birth weight – birth weight less than 1000g.less than 1000g.

CLASSIFICATION ACCORDING CLASSIFICATION ACCORDING TO SIZETO SIZE

Appropriate for Gestational Age (AGA)Appropriate for Gestational Age (AGA) – – birth weight falls between the 10birth weight falls between the 10thth and 90 and 90thth percentilepercentile

Small for Gestational Age (SGA)Small for Gestational Age (SGA) – birth – birth weight falls below the 10weight falls below the 10thth percentile percentile

Large for Gestational Age (LGA)Large for Gestational Age (LGA) – birth – birth weight falls above the 90weight falls above the 90thth percentile percentile

CLASSIFICATION ACCORDING CLASSIFICATION ACCORDING TO GESTATIONAL AGETO GESTATIONAL AGE

Premature InfantPremature Infant – born before the – born before the completion of 37 weeks of gestation, completion of 37 weeks of gestation, regardless of birth weightregardless of birth weight

Full-Term InfantFull-Term Infant – born between the – born between the beginning of the 38 weeks and the beginning of the 38 weeks and the completion of the 42 weeks of gestationcompletion of the 42 weeks of gestation

Postmature InfantPostmature Infant – born after 42 weeks of – born after 42 weeks of gestational age, regardless of birth weightgestational age, regardless of birth weight

PRETERM INFANTSPRETERM INFANTSAn infant born before term (</=36 weeks); An infant born before term (</=36 weeks);

premature or pretermpremature or pretermA low birth weight infant: </=1300-2000g A low birth weight infant: </=1300-2000g

(Philippine Standards) (,2.5kg)(Philippine Standards) (,2.5kg)Born before complete maturity; born Born before complete maturity; born

before body and organ system have before body and organ system have completely matured.completely matured.

PRETERM: refers to pregnancy (PT PRETERM: refers to pregnancy (PT labor); PREMATURE: to describe a babylabor); PREMATURE: to describe a baby

PRETERM INFANTSPRETERM INFANTS

INCIDENCE:INCIDENCE:Highest among low socio economic classHighest among low socio economic classLargest # of admission to NICULargest # of admission to NICU12% of all pregnancies12% of all pregnanciesMultiple pregnanciesMultiple pregnanciesPIHPIHPlacental problemsPlacental problems


CAUSES:CAUSES:UNKNOWNUNKNOWNMATERNAL FACTORMATERNAL FACTOR

MalnutritionMalnutrition Preeclampsia (toxemia of pregnancy)Preeclampsia (toxemia of pregnancy) Chronic Medial illness (Cardiac/kidney disease/DM)Chronic Medial illness (Cardiac/kidney disease/DM) Infection (UTI, vaginal infection)Infection (UTI, vaginal infection) Drug Use (coccaine, tobacco, alcohol)Drug Use (coccaine, tobacco, alcohol) Abnormal structure of the uterusAbnormal structure of the uterus Previous PT BirthsPrevious PT Births

PRETERM INFANTSPRETERM INFANTSCAUSES:CAUSES:

PREGNANCYPREGNANCY HypertensionHypertension Incompetent CervixIncompetent Cervix Placental Previa/ Abruptio PlacentaPlacental Previa/ Abruptio Placenta PP.OM, poly/oligohydramniosPP.OM, poly/oligohydramnios

FETUSFETUS Chromosomal abnormalitiesChromosomal abnormalities Intrauterine InfectionIntrauterine Infection Anatomic AbnormalitiesAnatomic Abnormalities IUGR, multiple gestationsIUGR, multiple gestations

PRETERM INFANTSPRETERM INFANTSDIAGNOSTIC EVALUATION:DIAGNOSTIC EVALUATION:

Appraisal is made as soon as possible after Appraisal is made as soon as possible after admission to the nursery.admission to the nursery.

HEAD – head circumference is large in comparison HEAD – head circumference is large in comparison with chest (reflects cephalocaudal direction of growth)with chest (reflects cephalocaudal direction of growth)

The fontanels are small and bones are softThe fontanels are small and bones are soft Soft cranium subject to characteristic nonintentional Soft cranium subject to characteristic nonintentional

deformation, “preemie head”deformation, “preemie head”

Absent eyebrows, eyes closed, and ears are poorly Absent eyebrows, eyes closed, and ears are poorly supported by cartilage (soft and pliable)supported by cartilage (soft and pliable)

Bones of skull and ribs – softBones of skull and ribs – soft Very small and appear scrawny – less subcutaneous Very small and appear scrawny – less subcutaneous

fat (skin is wrinkled)fat (skin is wrinkled)


DIAGNOSTIC EVALUATION:DIAGNOSTIC EVALUATION: SKIN – bright pink (often transluscent) with small SKIN – bright pink (often transluscent) with small

blood vesselsblood vessels Smooth and shiny (may be edematous) with small blood Smooth and shiny (may be edematous) with small blood

vessels clearly visible underneath thin epidermisvessels clearly visible underneath thin epidermis

Fine lanugo hair abundant over body, sparse, fine & Fine lanugo hair abundant over body, sparse, fine & fuzzy on headfuzzy on head

Soles and palms – minimal creasesSoles and palms – minimal creases Harlequin color – Skin color changes when preterm Harlequin color – Skin color changes when preterm

infant is moved; upper half or one side of the body is infant is moved; upper half or one side of the body is pale or one side of the body is red.pale or one side of the body is red.

Small breast bud size with underdeveloped nipplesSmall breast bud size with underdeveloped nipples Male Infants – few scrotal rugae, undescended testesMale Infants – few scrotal rugae, undescended testes


Labia and clitoris are prominent in femalesLabia and clitoris are prominent in females Posture - complete relaxation with marked flexion and abduction Posture - complete relaxation with marked flexion and abduction

of the thighs; random movements are common with slightest of the thighs; random movements are common with slightest stimulusstimulus

Activity – Inactive and listlessActivity – Inactive and listless Extremities maintain an attitude of extension and remain in any Extremities maintain an attitude of extension and remain in any

position in which they are placed.position in which they are placed. Reflexes – partially developedReflexes – partially developed

Sucking absent, weak or ineffectual; swallow, gag, cough reflexes – Sucking absent, weak or ineffectual; swallow, gag, cough reflexes – ABSENTABSENT

Temperature instability – Heat regulation poorly developed in the Temperature instability – Heat regulation poorly developed in the preterm infant because of poor development of CNSpreterm infant because of poor development of CNS

Increased susceptibility to infectionIncreased susceptibility to infection


Respirations are not efficient because of muscular weakness of Respirations are not efficient because of muscular weakness of lungs and rib cage and limited surfactant production;lungs and rib cage and limited surfactant production;

Retraction at xiphoid is evidence of air hungerRetraction at xiphoid is evidence of air hunger Infants should be stimulated if apnea occursInfants should be stimulated if apnea occurs HMD/RDS, chronic lung disease, BPD, apnea of prematurityHMD/RDS, chronic lung disease, BPD, apnea of prematurity

Greater tendency toward capillary fragility in the preterm infantGreater tendency toward capillary fragility in the preterm infant Red and white blood cell counts are low with resulting anemia Red and white blood cell counts are low with resulting anemia

during first few months of life.during first few months of life. Neuro – Higher incidence of intracranial hemorrhage in the Neuro – Higher incidence of intracranial hemorrhage in the

preterm infantpreterm infant Muscle twitching, convulsions, cyanosis, abnormal respirations, and Muscle twitching, convulsions, cyanosis, abnormal respirations, and

a short shrill crya short shrill cry Cerebral palsy, visual-motor deficits, altered intellectual functionsCerebral palsy, visual-motor deficits, altered intellectual functions


GIT: Nutrition is difficult to maintain – because of weak sucking GIT: Nutrition is difficult to maintain – because of weak sucking and swallowing reflexes, small capacity of stomach, and slow and swallowing reflexes, small capacity of stomach, and slow emptying time of the stomachemptying time of the stomach

Renal: Reduced glomerular filtration rate results in decreased Renal: Reduced glomerular filtration rate results in decreased ability to concentrate urine and conserve fluid.ability to concentrate urine and conserve fluid.

Higher ECF – vulnerable to fluid and electrolyte imbalanceHigher ECF – vulnerable to fluid and electrolyte imbalance Cardio: (+) murmurCardio: (+) murmur More susceptible to biochemical alterations – hyperbilirubinemia, More susceptible to biochemical alterations – hyperbilirubinemia,

hypoglycemiahypoglycemia The greater degree of immaturity, the greater the degree of The greater degree of immaturity, the greater the degree of

potential disability.potential disability.

PRETERM INFANTSPRETERM INFANTSTHERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT:

Team approach: neonatologist, advance Team approach: neonatologist, advance practice nurse, nurse staff, respiratory practice nurse, nurse staff, respiratory therapisttherapist

Incubator, IV lines, Oxygen therapyIncubator, IV lines, Oxygen therapyPREVENTION:PREVENTION:

PRENATAL CARE: key factorPRENATAL CARE: key factorGood nutrition and educationGood nutrition and educationID mothers at riskID mothers at riskEducate on symptoms of PT laborEducate on symptoms of PT laborAvoid heavy/repetitive work or standing long Avoid heavy/repetitive work or standing long

periods of timeperiods of time


THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT:TREATMENT:TREATMENT:

Oxygen, IVFOxygen, IVFUmbilical catheterization – IVF, meds, bld Umbilical catheterization – IVF, meds, bld

extractionextractionX-rayX-raySpecial feedings of breastmilk/formulaSpecial feedings of breastmilk/formulaMedicationsMedicationsKangaroo care – shorter stay in NICUKangaroo care – shorter stay in NICU

PRETERM INFANTSPRETERM INFANTSTHERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT:

DISCHARGE:DISCHARGE:Usually stay in hospital until reach pregnancy due Usually stay in hospital until reach pregnancy due

date depending on their conditiondate depending on their conditionGOALS:GOALS:

Serious illness resolvedSerious illness resolved Stable temperatureStable temperature Taking all feedings by breast/bottleTaking all feedings by breast/bottle No recent apnea/bradycardiaNo recent apnea/bradycardia Parents are able to provide care (meds and feedings)Parents are able to provide care (meds and feedings) Prior to discharge: eye examination, follow up visitsPrior to discharge: eye examination, follow up visits

PRETERM INFANTSPRETERM INFANTSNURSING CARE:NURSING CARE:

IMPLEMENTATION:IMPLEMENTATION: Maintain airway; check respirator function if employed; Maintain airway; check respirator function if employed;

position to promote ventilation; suction when necessary; position to promote ventilation; suction when necessary; maintain temperature of environment; administer oxygen only maintain temperature of environment; administer oxygen only if necessaryif necessary

Observe for changes in respirations, color, and vital signsObserve for changes in respirations, color, and vital signs Check efficacy of Isolette: maintain heat, humidity, and Check efficacy of Isolette: maintain heat, humidity, and

oxygen concentration; monitor oxygen carefully to prevent oxygen concentration; monitor oxygen carefully to prevent retrolental fibroplasiasretrolental fibroplasias

Maintain aseptic technique to prevent infectionMaintain aseptic technique to prevent infection Adhere to the techniques of gavages feeding for safety of the Adhere to the techniques of gavages feeding for safety of the

infantinfant

PRETERM INFANTSPRETERM INFANTSNURSING CARE:NURSING CARE:

IMPLEMENTATION:IMPLEMENTATION:Observe weight-gain patternsObserve weight-gain patternsDetermine blood gases frequently to prevent Determine blood gases frequently to prevent

acidosisacidosisInstitute phototherapy by letting them verbalize and Institute phototherapy by letting them verbalize and

ask questions to relieve anxietyask questions to relieve anxietyProvide flexible and liberal visiting hours for Provide flexible and liberal visiting hours for

parents as soon as possibleparents as soon as possibleAllow parents to do as much as possible for the Allow parents to do as much as possible for the

infant after appropriate teachinginfant after appropriate teachingArrange follow-up before and after discharge by a Arrange follow-up before and after discharge by a

visiting nurse or a Barangay Health Workervisiting nurse or a Barangay Health Worker

POST MATURE INFANTSPOST MATURE INFANTS

After 42 weeks AOG/ 294 days past 1After 42 weeks AOG/ 294 days past 1stst day of day of mother’s LMP; regardless of birth weightmother’s LMP; regardless of birth weight

Post term, post maturity, prolonged pregnancy, Post term, post maturity, prolonged pregnancy, post datismpost datism

INCIDENCE:INCIDENCE: 7% (3.5-15%) OF ALL PREGNANCIES7% (3.5-15%) OF ALL PREGNANCIES

CAUSES:CAUSES: unknown unknown History of >/= 1 previous post term pregnancies & History of >/= 1 previous post term pregnancies &

miscalculated due date (not sure of LMP)miscalculated due date (not sure of LMP)

POST MATURE INFANTSPOST MATURE INFANTSFETAL RISK:FETAL RISK:

Progressive placental dysfunction – placenta Progressive placental dysfunction – placenta (supplies nutrient & oxygen) ages toward the end of (supplies nutrient & oxygen) ages toward the end of pregnancy --- may not function efficientlypregnancy --- may not function efficiently

Amniotic fluid volume decreases, fetus may stop Amniotic fluid volume decreases, fetus may stop gaining weight/ weight lossgaining weight/ weight loss

Decreased amniotic fluid may lead to cord compression Decreased amniotic fluid may lead to cord compression during laborduring labor

Increased risk of MAS and hypoglycemiaIncreased risk of MAS and hypoglycemia Increasing size (mainly length) & hardening of skull Increasing size (mainly length) & hardening of skull

may contribute to CPDmay contribute to CPD GREATEST RISK: during stresses of labor & delivery GREATEST RISK: during stresses of labor & delivery

especially in infants of primigravidas.especially in infants of primigravidas.

POST MATURE INFANTSPOST MATURE INFANTSCHARACTERISTICS OF INFANTS (1-3wks of CHARACTERISTICS OF INFANTS (1-3wks of

AGE):AGE): Absent lanugo, little if any vernix caseosa, abundant Absent lanugo, little if any vernix caseosa, abundant

scalp hair, overgrown nailsscalp hair, overgrown nails Dry, peeling skin (cracked, parchmentlike & Dry, peeling skin (cracked, parchmentlike &

desquamating)desquamating) Wasted physical appearance (reflects intrauterine Wasted physical appearance (reflects intrauterine

deprivation)deprivation) Minimal fat deposit (depleted subcutaneous fat) – Minimal fat deposit (depleted subcutaneous fat) –

thin, elongated appearancethin, elongated appearance Meconium staining – seen in skin folds w/ vernix Meconium staining – seen in skin folds w/ vernix

caseosacaseosa Visible creases palms/ solesVisible creases palms/ soles

POST MATURE INFANTSPOST MATURE INFANTSDIAGNOSIS: P.EDIAGNOSIS: P.E

UTZ, non-stress testing, estimate amniotic fluid UTZ, non-stress testing, estimate amniotic fluid volumevolume

MANAGEMENT:MANAGEMENT: Check respiratory problems related to meconiumCheck respiratory problems related to meconium Blood test for hypoglycemiaBlood test for hypoglycemia PREVENTION: PREVENTION:

Accurate due date and UTZAccurate due date and UTZ

Cesarean section/ induction of labor - recommendedCesarean section/ induction of labor - recommended

HYPERBILIRUBINEMIAHYPERBILIRUBINEMIA

Refers to excessive level of accumulated Refers to excessive level of accumulated Bilirubin in the bloodBilirubin in the blood

JAUNDICE or ICTERUS – yellowish JAUNDICE or ICTERUS – yellowish discoloration of skin, sclera, nailsdiscoloration of skin, sclera, nails

Relatively benign but it can also be Relatively benign but it can also be pathologicpathologic


PATHOPHYSIOLOGY:PATHOPHYSIOLOGY:

RBC DESTRUCTION

Globin Heme

Unconjugated Bilirubin

liver

Bilirubin detched from albumin through enzyme glucoronyl transferase + glucoronic acid

Conjugated Bilirubin

Excreted into Bile (feces and urine)

Protein (used by the body)


PATHOPHYSIOLOGY:PATHOPHYSIOLOGY:Result from increased unconjugated/ Result from increased unconjugated/

conjugated bilirubinconjugated bilirubinBilirubin – one of the breakdown products of Bilirubin – one of the breakdown products of

hgb from RBC destructionhgb from RBC destructionUnconjugated Bilirubin – insoluble, bound to Unconjugated Bilirubin – insoluble, bound to

albuminalbumin Intestines – (+) bacterial action – reduces Intestines – (+) bacterial action – reduces

conjugated bilirubinconjugated bilirubinUrobilinogen – pigment that gives stool its Urobilinogen – pigment that gives stool its

characteristic odor.characteristic odor.

HYPERBILIRUBINEMIAHYPERBILIRUBINEMIACOMPARISON OF MAJOR TYPES OF COMPARISON OF MAJOR TYPES OF

UNCONJUGATED HYPERBILIRUBINEMIAUNCONJUGATED HYPERBILIRUBINEMIA

PHYSIOLOGIC PHYSIOLOGIC JAUNDICEJAUNDICE

BREAST-BREAST-FEEDING-FEEDING-

ASSOCIATED ASSOCIATED JAUNDICEJAUNDICE

(EARLY ONSET)(EARLY ONSET)

BREAST MILK BREAST MILK JAUNDICEJAUNDICE

(LATE ONSET)(LATE ONSET)

HEMOLYTIC HEMOLYTIC DISEASEDISEASE

CAUSE:CAUSE:

Immature hepatic Immature hepatic function + increased function + increased bilirubin load from bilirubin load from RBC hemolysisRBC hemolysis

Decreased milk Decreased milk intake related to intake related to fewer calories fewer calories consumed by infant consumed by infant before mother’s milk before mother’s milk is well established; is well established; enterohepatic enterohepatic shuntingshunting

Possible factors is Possible factors is breast milk that breast milk that prevent bilirubin prevent bilirubin conjugationconjugation

Less frequent Less frequent stoolingstooling

Blood antigen Blood antigen incompatibility incompatibility causes hemolysis of causes hemolysis of large # of RBCs.large # of RBCs.

