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PRETERM
INFANTSCarla Reinke, RN, MN, ARNP, CNM
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Delivery-Room Management
Certification by the Neonatal ResuscitationProgram (NRP) of the American HeartAssociation (AHA) and the American
Academy of Pediatrics (AAP) is essential forall nurses who work with premature infants.
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Tendency to have difficulty with transition
Vulnerable to cold stress
More lung immaturity and RDS
More intracranial hemorrhage
More hypoglycemia
Potential for oxygen-related injuries
High risk of developing NEC
Risks for the Preterm Infant
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Follow resuscitation from NRPguidelines.
Avoid rough handling during
resuscitation.Reduce heat loss even if resuscitation
is not required.
Preterm infants may requireendotracheal intubation and surfactantadministration soon after birth.
Delivery-Room Management Precautions
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Delivery-Room Management Precautions
Administer medication slowly asrecommended by NRP guidelines.
Follow glucose levels carefully. Glycogen
stores may be decreased. Infant mayexperience hypoglycemia secondary toperinatal compromise.
Maintain normal oxygen range after
resuscitation.
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Major Physiologic Problemsof the Premature Infant
Respiratory Distress Syndrome (RDS),Broncho pulmonary Dysplasia (BPD), apnea ofprematurity and chronic lung disease
Patent Ductus Arteriosus (PDA) and
hypotension (Retinopathy of Prematurity) ROP visual
impairment or blindness from O2 & ventilator
Immune-system immaturity that increases the
risk of infection (Necrotizing EnterocolitisNEC)
Periventricular - Intraventricular Hemorrhage(P-IVH) 30% of infants < 32 wks
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Additional Physiologic Problemsof the Premature Infant
Skin immaturity and fragility
Thermoregulation
GI issues
Fluid and electrolyte imbalances related toimmature renal function
Acid-base disorders
Pain management
Developmental issues related to the CNS Impact of the NICU environment
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RESPIRATORYDISTRESS
SYNDROME
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Respiratory Distress Syndrome
Incidence 10% for all premature infants
Incidence 50% for 26 week to 28 weeks
Risk factors: Low gestational age
Male
Born to diabetic mothers
Born after an asphyxial insult before birth
Born after maternal-fetal hemorrhage
Multiple gestation
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RDS Incidence by Gestational Age
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Respiratory Distress Syndrome
Complex respiratory diseasecharacterized by diffusealveolar atelectasis(collapse) of the lungs,
primarily caused by adeficiency of surfactant.
This leads to higher surfacetension at the surface of
alveoli, which interfereswith normal exchange ofoxygen and carbon dioxide.
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NIH Recommendationsfor Use of Antenatal Steroids
Give to all pregnant women 24 to 34 weeksgestation who are at risk for pretermdelivery within 7 days:
2 doses of 12 mg of betamethasone IM 24 hoursapart OR
4 doses of 6 mg of dexamethasone IM 12 hoursapart
Repeat courses of corticosteroids shouldnot be given routinely in pregnant women.
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Signs and Symptoms of RDS
Difficulty in establishing normalrespiration, especially if infant has riskfactors for RDS
Expiratory grunting while the infant is not
crying, tachypnea (>60). Sternal orintercostal retractions, nasal flaring
Central cyanosis Intercostal and sternal retractions due to
increased rib cage compliance anddecreased lung compliance
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Evaluation of respiratory status using theSilverman-Andersen index
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Limit Stress on the InfantThermoregulation
Fluid balance and nutrition
Skin care
Pain assessment
Developmental care
Family care
RDS Treatment
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RDS Treatment
Focus is to prevent and minimizeatelectasis.
Minimize untoward effects of oxygen andbarotrauma or volutrauma.
Treat underlying cardiovascular infectionsand other physiologic problems.
Maintain a balanced physiologicenvironment.
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Surfactant Therapy
Surfactant coats the insideof the alveoli. It preventscollapse (atelectasis) andkeeps alveoli open at the
end of expiration.
It is given via endotrachealtube.
Prophylactic therapyappears more beneficialthan rescue therapy.
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Infants who received synthetic surfactant treatment have adecreased risk of pneumothorax, pulmonary interstitialemphysema, intraventricular hemorrhage, BPD, adecreased risk of neonatal mortality, a decreased risk of
mortality prior to hospital discharge and at 1 year of age.
Multiple doses lead to improved clinical outcomes.
