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The preterm infant fall 2017


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preterm infant

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The preterm infant fall 2017

  1. 1. Joy A. Shepard, PhD, RN-BC, CNE Joyce Buck, PhD(c), MSN, RN-BC, CNE 1
  2. 2. Objectives Describe characteristics of the preterm neonate Describe nursing care of the preterm infant, particularly in regards to respiration, thermoregulation, and nutrition Discuss the pathophysiology, risk factors, and approach to treatment for respiratory distress syndrome, retinopathy of prematurity, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, in the preterm infant 2
  3. 3. Neonatal Intensive Care Nursing  Neonatal Intensive Care Nurses care for premature and critically ill newborns in the neonatal intensive care unit (NICU) of a hospital  Neonatal ICU nurses are responsible for managing and carrying out an at-risk newborn's plan of care, monitoring the newborn's condition, administering any necessary medications, and recording the progress of the newborn's development and recovery  Neonatal ICU nurses also play a major role in educating new mothers about the importance of breastfeeding as well as how to care for the baby once discharged from the hospital  3
  4. 4. Equipment in the NICU: What does what? 4
  5. 5. Neonatal Nurse Practitioner  Direct patient care from admission to discharge  Delivery room resuscitation and stabilization  Central line placement  Participation in transport of critically ill infants  Participation in outreach education and workshops  Participation in research projects  ECU CON Neonatal Nurse Practitioner concentration 5
  6. 6. 6
  7. 7. Gestational Classification (p. 817) Preterm (premature)—An infant born before completion of 37 weeks of gestation, regardless of birth weight Full-term—An infant born from 39-0/7 weeks through 40-6/7 weeks of gestation, regardless of birth weight Postterm (postmature)—An infant born after 42 weeks of gestation, regardless of birth weight 7
  8. 8. Birth Weight Classification (p. 817) Low-birth-weight (LBW) infant—An infant whose birth weight is less than 2500 g (5 lb, 8 oz), regardless of gestational age Very low–birth-weight (VLBW) infant—An infant whose birth weight is less than 1500 g (3 lb, 5 oz), regardless of gestational age Extremely low–birth-weight (ELBW) infant—An infant whose birth weight is less than 1000 g (2 lb, 3 oz), regardless of gestational age 8
  9. 9. Classification by Birth Weight and Gestational Age (p. 817)  Appropriate-for-gestational-age (AGA) infant—An infant whose weight falls between the 10th and 90th percentiles on intrauterine growth curves  Small-for-gestational age (SGA)—Any newborn whose weight is below the 10th percentile on intrauterine growth curves  Intrauterine growth restriction (IUGR)—Failure of normal fetal growth for any reason. Caused by multiple adverse affects on fetus (maternal, placental, or fetal factors) that inhibit potential growth (sometimes used as a more descriptive term for the SGA infant)  Large-for-gestational-age (LGA)—Weight is above 90th percentile on intrauterine growth curves 9
  10. 10. Review Question The infant weighs 2400 grams (5 pounds, 4 ounces) at birth. The neonatal nurse correctly classifies this infant as:  A. Low-birth-weight (LBW) infant  B. Very low–birth-weight (VLBW) infant  C. Extremely low–birth-weight (ELBW) infant  D. Small-for-gestational age (SGA) infant 10
  11. 11. 11
  12. 12. Gestational Age Assessment (p. 554)  Estimates infant’s age from conception  Alerts to possible complications of age and development  Early intervention: Pick up problems early  Plan care: Proper care initiated  Review Box 24-3 (p. 555): Maneuvers Used in Assessing Gestational Age 12
  13. 13. Neuromuscular Maturity: Posture 13
  14. 14. Neuromuscular Maturity: Square Window 14
  15. 15. Neuromuscular Maturity: Arm Recoil 15
  16. 16. Neuromuscular Maturity: Popliteal Angle 16
  17. 17. Neuromuscular Maturity: Scarf Sign 17
  18. 18. Neuromuscular Maturity: Heel to Ear 18