Liver unable to Liver unable to conjugate & excrete conjugate & excrete excess bilirubin excess bilirubin from hemolysisfrom hemolysis

HYPERBILIRUBINEMIAHYPERBILIRUBINEMIACOMPARISON OF MAJOR TYPES OF UNCONJUGATED COMPARISON OF MAJOR TYPES OF UNCONJUGATED









ONSET:ONSET:

After 24 hours After 24 hours (preterm infants, (preterm infants, prolonged)prolonged)

22ndnd – 4 – 4thth day day 55thth – 7 – 7thth day day During 1During 1stst 24 hrs 24 hrs (levels increase (levels increase faster than faster than 5mg/ml/day)5mg/ml/day)

PEAK:PEAK:

75 – 90 hours75 – 90 hours 33rdrd – 5 – 5thth day day 1010thth – 15 – 15thth day day VariableVariable

DURATION:DURATION:

Declines on 5Declines on 5thth-7-7thth dayday

VariableVariable May remain May remain jaundiced x 3-12 jaundiced x 3-12 weeks or moreweeks or more

Dependent on Dependent on severity & severity & treatmenttreatment










THERAPY:THERAPY:

Increase frequency Increase frequency of feedings & avoid of feedings & avoid supplements.supplements.

Evaluate stooling Evaluate stooling pattern.pattern.

Monitor Monitor Transcutaneous Transcutaneous Bilirubin (TcB)/ Bilirubin (TcB)/ Total Serum Total Serum Bilirubin (TSB)Bilirubin (TSB)

Frequent Frequent (10-12x/day) (10-12x/day) breastfeeding, avoid breastfeeding, avoid glucose water, glucose water, water supplements water supplements or formula.or formula.

Evaluate stooling Evaluate stooling pattern; stimulate as pattern; stimulate as needed.needed.

Increase frequency Increase frequency of breast feeding; of breast feeding; use no use no supplementations supplementations (glucose water); (glucose water); cessation of cessation of breastfeeding not breastfeeding not recommended.recommended.

Perform risk Perform risk assessment.assessment.

Monitor TcB/TSB Monitor TcB/TSB level.level.

Perform risk Perform risk assessmentassessment

POST NATALPOST NATAL – – phototherapy; phototherapy; administer IVIG per administer IVIG per protocol; if severe, protocol; if severe, perform exchange perform exchange transfusion.transfusion.










THERAPY:THERAPY:

Perform risk Perform risk assessment.assessment.

Use phototherapy if Use phototherapy if bilirubin level bilirubin level increases increases significantly significantly (>5mg/dl/day) or (>5mg/dl/day) or significant significant hemolysis is hemolysis is present.present.

Use phototherapy if Use phototherapy if bilirubin level bilirubin level increases increases significantly (17-significantly (17-22mg/dl) or 22mg/dl) or significant significant hemolysis is hemolysis is present.present.

Consider Consider performing performing additional additional evaluations: G6PD, evaluations: G6PD, direct and indirect direct and indirect serum bilirubin, serum bilirubin, family history & family history & others as others as necessary.necessary.

PRENATAL PRENATAL – – transfusion (fetus)transfusion (fetus)

Prevent sensitization Prevent sensitization (Rh Incompatibility) (Rh Incompatibility) of Rh-negative of Rh-negative mother with Rhig mother with Rhig (Rhogam)(Rhogam)



BREAST-FEEDING-BREAST-FEEDING-ASSOCIATED JAUNDICEASSOCIATED JAUNDICE




HEMOLYTIC DISEASEHEMOLYTIC DISEASE

THERAPY:THERAPY:

If phototherapy is instituted, If phototherapy is instituted, evaluate benefits & harm of evaluate benefits & harm of temporarily discontinuing temporarily discontinuing breastfeeding; additional breastfeeding; additional assessments may be required.assessments may be required.

Assist mother with maintaining Assist mother with maintaining milk supply, feed expressed milk milk supply, feed expressed milk as appropriate.as appropriate.

After discharge, follow up After discharge, follow up according to hour of discharge.according to hour of discharge.

May include home phototherapy May include home phototherapy with a temporary (10-12hr) with a temporary (10-12hr) discontinuation of a discontinuation of a breastfeeding; a subsequent breastfeeding; a subsequent TSB may be drawn to evaluate a TSB may be drawn to evaluate a drop in serum levels.drop in serum levels.

Assist mother with maintenance Assist mother with maintenance of milk supply & reassurance of milk supply & reassurance regarding her milk supply and regarding her milk supply and therapy.therapy.

Use formula supplements only at Use formula supplements only at practitioner’s discretion.practitioner’s discretion.

PRENATAL PRENATAL – If mother is – If mother is breastfeeding, assist with breastfeeding, assist with maintenance & storage of milk; maintenance & storage of milk; may bottle-feed expressed milk may bottle-feed expressed milk as appropriate to therapy.as appropriate to therapy.

Minimize maternal-infant Minimize maternal-infant separation & encourage separation & encourage contact as appropriate.contact as appropriate.

HYPERBILIRUBINEMIAHYPERBILIRUBINEMIAPOSSIBLE CAUSES:POSSIBLE CAUSES:

PHYSIOLOGIC (DEVELOPMENTAL) PHYSIOLOGIC (DEVELOPMENTAL) FACTORS (PREMATURITY):FACTORS (PREMATURITY):Physiologic Jaundice / Icterus Neonatorum – most Physiologic Jaundice / Icterus Neonatorum – most

common cause; no pathologic processcommon cause; no pathologic process2 PHASES: term infants2 PHASES: term infants

11STST phase – Bilirubin: 6mg/dl on 3 phase – Bilirubin: 6mg/dl on 3rdrd DOL DOL decreased to 2-3mg/dl by 5decreased to 2-3mg/dl by 5thth day day

22ndnd phase – Steady plateau without phase – Steady plateau without increase/decrease level increase/decrease level 12 12thth-14-14thth day: levels day: levels decresed to normal (1mg/dl)decresed to normal (1mg/dl)

Pattern varies according to racial group, method of Pattern varies according to racial group, method of feeding, gestational agefeeding, gestational age

PRETERM: Bilirubin – 10-12mg/dl at 4-5days PRETERM: Bilirubin – 10-12mg/dl at 4-5days slowly decrease by 2-4 weeks.slowly decrease by 2-4 weeks.


PHYSIOLOGIC (DEVELOPMENTAL) PHYSIOLOGIC (DEVELOPMENTAL) FACTORS (PREMATURITY):FACTORS (PREMATURITY):Mechanisms Involved:Mechanisms Involved:

NB produce 2x as much bilirubin as do adults due to NB produce 2x as much bilirubin as do adults due to higher concentrations of circulating RBC & shorter life higher concentrations of circulating RBC & shorter life span of RBC (70-90days)span of RBC (70-90days)

Liver’s ability to conjugate bilirubin reduced – due to Liver’s ability to conjugate bilirubin reduced – due to limited production of glucoronyl transferaselimited production of glucoronyl transferase

Lower plasma binding capacity for bilirubin because of Lower plasma binding capacity for bilirubin because of lower albumin concentrations than other children.lower albumin concentrations than other children.


POSSIBLE CAUSES:POSSIBLE CAUSES:PHYSIOLOGIC (DEVELOPMENTAL) PHYSIOLOGIC (DEVELOPMENTAL)

FACTORS (PREMATURITY):FACTORS (PREMATURITY):Primary Mechanism : enterohepatic Primary Mechanism : enterohepatic

circulation/shuntingcirculation/shunting Normally: Conjugated bilirubin Normally: Conjugated bilirubin urobilinogen (excreted) urobilinogen (excreted) Sterile & less motile NB bowel is less effective in Sterile & less motile NB bowel is less effective in

excreting urobilinogenexcreting urobilinogen Conjugated bilirubin Conjugated bilirubin thru B-glucoronidasethru B-glucoronidase

converted back to unconjugated bilirubin converted back to unconjugated bilirubin reabsorbed by intestinal mucosa reabsorbed by intestinal mucosa liver liver


An association with breast feeding or breast milkAn association with breast feeding or breast milk BREASTFEEDING JAUNDICE – early onsetBREASTFEEDING JAUNDICE – early onset

Begins at 2-4days of age; 12-13% of Breastfeeding infantsBegins at 2-4days of age; 12-13% of Breastfeeding infants Related to process of breastfeeding, results from decreased Related to process of breastfeeding, results from decreased

caloric & fluid intake by Breastfeeding infants before milk supply caloric & fluid intake by Breastfeeding infants before milk supply is well-established (fasting is associated with decrease hepatic is well-established (fasting is associated with decrease hepatic clearance of bilirubin)clearance of bilirubin)

Feeding (+) peristalsis Feeding (+) peristalsis more rapid passage of meconium more rapid passage of meconium decreased amount of reabsorption of unconjugated decreased amount of reabsorption of unconjugated bilirubinbilirubin

Feeding introduces bacteria to aid in reduction of bilirubin Feeding introduces bacteria to aid in reduction of bilirubin to urobilinogento urobilinogen

Colostrums, natural cathartic, facilitates meconium Colostrums, natural cathartic, facilitates meconium evacuationevacuation


An association with breast feeding or breast An association with breast feeding or breast milkmilkBREAST MILK JAUNDICE – late onsetBREAST MILK JAUNDICE – late onset

Onset: 4Onset: 4thth-7-7thth day of age; 12-13% of Breastfeeding day of age; 12-13% of Breastfeeding infantsinfants

Rising levels peak at 2Rising levels peak at 2ndnd week week gradually diminish gradually diminish May remain jaundiced x 3-12 weeks or more May remain jaundiced x 3-12 weeks or more infants infants

are wellare well May be caused by factors in BM (pregnanediol, fatty May be caused by factors in BM (pregnanediol, fatty

acids, B-glucorinidase) that either inhibit conjugation or acids, B-glucorinidase) that either inhibit conjugation or decrease excretion of bilirubindecrease excretion of bilirubin

Less frequent stooling by Breastfeeding infants may Less frequent stooling by Breastfeeding infants may allow for extended time for reabsorption of bilirubin from allow for extended time for reabsorption of bilirubin from stoolsstools


Excess production of bilirubin – Hemolytic Excess production of bilirubin – Hemolytic disease, biochemical defects, bruisesdisease, biochemical defects, bruisesHemolytic disease – blood antigen incompatibility – Hemolytic disease – blood antigen incompatibility –

hemolysis of RBC ; liver unable to conjugate & hemolysis of RBC ; liver unable to conjugate & excrete excess bilirubin from hemolysisexcrete excess bilirubin from hemolysis

Onset: 1Onset: 1stst 24 hours (levels increase faster than 24 hours (levels increase faster than 5mg/dl/day)5mg/dl/day)

Treatment: Postnatal – phototherapy ; exchange Treatment: Postnatal – phototherapy ; exchange transfusion – severetransfusion – severe

Prenatal – transfusion (fetus) ; RhogamPrenatal – transfusion (fetus) ; Rhogam


POSSIBLE CAUSES:POSSIBLE CAUSES:Disturbed capacity of liver to secrete Disturbed capacity of liver to secrete

conjugated bilirubin – enzyme deficiency, bile conjugated bilirubin – enzyme deficiency, bile duct obstructionduct obstruction

Combined overproduction & undersecretion – Combined overproduction & undersecretion – sepsissepsis

Some disease states – hypothyroidism, Some disease states – hypothyroidism, galactosemia, infant of a diabetic mothergalactosemia, infant of a diabetic mother

Genetic predisposition to increase production Genetic predisposition to increase production – Native Americans, Asians – Native Americans, Asians

HYPERBILIRUBINEMIAHYPERBILIRUBINEMIACLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS

Jaundice – most obvious signJaundice – most obvious signYellowish discoloration: sclera, nails, skinYellowish discoloration: sclera, nails, skinIf it appears within 1If it appears within 1stst 24 hours: hemolytic disease 24 hours: hemolytic disease

of Newborn, sepsis, maternally-derived diseases of Newborn, sepsis, maternally-derived diseases (DM, infections)(DM, infections)

Appears on 2Appears on 2ndnd or 3 or 3rdrd day, peaks on 3 day, peaks on 3rdrd – 4 – 4thth day, day, declines on 5declines on 5thth – 7 – 7thth day: physiologic jaundice day: physiologic jaundice (varies according to ethnicity)(varies according to ethnicity)

Intensity of jaundice is not always related to Intensity of jaundice is not always related to the degree of hyperbilirubinemiathe degree of hyperbilirubinemia

HYPERBILIRUBINEMIAHYPERBILIRUBINEMIADIAGNOSTIC EVALUATIONDIAGNOSTIC EVALUATION

Serum Bilirubin (B1: 0.2-1.4mg/dl)Serum Bilirubin (B1: 0.2-1.4mg/dl) Jaundice appears at >5mg/dlJaundice appears at >5mg/dl Evaluation based on:Evaluation based on:

Timing of appearance of clinical jaundiceTiming of appearance of clinical jaundice Gestational age at birthGestational age at birth Age in days since birthAge in days since birth Family history including maternal Rh factorFamily history including maternal Rh factor Evidence of hemolysisEvidence of hemolysis Feeding methodFeeding method Infant’s physiologic statusInfant’s physiologic status Progression of serum bilirubin levelsProgression of serum bilirubin levels


Indicators of physiologic jaundice – warrants further Indicators of physiologic jaundice – warrants further investigation as to the cause of jaundiceinvestigation as to the cause of jaundice

Clinical jaundice within 24 hrs. of birthClinical jaundice within 24 hrs. of birth Persistent jaundice over 2 weeks in full-term, formula fed Persistent jaundice over 2 weeks in full-term, formula fed

infantinfant Total serum bilirubin levels 12.9mg/dl (term infant) or over Total serum bilirubin levels 12.9mg/dl (term infant) or over

15mg/dl (preterm); upper limit for breastfeeding infant – 15mg/dl (preterm); upper limit for breastfeeding infant – 15mg/dl15mg/dl

Increase serum bilirubin >5mg/dl/dayIncrease serum bilirubin >5mg/dl/day Direct bilirubin (B2) 1.5-2mg/dlDirect bilirubin (B2) 1.5-2mg/dl Total serum Bilirubin – over 95Total serum Bilirubin – over 95thth percentile for age (in hours) percentile for age (in hours)

on hour-specific risk nomogramon hour-specific risk nomogram


Transcutaneous Bilirubinometry – noninvasive Transcutaneous Bilirubinometry – noninvasive monitoring of bilirubin via cutaneous monitoring of bilirubin via cutaneous reflectance mechanisms; allow for repetetive reflectance mechanisms; allow for repetetive estimations of bilirubinestimations of bilirubin

Hour-specific Serum Bilirubin Levels – predict Hour-specific Serum Bilirubin Levels – predict newborn at risk for rapidly rising levelsnewborn at risk for rapidly rising levelsRecommended by AAP for monitoring healthy Recommended by AAP for monitoring healthy

Newborn >35wks AOG before discharge from Newborn >35wks AOG before discharge from hospitalhospital

Carbon monoxide indices in exhaled breath – Carbon monoxide indices in exhaled breath – CO is produced when RBC is broken downCO is produced when RBC is broken down

HYPERBILIRUBINEMIAHYPERBILIRUBINEMIACOMPLICATIONSCOMPLICATIONS

BILIRUBIN ENCEPHALOPATHY/ BILIRUBIN ENCEPHALOPATHY/ KERNICTERUS – unconjugated bilirubin KERNICTERUS – unconjugated bilirubin highly toxic to the neuronshighly toxic to the neuronsSyndrome of severe brain damage due to Syndrome of severe brain damage due to

deposition of unconjugated bilirubin in brain cells deposition of unconjugated bilirubin in brain cells (extremely high B1 level increase crosses the (extremely high B1 level increase crosses the blood-brain barrier)blood-brain barrier)

KERNICTERUS – yellow staining of brain KERNICTERUS – yellow staining of brain cells that may result in bilirubin cells that may result in bilirubin encephalopathyencephalopathy


FACTORS THAT CONTRIBUTE TO FACTORS THAT CONTRIBUTE TO BILIRUBIN NEUROTOXICITY:BILIRUBIN NEUROTOXICITY:Serum bilirubin alone do not predict the risk of Serum bilirubin alone do not predict the risk of

brain injurybrain injuryMetabolic acidosisMetabolic acidosisLow serum albumin levelLow serum albumin levelIntracranial infections (meningitis)Intracranial infections (meningitis)Abrupt increase in BPAbrupt increase in BPConditions that increase metabolic demands for Conditions that increase metabolic demands for

oxygen and glucose – fetal distress, hypoxia, oxygen and glucose – fetal distress, hypoxia, hypothermia, hypoglycemiahypothermia, hypoglycemia


SIGNS OF CNS DEPRESSION/ SIGNS OF CNS DEPRESSION/ EXCITATION:EXCITATION:Prodrome: decreased activity, lethargy, irritability, Prodrome: decreased activity, lethargy, irritability,

hypotonia, seizureshypotonia, seizuresAthetoid CP, mental retardation, deafnessAthetoid CP, mental retardation, deafnessThose who survived: NEUROLOGIC DAMAGEThose who survived: NEUROLOGIC DAMAGE

Mental retardation, ADHD, delayed/ abnormal motor Mental retardation, ADHD, delayed/ abnormal motor movements (ataxia, athetosis), behavior disorders, movements (ataxia, athetosis), behavior disorders, perceptual problems, sensorineural hearing lossperceptual problems, sensorineural hearing loss

HYPERBILIRUBINEMIAHYPERBILIRUBINEMIATHERAPEUTIC MANAGEMENTTHERAPEUTIC MANAGEMENT

Phototherapy – main formPhototherapy – main form Exchange transfusion – reduce high bilirubin levels Exchange transfusion – reduce high bilirubin levels

that occur with hemolytic diseasethat occur with hemolytic disease Phenobarbital – hemolytic disease; effective when Phenobarbital – hemolytic disease; effective when

given to mother several days before deliverygiven to mother several days before delivery Promotes hepatic glucoronyl transferase synthesis Promotes hepatic glucoronyl transferase synthesis

increases bilirubin conjugation & hepatic clearance of increases bilirubin conjugation & hepatic clearance of pigment in bilepigment in bile

Promotes protein synthesis – increase albumin for more Promotes protein synthesis – increase albumin for more bilirubin binding sitesbilirubin binding sites

Heme-oxygenase inhibitors – decrease bilirubin Heme-oxygenase inhibitors – decrease bilirubin productionproduction