Surfactant Therapy
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Adjunct Treatments for RDS
CPAP
A method of assisting lung expansion withcontinuous distending pressure
A valuable adjunct when spontaneousbreathing is adequate and pulmonarydisease is not excessive
Increases transpulmonary pressure;
improves oxygenation and ventilation Reduces tachypnea and grunting
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Continuous Positive Airway Pressure (CPAP)
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HFV (High Frequency Ventilation) Allows the use of small tidal volumes (smaller than
anatomic dead space) and high frequencies. Rates of 150 to 3,000 breaths per minute can be
used depending on the type of HFV. HFV limits large tidal volumes and wide ventilator
pressure swings associated with volutrauma/barotrauma caused by traditional mechanicalventilation.
Oscillation
Adjunct Treatments for RDS
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High Frequency Ventilation
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RDS Nursing Care
Any nurse caring for an infant with RDSmust:
Be familiar with RDS pathophysiology
Recognize symptoms of RDS Initiate interventions as indicated
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RDS Nursing Care
Maintain paO2 and oxygen saturation levels. Recognize importance of weaning oxygen
and other ventilator parameters. Recognize complications arising from RDS,
intubation and mechanical ventilation. Utilize proper endotracheal suctioning
techniques.
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Provide mouth and skin care. Maintain proper positioning. Provide adequate fluid and electrolyte
balance. Monitor blood glucose levels. Reduce environmental stressors. Provide parental support.
RDS Nursing Care
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BRONCHOPULMONARY
DYSPLASIA(BPD)
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BPD
A significant problem forpremature infants
Uncommon after 32 weeksgestation
A secondary disease thatdevelops in neonates treatedwith positive pressureventilation and oxygen forprimary lung problems such asRDS
7,500 new cases every year inthe United States
10% die by 1 year of age
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Signs and Symptoms of BPD
Hypoxemia with prolonged oxygenrequirement
Hypercapnia, tachypnea with increasedwork of breathing, retractions, nasal flaring
Exercise intolerance, fatigue with handling Tachycardia Episodic bronchospasm with wheezing In severe cases, CHF with cor pulmonale
Abnormal postures of neck and upper trunkAuscultation: crackles, decreased air
movement, ocas. expiratory wheezing
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Cascade of Events Occurring in BPD
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BPD Treatment
Therapy is preventive andsupportive.
Prenatally preventprematurity and using a
single course of antenatalsteroids. Includes early, careful
management of RDS, useof low ventilator
pressures, and carefuluse of oxygen andexogenous surfactanttreatment.
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APNEA OFPREMATURITY
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Apnea of Prematurity
50% of NICU infants Periods of cessation of respiration for longer
than 10 seconds to 15 seconds
Apneic episodes frequently accompanied bycyanosis, bradycardia, pallor or hypotonia
Exact cause unknown but thought to be dueto immature CNS
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Types of Apnea in Premature Infants
Central: Absent breathingmovements/ effort
Obstructive: Breathing movements
but no air flow
Mixed: Mixture of obstructive andcentral apnea
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Apnea Treatment
Cardiac and respiratory monitoring untilno apnea episodes for 5 to 7 days
Neutral thermal environment Careful positioning; avoid flexion and
hyperextension of the neck
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Attention to gastric tube placement andinfusion rate during tube feeding
Nasal CPAP Methyxanthines (oral to intravenous
aminophylline, theophylline and caffeine)
Apnea Treatment
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Apnea Nursing Care
Assess infants color, perfusion,respiratory rate, heart rate, position andoxygen saturation.
Document frequency and severity ofepisodes and type and amount ofstimulation required to interrupt theevent.
Ensure bag and mask set-ups with oxygenavailable at infant bedside.
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PATENTDUCTUS
ARTERIOSUS
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PDA
The most common cardiac complication inpremature infants
Incidence inversely related to gestational age Occurs in 45% of infants with a birth weight
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Left-to-Right Shunt Through PDA
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Signs and Symptoms of PDA
Signs and symptoms of congestive heartfailure, increased need for oxygen andinability to wean from ventilator
Widened pulse pressure, an active
precordium, bounding peripheral pulsesand tachycardia with or without a gallop
Echocardiogram most useful to evaluatePDA
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PDA Treatment
Treatment is controversial.
Medical management with fluid restrictionand diuretics may be the initial approach.
Indomethacin has been effective in closingPDAs (dosage depends on weight, gestationand renal function).