  19. 19. Physical Maturity: Skin Skin ranges from translucent and friable in preterm newborns to leathery, cracked, and wrinkled in post- term newborns Assess the skin for transparency, cracks, veins, peeling, and wrinkles 19
  20. 20. Physical Maturity: Lanugo  Lanugo: very fine body hair  Extremely premature newborns have none  During the middle of third trimester, most fetuses have plentiful lanugo  Closer to term, body hair thins  Terms newborns have little  Absent in post-term newborns 20
  21. 21. Physical Maturity: Plantar Surface Inspect plantar surface of foot for creases Term newborns have creases over the entire plantar surface Creases of preterm newborn range from absent to faint red markings 21 Preterm infant at 28 weeks' gestation. Note the flat smooth sole. Term gestation. Note the multiple creases
  22. 22. Physical Maturity: Breast  Assess the size of the breast bud in millimeters and the development of the areola  Preterm newborns lack developed breast tissue  Term newborns have a raised to a full areola with breast buds that are 3 to 10 millimeters in diameter 22
  23. 23. Physical Maturity: Eyes/ Ear  Ear cartilage and shape of pinna  Pinna less curved in preterm newborns  Term newborns: well-curved pinna with firm cartilage  Ear recoil: fold pinna down; assess how quickly it returns to position  Very preterm newborns – fused eyelids 23 A term infant has well- developed cartilage with instant recoil. Preterm infant at 28 weeks' gestation. Note the small amount of ear cartilage and/or flattened pinna.
  24. 24. Physical Maturity: Genitalia  Males: testes descend near term; rugae visible on scrotum  Extreme prematurity: scrotum flat and smooth  Term female: labia majora larger than clitoris & labia minora  Preterm female: prominent clitoris & labia minor; smaller labia majora 24 • Large genitalia (relatively speaking) with full-term infants • With preterm babies, the genitalia are smaller
  25. 25. 25
  26. 26. Demographics & Statistical Information (p. 816)  Birth before completion of 37 weeks of gestation  Common:1 out of 9 births (USA); up to 1 out of 6 births (ENC)  35% of infant deaths  Leading cause of neurological disabilities  Costly  Etiology 26
  27. 27. 27
  28. 28. Prematurity/ Low Birth Weight – Leading cause of infant death in North Carolina 28
  29. 29. Clinical Picture  Preterm infant lacks maturity  Organs not developed  Difficulty adjusting to extrauterine life because of underdeveloped tissues and organs  Biggest problems: respiratory, thermoregulation, and nutrition  Preterm infants vary greatly by gestational age 29
  30. 30. Characteristics  Very small  Often inactive and listless, posture of extension (not well-flexed)  Skin is thin (small blood vessels visible under skin)  Lacks fat deposits (regular and brown fat)  Lacks glycogen stores  Head large in proportion to body  Pliable ear cartilage  Minimal creases on the palms and soles of feet  Lanugo present 30
  31. 31. Characteristics cont’d…  Testes undescended in a male; few rugae on scrotum  Labia majora narrow in females; prominent labia minora  Minimal to absent reflexes (sucking and swallowing reflex absent if born < 32 weeks gestation)  Immature  Lung tissue (often not enough surfactant)  CNS (inability to regulate temperature)  GI system (diminished bowel sounds)  Fluid balance  Murmurs (persistence of fetal circulation patterns) 31
  32. 32. Madeline Mann, once the world's smallest surviving newborn…. 32 9.9 ounces at birth Adult: 4 ft, 8 in tall
  33. 33. 33
  34. 34. Biggest problem: Respiratory Function  Lungs of preterm infants (more than 6 weeks early) lack adequate surfactant  Lungs are noncompliant (lungs don’t expand easily; hard to breathe in)  Prone to atelectasis (collapse of alveoli)  Increased energy required to breathe (breathing is difficult)  Baby breathes shallowly and rapidly  Poor cough/ gag reflex  Narrow respiratory passages  Weak respiratory muscles 34
  35. 35. Prenatal Development of Alveolar Unit 35
  36. 36. Respiratory: Nursing Diagnoses Ineffective Airway Clearance Risk for Aspiration Ineffective Breathing Pattern Impaired Spontaneous Ventilation Impaired Gas Exchange 36