THERAPEUTIC MANAGEMENTTHERAPEUTIC MANAGEMENTEarly initiation of feedings & frequent Early initiation of feedings & frequent

breastfeeding – promotes increased intestinal breastfeeding – promotes increased intestinal motility, decreases enterohepatic shunting, motility, decreases enterohepatic shunting, establish normal bacterial flora in the bowel establish normal bacterial flora in the bowel excrete B2excrete B2Frequent breastfeeding every 2 hrsFrequent breastfeeding every 2 hrsAvoid glucose water, formula or water Avoid glucose water, formula or water

supplementationsupplementation


Phototherapy – application of fluorescent light Phototherapy – application of fluorescent light (bili light) to infant’s exposed skin(bili light) to infant’s exposed skinLight Light promotes bilirubin excretion by promotes bilirubin excretion by

photoisomerizationphotoisomerization (alters structure of bilirubin to a (alters structure of bilirubin to a soluble form – soluble form – lumirubinlumirubin) for easier excretion) for easier excretion

Blue Light – more effective in reducing bilirubin but Blue Light – more effective in reducing bilirubin but alters the color of the infantalters the color of the infant

Fluorescent bulbs with spectrum 420-460nm Fluorescent bulbs with spectrum 420-460nm preferredpreferred

Infant skin is fully exposedInfant skin is fully exposed


Phototherapy – application of fluorescent light (bili light) to Phototherapy – application of fluorescent light (bili light) to infant’s exposed skininfant’s exposed skin

Rapidly rising bilirubin/ critical level – double intensive phototherapyRapidly rising bilirubin/ critical level – double intensive phototherapy Conventional overhead lamps while infant is lying on fiber optic blanketConventional overhead lamps while infant is lying on fiber optic blanket BEST RESULT: occur within 1BEST RESULT: occur within 1stst 24-48hrs of treatment 24-48hrs of treatment

Fiberoptic blanket/panelFiberoptic blanket/panel – light generating illuminator – light generating illuminator blanket delivers therapeutic light consistently & continuously to infant & blanket delivers therapeutic light consistently & continuously to infant &

achieve same photoisomerization as conventional phototherapyachieve same photoisomerization as conventional phototherapy For home phototherapy, permits more infant-parent interaction, better For home phototherapy, permits more infant-parent interaction, better

temperature controltemperature control Eliminates the need for eye patchesEliminates the need for eye patches SPECIAL CAUTION: plastic pad must completely be covered to SPECIAL CAUTION: plastic pad must completely be covered to

prevent exposing fragile skin of extremely immature/compromised prevent exposing fragile skin of extremely immature/compromised infant to fiberoptic blanket (dermal injury)infant to fiberoptic blanket (dermal injury)

When blood is drawn, phototherapy lights are turned off, blood is When blood is drawn, phototherapy lights are turned off, blood is transported in covered tube to avoid false reading as a result of transported in covered tube to avoid false reading as a result of bilirubin destruction in test tube.bilirubin destruction in test tube.

HYPERBILIRUBINEMIAHYPERBILIRUBINEMIAMANAGEMENT OF HYPERBILIRUBINEMIA IN HEALTHY TERM MANAGEMENT OF HYPERBILIRUBINEMIA IN HEALTHY TERM

NEWBORNNEWBORNTSB LEVEL (mg/dl/mmol/L)TSB LEVEL (mg/dl/mmol/L)

AGE AGE (HOURS)(HOURS)

CONSIDER CONSIDER PHOTOTHERAPYPHOTOTHERAPY

PHOTOTHERAPYPHOTOTHERAPY EXCHANGE EXCHANGE TRANSFUSION IF TRANSFUSION IF

INTENSIVE INTENSIVE PHOTOTHERAPY PHOTOTHERAPY

FAILSFAILS

EXCHANGE EXCHANGE TRANSFUSION TRANSFUSION AND INTENSIVE AND INTENSIVE

PHOTOTHERAPYPHOTOTHERAPY

2424 ------ ------ ------ ------

25-4825-48 >/= 12 (170)>/= 12 (170) >/= 15 (260)>/= 15 (260) >/= 20 (340)>/= 20 (340) >/= 25 (430)>/= 25 (430)

48-7248-72 >/= 15 (260)>/= 15 (260) >/= 18 (310)>/= 18 (310) >/= 25 (430)>/= 25 (430) >/= 30 (510)>/= 30 (510)

>72>72 >/= 17 (290)>/= 17 (290) >/= 20 (340)>/= 20 (340) >/= 25 (430)>/= 25 (430) >/= 30 (510)>/= 30 (510)


PROGNOSIS:PROGNOSIS:Early recognition prevents brain damageEarly recognition prevents brain damageBilirubin encephalopathy: athetosis, Bilirubin encephalopathy: athetosis,

sensorineural hearing loss, paralytic gaze sensorineural hearing loss, paralytic gaze palsy, gaze abnormalities, delayed motor palsy, gaze abnormalities, delayed motor skills, dental enamel hypoplasiaskills, dental enamel hypoplasia

HYPERBILIRUBINEMIAHYPERBILIRUBINEMIANURSING CONSIDERATIONSNURSING CONSIDERATIONS

ASSESSMENTASSESSMENTObserve for evidence of jaundice at regular Observe for evidence of jaundice at regular

intervalsintervals Observe color from head-toe, color of sclera & mucous Observe color from head-toe, color of sclera & mucous

membranesmembranes Apply direct pressure to skin especially bony Apply direct pressure to skin especially bony

prominences (tip of nose or sternum) prominences (tip of nose or sternum) blanching blanching allow yellow stain to be more pronouncedallow yellow stain to be more pronounced

Dark-skinned – color of sclera, conjunctiva, oral mucosaDark-skinned – color of sclera, conjunctiva, oral mucosa Observe natural daylightObserve natural daylight

Evidence of jaundice that appears before infant is Evidence of jaundice that appears before infant is 24 hrs of age – indication for assessing bilirubin 24 hrs of age – indication for assessing bilirubin levelslevels


NURSING CONSIDERATIONSNURSING CONSIDERATIONSPhototherapy – nude under light source, Phototherapy – nude under light source,

repositioned frequently to expose all body surface repositioned frequently to expose all body surface areas to lightareas to light

Frequent bilirubin determination – every 6-12hrs (visual Frequent bilirubin determination – every 6-12hrs (visual assessment is no longer considered valid)assessment is no longer considered valid)


PHOTOTHERAPY:PHOTOTHERAPY: PRECAUTIONS: PRECAUTIONS:

Eye Shield – opaque mask to prevent exposure to lightEye Shield – opaque mask to prevent exposure to light Properly sized, correctly positioned without occluding the naresProperly sized, correctly positioned without occluding the nares Infant’s eyelids are closed before mask is applied, corneas may Infant’s eyelids are closed before mask is applied, corneas may

become excoriatedbecome excoriated Eyes checked every shift for discharge, excessive pressure on lids, Eyes checked every shift for discharge, excessive pressure on lids,

corneal irritationcorneal irritation Removed during feedingsRemoved during feedings

Infants in open crib must have a protective plexiglass shield Infants in open crib must have a protective plexiglass shield between them & fluorescent lights to minimize amount of between them & fluorescent lights to minimize amount of undesirable UV lights reaching skin & protect them from undesirable UV lights reaching skin & protect them from accidental bulb breakageaccidental bulb breakage

Temperature monitoredTemperature monitored Maintain in flexed position w/ rolled blankets alongside bodyMaintain in flexed position w/ rolled blankets alongside body


PHOTOTHERAPY:PHOTOTHERAPY:ACCURATE CHARTING:ACCURATE CHARTING:

Times that phototherapy is started and stoppedTimes that phototherapy is started and stopped Proper shielding of the eyesProper shielding of the eyes Type of fluorescent lampType of fluorescent lamp Number of lampsNumber of lamps Distance between surface of lamps & infant (not <18 in)Distance between surface of lamps & infant (not <18 in) Use of phototherapy in combination with an incubator or Use of phototherapy in combination with an incubator or

open bassinetopen bassinet Photometer measurement of light intensityPhotometer measurement of light intensity Occurrence of side effectsOccurrence of side effects

Side effects: loose greenish stools transient skin Side effects: loose greenish stools transient skin rashes, hypothermia, Increase BMR, DHN, rashes, hypothermia, Increase BMR, DHN, electrolyte imbalance (hypocalcemia), priapismelectrolyte imbalance (hypocalcemia), priapism


PHOTOTHERAPY:PHOTOTHERAPY: Informed consent prior to treatmentInformed consent prior to treatment Oily lubricants/lotions not used – “frying effect”Oily lubricants/lotions not used – “frying effect” Full-term newborn – additional fluid volume to compensate Full-term newborn – additional fluid volume to compensate

for fluid lossfor fluid loss Meticulous skin careMeticulous skin care Rebound effect – after phototherapy is permanently Rebound effect – after phototherapy is permanently

discontinued discontinued subsequent increase in serum bilirubin level; subsequent increase in serum bilirubin level; transienttransient

““Bronze Baby Syndrome” – serum, urine, skin turn grayish Bronze Baby Syndrome” – serum, urine, skin turn grayish brown hours after infant is placed under lightbrown hours after infant is placed under light

Due to retention of bilirubin breakdown product of phototherapy Due to retention of bilirubin breakdown product of phototherapy (copper prophyrin)(copper prophyrin)

Infants with elevated B2 level & some degree of cholestasisInfants with elevated B2 level & some degree of cholestasis Resolves after discontinuation of phototherapyResolves after discontinuation of phototherapy

RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)

Condition of surfactant deficiency & physiologic immaturity of thoraxCondition of surfactant deficiency & physiologic immaturity of thorax Seen almost exclusively in preterm infants; seen in infants <32 wks Seen almost exclusively in preterm infants; seen in infants <32 wks

AOGAOG A disease related to developmental delay in lung maturation A disease related to developmental delay in lung maturation Also associated with multifetal pregnancies, infants of diabetic Also associated with multifetal pregnancies, infants of diabetic

mothers, Caesarean Section delivery, delivery before 37 weeks mothers, Caesarean Section delivery, delivery before 37 weeks AOG, low birth weight, precipitous delivery, cold stress, asphyxia, AOG, low birth weight, precipitous delivery, cold stress, asphyxia, history of previous RDShistory of previous RDS

Rare in drug-exposed infants or those who have been exposed to Rare in drug-exposed infants or those who have been exposed to chronic intrauterine stress (HPN, preeclampsia)chronic intrauterine stress (HPN, preeclampsia)

RDS of nonpulmonary origin in Newborn: sepsis, cardiac defects, RDS of nonpulmonary origin in Newborn: sepsis, cardiac defects, exposure to cold, airway obstruction, IVH, hypoglycemia, metabolic exposure to cold, airway obstruction, IVH, hypoglycemia, metabolic acidosis, acute blood loss, drugs.acidosis, acute blood loss, drugs.


PATHOPHYSIOLOGYPATHOPHYSIOLOGYDeficient Surfactant

Collapse of Alveoli

Great deal of effort to reexpand the alveoli with each breath

Exhaustion

Fewer and fewer alveoli opens

Atelectasis

Hypoperfusion to the lung tissue

Hypoxemia and hypercapnia


PATHOPHYSIOLOGYPATHOPHYSIOLOGYPreterm – born before lungs are fully Preterm – born before lungs are fully

prepared for gas exchange (critical factor in prepared for gas exchange (critical factor in RDS)RDS)

Combination of structural and functional Combination of structural and functional immaturity of lungsimmaturity of lungs

(+) fetal respiratory activity before birth: lungs (+) fetal respiratory activity before birth: lungs have feeble respiratory movements, fluid have feeble respiratory movements, fluid excreted thru alveoliexcreted thru alveoli


PATHOPHYSIOLOGYPATHOPHYSIOLOGYFinal unfolding of alveolar septa (increase Final unfolding of alveolar septa (increase

surface area of the lungs) occurs on last surface area of the lungs) occurs on last trimester of pregnancytrimester of pregnancyPreterms are born with underdeveloped and uninflatable alveoli

Limited pulmonary blood flow

Collapsed lungs

Increased pulmonary vascular resistance

Fetal blood shunted from lungs by ductus arteriosus and foramen ovale


PATHOPHYSIOLOGYPATHOPHYSIOLOGY Rib Cage: weak and compliantRib Cage: weak and compliant

Fetal chest highly compliant because of predominance of Fetal chest highly compliant because of predominance of cartilage; diaphragm is prone to fatiguecartilage; diaphragm is prone to fatigue

Fetal Lungs deficient in surfactant due to immaturity Fetal Lungs deficient in surfactant due to immaturity of surfactant producing type 2 alveolar cellsof surfactant producing type 2 alveolar cells

Surfactant – 1Surfactant – 1stst produced at 24 wks AOG, type 2 cells do not produced at 24 wks AOG, type 2 cells do not fully mature until about 36 wks AOGfully mature until about 36 wks AOG

Reduces surface tension of fluids that line the alveoli & Reduces surface tension of fluids that line the alveoli & respiratory passages respiratory passages uniform expansion and maintains lung uniform expansion and maintains lung expansionexpansion


PATHOPHYSIOLOGYPATHOPHYSIOLOGYDeficient surfactant – unequal inflation of alveoli on Deficient surfactant – unequal inflation of alveoli on

inspiration, collapse of alveoli of end expirationinspiration, collapse of alveoli of end expiration Without surfactant – infants unable to keep lungs Without surfactant – infants unable to keep lungs

inflated, exerts great effort to reexpand the alveoli inflated, exerts great effort to reexpand the alveoli exhaustion exhaustion atelectasis atelectasis


PATHOPHYSIOLOGYPATHOPHYSIOLOGYInadequate pulmonary perfusion and ventilation

Hypoxemia and hypercapnia

Markedly reactive pulmonary arterioles and thickMuscular layer decreased oxygen concentration

Decreased oxygen tension + decreased blood pH

Vasospasm in pulmonary arterioles

Increased PVR

Intrapulmonary shunting

Anaerobic glycolysis

Metabolic acidosis, cyanosis


PATHOPHYSIOLOGYPATHOPHYSIOLOGY (+) pulmonary edema – impaired gas exchange(+) pulmonary edema – impaired gas exchange (+) pulmonary interstitial emphysema – (+) pulmonary interstitial emphysema –

overdistention of distal airwaysoverdistention of distal airways

MAJOR FACTORS IN RDSMAJOR FACTORS IN RDS

CAUSECAUSE EFFECTEFFECT

Increased surface tension of alveoli Increased surface tension of alveoli (surfactant deficiency)(surfactant deficiency)

Alveolar collapse, atelectasis, increased Alveolar collapse, atelectasis, increased difficulty in breathingdifficulty in breathing

Impaired gas exchangeImpaired gas exchange Hypoxemia, and hypercapnia with Hypoxemia, and hypercapnia with respiratory acidosisrespiratory acidosis

Increased pulmonary vascular resistanceIncreased pulmonary vascular resistance Hypoperfusion of pulmonary circulationHypoperfusion of pulmonary circulation

Hypoperfusion (with hypoxemia)Hypoperfusion (with hypoxemia) Tissue hypoxia & metabolic acidosisTissue hypoxia & metabolic acidosis

Increased transudation of fluid into lungsIncreased transudation of fluid into lungs Hyaline membrane formation; impaired gas Hyaline membrane formation; impaired gas exchangeexchange


CLINICAL MANIFESTATIONS:CLINICAL MANIFESTATIONS: Respiratory Signs and Symptoms:Respiratory Signs and Symptoms:

Tachypnea (80-120/min) initially : dyspneaTachypnea (80-120/min) initially : dyspnea Pronounced intercostals and/or substernal retractionsPronounced intercostals and/or substernal retractions Fine inspiratory crackles ; audible expiratory gruntFine inspiratory crackles ; audible expiratory grunt Flaring of external naresFlaring of external nares Cyanosis / pallorCyanosis / pallor

As disease progressesAs disease progresses Apnea ; flaccidity ; absent spontaneous movementApnea ; flaccidity ; absent spontaneous movement Unresponsive ; diminished breath sounds ; mottlingUnresponsive ; diminished breath sounds ; mottling

Severe disease: shock-like stateSevere disease: shock-like state Decreased cardiac output and bradycardiaDecreased cardiac output and bradycardia Low systemic BPLow systemic BP


EVALUATION:EVALUATION:Blood glucose testBlood glucose testChest x-ray with fine, diffuse, recticogranular Chest x-ray with fine, diffuse, recticogranular

or “ground glass appearance and air or “ground glass appearance and air bronchogrambronchogram

Arterial blood gas (ABGs) ; pulse oximetry Arterial blood gas (ABGs) ; pulse oximetry and carbon dioxide monitoring, pulmonary and carbon dioxide monitoring, pulmonary function testsfunction tests


EVALUATION:EVALUATION: Prenatal diagnosis:Prenatal diagnosis:

Problems like maternal diabetes – delay fetal lung maturationProblems like maternal diabetes – delay fetal lung maturation Antenatal administration of glucocorticoids – enhance fetal lung Antenatal administration of glucocorticoids – enhance fetal lung

maturationmaturation Lecithin / sphingomyelin ratio (L:S ratio) : relationship Lecithin / sphingomyelin ratio (L:S ratio) : relationship

between these 2 lipids during gestationbetween these 2 lipids during gestation L:S = 2:1L:S = 2:1

““Shake/ bubble test” – stable foam bubbles form when Shake/ bubble test” – stable foam bubbles form when amniotic fluid is shaken in presence of ethanolamniotic fluid is shaken in presence of ethanol

Tap Test – abundant bubbles appear in test tube of amniotic Tap Test – abundant bubbles appear in test tube of amniotic fluid with 6N – HCL and diethyl etherfluid with 6N – HCL and diethyl ether

TDx fetal lung maturity assay TDx fetal lung maturity assay


TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT: Immediate establishment of adequate oxygen and ventilation Immediate establishment of adequate oxygen and ventilation

and supportive measures required for a preterm, prevent further and supportive measures required for a preterm, prevent further complicationscomplications

SUPPORTIVE MEASURES:SUPPORTIVE MEASURES: Maintain adequate ventilation and oxygenMaintain adequate ventilation and oxygen Maintain acid-base balanceMaintain acid-base balance Maintain neutral thermal environmentMaintain neutral thermal environment Maintain adequate tissue perfusion and oxygenMaintain adequate tissue perfusion and oxygen Prevent hypotensionPrevent hypotension Maintain adequate hydration and electrolyte statusMaintain adequate hydration and electrolyte status