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PDA Nursing Care
Continually assess high-risk infants forpulse, heart rate, pulse pressure,perfusion, and auscultation for thepresence of a murmur.
Know dosage and contraindications forindomethacin.
Assess infant after indomethacin forductal closure, decreased urine output
and thrombocytopenia. Teach and reassure parents.
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RETINOPATHYOF
PREMATURITY
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ROP
A significant cause of blindness in childreninitiated by delay in retinal vascular growth
Retinopathy of prematurity is a disease thataffects the developing neural retina and itsvasculature
The more premature the infant, the morelikely the infant is to have ROP.
82% of infants weighing
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47% of infants weighing1,000 g to 1,500 g at birthdevelop ROP.
Other risk factors:
prolonged mechanicalventilation and oxygenadministration, hyperoxia,hypoxia, sepsis, acidosis,
shock
ROP
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Long-Term Consequences of ROP
Myopia(nearsightedness)
Strabismus (crossedeye)
Amblyopia (lazy eye) Astigmatism
Glaucoma
Late retinal
detachment Blindness
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AAP: Screening Premature
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AAP: Screening PrematureInfants for ROP
First exam occurs 4 to 6 weeks after birthor 31 to 33 weeks post conceptional age.
Two exams after pupillary dilation using
indirect ophthalmoscopy if: Weight at birth
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ROP Treatment
ROP progresses at different rates indifferent infants.
The goal of treatment for ROP is preventionof blindness.
Surgical therapiesLaser photocoagulationand cryotherapy
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LATEPRETERM
INFANTSCarla Reinke, RN, MN, ARNP, CNM
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Near Term/Late Term
Infants born at 34, 35, 36 and 37 weeks gestationalage are called NEAR TERM (AKA Late Preterm)Infants -4-5 weeks before due date
Near terms have a higher rate of post-discharge re-hospitalization and illness (sepsis) than full terminfants (Raju et al., 2006; Wang et al., 2004)
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Prevalence of Near Term Births
Near terms comprise the largest and a growingproportion of preterm (
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Near term characteristics
AGA Normal APGARS
Usually go home with MOM in 2-3 days
Considered to be healthy, like full term infant,
BUT
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They are more like preterm infants than
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They are more like preterm infants thanfull term infants
though often treated like full term newborns, near-term newborns are at risk for same problems thatprematures experience: respiratory distress,hyperbilirubinemia, hypoglycemia, feeding
problems, and neurodevelopmental delays(AWHONN).
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Risks of the Late Preterm Infant
1. Increased Mortality2. Increased Morbidity3. Respiratory Instabilityapnea4. Cardiovascular
instability5. Thermoregulation
6. Hypoglycemia7. Sepsis8. Hyperbilirubinemia9. Feeding Problems10. Neurodevelopmental
delay
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Parent Teaching
Special emphasis on warning signs to watch for
Follow up visit in 2 days.
Getting support for breastfeeding. Routine
lactation consultation.
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Hyperbilirubinemia
Hyperbilirubinemia in the Late Preterm infant hashad more cases of Kernicterus than Preterm infants.
Due to immaturity of liver and intestine,
production, elimination, and more common inBreastfed infants
Being at home predisposes them to poor feeding,poor fluid intake, poor voiding and bms which
decrease excretion of bilirubin. bilirubin usually occurs in 1st week, so the earlier
the discharge the more likely readmission
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F ll h bl h KC
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For all these problems, theres KC
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Kangaroo care
Kangaroo care is a technique practiced onnewborn, usually preterm, infants wherein the infantis held, skin-to-skin, with an adult.
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Kangaroo Care improves outcomes for preterm
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Kangaroo Care improves outcomes for pretermand near term infants
Reduces LOS in preterm
Decreases apnea
Improves sleep quality Keeps baby warm
Improves blood glucose
Decreases crying by producing calm
Improves parental bonding attachment andassumption of parental role.