NUTRITION: parenteral therapy during 1NUTRITION: parenteral therapy during 1stst phase of disease phase of disease Nipple and gavage feedings are contraindicated – causes increase Nipple and gavage feedings are contraindicated – causes increase

RR, prone to aspirationRR, prone to aspiration Enteral substrate to infant with transient hypoxia – increase risk Enteral substrate to infant with transient hypoxia – increase risk

Necrotizing EnterocolitisNecrotizing Enterocolitis


TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT: EXOGENOUS SURFACTANT REPLACEMENT (via ET Tube)EXOGENOUS SURFACTANT REPLACEMENT (via ET Tube)

Decrease oxygen requirements and mean airway pressure (MAP)Decrease oxygen requirements and mean airway pressure (MAP) Improves blood gas values & ventilator settingsImproves blood gas values & ventilator settings Decrease incidence of pulmonary air leaksDecrease incidence of pulmonary air leaks Decrease deaths from RDSDecrease deaths from RDS Decrease mortality rateDecrease mortality rate COMPLICATIONS: pulmonary hemorrhage, mucous pluggingCOMPLICATIONS: pulmonary hemorrhage, mucous plugging Given at birth via endotracheal (ET) tube directly into infants tracheaGiven at birth via endotracheal (ET) tube directly into infants trachea NURSING RESPONSIBILITIES:NURSING RESPONSIBILITIES:

Assist in delivery of the product, collection, and monitoring of ABG’s, Assist in delivery of the product, collection, and monitoring of ABG’s, scrupulous monitoring of oxygen with pulse oximetryscrupulous monitoring of oxygen with pulse oximetry

Assess infant’s tolerance of procedureAssess infant’s tolerance of procedure Delay suctioning for an hour or so to allow maximum effects to occurDelay suctioning for an hour or so to allow maximum effects to occur


TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT: OXYGEN THERAPYOXYGEN THERAPY

Aggressive respiratory support: Oxygen, continuous positive Aggressive respiratory support: Oxygen, continuous positive airway pressure (CPAP), intubation, mechanical ventilationairway pressure (CPAP), intubation, mechanical ventilation

Goals of Oxygen therapy: provide adequate oxygen to Goals of Oxygen therapy: provide adequate oxygen to tissuestissues

Prevent lactic acidosis resulting from hypoxiaPrevent lactic acidosis resulting from hypoxia Avoid negative effects of oxygen barotrauma / toxicityAvoid negative effects of oxygen barotrauma / toxicity

Gas should be warmed before entering respiratory tractGas should be warmed before entering respiratory tract Oxygen can be supplied via plastic hoodOxygen can be supplied via plastic hood If oxygen saturation of blood cannot be maintained at If oxygen saturation of blood cannot be maintained at

satisfactory level and PaO2 rises satisfactory level and PaO2 rises ventilatory assistance ventilatory assistance


TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT:

METHODMETHOD DESCRIPTIONDESCRIPTION HOW PROVIDEDHOW PROVIDED

CONVENTIONAL CONVENTIONAL METHODSMETHODS

Continuous Positive Airway Continuous Positive Airway Pressure (CPAP)Pressure (CPAP)

Provides contrast distending Provides contrast distending pressure to airway in pressure to airway in spontaneously breathing spontaneously breathing infant.infant.

Nasal prongs, endotracheal Nasal prongs, endotracheal tube, face mask, nasal tube, face mask, nasal cannulacannula

Positive End-Expiratory Positive End-Expiratory Pressure (PEEP)Pressure (PEEP)

Provides increase end-Provides increase end-expiratory pressure during expiratory pressure during expiration and between expiration and between Mandatory breaths which Mandatory breaths which prevents alveolar collapse; prevents alveolar collapse; maintains residual airway maintains residual airway pressurepressure

Endotracheal intubation, and Endotracheal intubation, and either volume-limited or either volume-limited or pressure-limited ventilatorpressure-limited ventilator


TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT:METHODMETHOD DESCRIPTIONDESCRIPTION HOW PROVIDEDHOW PROVIDED

Intermittent Mandatory Intermittent Mandatory Ventilation (IMV)Ventilation (IMV)

Allows infant to breath Allows infant to breath spontaneously at own rate but spontaneously at own rate but provides mechanical cycled provides mechanical cycled respirations and pressure at respirations and pressure at regular preset intervalsregular preset intervals

Endotracheal Endotracheal intubation and intubation and ventilatorventilator

Synchronized Intermittent Synchronized Intermittent Mandatory Ventilation Mandatory Ventilation (SIMV)(SIMV)

Mechanically delivered breaths Mechanically delivered breaths are synchronized to the onset of are synchronized to the onset of spontaneous patient breaths; spontaneous patient breaths; assist/control mode facilities full assist/control mode facilities full inspiratory synchrony; involves inspiratory synchrony; involves signal detection of onset of signal detection of onset of spontaneous respiration from spontaneous respiration from abdominal movement, thoracic abdominal movement, thoracic impedance, airway pressure, or impedance, airway pressure, or flow changesflow changes

Patient-triggered infant Patient-triggered infant ventilator with signal ventilator with signal detector and detector and assist/control mode; assist/control mode; endotracheal tubeendotracheal tube




Volume Guarantee Volume Guarantee VentilationVentilation

Delivers predetermined volume Delivers predetermined volume of gas using an inspiratory of gas using an inspiratory pressure that varies according pressure that varies according to infant’s lung compliance to infant’s lung compliance (often used in conjunction with (often used in conjunction with SIMV)SIMV)

Volume guarantee Volume guarantee ventilator with flow ventilator with flow sensor; endotracheal sensor; endotracheal tubetube

ALTERNATIVE ALTERNATIVE METHODSMETHODS

High frequency Oscillation High frequency Oscillation (HFO)(HFO)

Application of high-frequency, Application of high-frequency, low-volume, sine wave flow low-volume, sine wave flow oscillations to airway at rates oscillations to airway at rates between 480 and 1200 between 480 and 1200 breaths/minbreaths/min

Variable-speed piston Variable-speed piston pump (or loudspeaker, pump (or loudspeaker, fluidic oscillator) ; fluidic oscillator) ; endotracheal tubeendotracheal tube




High-Frequency Jet High-Frequency Jet Ventilation (HFJV)Ventilation (HFJV)

Uses separate, parallel, Uses separate, parallel, low compliant circuit and low compliant circuit and injector port to deliver injector port to deliver small pulses or jets of small pulses or jets of fresh gas deep into airway fresh gas deep into airway at rates between 250 and at rates between 250 and 900 breaths/min900 breaths/min

May be used alone or with May be used alone or with low-rate IMV; endotracheal low-rate IMV; endotracheal tubetube


TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT: COMPLICATIONS OF POSITIVE PRESSURE COMPLICATIONS OF POSITIVE PRESSURE

VENTILATION:VENTILATION: Increased incidence of air leaks that produce complications:Increased incidence of air leaks that produce complications:

Pulmonary Interstitial EmphysemaPulmonary Interstitial Emphysema PneumothoraxPneumothorax PneumomediastinumPneumomediastinum

Associated with Intubation:Associated with Intubation: Nasal/tracheal/pharyngeal perforationNasal/tracheal/pharyngeal perforation Stenosis; inflammationStenosis; inflammation Palatal grooves; subglottic stenosisPalatal grooves; subglottic stenosis Tube obstruction and infectionTube obstruction and infection


TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT: INHALED NITRIC OXIDE (NO): for newborn with conditions that INHALED NITRIC OXIDE (NO): for newborn with conditions that

cause persistent pulmonary HPN, pulmonary vasoconstriction, cause persistent pulmonary HPN, pulmonary vasoconstriction, subsequent acidosis, and severe hypoxiasubsequent acidosis, and severe hypoxia

Colorless, highly diffusible gas: cause smooth muscle relaxation and Colorless, highly diffusible gas: cause smooth muscle relaxation and reduce pulmonary vasoconstriction and subsequent pulmonary HPN reduce pulmonary vasoconstriction and subsequent pulmonary HPN when inhaled into lungswhen inhaled into lungs

Administered through ventilator circuit and blended with oxygenAdministered through ventilator circuit and blended with oxygen Attaches readily to hemoglobin and deactivated so that systemic Attaches readily to hemoglobin and deactivated so that systemic

vasculature is not affectedvasculature is not affected Toxic in large quantitiesToxic in large quantities Mucus may collect I respiratory tract as a result of infant’s Mucus may collect I respiratory tract as a result of infant’s

pulmonary condition pulmonary condition interferes with gas flow and obstruct interferes with gas flow and obstruct passagespassages

Catheter inserted gently but quickly; intermittent suctioning (limited Catheter inserted gently but quickly; intermittent suctioning (limited to <5secs)to <5secs)

FiO2 increased by 10% before suctioningFiO2 increased by 10% before suctioning


TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT:Most advantageous position for facilitating an Most advantageous position for facilitating an

infant’s open airway are on the side with head infant’s open airway are on the side with head supported in alignment by small folded supported in alignment by small folded blanketblanketBack position – keep neck slightly extendedBack position – keep neck slightly extended

Head in “sniffing” positionHead in “sniffing” position

Inspection of skin – position changes and use Inspection of skin – position changes and use of water pillows (prevents skin breakdown)of water pillows (prevents skin breakdown)

Mouth careMouth care


TRANSIENT TACHYPNEA OF THE TRANSIENT TACHYPNEA OF THE NEWBORN (RDS TYPE 2)NEWBORN (RDS TYPE 2)Delayed resorption of fetal lung fluid; Delayed resorption of fetal lung fluid;

decrease lung compliancedecrease lung complianceManagement: Oxygen therapyManagement: Oxygen therapySigns and symptoms similar to RDS 1 Signs and symptoms similar to RDS 1

(hyaline membrane disease) but resolves 48-(hyaline membrane disease) but resolves 48-72 hrs.72 hrs.

SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA Generalized bacterial infection in the Generalized bacterial infection in the

bloodstreambloodstream Newborns are highly susceptible to infection as Newborns are highly susceptible to infection as

a result of diminished nonspecific (inflammatory) a result of diminished nonspecific (inflammatory) & specific (humoral) immunity: impaired & specific (humoral) immunity: impaired phagocytosis, delayed chemotactic response, phagocytosis, delayed chemotactic response, minimal/absent IgA & IgM, decreased minimal/absent IgA & IgM, decreased complement levelscomplement levels

High-Risk Infant 4x greater chance; males > High-Risk Infant 4x greater chance; males > femalesfemales

SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA

RISK FACTORS:RISK FACTORS: PrematurityPrematurity Congenital AnomaliesCongenital Anomalies Acquired injuries that disrupt the skin, mucous Acquired injuries that disrupt the skin, mucous

membranesmembranes Invasive procedures – IV lines, ET tubesInvasive procedures – IV lines, ET tubes Administration of TPNsAdministration of TPNs Nosocomial exposures – NICUNosocomial exposures – NICU Infant born after a difficult or traumatic labor & Infant born after a difficult or traumatic labor &

deliverydelivery


PATHOPHYSIOLOGY:PATHOPHYSIOLOGY:Premature withdrawal of placental barrier – Premature withdrawal of placental barrier –

leaves infants vulnerable to viral, fungal, leaves infants vulnerable to viral, fungal, bacterial, parasitic infectionsbacterial, parasitic infections

Early birth interrupts transplacental Early birth interrupts transplacental transmission of passive immunity (IgG)transmission of passive immunity (IgG)Preterms – low IgG; IgA & IgM not transferred to Preterms – low IgG; IgA & IgM not transferred to

fetusfetus


SOURCES OF INFECTION:SOURCES OF INFECTION:Acquired prenatally across placenta from Acquired prenatally across placenta from

maternal blood stream or during labor from maternal blood stream or during labor from ingestion or aspiration of infected amniotic ingestion or aspiration of infected amniotic fluidfluidProlonged rupture of membranes – maternal-fetal Prolonged rupture of membranes – maternal-fetal

transfer of pathogenic organismstransfer of pathogenic organismsTransplacental transfer of CMV, toxoplasmosis, Transplacental transfer of CMV, toxoplasmosis,

syphilis can occursyphilis can occur


SOURCES OF INFECTION:SOURCES OF INFECTION: Early Sepsis (< 3days) – acquired in perinatal periodEarly Sepsis (< 3days) – acquired in perinatal period

Direct contact with organisms from maternal GIT & GUTDirect contact with organisms from maternal GIT & GUT Group B streptococcus (GBS), E. ColiGroup B streptococcus (GBS), E. Coli H. influenza, coagulase-negative staphylococci – Very Low H. influenza, coagulase-negative staphylococci – Very Low

Birth Weight infantsBirth Weight infants Gonococci, Candida albicans, Herpes Simplex Virus II, Gonococci, Candida albicans, Herpes Simplex Virus II,

Listeria organism, ChlamydiaListeria organism, Chlamydia

Late Sepsis (1-3 weeks after birth) – nosocomialLate Sepsis (1-3 weeks after birth) – nosocomial Staphylococci, Kleibsiella, enterococci, PseudomonasStaphylococci, Kleibsiella, enterococci, Pseudomonas Coagulase-negative staphylococci – Extremely Low Birth Coagulase-negative staphylococci – Extremely Low Birth

Weight, Very Low Birth Weight InfantsWeight, Very Low Birth Weight Infants


SOURCES OF INFECTION:SOURCES OF INFECTION:Bacterial Invasion: umbilical stump, mucous Bacterial Invasion: umbilical stump, mucous

membranes of the eyes, nose, pharynx, ear; membranes of the eyes, nose, pharynx, ear; internal systems (respiratory, nervous, internal systems (respiratory, nervous, urinary, GIT)urinary, GIT)

Postnatal Infection: cross-contamination from Postnatal Infection: cross-contamination from other infants, personnel, object in the other infants, personnel, object in the environmentenvironment


SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS: Systemic InfectionsSystemic Infections – subtle, vague, nonspecific – subtle, vague, nonspecific General:General: Fever, Temperature instability; “not doing Fever, Temperature instability; “not doing

well”; poor feeding, edemawell”; poor feeding, edema GI System:GI System: poor feeding, abdominal distention; poor feeding, abdominal distention;

vomiting; diarrhea/ decreased stooling; vomiting; diarrhea/ decreased stooling; Hepatomegaly, hemoccult-positive stoolsHepatomegaly, hemoccult-positive stools

Respiratory System:Respiratory System: irregular respirations, irregular respirations, Apnea/tachypnea; dyspnea, retractions; flaring, Apnea/tachypnea; dyspnea, retractions; flaring, grunting; cyanosisgrunting; cyanosis

Renal System:Renal System: Oliguria Oliguria


SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS: Cardiovascular System/ Circulatory: Pallor/ cyanosis/ Cardiovascular System/ Circulatory: Pallor/ cyanosis/

mottling, cold clammy skin; hypotension; irregular mottling, cold clammy skin; hypotension; irregular heartbeat : Tachycardia/ Bradycardia, edemaheartbeat : Tachycardia/ Bradycardia, edema

CNS: diminished activity – lethargy, hyporeflexia, CNS: diminished activity – lethargy, hyporeflexia, comacoma

Increased activity – irritability, tremors, seizuresIncreased activity – irritability, tremors, seizures Full fontanelle, High-pitched cry, increased/ decreased tone, Full fontanelle, High-pitched cry, increased/ decreased tone,

abnormal eye movementsabnormal eye movements

Hematologic System: Jaundice, splenomegaly, pallor, Hematologic System: Jaundice, splenomegaly, pallor, petechiae, purpura, ecchymosis petechiae, purpura, ecchymosis


DIAGNOSIS:DIAGNOSIS: Based on suspicion of presenting clinical signs and Based on suspicion of presenting clinical signs and

symptomssymptoms Laboratory and radiographic examination – definitive Laboratory and radiographic examination – definitive

diagnosisdiagnosis Blood/ urine/ CSF cultures – 10% will have negative culturesBlood/ urine/ CSF cultures – 10% will have negative cultures CBC: anemia, leukocytosis/ leucopeniaCBC: anemia, leukocytosis/ leucopenia

Leucopenia – ominous signLeucopenia – ominous sign C-reactive protein serial measurementsC-reactive protein serial measurements Chest x-rayChest x-ray Lumbar puncture if < 28 days old, and if with altered mental Lumbar puncture if < 28 days old, and if with altered mental

status or meningeal signsstatus or meningeal signs

SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT:

SUPPORTIVE THERAPY: Circulatory, respiratorySUPPORTIVE THERAPY: Circulatory, respiratory Respiratory distress/ hypoxia : Oxygen therapyRespiratory distress/ hypoxia : Oxygen therapy IVF regulationIVF regulation Correct electrolytes and acid-base balanceCorrect electrolytes and acid-base balance NPO temporarilyNPO temporarily Blood transfusions for anemia and shockBlood transfusions for anemia and shock Vital signs, thermoregulationVital signs, thermoregulation

Aggressive administration of antibiotics, Aggressive administration of antibiotics, immunotherapyimmunotherapy

Antibiotics X7-10 days if cultures are positive, discontinue in Antibiotics X7-10 days if cultures are positive, discontinue in 3 days if culture is negative & infant is asymptomatic (thru IV 3 days if culture is negative & infant is asymptomatic (thru IV infusion)infusion)

Antifungal/ antiviral therapies Antifungal/ antiviral therapies


PROGNOSISPROGNOSISVariableVariableELBW/ VLBW infants: Early onset sepsis ELBW/ VLBW infants: Early onset sepsis

severe neurologic & respiratory sequelaesevere neurologic & respiratory sequelaeLate-onset sepsis & meningitis: poor outcomeLate-onset sepsis & meningitis: poor outcome


NURSING CONSIDERATIONS:NURSING CONSIDERATIONS: Recognize existing problem: “something is wrong”Recognize existing problem: “something is wrong” Awareness of potential modes of infection Awareness of potential modes of infection

transmissiontransmission Knowledge of the side effects of specific antibiotic & Knowledge of the side effects of specific antibiotic &

proper regulation & administration of drug are vitalproper regulation & administration of drug are vital Prolonged antibiotic therapy – (+) growth of resistant Prolonged antibiotic therapy – (+) growth of resistant

organisms & superinfection from fungal/ mycotic agents organisms & superinfection from fungal/ mycotic agents (Candida albicans) (Candida albicans)

Nystatin oral suspension swabbed on oral mucosa – Nystatin oral suspension swabbed on oral mucosa – prophylaxisprophylaxis

Avoid fully flexed position for obtaining spinal fluid.Avoid fully flexed position for obtaining spinal fluid.

SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA NURSING CONSIDERATIONS:NURSING CONSIDERATIONS:

Continual cardiorespiratory & pulse oximetry Continual cardiorespiratory & pulse oximetry monitoring provides an ongoing assessment of monitoring provides an ongoing assessment of infant’s conditioninfant’s condition

Decrease additional physiologic or environmental Decrease additional physiologic or environmental stressstress

Thermoregulated environmentThermoregulated environment Anticipate potential problems – dehydration, hypoxiaAnticipate potential problems – dehydration, hypoxia

Precautionary measures: proper hand washing, use Precautionary measures: proper hand washing, use disposable equipmentdisposable equipment

Proper disposal of excretions (vomitus, stool)Proper disposal of excretions (vomitus, stool) Adequate housekeepingAdequate housekeeping

Observe for signs of complications – meningitis, Observe for signs of complications – meningitis, septic shockseptic shock

NECROTIZING ENTEROCOLITISNECROTIZING ENTEROCOLITISAcute inflammatory disease of the bowelAcute inflammatory disease of the bowelSeen primarily in premature infants, Seen primarily in premature infants,

although, described in full-term neonates although, described in full-term neonates as wellas well

Occurs several weeks after birthOccurs several weeks after birth

ETIOLOGY:ETIOLOGY:Precise Cause: unknownPrecise Cause: unknownPrematurity: risk factorPrematurity: risk factor

NECROTIZING ENTEROCOLITISNECROTIZING ENTEROCOLITISETIOLOGY:ETIOLOGY:

3 FACTORS THAT PLAY ROLE IN 3 FACTORS THAT PLAY ROLE IN DEVELOPMENT OF NEC:DEVELOPMENT OF NEC:Intestinal Ischemia – vascular compromise on GITIntestinal Ischemia – vascular compromise on GIT

Diminished Blood Supply

Cell death

No secretion of protective, lubricating mucus

Thin unprotected wall attacked by proteolytic enzyme

Bowel wall swell and break down

Unable to synthesize IgM, mucosa permeable to toxins

Gas-forming bacteria invasion

(+) pneumatosis intestinalis (air in submucosa / subserosa)

NECROTIZING ENTEROCOLITISNECROTIZING ENTEROCOLITIS

ETIOLOGY:ETIOLOGY: 3 FACTORS THAT PLAY ROLE IN DEVELOPMENT 3 FACTORS THAT PLAY ROLE IN DEVELOPMENT

OF NEC:OF NEC: Colonization by pathogenic bacteriaColonization by pathogenic bacteria Substrate (formula feeding) in intestinal lumen – stress on Substrate (formula feeding) in intestinal lumen – stress on

ischemic bowelischemic bowel

SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS: Nonspecific Clinical Signs:Nonspecific Clinical Signs:

Lethargy, poor feeding, hypotensionLethargy, poor feeding, hypotension Vomiting, oliguria, hypotensionVomiting, oliguria, hypotension Unstable temperature, jaundiceUnstable temperature, jaundice


SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS: Specific Signs:Specific Signs:

Distended (often shiny) abdomen; blood in stools/gastric Distended (often shiny) abdomen; blood in stools/gastric contentcontent

Gastric retention; bilious vomitusGastric retention; bilious vomitus Localized abdominal wall erythema/ indurationLocalized abdominal wall erythema/ induration

DIAGNOSIS:DIAGNOSIS: Abdominal x-ray: Sausage-shaped dilation of intestine Abdominal x-ray: Sausage-shaped dilation of intestine

distended loops of bowel; “pneumatosis distended loops of bowel; “pneumatosis intestinalis” --- “soapsuds” or bubbly appearance of intestinalis” --- “soapsuds” or bubbly appearance of thickened bowel wall & ultralumina;thickened bowel wall & ultralumina;

Air in portal vein; free air under the diaphragm (perforation)Air in portal vein; free air under the diaphragm (perforation)


DIAGNOSIS:DIAGNOSIS: Occult blood in the stoolOccult blood in the stool Blood culture – bacteremia / septicemiaBlood culture – bacteremia / septicemia CBC: anemia, leucopenia/ leukocytosisCBC: anemia, leucopenia/ leukocytosis Metabolic acidosis, electrolyte imbalanceMetabolic acidosis, electrolyte imbalance

TREATMENT: TREATMENT: Begins with preventionBegins with prevention

NPO x 24-48 hours – infants who have suffered birth NPO x 24-48 hours – infants who have suffered birth asphyxia, ELBW, VLBW infantsasphyxia, ELBW, VLBW infants

Breast milkBreast milk Minimal enteral feedings – trophic feeding, GIT priming Minimal enteral feedings – trophic feeding, GIT priming


TREATMENT: TREATMENT: Confirmed NEC:Confirmed NEC:

Discontinue all oral feedingsDiscontinue all oral feedings Place NGT – for decompressionPlace NGT – for decompression IV fluids; IV antibioticsIV fluids; IV antibiotics Surgery in extreme casesSurgery in extreme cases

PROGNOSIS:PROGNOSIS: Sequelae of surgical intervention: shirt-gut syndrome, Sequelae of surgical intervention: shirt-gut syndrome,

colonic stricture with obstruction, fat malabsorption, colonic stricture with obstruction, fat malabsorption, failure to thrivefailure to thrive


NURSING CONSIDERATIONS:NURSING CONSIDERATIONS: Prompt recognition of early warning signs of NEC: abdominal Prompt recognition of early warning signs of NEC: abdominal

distention, absent bowel soundsdistention, absent bowel sounds Measure abdominal girth, residual gastric contents before feedings, Measure abdominal girth, residual gastric contents before feedings,

listen for presence of bowel soundslisten for presence of bowel sounds Vital signs including blood pressureVital signs including blood pressure

Avoid rectal temperatures (danger of perforation)Avoid rectal temperatures (danger of perforation) Avoid pressure on distended abdomenAvoid pressure on distended abdomen

Infants are left undiapered & positioned supine or on the sideInfants are left undiapered & positioned supine or on the side Conscientious attention to nutritional and hydration needs, Conscientious attention to nutritional and hydration needs,

administration of antibioticsadministration of antibiotics Oral feedings: started 7-10 days after diagnosis & treatment using Oral feedings: started 7-10 days after diagnosis & treatment using

human milk, elemental formulahuman milk, elemental formula Sterile water may be given initiallySterile water may be given initially Strict hand washingStrict hand washing

FAILURE TO THRIVEFAILURE TO THRIVE Sign of inadequate growth resulting from inability Sign of inadequate growth resulting from inability

to obtain or use calories required for growthto obtain or use calories required for growth No universal definitionNo universal definition Common parameter: WEIGHT, sometimes Common parameter: WEIGHT, sometimes

height that falls below 5height that falls below 5thth percentile for child’s percentile for child’s ageage

Weight for age (height) Weight for age (height) z z value of less than -2.0value of less than -2.0 Weight curve (loss) that crosses >2 percentile Weight curve (loss) that crosses >2 percentile

lines on National Center for Health Statistics lines on National Center for Health Statistics (NCHS) growth (NCHS) growth after previous achievement of a after previous achievement of a stable growth pattern.stable growth pattern.

FAILURE TO THRIVEFAILURE TO THRIVE 3 GENERAL CATEGORIES:3 GENERAL CATEGORIES:

Organic Failure to Thrive Organic Failure to Thrive Physical CausePhysical Cause

Congenital heart defects, neurologic lesions, cerebral palsy, Congenital heart defects, neurologic lesions, cerebral palsy, microcephalymicrocephaly

Chronic renal failure, gastroesophageal refluxChronic renal failure, gastroesophageal reflux Malabsorption syndrome, endocrine dysfunction Malabsorption syndrome, endocrine dysfunction Cystic fibrosis, acquired immunodeficiency syndrome (AIDS)Cystic fibrosis, acquired immunodeficiency syndrome (AIDS)

Nonorganic Failure to Thrive (NFTT)Nonorganic Failure to Thrive (NFTT) Unrelated to diseaseUnrelated to disease Result of psychosocial factors – inadequate nutritional information by Result of psychosocial factors – inadequate nutritional information by

parentparent Deficiency of maternal care of disturbance in maternal-child attachmentDeficiency of maternal care of disturbance in maternal-child attachment Disturbance in child’s ability to separate from parent leading to food Disturbance in child’s ability to separate from parent leading to food

refusal to maintain attentionrefusal to maintain attention Idiopathic Failure to Thrive – unexplained by usual organic and Idiopathic Failure to Thrive – unexplained by usual organic and

environmental etiologies but may also be classified as NFTT.environmental etiologies but may also be classified as NFTT.

FAILURE TO THRIVEFAILURE TO THRIVE

Some experts suggest that classifications are Some experts suggest that classifications are too simplistic because most cases of growth too simplistic because most cases of growth failure have mixed causes.failure have mixed causes. FTT be classified according to pathophysiology for the FTT be classified according to pathophysiology for the

following categories:following categories: Inadequate Caloric IntakeInadequate Caloric Intake

Incorrect formula preparationsIncorrect formula preparations Neglect, food fadsNeglect, food fads Excessive juice consumptionExcessive juice consumption PovertyPoverty Behavioral problems affecting eatingBehavioral problems affecting eating CNS problems affecting intakeCNS problems affecting intake


Inadequate absorptionInadequate absorption Cystic fibrosis, celiac disease, vitamin/ mineral Cystic fibrosis, celiac disease, vitamin/ mineral

deficiencies, biliary atresia, hepatic diseasedeficiencies, biliary atresia, hepatic disease

Increase metabolismIncrease metabolism Hyperthyroidism, congenital heart defects, chronic Hyperthyroidism, congenital heart defects, chronic

immunodeficiency immunodeficiency

Defective utilizationDefective utilization Trisomy 21 or 18, congenital infection, metabolic storage Trisomy 21 or 18, congenital infection, metabolic storage

diseasesdiseases


ETIOLOGY – multifactorialETIOLOGY – multifactorial Infant organic diseaseInfant organic diseaseDysfunctional parenting behaviorsDysfunctional parenting behaviorsSubtle neurologic/ behavioral problemsSubtle neurologic/ behavioral problemsDisturbed parent-child interactionsDisturbed parent-child interactions

FACTORS LEADING TO INADEQUATE FACTORS LEADING TO INADEQUATE FEEDING OF INFANTFEEDING OF INFANTPoverty – dilute formula to extend available Poverty – dilute formula to extend available

supply; no insurancesupply; no insuranceNo primary care practitioner; homelessness No primary care practitioner; homelessness

FAILURE TO THRIVEFAILURE TO THRIVE Health or childbearing beliefs – fad diets, excessive concern with Health or childbearing beliefs – fad diets, excessive concern with

obesity, hypercholesterolemia, nursing caries obesity, hypercholesterolemia, nursing caries Strict use of scheduled feedingsStrict use of scheduled feedings Inappropriate food source; excessive juice intakeInappropriate food source; excessive juice intake

Inadequate nutritional knowledge – cultural confusion (immigrant Inadequate nutritional knowledge – cultural confusion (immigrant to USA); cognitive impairmentsto USA); cognitive impairments

Family Stress – overwhelming involvement with another Family Stress – overwhelming involvement with another chronically ill childchronically ill child

Financial, marital, excessive parenting & employment Financial, marital, excessive parenting & employment responsibilitiesresponsibilities

Single parent employed full time, depression, substance abuse, Single parent employed full time, depression, substance abuse, acute griefacute grief


Psychosocial factors – maternal depression, Psychosocial factors – maternal depression, Munchausen syndrome by proxy, child temperamentMunchausen syndrome by proxy, child temperament

Feeding resistance – oral tactile hypersensitivityFeeding resistance – oral tactile hypersensitivity Infant receiving nonoral nutritional therapy early in life or Infant receiving nonoral nutritional therapy early in life or

exclusively fed with feeding tubesexclusively fed with feeding tubes

Insufficient breast milk – fatigue, poor release of milk, Insufficient breast milk – fatigue, poor release of milk, breast surgery augmentation, lack of maternal breast surgery augmentation, lack of maternal confidence / support. confidence / support.

FAILURE TO THRIVEFAILURE TO THRIVE CLINICAL MANIFESTATIONS:CLINICAL MANIFESTATIONS:

Growth Failure – 5Growth Failure – 5thth percentile in weight only or weight and percentile in weight only or weight and heightheight

Developmental delays – social, motor, adaptive, languageDevelopmental delays – social, motor, adaptive, language ApathyApathy Poor hygienePoor hygiene Withdrawn behaviorWithdrawn behavior Feeding/ eating disorder: vomiting, anorexia, pica, ruminationFeeding/ eating disorder: vomiting, anorexia, pica, rumination No fear of strangers (stage when stranger anxiety is normal)No fear of strangers (stage when stranger anxiety is normal) Avoidance of eye contactAvoidance of eye contact Wide-eyed gaze & continual scan of environment (radar gaze)Wide-eyed gaze & continual scan of environment (radar gaze) Stiff & unyielding or flaccid & unresponsiveStiff & unyielding or flaccid & unresponsive Minimal smilingMinimal smiling

FAILURE TO THRIVEFAILURE TO THRIVE DIAGNOSTIC EVALUATION:DIAGNOSTIC EVALUATION:

Evidence of growth retardation & caloric deprivationEvidence of growth retardation & caloric deprivation Anthropometric measurementsAnthropometric measurements

Onset of FTT is fairly recent: weigh (not height) is below accepted Onset of FTT is fairly recent: weigh (not height) is below accepted standards (5standards (5thth percentile) percentile)

Long standing FTT: height and weight depressed; chronic Long standing FTT: height and weight depressed; chronic malnutritionmalnutrition

Complete health and dietary history --- history of food consumed Complete health and dietary history --- history of food consumed over 3-5 day periodover 3-5 day period

Child’s activity level, perceived food allergies, dietary restrictionsChild’s activity level, perceived food allergies, dietary restrictions P.E for evidence of organic causes, developmental assessmentP.E for evidence of organic causes, developmental assessment Family assessment – parental height, household organizations & Family assessment – parental height, household organizations &

mealtime behaviors & ritualsmealtime behaviors & rituals Rule out organic causesRule out organic causes

Lead toxicity, anemia, stool-reducing substance, occult blood, ova, Lead toxicity, anemia, stool-reducing substance, occult blood, ova, parasitesparasites

Alkaline phospatase, zinc levelsAlkaline phospatase, zinc levels


THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT: Directed as reversing the malnutrition & underlying Directed as reversing the malnutrition & underlying

causecause Goal: provide sufficient calories to support “catch up” Goal: provide sufficient calories to support “catch up”

growthgrowth Treat any coexisting problemsTreat any coexisting problems Multidisciplinary team: physician, nurse, dietitian, Multidisciplinary team: physician, nurse, dietitian,

gastroenterologist, child-life specialist, social worker gastroenterologist, child-life specialist, social worker or mental health professionalor mental health professional

Relieve any additional stresses on family – referrals to Relieve any additional stresses on family – referrals to welfare agencies or supplemental food programswelfare agencies or supplemental food programs


THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT: Family therapyFamily therapy Behavior modificationBehavior modification Hospitalization indications:Hospitalization indications:

Evidence (anthropometric) of severe acute malnutritionEvidence (anthropometric) of severe acute malnutrition Child abuse / neglectChild abuse / neglect Significant dehydrationSignificant dehydration Caretaker substance abuse or psychosisCaretaker substance abuse or psychosis Outpatient management that does not result in weight gainOutpatient management that does not result in weight gain


NURSING CONSIDERATIONS:NURSING CONSIDERATIONS:Accurate assessment of initial weight & height Accurate assessment of initial weight & height

and daily weight & recording of all food intakeand daily weight & recording of all food intakeFeeding behavior is documented & parent-Feeding behavior is documented & parent-

child interaction during feedingchild interaction during feedingFeeding checklistFeeding checklistShould be placed in a room with noninfectious Should be placed in a room with noninfectious

children of similar age children of similar age Structure feeding environment to encourage Structure feeding environment to encourage

eatingeating

FAILURE TO THRIVEFAILURE TO THRIVE NURSING CONSIDERATIONS:NURSING CONSIDERATIONS:

The childThe child May exhibit altered behavioral interactionsMay exhibit altered behavioral interactions Display intense interest in inanimate objects (toys) but less in Display intense interest in inanimate objects (toys) but less in

social interactionssocial interactions Watchful of people at a distance but become distressed as Watchful of people at a distance but become distressed as

others come closerothers come closer Dislike being touched or held & avoid face-to-face contact; Dislike being touched or held & avoid face-to-face contact;

when held they protest briefly on being put down& apathetic when held they protest briefly on being put down& apathetic when left alonewhen left alone

History of difficulty in feeding, vomiting, sleep disturbance, History of difficulty in feeding, vomiting, sleep disturbance, excessive irritabilityexcessive irritability

Crying during feedings, hoarding food in mouth, rumination Crying during feedings, hoarding food in mouth, rumination after feeding, refusing to switch from liquids to solids, after feeding, refusing to switch from liquids to solids, aversion behaviors (turning from food, spitting)aversion behaviors (turning from food, spitting)

Difficult temperament or passive, sleepy, lethargic infant who Difficult temperament or passive, sleepy, lethargic infant who does not wake up for feedingsdoes not wake up for feedings


NURSING CONSIDERATIONS:NURSING CONSIDERATIONS:The parentThe parent

Increased risk for altered parent-infant interactions Increased risk for altered parent-infant interactions because:because:

Isolation and social crisisIsolation and social crisis Inadequate support systemsInadequate support systems Poor / absent parenting role models when they were Poor / absent parenting role models when they were

childrenchildrenLack of education, physical/ mental health Lack of education, physical/ mental health

problemsproblems Physical and sexual abuse, depression, drug Physical and sexual abuse, depression, drug

dependence, immaturitydependence, immaturity


NUTRITIONAL MANAGEMENT:NUTRITIONAL MANAGEMENT:4 Primary Goals in Nutritional management of 4 Primary Goals in Nutritional management of

FTT:FTT:Correct nutritional deficiencies & achieve ideal Correct nutritional deficiencies & achieve ideal

weight for heightweight for height Increase caloric intake in formula fed infants: Increase caloric intake in formula fed infants:

supplements like Polycose, medium chain triglycerides supplements like Polycose, medium chain triglycerides may be added slowly – in 2kcal/oz increments q2-3 days may be added slowly – in 2kcal/oz increments q2-3 days to yield up 28-30 kcal/ozto yield up 28-30 kcal/oz

Carbohydrate additives (8 kcal/tsp)Carbohydrate additives (8 kcal/tsp)


NUTRITIONAL MANAGEMENT:NUTRITIONAL MANAGEMENT: Rice cereal & vegetable oilRice cereal & vegetable oil Multivitamin supplementation – zinc and ironMultivitamin supplementation – zinc and iron Breast-fed infants: add 1 tsp of 24 kcal/oz formula to 3 oz Breast-fed infants: add 1 tsp of 24 kcal/oz formula to 3 oz

breast milkbreast milk Toddlers: high caloric milk (PediaSure)Toddlers: high caloric milk (PediaSure) Fruit juices – minimized in infants < 6 monthsFruit juices – minimized in infants < 6 months Extreme cases: tube feedings or IV therapyExtreme cases: tube feedings or IV therapy

Allow for catch up growthAllow for catch up growthRestore optimum body compositionRestore optimum body composition


NUTRITIONAL MANAGEMENT:NUTRITIONAL MANAGEMENT:Educate parents/ primary caregivers regarding Educate parents/ primary caregivers regarding

child’s nutritional requirements & appropriate child’s nutritional requirements & appropriate feeding methodsfeeding methods

Step-by-step directions for formula preparations, written Step-by-step directions for formula preparations, written schedule of feeding timesschedule of feeding times

Juices should be avoided in children with growth failure Juices should be avoided in children with growth failure until adequate weight gain has been achieved (should until adequate weight gain has been achieved (should not exceed 4oz/day)not exceed 4oz/day)

Family-system approachFamily-system approach

HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN

Erythroblastosis fetalisErythroblastosis fetalisHyperbilirubinemia in 1Hyperbilirubinemia in 1stst 24 hrs of life 24 hrs of lifeAbnormally rapid rate of RBC destructionAbnormally rapid rate of RBC destructionAnemia caused by this destruction (+) Anemia caused by this destruction (+)

production of RBCs production of RBCs increased # cells increased # cells for hemolysisfor hemolysis

Major causes: isoimmunization (primarily Major causes: isoimmunization (primarily Rh) & ABO incompatibilityRh) & ABO incompatibility


Blood IncompatibilityBlood Incompatibility Antigen / Agglutinogens – substance capable of Antigen / Agglutinogens – substance capable of

producing an immune response if recognized by the producing an immune response if recognized by the body as foreignbody as foreign

Antigens + Antibodies = agglutination (clumping)Antigens + Antibodies = agglutination (clumping) Antibodies in plasma of 1 blood group (except AB Antibodies in plasma of 1 blood group (except AB

group – no antibodies) produce agglutination when group – no antibodies) produce agglutination when mixed with antigens of a different blood groupmixed with antigens of a different blood group

ABO blood group system – antibodies occur naturallyABO blood group system – antibodies occur naturally Rh system - isoimmunizationRh system - isoimmunization


1. Rh Incompatibility1. Rh Incompatibility The presence of naturally occurring Rh The presence of naturally occurring Rh

factor determines the blood type.factor determines the blood type. Rh (+) – presence of antigenRh (+) – presence of antigen Rh (-) – absence of antigenRh (-) – absence of antigen No problems occur when Rh blood type are No problems occur when Rh blood type are

same in both mother and fetus or if mother same in both mother and fetus or if mother is Rh (+) and infant is Rh (-).is Rh (+) and infant is Rh (-).

Mother Rh (-) and Infant Rh (+) : problemMother Rh (-) and Infant Rh (+) : problem


Isoimmunization – no effect on 1Isoimmunization – no effect on 1stst pregnancy pregnancyInitial sensitization to Rh antigens rarely occurs Initial sensitization to Rh antigens rarely occurs

before the onset of laborbefore the onset of laborWith increased risk of fetal blood transferred to With increased risk of fetal blood transferred to

maternal circulation during placental separation, maternal circulation during placental separation, maternal antibody production is stimulated.maternal antibody production is stimulated.

Fetal RBCs (with antigens foreign to mother)

Enters maternal circulation

Mother produces anti-Rh antibodies


Factors that increase incidence of Factors that increase incidence of transpalcental hemorrhage & subsequent transpalcental hemorrhage & subsequent isoimmunization:isoimmunization:Multiple gestation, abruptio placenta, placenta Multiple gestation, abruptio placenta, placenta

previa, manual removal of placenta, cesarean previa, manual removal of placenta, cesarean deliverydelivery

Subsequent pregnancy with Rh (+) fetus

Previously formed maternal antibodies to Rh (+) blood cells enter fetal circulation

Attack and destroy fetal RBCs


Sensitization may occur during 1Sensitization may occur during 1stst pregnancy pregnancy if woman had previously received an Rh (+) if woman had previously received an Rh (+) blood transfusionblood transfusion

Fetus compensate for hemolysis and anemia

Increase rate of erythropoiesis

(+) erythroblasts in circulation

Erythroblastosis fetalis


No sensitization: if there’s strong placental barrier No sensitization: if there’s strong placental barrier which prevents transfer of fetal blood into maternal which prevents transfer of fetal blood into maternal circulationcirculation

10-15% of sensitized mothers: no hemolytic reaction in 10-15% of sensitized mothers: no hemolytic reaction in NewbornNewborn

Some Rh (-) women even though exposed to Rh (+) fetal Some Rh (-) women even though exposed to Rh (+) fetal blood are unable to produce antibodies to foreign antigenblood are unable to produce antibodies to foreign antigen

Most severe form: hydrops fetalisMost severe form: hydrops fetalis Fetal hypoxia, cardiac failure, anasarca, effusions (pleural, Fetal hypoxia, cardiac failure, anasarca, effusions (pleural,

pericardial, peritoneal)pericardial, peritoneal) Stillborn or in severe respiratory distressStillborn or in severe respiratory distress

Early intrauterine detection: ultrasound, fetal blood Early intrauterine detection: ultrasound, fetal blood samplingsampling

Management: fetal blood transfusionsManagement: fetal blood transfusions


2. ABO Incompatibility2. ABO Incompatibility Major blood group antigens of fetus are Major blood group antigens of fetus are

different from those of the motherdifferent from those of the mother Major blood groups: A, B, AB, OMajor blood groups: A, B, AB, O Presence / absence of antibodies & antigens Presence / absence of antibodies & antigens

determines whether agglutination will occurdetermines whether agglutination will occur


ABO RELATIONSHIP OF ANTIGENS / ANTIBODIES & ABO RELATIONSHIP OF ANTIGENS / ANTIBODIES & DONOR- RECIPIENT COMPATIBILITYDONOR- RECIPIENT COMPATIBILITY

RBC RBC COMPATIBILITYCOMPATIBILITY

BLOOD GROUP BLOOD GROUP (PHENOTYPE)(PHENOTYPE)

GENOTYPEGENOTYPE RBC RBC ANTIGENSANTIGENS

PLASMA PLASMA ANTIBODIESANTIBODIES

AS DONOR AS DONOR TO TYPETO TYPE

AS AS RECIPIENT RECIPIENT

FROM FROM TYPETYPE

AA

BB

ABAB

OO

AA, AOAA, AO

BB, BOBB, BO

ABAB

OOOO

AA

BB

A & BA & B

NONENONE

BB

AA

NONENONE

A & BA & B

AB, AAB, A

AB, BAB, B

ABAB

AB, A, B, OAB, A, B, O

O, AO, A

O, BO, B

O, A, B, ABO, A, B, AB

OO


Antibodies in plasma of 1 blood group (except type AB) + Antigens of a different blood group

= agglutination (clumping)

hemolysis

Release large amounts of bilirubin into circulation


Most common: mother – type O and infant – Most common: mother – type O and infant – type A or Btype A or B

May occur in 1May occur in 1stst pregnancy and subsequent pregnancy and subsequent pregnancy.pregnancy.

Naturally occurring anti-A or anti-B antibodiesPresent in maternal circulation cross placenta

Attack fetal RBC

Hemolysis (less severe than Rh incompatibility)


POTENTIAL MATERNAL-FETAL ABO POTENTIAL MATERNAL-FETAL ABO INCOMPATIBILITIESINCOMPATIBILITIES

MATERNAL BLOOD MATERNAL BLOOD GROUPGROUP

INCOMPATIBLE FETAL INCOMPATIBLE FETAL BLOOD BROUPBLOOD BROUP

OO

BB

AA

A or BA or B

A or ABA or AB

B or ABB or AB


CLINICAL MANIFESTATIONS:CLINICAL MANIFESTATIONS: Anemia (hemolysis of RBCs) Anemia (hemolysis of RBCs) jaundice on 1 jaundice on 1stst 24 hours; serum bilirubin 24 hours; serum bilirubin

elevated (result from liver’s inability to conjugate & excrete excess elevated (result from liver’s inability to conjugate & excrete excess bilirubin)bilirubin)

Hepatosplenomegaly, varying degrees of hydrops, sign of hypovolemic Hepatosplenomegaly, varying degrees of hydrops, sign of hypovolemic shockshock

Hypoglycemia – due to pancreatic cell hyperplasiaHypoglycemia – due to pancreatic cell hyperplasia

DIAGNOSTIC EVALUATION:DIAGNOSTIC EVALUATION: Genetic testingGenetic testing Chorionic Villus Sampling – determine fetal group and type Chorionic Villus Sampling – determine fetal group and type can lead can lead

to abortionto abortion Amniocentesis – fetal blood type Amniocentesis – fetal blood type can lead to infection or leaking can lead to infection or leaking Ultrasonography – allow early treatment; used to check amniotic fluid Ultrasonography – allow early treatment; used to check amniotic fluid

and condition of the placentaand condition of the placenta Indirect Coombs Test – evaluate rising anti Rh antibody titers in maternal Indirect Coombs Test – evaluate rising anti Rh antibody titers in maternal

circulation; done Rh (-) mothers; 1circulation; done Rh (-) mothers; 1stst prenatal visit prenatal visit Direct Coombs Test – detect antibodies attached to the circulating Direct Coombs Test – detect antibodies attached to the circulating

erythrocytes of affected infants ; done to baby; to determine how erythrocytes of affected infants ; done to baby; to determine how extensive is the hemolysisextensive is the hemolysis


THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT: Postnatal therapy: phototherapy for mild cases, Postnatal therapy: phototherapy for mild cases,

exchange transfusion for severe casesexchange transfusion for severe cases Prevention of Rh isoimmunization: Rho immune Prevention of Rh isoimmunization: Rho immune

globulin (Rhogam)globulin (Rhogam) Human gamma globulin concentrate of anti-D to all Human gamma globulin concentrate of anti-D to all

unsensitized Rh (-) mothers after delivery or abortion of an unsensitized Rh (-) mothers after delivery or abortion of an Rh-positive infant or fetusRh-positive infant or fetus

Destroys (by phagocytosis & agglutination) fetal RBCs Destroys (by phagocytosis & agglutination) fetal RBCs passing into maternal circulation before they can be passing into maternal circulation before they can be recognized by mother’s immune system recognized by mother’s immune system immune immune response is blocked, anti-D antibodies & memory cells not response is blocked, anti-D antibodies & memory cells not formedformed


THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT: Must be administered to unsensitized mothers within 72 Must be administered to unsensitized mothers within 72

hours (possibly as long as 3-4 weeks) after the 1hours (possibly as long as 3-4 weeks) after the 1stst delivery or delivery or abortion & repeated after subsequent onesabortion & repeated after subsequent ones

Administration of RhIg at 26-28 weeks AOG reduces risk of Administration of RhIg at 26-28 weeks AOG reduces risk of Rh isoimmunizationRh isoimmunization

Administered thru IM to Rh (-) sensitized women, never to Administered thru IM to Rh (-) sensitized women, never to newborn or fathernewborn or father

Intravenous immunoglobulin (IVIG) – decreased Intravenous immunoglobulin (IVIG) – decreased severity of RBC destruction (hemolysis) in HDN & severity of RBC destruction (hemolysis) in HDN & subsequent development of jaundicesubsequent development of jaundice

Attacks maternal cells that destroy neonatal RBCs, slows Attacks maternal cells that destroy neonatal RBCs, slows down the progression of bilirubin production down the progression of bilirubin production

Used in conjunction with phototherapy; decreased necessity Used in conjunction with phototherapy; decreased necessity for exchange transfusionfor exchange transfusion


THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT: Intrauterine transfusion – infuse blood into umbilical Intrauterine transfusion – infuse blood into umbilical

vein of fetusvein of fetus Infuse Rh O-negative packed RBCs to raise fetal hematocrit Infuse Rh O-negative packed RBCs to raise fetal hematocrit

to 40-50% every 2 weeks until fetus reaches 37-38 weeksto 40-50% every 2 weeks until fetus reaches 37-38 weeks

Exchange transfusion – infant’s blood removed in Exchange transfusion – infant’s blood removed in small amounts (5-10ml at a time) & replaced with small amounts (5-10ml at a time) & replaced with compatible blood (Rh – negative blood) compatible blood (Rh – negative blood)

Removes sensitized RBCs, lowers serum bilirubin, corrects Removes sensitized RBCs, lowers serum bilirubin, corrects anemia, prevents cardiac failureanemia, prevents cardiac failure

Indications:Indications: Rapidly increasing bilirubin level, hemolysis despite intensive Rapidly increasing bilirubin level, hemolysis despite intensive

phototherapyphototherapy Infant born with hydrops fetalis or sign or cardiac failureInfant born with hydrops fetalis or sign or cardiac failure


THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT:Fresh whole blood typed & crossmatched to Fresh whole blood typed & crossmatched to

mother’s serummother’s serumAmount of donor blood is double the blood volume Amount of donor blood is double the blood volume

of infant (85ml/kgBW) but not >500mlof infant (85ml/kgBW) but not >500mlSterile surgical procedure: catheter Sterile surgical procedure: catheter umbilical umbilical

vein vein inferior vena cava inferior vena cava 5-10 ml withdrawn within 15-20 secs 5-10 ml withdrawn within 15-20 secs same volume x same volume x

60-90 secs60-90 secs


THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT:ABO INCOMPATIBILITYABO INCOMPATIBILITY

Early detection & implementation of phototherapyEarly detection & implementation of phototherapy(+) jaundice within 1(+) jaundice within 1stst 24 hours, increased serum 24 hours, increased serum

bilirubin levels, RBC spherocytosis, increased bilirubin levels, RBC spherocytosis, increased ESR: diagnostic of ABO incompatibilityESR: diagnostic of ABO incompatibility

IVIG + phototherapyIVIG + phototherapyExchange transfusion – not commonly required Exchange transfusion – not commonly required

except when phototherapy fails to decrease except when phototherapy fails to decrease bilirubin concentration bilirubin concentration


PROGNOSIS:PROGNOSIS:Severe anemia: result in stillbirth, shock, Severe anemia: result in stillbirth, shock,

congestive heart failure, pulmonary/ cerebral congestive heart failure, pulmonary/ cerebral complications (cerebral palsy)complications (cerebral palsy)

With early detection & intrauterine treatment – With early detection & intrauterine treatment – erythroblastic Newborn rare, exchange erythroblastic Newborn rare, exchange transfusions for the conditions less commontransfusions for the conditions less common


NURSING CONSIDERATIONS: NURSING CONSIDERATIONS: Initial nursing responsibility – recognizing jaundiceInitial nursing responsibility – recognizing jaundice

Thru prenatal & perinatal history Thru prenatal & perinatal history

Exchange transfusion: prepare infant and family Exchange transfusion: prepare infant and family assist practitioner with procedureassist practitioner with procedure

Document blood volume exchanged: amount of blood Document blood volume exchanged: amount of blood volume withdrawn & infused, time of each procedure, volume withdrawn & infused, time of each procedure, cumulative record of total volume exchangedcumulative record of total volume exchanged

Vital signs monitoredVital signs monitored (+) signs of cardiac/ respiratory problems: procedure stopped (+) signs of cardiac/ respiratory problems: procedure stopped

temporarily & resumed once stabletemporarily & resumed once stable Observe for transfusion reactionObserve for transfusion reaction


NURSING CONSIDERATIONS: NURSING CONSIDERATIONS: Attention on thermoregulationAttention on thermoregulation

Hypothermia – increase oxygen and glucose Hypothermia – increase oxygen and glucose consumption consumption metabolic acidosis; (-) binding capacity metabolic acidosis; (-) binding capacity of albumin & bilirubin & hepatic enzyme reaction of albumin & bilirubin & hepatic enzyme reaction kernicteruskernicterus

Hyperthermia – damages donor’s RBC, increase free K+, Hyperthermia – damages donor’s RBC, increase free K+, predisposes infant to cardiac arrestpredisposes infant to cardiac arrest

Performed with infant under radiant warmer, with Performed with infant under radiant warmer, with sterile drapes, blood is warmedsterile drapes, blood is warmed

After procedure: nurse inspects umbilical vein (for After procedure: nurse inspects umbilical vein (for bleeding), catheter may remain in placebleeding), catheter may remain in place

SUDDEN INFANT DEATH SUDDEN INFANT DEATH SYNDROME (SIDS)SYNDROME (SIDS)

Sudden death of infant < 1 years oldSudden death of infant < 1 years old Unexplained after a complete mortem examination, Unexplained after a complete mortem examination,

including an investigation of death scene & review of including an investigation of death scene & review of case historycase history

33rdrd leading cause of death in children between 1 month – leading cause of death in children between 1 month – 1 year ; increased incidence in winter1 year ; increased incidence in winter

Incidence: 0.65:1000 live births (1999); males > femalesIncidence: 0.65:1000 live births (1999); males > females Peak age: 2-4 months; 95% occur by 6 monthsPeak age: 2-4 months; 95% occur by 6 months Time of death: during sleepTime of death: during sleep Racial: Native Americans, African Americans, HispanicsRacial: Native Americans, African Americans, Hispanics Lower socioeconomic classLower socioeconomic class


Risks: Preterm especially low birth weight; Risks: Preterm especially low birth weight; multiple births (2multiple births (2ndnd twin, male twin & small- twin, male twin & small-for-date twin)for-date twin)Newborn with low APGAR scoreNewborn with low APGAR score Infants with CNS disturbances & respiratory Infants with CNS disturbances & respiratory

disorder (bronchopulmonary dysplasia/ disorder (bronchopulmonary dysplasia/ chronic lung disease) chronic lung disease)

Increased birth order (subsequent siblings as Increased birth order (subsequent siblings as opposed to 1opposed to 1stst born child) born child)

Infants with recent history of mild illnessInfants with recent history of mild illness


Sleep in prone positionSleep in prone position Cause oropharyngeal obstruction or affect thermal balance Cause oropharyngeal obstruction or affect thermal balance

or arousal stateor arousal state Rebreathing of carbon dioxide by prone infant & impaired Rebreathing of carbon dioxide by prone infant & impaired

arousal from active & quiet sleeparousal from active & quiet sleep Side-lying position no longer recommended – tends to turn to Side-lying position no longer recommended – tends to turn to

prone positionprone position Use of soft bedding – not able to move their heads to Use of soft bedding – not able to move their heads to

the side the side suffocation and lethal rebreathing suffocation and lethal rebreathing Overheating (thermal stress); co-sleeping with adult Overheating (thermal stress); co-sleeping with adult

especially on sofaespecially on sofa Adult beds/ sofas are not designed for infants & may carry Adult beds/ sofas are not designed for infants & may carry

risk of accidental entrapment & suffocationrisk of accidental entrapment & suffocation


Lower incidence in breast-fed infants – pacifier Lower incidence in breast-fed infants – pacifier may be protective against SIDSmay be protective against SIDS

Maternal risk: young age, cigarette smoking Maternal risk: young age, cigarette smoking especially during pregnancyespecially during pregnancy Poor prenatal care, substance abuse (heroin, Poor prenatal care, substance abuse (heroin,

methadone, cocaine)methadone, cocaine) 12% of all SIDS death could be prevented with 12% of all SIDS death could be prevented with

prenatal smoking cessationprenatal smoking cessation Maternal smoking decreases infant’s ability to arouse to Maternal smoking decreases infant’s ability to arouse to

auditory stimuli in mothers who smoke prenatally. auditory stimuli in mothers who smoke prenatally.