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POST TERM
INFANTSCarla Reinke, RN, MN, ARNP, CNM
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Post Term Infants
Born after 42 weeks Increase risk of meconium aspiration
Hypoglycemia
Loss of subcutaneous fat
Skin peeling, vernix sparse, lanugo absent,fingernails long
Focus on prevention due date
Attention to thermoregulation & feeding
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LGA -MACROSOMIC
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f i l
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Large for Gestational Age
Infants weight is in the 90th % for neonates samegestational age, may be pre, post, or full term infants
LGA does not mean post term
Most common cause maternal diabetes Infant at risk: birth injuries, hypoglycemia, and
polycythemia - macrosomia
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SMALL FORGESTATIONAL
AGE
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S ll f G t ti l A
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Small for Gestational Age
Infant whose wt is at or below the 10th % Results from failure to thrive
Is a high risk condition
SGA does not mean premature. Causes: anything restricting uteroplacental blood
flow, smoking, DM, PIH, infections
Complications: hypoglycemia, meconium aspiration,
hypothermia, polycythemia
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INFANTS OFDIABETIC
MOTHERSCarla Reinke, RN, MN, ARNP, CNM
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Infant of a Diabetic Mother
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Infant of a Diabetic Mother
Macrosomia face round, red, body obese, poormuscle tone, irritable, tremors
High risk for trauma during birth, congenitalanomalies, RDS, hypocalcemia
Hypoglycemia occurs 15-50% of time
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HYPO-
GLYCEMIACarla Reinke, RN, MN, ARNP, CNM
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Neonatal Hypoglycemia
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Neonatal Hypoglycemia
Clinically significant NH is the result of an imbalancebetween glucose supply and other fuels such asketone bodies, which are released from fat. Bloodglucose concentrations often dip to 30 mg/dL within
1 to 2 hours after birth in healthy neonates, but theytypically return to more than 45 mg/dL with normalfeeding within 12 hours.
PEDIATRICS Vol. 127 No. 3 March 2011, pp. 575-579 (doi:10.1542/peds.2010-3851
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Neonatal Hypoglycemia
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Neonatal Hypoglycemia
Highest Risk: SGA, LGA, infant of diabetic mothers,late-preterm.
Clinical Manifestations: as jitteriness, cyanosis,seizures, an apneic episode, tachypnea, weak or high-pitched cry, floppiness, or lethargy, poor feeding, oreye-rolling
If symptomatic and blood glucose < 40 mg/dL treatwith IV glucose immediately.
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Neonatal Hypoglycemia
For asymptomatic at-risk infants, the initial feedshould be within 1 hour of birth, with glucosescreening 30 minutes after the first feed.
Because there is no point-of-care screening methodreliable enough to be used as the sole method forscreening for NH, the blood or plasma glucoseconcentration must be confirmed by laboratorytesting ordered stat.
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Neonatal Hypoglycemia
If the initial screen is lower than 25 mg/dL, theguidelines call for feeding and checking again in 1hour. If the level remains lower than 25 mg/dL,intravenous glucose is called for. If it is 26 to 40
mg/dL, the guidelines call for re-feeding and/orintravenous glucose as needed. The target glucoselevel is 45 mg/dL or higher before routine feeds.
The recommended glucose dose is a minibolus 200
mg/kg (dextrose 10% at 2 mL/kg) and/orintravenous infusion at 5 to 8 mg/kg per minute (80- 100 mL/kg/day).
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Neonatal Hypoglycemia
During the 4 to 24 hours after birth, feeds should becontinued every 2 to 3 hours, with glucose screeningtaking place before each feed. If a screen shows lessthan 35 mg/dL, the guideline is to feed and check
again in 1 hour.
If the glucose levels remain lower than 35 mg/dL, theguideline calls for intravenous glucose. If the level is35 to 45 mg/dL, the guideline calls for re-feeding
with intravenous glucose as needed to reach thetarget.
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Neonatal Hypoglycemia
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Neonatal Hypoglycemia
SGA and Late Preterm - The screening schedulevaries slightly.
should be fed every 2 to 3 hours and screened beforeeach feeding for at least the first 24 hours after birth.
Infants of diabetic mothers and LGA with 34 weeks'gestation or more should be screened for the first 12hours after birth.
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Neonatal Hypoglycemia
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Neonatal Hypoglycemia
At-risk infants should maintain normal plasmaglucose on a routine diet for at least 3 feedfastperiods before discharge.
Plasma glucose levels tend to be lower in breastfedinfants, whereas ketone body concentrations tend to
be higher than in formula-fed infants. They suggestthat breastfed infants might tolerate lower plasmaglucose because of the increased ketoneconcentrations.
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Neonatal Hypoglycemia
the guidelines stress that managing neonatalhypoglycemia should "not unnecessarily disrupt themother-infant relationship and breastfeeding."