ETIOLOGY:ETIOLOGY: UnknownUnknown Hypothesis: related to brainstem abnormality in Hypothesis: related to brainstem abnormality in

neurologic regulation of cardiorespiratory controlneurologic regulation of cardiorespiratory control Abnormalities: prolonged sleep apnea, increased frequency Abnormalities: prolonged sleep apnea, increased frequency

of brief inspiratory pauses, excessive periodic breathing, of brief inspiratory pauses, excessive periodic breathing, impaired arousal responsiveness to increase carbon dioxide impaired arousal responsiveness to increase carbon dioxide or decrease oxygenor decrease oxygen

Sleep apnea is not the cause of SIDS; genetic predisposition Sleep apnea is not the cause of SIDS; genetic predisposition has been postulated as the causehas been postulated as the cause

Autopsies: pulmonary edema & intrathoracic Autopsies: pulmonary edema & intrathoracic hemorrhageshemorrhages

Should be performed on all infants suspected of dying of Should be performed on all infants suspected of dying of SIDSSIDS


INFANTS AT RISK FOR SIDS:INFANTS AT RISK FOR SIDS: Infants with 1 or more ALTEs requiring Infants with 1 or more ALTEs requiring

cardiopulmonary resuscitation (CPR) or vigorous cardiopulmonary resuscitation (CPR) or vigorous stimulationstimulation

Preterm infants who continue to have apnea at the Preterm infants who continue to have apnea at the time of hospital dischargetime of hospital discharge

Siblings of 2 or more SIDS victimSiblings of 2 or more SIDS victim Infants with certain types of disease or conditions – Infants with certain types of disease or conditions –

central hypoventilationcentral hypoventilation Home monitoring and/or use of respiratory stimulant drugs Home monitoring and/or use of respiratory stimulant drugs

recommendedrecommended No diagnostic tests exist to predict which infants will survive No diagnostic tests exist to predict which infants will survive


NURSING CONSIDERATIONS:NURSING CONSIDERATIONS: Educate families in prevention of SIDSEducate families in prevention of SIDS

Risk of prone sleeping position in infant births – 6 monthsRisk of prone sleeping position in infant births – 6 months Use of appropriate beddings, parental smoking around infant Use of appropriate beddings, parental smoking around infant

and dangers of sharing an adult bed with infantand dangers of sharing an adult bed with infant

Post partum discharge planning, newborn discharge Post partum discharge planning, newborn discharge teaching and newborn-care classesteaching and newborn-care classes

Follow-up visits, well-baby clinic visits, immunization Follow-up visits, well-baby clinic visits, immunization visitsvisits

Discuss infant sleep positionDiscuss infant sleep position


NURSING CONSIDERATIONS:NURSING CONSIDERATIONS:Psychologic intervention – loss of childPsychologic intervention – loss of childPractices that may reduce the risk of SIDSPractices that may reduce the risk of SIDS

Avoid smoking during pregnancy and near the Avoid smoking during pregnancy and near the infantinfant

Encouraging supine sleeping positionEncouraging supine sleeping position ““back to sleep”back to sleep”

Avoid soft, moldable mattresses, blankets, pillowsAvoid soft, moldable mattresses, blankets, pillows No pillows/ quilts, stuffed toys, towelsNo pillows/ quilts, stuffed toys, towels

Discouraging bed sharingDiscouraging bed sharingEncourage breastfeedingEncourage breastfeeding


NURSING CONSIDERATIONS:NURSING CONSIDERATIONS: Avoid overheating during sleepAvoid overheating during sleep

Infants should wear light-clothing, comfortable room Infants should wear light-clothing, comfortable room temperaturetemperature

Infant’s head position should be varied to prevent flattening Infant’s head position should be varied to prevent flattening of the skullof the skull

Use of pacifier – protective against occurrence of SIDS; Use of pacifier – protective against occurrence of SIDS; naptime and bedtime, no sweetened coatingnaptime and bedtime, no sweetened coating

Finding the infantFinding the infant it’s always the mother who finds child dead in cribit’s always the mother who finds child dead in crib Child is in disheveled bed w/ blankets over head, huddled in Child is in disheveled bed w/ blankets over head, huddled in

1 corner1 corner


NURSING CONSIDERATIONS:NURSING CONSIDERATIONS:Frothy, blood-tinged fluid fills the mouth & nostrils, Frothy, blood-tinged fluid fills the mouth & nostrils,

lying face down in secretions (bled to death)lying face down in secretions (bled to death)Diaper is wet and full of stool – cataclysmic type of Diaper is wet and full of stool – cataclysmic type of

deathdeathParents must deal with his/her initial shock, panic, Parents must deal with his/her initial shock, panic,

griefgriefCompassionate, sensitive approach to familyCompassionate, sensitive approach to family


NURSING CONSIDERATIONS:NURSING CONSIDERATIONS:Arriving at emergency departmentArriving at emergency department

No attempt at resuscitationNo attempt at resuscitationParents are asked only factual questions – when Parents are asked only factual questions – when

they found the infant, how he/she lookedthey found the infant, how he/she looked No misguided statements: “this looks like suffocation” No misguided statements: “this looks like suffocation”

(guilt)(guilt)

Discuss possible autopsyDiscuss possible autopsyCompassionate care – allow them to say good-bye Compassionate care – allow them to say good-bye

to their childto their child

APNEA OF PREMATURITY (AOP)APNEA OF PREMATURITY (AOP)

Preterm infants; rare: full-termPreterm infants; rare: full-term Apneic spells increase in prevalence the younger the gestational Apneic spells increase in prevalence the younger the gestational

ageage 1/3 infants <33 weeks AOG, >1/2 healthy infants < 30 weeks AOG1/3 infants <33 weeks AOG, >1/2 healthy infants < 30 weeks AOG Resolves as infant reaches 37 weeks postmenstrual ageResolves as infant reaches 37 weeks postmenstrual age Preterms are periodic breathers – periods of rapid respirations Preterms are periodic breathers – periods of rapid respirations

separated by periods of very slow breathing, often short periods with separated by periods of very slow breathing, often short periods with no visible or audible respirationsno visible or audible respirations

Apnea – extension of periodic breathingApnea – extension of periodic breathing Lapse of spontaneous breathing for 20 seconds or longer, that may Lapse of spontaneous breathing for 20 seconds or longer, that may

or may not be followed by bradycardia, oxygen desaturation and or may not be followed by bradycardia, oxygen desaturation and color changecolor change

Temporary apnea - <15-20 secondsTemporary apnea - <15-20 seconds Pathologic apnea - > 20 secondsPathologic apnea - > 20 seconds


Classification according to origin:Classification according to origin: Central Apnea – absence of diaphragmatic and other Central Apnea – absence of diaphragmatic and other

respiratory effortrespiratory effort Occurs when CNS does not transmit signals to the Occurs when CNS does not transmit signals to the

respiratory musclerespiratory muscle

Obstructive Apnea – air flow ceases because of upper Obstructive Apnea – air flow ceases because of upper airway obstruction yet chest or abdominal wall airway obstruction yet chest or abdominal wall movement is presentmovement is present

Mixed Apnea: combination of central and obstructive Mixed Apnea: combination of central and obstructive apneaapnea

Most common apnea seen in preterm infantsMost common apnea seen in preterm infants


PATHOPHYSIOLOGY:PATHOPHYSIOLOGY: Reflects the immature and poorly refined neurologic Reflects the immature and poorly refined neurologic

and chemical respiratory control mechanism in and chemical respiratory control mechanism in premature infantspremature infants

Not responsive to hypercarbia and hypoxemia, have Not responsive to hypercarbia and hypoxemia, have fewer dendritic associations than those of more fewer dendritic associations than those of more mature infantsmature infants

Respiratory reflexes less mature – contributing factor Respiratory reflexes less mature – contributing factor in etiologyin etiology

Weakness of muscles of thorax, diaphragm and upper Weakness of muscles of thorax, diaphragm and upper airway – contribute to apneic episodes airway – contribute to apneic episodes


PATHOPHYSIOLOGY:PATHOPHYSIOLOGY: Apnea – observed during periods of REM sleepApnea – observed during periods of REM sleep Precipitated/ worsened by a variety of factors:Precipitated/ worsened by a variety of factors:

InfectionInfection Intracranial hemorrhageIntracranial hemorrhage PDAPDA

Secondary causes: investigated in infants with new-Secondary causes: investigated in infants with new-onset apnea or when there’s significant change in onset apnea or when there’s significant change in frequency or severity of apneic episodesfrequency or severity of apneic episodes

Apnea in full-term: consider secondary causeApnea in full-term: consider secondary cause

APNEA OF PREMATURITY (AOP)APNEA OF PREMATURITY (AOP) POSSIBLE CAUSES OF APNEA OF PREMATURITY:POSSIBLE CAUSES OF APNEA OF PREMATURITY:

PrematurityPrematurity Airway obstruction with mucus or milk, or poor positioningAirway obstruction with mucus or milk, or poor positioning Anemia, polycythemiaAnemia, polycythemia DehydrationDehydration Cooling / overheatingCooling / overheating HypoxemiaHypoxemia Hypercapnia / hypocapniaHypercapnia / hypocapnia Hypoglycemia, hypocalcemia, hyponatremiaHypoglycemia, hypocalcemia, hyponatremia Sepsis, meningitisSepsis, meningitis SeizuresSeizures Increased vaga tone (in response to suctioning nasopharynx, gavage Increased vaga tone (in response to suctioning nasopharynx, gavage

tube insertion, reflux of gastric contents, endotracheal intubation)tube insertion, reflux of gastric contents, endotracheal intubation) CNS depression – pharmacologic agentsCNS depression – pharmacologic agents Intraventricular hemorrhage (IVH)Intraventricular hemorrhage (IVH) Patent ductus arteriosus (PDA), congestive heart failure (CHF)Patent ductus arteriosus (PDA), congestive heart failure (CHF) Depression following maternal obstetric sedationDepression following maternal obstetric sedation Respiratory distress – pnemonia, inborn errors of metabolism Respiratory distress – pnemonia, inborn errors of metabolism

(hyperammonemia), congenital defects of upper airways(hyperammonemia), congenital defects of upper airways


CLINICAL MANIFESTATIONS:CLINICAL MANIFESTATIONS: Persistent apneic spellsPersistent apneic spells

TREATMENTTREATMENT Observe for apneaObserve for apnea Check for thermal stabilityCheck for thermal stability Administration of methylxanthines (theophylline, aminophylline Administration of methylxanthines (theophylline, aminophylline

or caffeine)or caffeine) Reduce frequency of primary apnea-bradycardia spells in newbornReduce frequency of primary apnea-bradycardia spells in newborn CNS stimulants to breathingCNS stimulants to breathing Observe for symptoms of toxicityObserve for symptoms of toxicity Caffeine – fewer side effects ; once daily dosingCaffeine – fewer side effects ; once daily dosing Monitor weight and urine outputMonitor weight and urine output


TREATMENT:TREATMENT:Nasal continuous positive airway pressure Nasal continuous positive airway pressure

(NCPAP) and intermittent positive pressure (NCPAP) and intermittent positive pressure ventilationventilationCPAP acts to maintain airway patencyCPAP acts to maintain airway patencyMore effective for obstructive/ mixed apneaMore effective for obstructive/ mixed apnea


NURSING CONSIDERATION:NURSING CONSIDERATION: Monitor respiration and heart rate routinely in all preterm infantsMonitor respiration and heart rate routinely in all preterm infants Observe for presence of respirationsObserve for presence of respirations Observe colorObserve color Provide gentle tactile stimulation – rubbing the back/ chest Provide gentle tactile stimulation – rubbing the back/ chest

gently, turning infant to supine positiongently, turning infant to supine position If tactile stimulation fails to reinstitute respiration – flow by If tactile stimulation fails to reinstitute respiration – flow by

oxygen and suctioning of nose and mouthoxygen and suctioning of nose and mouth Apply artificial ventilation with bag-valve mask and with sufficient Apply artificial ventilation with bag-valve mask and with sufficient

pressure to lift rib cagepressure to lift rib cage If breathing does not beginIf breathing does not begin Raise chin gently to open airwayRaise chin gently to open airway Infant is never shakenInfant is never shaken


NURSING CONSIDERATION:NURSING CONSIDERATION: After breathing is restored: assess for and manage any After breathing is restored: assess for and manage any

precipitating factors (temperature instability, abdominal precipitating factors (temperature instability, abdominal distention, ambient oxygen) – use pulse oximetrydistention, ambient oxygen) – use pulse oximetry

Record episodes of apnea - # apneic spells, appearance during Record episodes of apnea - # apneic spells, appearance during and after the episode, did infant self-recover or whether tactile and after the episode, did infant self-recover or whether tactile stimulation or other measures were done to restore breathing.stimulation or other measures were done to restore breathing.

Investigate possible cause of apneic episodeInvestigate possible cause of apneic episode Observe for signs of theophylline or caffeine toxicity; tachycardia Observe for signs of theophylline or caffeine toxicity; tachycardia

(rate 180-190/ min) and later, vomiting, restlessness, irritability(rate 180-190/ min) and later, vomiting, restlessness, irritability Assess skin (with NCPAP) for breakdown, irritation, and nasal Assess skin (with NCPAP) for breakdown, irritation, and nasal

septumseptum

AUTISTIC SPECTRUM AUTISTIC SPECTRUM DISORDER (AUTISM)DISORDER (AUTISM)

Complex developmental disorder of brain Complex developmental disorder of brain function accompanied by intellectual and function accompanied by intellectual and behavioral deficitsbehavioral deficits

Manifested during early childhood: 18-36 Manifested during early childhood: 18-36 months of agemonths of age

1-2 in 500 children; males > females 1-2 in 500 children; males > females (females more severely affected)(females more severely affected)

Not related to socioeconomic level, race, Not related to socioeconomic level, race, parenting styleparenting style


ETIOLOGYETIOLOGY UnknownUnknown Multiple biologic causesMultiple biologic causes Abnormal EEG, epileptic seizures, delayed development of hand Abnormal EEG, epileptic seizures, delayed development of hand

predominance, persistence of primitive reflexes, metabolic predominance, persistence of primitive reflexes, metabolic abnormalities (increased serotonin), hypoplasia of vermis of abnormalities (increased serotonin), hypoplasia of vermis of cerebellumcerebellum

Increased in twinsIncreased in twins High risk of recurrence of ASD in families with one affected childHigh risk of recurrence of ASD in families with one affected child Not caused by thimerosal-containing vaccinesNot caused by thimerosal-containing vaccines Associated with fragile X syndrome, tuberous sclerosis, Associated with fragile X syndrome, tuberous sclerosis,

metabolic disorder, fetal rubella syndrome, H. influenza metabolic disorder, fetal rubella syndrome, H. influenza meningitis, structural brain anomaliesmeningitis, structural brain anomalies

Perinatal events: higher incidence of maternal uterine bleeding Perinatal events: higher incidence of maternal uterine bleeding during pregnancyduring pregnancy

Lower incidence of maternal vaginal infections during pregnancyLower incidence of maternal vaginal infections during pregnancy Decreased maternal use of contraceptivesDecreased maternal use of contraceptives Higher incidence of neonatal hyperbilirubinemiaHigher incidence of neonatal hyperbilirubinemia


CLINICAL MANIFESTATIONS AND CLINICAL MANIFESTATIONS AND DIAGNOSTIC EVALUATION:DIAGNOSTIC EVALUATION: Hallmark: inability to maintain eye contact with Hallmark: inability to maintain eye contact with

another personanother person Display limited functional play and may interact with Display limited functional play and may interact with

toys in an unusual mannertoys in an unusual manner Deficits in social development: primary feature of Deficits in social development: primary feature of

illnessillness Majority have some degree of mental retardationMajority have some degree of mental retardation