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MECONIUM
ASPIRATIONCarla Reinke, RN, MN, ARNP, CNM
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Meconium Aspiration Syndrome
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Meconium Aspiration Syndrome
Occurs most often post term infants, decreasedamniotic fluid /cord compression, intrauterinegasping in response to hypoxia
Meconium enters lung obstruction & pneumonia
S & S vary from mild to severe respiratory distress:tachypnea, cyanosis, retractions, nasal flaring,grunting
Tx suction at birth, may need warmed, humidifiedoxygen, or ventilators or if Severe ECMO
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HYPOCALCEMIA
HYPOMAGNESEMIA
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Hypocalcemia occurs in 50% infants ofIDMs, also related to hypoxia andprematurity, perinatal asphyxia.
Sx: tremors
Hypomagnesemia is associated with
maternal IDM.
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HYPER
BILIRUBINEMIASEE OTHER PPT
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NECROTIZINGENTEROCOLITIS
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NEC
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NEC
The most common neonatal intestinalemergency
Characterized by intestinal ischemia, mostoften involving the terminal ileum
Pathogenesis is uncertain.
Three major factors: bowel wall ischemia;bacterial invasion of the bowel wall; enteral
feedings
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Pathogenesis of NEC
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Pathogenesis of NEC
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Three Stages of NEC
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Three Stages of NEC
1. Generalized symptoms of early sepsis, includingtemperature instability, lethargy, apnea andbradycardia, feeding intolerance, abdominaldistention, and stools that test positive for
occult blood2. Severe abdominal distention and tenderness,
visible bowel loops, grossly bloody stools,metabolic acidosis, poor perfusion and amottled skin color
3. Fulminant signs of SIRS, including shock,mixed acidosis, DIC and neutropenia
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NEC Treatment
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NEC Treatment
Goals: Stabilize the neonate. Treat the infection. Rest the intestinal tract.
Discontinue feedings. Initiate IV access for fluids and antibiotics.
NG tube to decompress GI tract
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NEC Nursing Care
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NEC Nursing Care
Monitor vital signs. Monitor blood gases and pH.
NPO
Examine for abdominal distention,tenderness, emesis, bloody stools,temperature instability, metabolic acidosis,apnea, bradycardia.
Support parents. Encourage mother to pump breasts and
freeze breastmilk.
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NOSOCOMIALINFECTIONS
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Prevention of Nosocomial Infections in
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Prevention of Nosocomial Infections inNICUs
Increased compliance withhand-hygiene standards
Improved accuracy of the diagnosis of
bacteremia Reduced line and line connection (hub)
bacterial contamination
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Prevention of Nosocomial Infections in NICUs,Continued
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Maximal barrier precautions forcentral line placement
DecreasedNumber of skin puncturesDuration of IV lipid infusionDuration of central venous line use
Continued
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INTRAVENTRICULARHEMORRHAGE (IVH)
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Intracranial Hemorrhage
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Intracranial Hemorrhage
Causes:1. Sudden compression and decompression of the
head as in breech and precipitate labor.
2. Marked compression by forceps or incephalopelvic disproportion.
3. Fracture skull.
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Intracranial Hemorrhage
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Intracranial Hemorrhage
Predisposing Factors:1. Prematurity due to physiological
hypoprothrombinaemia, fragileblood vessels and liability to trauma.
2. Asphyxia due to anoxia of the
vascular wall .3. Blood diseases.
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Intracranial Hemorrhage
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t ac a a e o age
Predisposing Factors:1. Subdural : results from damage to the superficial veins where
the vein of Galen and inferior sagittal sinus combine to form thestraight sinus.
2. Subarachnoid: The vein of Galen is damaged due to tear inthe dura at the junction of the falx cerebri and tentorium cerebelli.
3. Intraventricular :into the brain ventricles.
4. Intracerebral : into the brain tissues . In (1) and (2) it is usually due to birth trauma,
in (3) and (4) the fetus is usually a premature exposed to hypoxia.
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IVH/PVH
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/
50% will die. Occurs in 25% to 30% of all VLBW infants
discharged from Level III NICUs
Associated primarily with prematurity
Infants
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Small (Grades I and II) Grade I hemorrhage is an isolated germinal
matrix hemorrhage.
Grade Il is an IVH with normal ventricular size.
Moderate (Grade III) is an IVH with acuteventricular dilation.
Severe (Grade IV) is an IVH withparenchymal hemorrhage.
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Signs and Symptoms of IVH/PVH
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g y p /
Can be subtle; sometimes only decreasedhematocrit or hemoglobin levels
May evolve over several hours and includedecreased activity, hypotonia, altered
consciousness, respiratory disturbances Can develop rapidly, with seizures,
decerebrate posturing, fixed pupils
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Signs and Symptoms of IVH/PVH
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g y p /
1- Altered consciousness.2- Flaccidity.
3- Breathing is absent, irregular and periodic or gasping.
4- Eyes: no movement, pupils may be fixed and dilated.
5- Opisthotonus, rigidity, twitches and convulsions.
6- Vomiting .
7- High pitched cry.
8- Anterior fontanelle is tense and bulging.9- Lumbar puncture reveals bloody C.S.F.
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IVH/PVH Nursing Care
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/ g
Optimal treatment is prevention. Minimize brain tissue destruction.
Minimize pain and stress.
Minimize crying, suctioning, rapid bolusinfusions.
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IVH/PVH Nursing Care
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Maintain neutral thermal environment. Elevate head 30.
Use sucrose pacifiers, topical anesthetics forprocedures.
Provide parental support.
/ g
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Prevention of IVH and PVH
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Administer antenatal steroids. Optimize peripartum management.
Administer antenatal antibiotics forpreterm rupture of the membranes.
Delivery-room resuscitation byneonatologists and an experienced team
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Prevention of IVH and PVH
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Maintain the babys temperature >36centigrade.
Maintain cardiorespiratory stability whileadministering surfactant.
Optimize direct clinical management byneonatologists.
Implement measures to minimize pain andstress responses.
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Prevention of IVH and PVH
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Use developmentalcare.
Judiciously usenarcotic sedation (low
dose, continuous).Avoid early lumbar
puncture ( 72 hoursold).
Use optimalpositioning.
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Prevention of IVH and PVH
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In terms of fluid volume treatment ofhypotension, there is no evidencedemonstrating benefit of using MAP 30rather than MAP > estimated gestational
age weeks. Use postnatal indomethacin judiciously.
Optimize respiratory management.
Use postnatal dexamethasone judiciously.
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GAVAGEFEEDING
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Gavage Feeding
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g g
Used with preterm infants who have poor suck,swallow, and feeding.
Either naso or orogastric
Early feeding in 24-72 hrs not assoc with NEC,benefits fewer days on TPN, less jaundice, increasedweight gain, lower risk of osteopenia,
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Measure from tip of nose to ear lobe then to xiphoidprocess.
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Placement of Gavage Feeding tube
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Measure from tip of nose tolobe of the ear to themidpoint between thexiphoid and umbilicus.Mark the tube with tape.
Lubricate tip with sterilewater and gently insertthrough nose or mouth until placed to mark.
Placement in the tracheawill cause gag, cough orcyanosis.
Placement of Gavage Feeding tube
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Check placement: Aspirate stomach contents
Inject air and listen withstethoscope
Xray Tape tube in place Monitor babys skin integrity
at tape site and pressure
points Assess tube placement
before every feeding.
Gavage Feeding
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Attach the syringe to tube Clamp or Pinch tube and add ordered amount of
formula or breastmilk
Release clamp and allow gravity to cause flow about
1 ml/min At end of feeding clamp tube
Position to prevent aspiration right side or tummy
Document size of tube, amount & quality of residual,
type and quantity of fluid instilled and infantsresponse.
Gavage Feeding
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Method of feeding breast milk or formula through anoro or nasogastric tube.
Document: residual gastric contents (by aspirationbefore each feeding) if of previous intake can be
refed.
Document type of fluid, hourly intake
Feeding maybe stopped if residual >2/4 ml/kg or a 1
hr volume and is not resumed until assessed forfeeding intolerance.
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Auscultation for placement of gavage tube.
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PARENTALATTACHMENT
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Promote Parental Attachment
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Opening the intensive care nursery toparents
Familiarizing parents with equipment andcare.
Transporting the mother to be near herinfant
Maternal day care for premature infants
Rooming in for parents
Individualized nursing care plans
Early discharge
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Promote Parental Attachment
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Listening to parents during the infantshospitalization and after discharge
Parent support groups
Programmed contact and reciprocal
interaction Transporting the healthy premature infant to
the mother
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Promote Parental Attachment
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Home-based interventionsfor young parents
Discussion with parentsafter discharge
Kangaroo care Nurse home visitation
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