Females tend to have very low intelligence scoresFemales tend to have very low intelligence scores Savants – children with ASD who excel in particular Savants – children with ASD who excel in particular

areas: art, music, memory, mathematics, perceptual areas: art, music, memory, mathematics, perceptual skills (puzzle building)skills (puzzle building)


Speech and language delaysSpeech and language delaysImmediate evaluation of any child who does not Immediate evaluation of any child who does not

display such language skills as babbling or display such language skills as babbling or gesturing by 12 months, single word by 16 months, gesturing by 12 months, single word by 16 months, 2-word phrases by 24 months2-word phrases by 24 months

Sudden deterioration in extant expressive speech Sudden deterioration in extant expressive speech is also a red-flag event for further evaluationis also a red-flag event for further evaluation


DIAGNOSTIC CRITERIA FOR ASD:DIAGNOSTIC CRITERIA FOR ASD: Total of 6 (or more) items from (1), (2), (3) with at Total of 6 (or more) items from (1), (2), (3) with at

least two from (1), and one each from (2) & (3)least two from (1), and one each from (2) & (3)(1) Qualitative impairment in social interaction, as manifested (1) Qualitative impairment in social interaction, as manifested

by at least 2 of the following:by at least 2 of the following: Marked impairment in use of multiple nonverbal behaviors such Marked impairment in use of multiple nonverbal behaviors such

as eye-to-eye gaze, facial expression, body postures, & as eye-to-eye gaze, facial expression, body postures, & gestures to regulate social interactiongestures to regulate social interaction

Failure to develop peer relationships appropriate to Failure to develop peer relationships appropriate to developmental leveldevelopmental level

A lack of spontaneous seeking to share enjoyment, interests, or A lack of spontaneous seeking to share enjoyment, interests, or achievements w/ other people (ex. By a lack of showing, achievements w/ other people (ex. By a lack of showing, bringing, or pointing out objects of interest)bringing, or pointing out objects of interest)

Lack of social/ emotional reciprocityLack of social/ emotional reciprocity


(2) Qualitative impairments in communication as (2) Qualitative impairments in communication as manifested by at least 1 of the following:manifested by at least 1 of the following:

Delay in, or total lack, of the development of spoken Delay in, or total lack, of the development of spoken language (not accompanied by an attempt to language (not accompanied by an attempt to compensate through alternative modes of compensate through alternative modes of communication such as gesture or mime)communication such as gesture or mime)

In individuals w/ adequate speech, marked impairment in In individuals w/ adequate speech, marked impairment in the ability to initiate or sustain a conversation with othersthe ability to initiate or sustain a conversation with others

Stereotyped and repetitive use of language or Stereotyped and repetitive use of language or idiosyncratic languageidiosyncratic language

Lack of varied, spontaneous, make-believe play or social Lack of varied, spontaneous, make-believe play or social imitative play appropriate to developmental levelimitative play appropriate to developmental level


(3) Restricted repetitive and stereotyped patterns of behavior, interests (3) Restricted repetitive and stereotyped patterns of behavior, interests & activities, as manifested by at least 1 of the following:& activities, as manifested by at least 1 of the following:

Encompassing preoccupation with one or more stereotyped and Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focusrestricted patterns of interest that is abnormal either in intensity or focus

Apparently inflexible adherence to specific, nonfunctional routines or Apparently inflexible adherence to specific, nonfunctional routines or ritualsrituals

Stereotyped & repetitive motor mannerisms (ex. Hand or finger flapping Stereotyped & repetitive motor mannerisms (ex. Hand or finger flapping or twisting, or complex whole-body movements)or twisting, or complex whole-body movements)

Persistent preoccupation w/ parts of objectsPersistent preoccupation w/ parts of objects Delays or abnormal functioning in at least 1 of the following Delays or abnormal functioning in at least 1 of the following

areas with onset before age 3 yearsareas with onset before age 3 years Social interactionSocial interaction Language as used in social communicationLanguage as used in social communication Symbolic or imaginative playSymbolic or imaginative play

The disturbance is not better accounted for by Rett disorder or The disturbance is not better accounted for by Rett disorder or childhood disintegrative disorderchildhood disintegrative disorder


PROGNOSIS:PROGNOSIS: Severely disabling conditionSeverely disabling condition Some improve with acquisition of language skills & Some improve with acquisition of language skills &

communication w/ otherscommunication w/ others Some achieve independence, but most require Some achieve independence, but most require

lifelong adult supervisionlifelong adult supervision Aggravation of psychiatric symptoms – ½ children Aggravation of psychiatric symptoms – ½ children

during adolescence, w/ girls having tendency for during adolescence, w/ girls having tendency for continued deteriorationcontinued deterioration

Most favorable for children who develop Most favorable for children who develop communicative speech by age, years & have an IQ communicative speech by age, years & have an IQ higher than 50 at time of diagnosishigher than 50 at time of diagnosis


NURSING CARE MANAGEMENT:NURSING CARE MANAGEMENT: No cure for ASD but there are numerous therapiesNo cure for ASD but there are numerous therapies Highly structured & intensive behavior modification Highly structured & intensive behavior modification

programsprograms Promote positive reinforcement, increase social Promote positive reinforcement, increase social

awareness of others, teach verbal communication awareness of others, teach verbal communication skills and decrease unacceptable behaviorskills and decrease unacceptable behavior

Provide a structured routine for the child to follow – Provide a structured routine for the child to follow – key management in ASDkey management in ASD


NURSING CARE MANAGEMENT:NURSING CARE MANAGEMENT: Hospitalized child with ASD: dcrease stimulationHospitalized child with ASD: dcrease stimulation

Place child in private roomPlace child in private room Avoid extraneous auditory & visual distractionAvoid extraneous auditory & visual distraction Encourage parents to bring in possessions to which child is Encourage parents to bring in possessions to which child is

attachedattached Minimum holding & eye contactMinimum holding & eye contact Care must be taken when performing procedures, Care must be taken when performing procedures,

administering meds, feeding these children – may swallow administering meds, feeding these children – may swallow thermometer, gags when eatingthermometer, gags when eating

Family support - counselingFamily support - counseling

MAJOR STRESSORS OF MAJOR STRESSORS OF HOSPITALIZATIONHOSPITALIZATION

SEPARATION ANXIETYSEPARATION ANXIETYMiddle infancy – preschool ageMiddle infancy – preschool ageSTAGES:STAGES:

PROTEST PHASE:PROTEST PHASE: Cry and screamCry and scream Cling to parentCling to parent Avoids/ rejects contact with strangersAvoids/ rejects contact with strangers Verbally and physically attack strangersVerbally and physically attack strangers Attempts to escape and find parentsAttempts to escape and find parents


DESPAIR PHASE:DESPAIR PHASE: Crying stops, evidence of depressionCrying stops, evidence of depression Less activeLess active Uninterested in foodUninterested in food Withdraws from othersWithdraws from others Child’s physical condition may deteriorate from refusal to Child’s physical condition may deteriorate from refusal to

eat, drink, or moveeat, drink, or move

DETACHMENT PHASE:DETACHMENT PHASE: Denial; resignation and not contentmentDenial; resignation and not contentment Child becomes more interested in the surroundingsChild becomes more interested in the surroundings Forms new but superficial relationshipForms new but superficial relationship May have serious attachment to parent after separationMay have serious attachment to parent after separation


LOSS OF CONTROLLOSS OF CONTROL INFANTSINFANTS

TrustTrust Consistent, loving caregiversConsistent, loving caregivers Attempts to control their environment through emotional Attempts to control their environment through emotional

expressionsexpressions

TODDLERSTODDLERS AutonomyAutonomy When their egocentric pleasures meet with obstacles, they When their egocentric pleasures meet with obstacles, they

react with negativismreact with negativism Results from altered routines and ritualsResults from altered routines and rituals


PRESCHOOLERSPRESCHOOLERSSuffer loss of control by physical restriction, altered Suffer loss of control by physical restriction, altered

routines, and enforced dependencyroutines, and enforced dependencyEgocentric and magical thinking typical of ageEgocentric and magical thinking typical of ageMay view illness and hospitalization as punishment May view illness and hospitalization as punishment

for misdeedfor misdeedPREOPERATIONAL THOUGHT – explanations PREOPERATIONAL THOUGHT – explanations

are understood only in terms of real eventsare understood only in terms of real eventsTRANSDUCTIVE REASONING – deduct from the TRANSDUCTIVE REASONING – deduct from the

particular to particular, rather than from the specific particular to particular, rather than from the specific to the generalto the general


SCHOOL AGESCHOOL AGE Striving for independence and productivityStriving for independence and productivity Altered family roles, physical disability, fears of death, Altered family roles, physical disability, fears of death,

abandonment, permanent injury, loss of peer acceptance, abandonment, permanent injury, loss of peer acceptance, lack of productivitylack of productivity

BoredomBoredom

ADOLESCENTSADOLESCENTS Struggle for independence, self assertion and liberation – Struggle for independence, self assertion and liberation –

personal identitypersonal identity Separation from peer groupSeparation from peer group May respond with anger, frustrationMay respond with anger, frustration Voluntarily isolate themselves from age mates until they can Voluntarily isolate themselves from age mates until they can

feel they can competefeel they can compete Need for information about their conditionNeed for information about their condition


FEARS OF BODILY INJURY AND PAINFEARS OF BODILY INJURY AND PAIN Common fear among childrenCommon fear among children May persist into adulthood and result in avoidance of May persist into adulthood and result in avoidance of

needed careneeded care

YOUNG INFANT’S RESPONSE TO PAIN: <6 monthsYOUNG INFANT’S RESPONSE TO PAIN: <6 months Generalized response of rigidity, thrashingGeneralized response of rigidity, thrashing Loud cryingLoud crying Facial expressions of discomfort – most consistent indicator Facial expressions of discomfort – most consistent indicator

of stressof stress No understanding of the relationship between stimuli and No understanding of the relationship between stimuli and

subsequent pain.subsequent pain.


OLDER INFANT’S RESPONSE TO PAIN: (6months – 1year)OLDER INFANT’S RESPONSE TO PAIN: (6months – 1year) Withdrawal from painful stimuliWithdrawal from painful stimuli Loud cryingLoud crying Facial grimaceFacial grimace Physical resistancePhysical resistance

YOUNG CHILD’S RESPONSE TO PAIN: (toddlers)YOUNG CHILD’S RESPONSE TO PAIN: (toddlers) Loud crying; screamingLoud crying; screaming Verbalization, “ow”, “ouch”, “it hurts”Verbalization, “ow”, “ouch”, “it hurts” Thrashing of limbsThrashing of limbs Attempts to push away stimulusAttempts to push away stimulus Uncooperative; needs restraintsUncooperative; needs restraints Clings to parent, nurse, or other significant personClings to parent, nurse, or other significant person Request emotional supportRequest emotional support


SCOOL-AGE CHILD’S RESPONSE TO PAINSCOOL-AGE CHILD’S RESPONSE TO PAINStalling behavior – “wait a minute”, “I’m not ready”Stalling behavior – “wait a minute”, “I’m not ready”Muscle rigidityMuscle rigidityMay use all behaviors of young childMay use all behaviors of young child

ADOLESCENT’S RESPONSE TO PAINADOLESCENT’S RESPONSE TO PAINLess vocal protest, less motor activityLess vocal protest, less motor activityIncreased muscle tension and body controlIncreased muscle tension and body controlMore verbalization (“It hurts”, You’re hurting me!”)More verbalization (“It hurts”, You’re hurting me!”)

INDIVIDUAL RISK FACTORS THAT INDIVIDUAL RISK FACTORS THAT INCREASE VULNERABILITY TO INCREASE VULNERABILITY TO

STRESSES OF STRESSES OF HOSPITALIZATIONHOSPITALIZATION

““Difficult” temperamentDifficult” temperament Lack of fit between child and parentLack of fit between child and parent Age (especially between 6 months and 5 years Age (especially between 6 months and 5 years

old)old) Male genderMale gender Below average intelligenceBelow average intelligence Multiple and continuing stresses (ex. Frequent Multiple and continuing stresses (ex. Frequent

hospitalizations)hospitalizations)

BENEFICIAL EFFECT OF BENEFICIAL EFFECT OF HOSPITALIZATIONHOSPITALIZATION

Recovery from illnessRecovery from illness

Increase coping skillsIncrease coping skills

Master stress and feel competent in Master stress and feel competent in copingcoping

New socialization experiencesNew socialization experiences

PREVENTING OR MINIMIZING PREVENTING OR MINIMIZING SEPARATIONSEPARATION

Primary nursing goalPrimary nursing goal

Especially for children < 5 years oldEspecially for children < 5 years old

Family-centered careFamily-centered care

Parents are not “visitors”Parents are not “visitors”

Familiar items from homeFamiliar items from home

NORMALIZING THE HOSPITAL NORMALIZING THE HOSPITAL ENVIRONMENTENVIRONMENT

Maintain child’s routine, if possibleMaintain child’s routine, if possible

Time structuringTime structuring

Self-care (age appropriate)Self-care (age appropriate)

School workSchool work

Friends and visitorsFriends and visitors

PREVENTING OR MINIMIZING PREVENTING OR MINIMIZING FEAR OF BODILY INJURYFEAR OF BODILY INJURY

All children fear bodily injury from mutation, All children fear bodily injury from mutation, bodily intrusion, body-image change, disability, bodily intrusion, body-image change, disability, or death.or death.

Preparation of children for painful procedures Preparation of children for painful procedures decreases their fears.decreases their fears.

Use of bandagesUse of bandages Repeatedly stress the reason for a procedureRepeatedly stress the reason for a procedure Adolescents may express concern about the Adolescents may express concern about the

actual procedure but more anxious about the actual procedure but more anxious about the resulting scar.resulting scar.

PAIN FACTS AND FALLACIESPAIN FACTS AND FALLACIES

FACT: Children are under treated for pain.FACT: Children are under treated for pain.

FACT: Analgesia is withheld for fear of the child FACT: Analgesia is withheld for fear of the child becoming addictedbecoming addicted

FALLACY: Analgesia should be withheld FALLACY: Analgesia should be withheld because it may cause respiratory depression in because it may cause respiratory depression in childrenchildren

FALLACY: Infants do not feel pain.FALLACY: Infants do not feel pain.

PRINCIPLE OF PAIN PRINCIPLE OF PAIN ASSESSMENT IN CHILDREN: ASSESSMENT IN CHILDREN:

QUESTTQUESTT Question the child.Question the child. Use pain rating scale.Use pain rating scale. Evaluate behavioral & physiologic changes.Evaluate behavioral & physiologic changes. Secure parent’s involvement.Secure parent’s involvement. Take the cause of pain into account.Take the cause of pain into account. Take action and evaluate result.Take action and evaluate result.

Question the child – verbal & description of pain. Ask child to Question the child – verbal & description of pain. Ask child to point where it hurts.point where it hurts.

Use of Pain Rating Scale – provide a quantitative self-reporting Use of Pain Rating Scale – provide a quantitative self-reporting measure of pain.measure of pain.

PAIN RATING SCALESPAIN RATING SCALES

Not all pain rating scale are reliable or Not all pain rating scale are reliable or appropriate for childrenappropriate for children

Should be age appropriateShould be age appropriate

Consistent use of same scale by all staff.Consistent use of same scale by all staff.

Familiarize child with scaleFamiliarize child with scale

PAIN RATING SCALEPAIN RATING SCALE

F.L.A.C.C (FACE, LEGS, ACTIVITY, CRY, CONSOLABILITYF.L.A.C.C (FACE, LEGS, ACTIVITY, CRY, CONSOLABILITY

00 11 22

FACEFACE No particular No particular expression or smileexpression or smile

Occasional grimace Occasional grimace or frown, withdrawn, or frown, withdrawn, disinteresteddisinterested

Frequent to constant Frequent to constant frown, clenched jaw, frown, clenched jaw, quivering chinquivering chin

LEGSLEGS

ACTIVITYACTIVITY

Normal, relaxed Normal, relaxed position, moves position, moves easilyeasily

Uneasy, restless, Uneasy, restless, tense, shifting back tense, shifting back and forthand forth

Arched, rigid or Arched, rigid or jerkingjerking

CRYCRY No cry (awake or No cry (awake or asleep)asleep)

Moans, whimpers, Moans, whimpers, occasional occasional complaintcomplaint

Crying steadily, Crying steadily, screams or sobs, screams or sobs, frequent complaintsfrequent complaints

CONSOLABILITYCONSOLABILITY Content, relaxedContent, relaxed Reassured by Reassured by occasional touching, occasional touching, hugging or talking tohugging or talking to

Difficult to console Difficult to console or comfortor comfort

CHILDREN’S DEVELOPMENTAL CHILDREN’S DEVELOPMENTAL CONCEPT OF ILLNESSCONCEPT OF ILLNESS

PREOPERATIONAL THOUGHT PREOPERATIONAL THOUGHT

(2-7years)(2-7years)PHENOMENISM – perceives an external, PHENOMENISM – perceives an external,

unrelated, concrete phenomenon as cause of unrelated, concrete phenomenon as cause of illnessillness

CONTAGION – perceives cause of illness as CONTAGION – perceives cause of illness as proximity between 2 events that occur by proximity between 2 events that occur by magicmagic


CONCRETE OPERATIONAL THOUGHTCONCRETE OPERATIONAL THOUGHT

(7-10years)(7-10years)CONTAMINATION – perceives cause as a CONTAMINATION – perceives cause as a

person, object, or action external to the child person, object, or action external to the child that is “bad” or “harmful” to the bodythat is “bad” or “harmful” to the body

INTERNALIZATION – perceives illness as INTERNALIZATION – perceives illness as having an external cause but as being located having an external cause but as being located inside the bodyinside the body


FORMAL OPERATIONAL THOUGHTFORMAL OPERATIONAL THOUGHT (13yrs & above)(13yrs & above)

PHYSIOLOGIC – perceives cause as PHYSIOLOGIC – perceives cause as malfunctioning or nonfunctioning organ or malfunctioning or nonfunctioning organ or process; can explain illness in sequence of process; can explain illness in sequence of eventsevents

PSYCHOPHYSIOLOGIC – realizes that PSYCHOPHYSIOLOGIC – realizes that psychologic actions and attitudes affect health psychologic actions and attitudes affect health and illness. and illness.

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High-Risk Newborns and Child during illness and hospitalization - Pediatric Nursing

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