  37. 37. Nursing Interventions: Maintain Airway, Breathing, Oxygenation Assess for respiratory distress (hypoxemia) (pp. 556, 567)  Respirations greater than 60 or less than 30  Tachycardia (early sign)  Bradycardia (late sign)  Apneic episodes > 20 seconds  Retractions, labored breathing  Nasal flaring  Grunting  Crackles, rhonchi, wheezing  Stridor  See-saw respirations  Central cyanosis 37
  38. 38. Nursing Interventions: Maintain Patent Airway Suction as needed Use two-person suction technique (immediate hyperoxygenation) Avoid neck hyperextension (shuts off trachea) Terminate suctioning immediately: bradycardic, hypotensive, cyanotic, mottled, or develops pallor Manually bag until patient stable 38
  39. 39. Nursing Interventions: Maintain Patent Airway/ Breathing Pattern  To facilitate drainage of mucous, regurgitated feedings:  Position the infant in a side-lying or prone position  Frequently change infant’s position  If the baby needs to lay supine, place a small roll under the shoulders to straighten the airway, elevate the HOB, and turn the infant’s head to the side 39 •Normal apnea (periodic breathing): 5 – 10 seconds without bradycardia or color change. Followed by 10-15 seconds of compensatory rapid respirations •Apneic spells: Cessation of breathing for more than 20 seconds, or for less than 20 seconds, when accompanied by cyanosis or bradycardia
  40. 40. Prone Position 40
  41. 41. Review Question To promote drainage of lung secretions in the preterm infant, the nurse should:  A. Position the infant in a head-down position.  B. Frequently change the infant’s position.  C. Keep the infant in a supine position with the head elevated.  D. Place a small roll under the infant’s neck and shoulders. 41
  42. 42. Nursing Interventions: Maintain Oxygenation Status (pp. 824-825)  The need for oxygen administration is determined by S/S of respiratory distress, Pa02 (arterial oxygen pressure) of less than 60 mmHg and Sp02 (oxygen saturation) of less than 92%  Oxygen is administered by nasal cannula, hood, positive-pressure mask, or endotracheal tube  Oxygen should not be free flowing in the incubator because the amount cannot be controlled  Oxygen needs to be warmed and humidified to prevent cold stress and moisten airway 42
  43. 43. Oxygen Therapy: Modes of Delivery  Start with the least invasive method of oxygen delivery and minimal concentration of oxygen possible  Hood  Nasal cannula  Continuous positive airway pressure (CPAP)  Ventilator 43
  44. 44. Hood Therapy (p. 824)  Most common mode O2 delivery in newborn  Infant can breathe alone but needs higher levels of O2  Easy access to chest, trunk, and extremities.  Delivers 80-90% O2 @ 5-7 liters per minute 44
  45. 45. Nasal Cannula (p. 824)  Infant breathes well alone but needs low amounts of O2 (1/8 LPM to 1 LPM)  Least invasive way to deliver O2  Preferred method for home administration  Allows optimal vision, positioning, and parental holding  Proper fit is important 45
  46. 46. High-Flow Nasal Cannula  Used when higher flows are required (1- 8 liters per minute)  Given with heated humidifier/ circuit and special cannula  Respiratory support post-extubation and mechanical ventilation  Weaning therapy from CPAP  Apnea of prematurity  Contraindications: blocked nasal passages; trauma/ surgery to nasopharynx 46
  47. 47. Continuous PositiveAirway Pressure Therapy (CPAP) (pp. 824-825)  Must be breathing spontaneously  Prevents alveoli from collapsing at end of exhalation  Advantages:  ↑ Oxygenation, ↓ Work of breathing  ↑ Perfusion, ↓ Pulmonary shunting  ↓ Lung damage (BPD)  Helps resolve atelectasis  Possible complications:  Pulmonary hypertension  Pneumothorax 47 • Method of positive pressure ventilation (application of O2 under a preset pressure) • Delivers controlled and constant airway pressure
  48. 48. Mechanical Ventilation (pp. 825-826)  Severe hypoxemia  Automatic mechanical device forces air into lungs, using positive pressure through an artificial airway (endotracheal or tracheostomy tube)  Shock, asphyxia, infection, meconium aspiration, or respiratory distress syndrome (RDS)  Can damage lung tissue; may be difficult to wean off 48
  49. 49. High-FrequencyOscillatoryVentilation(HFOV)  Post-surfactant use  Very fast, frequent respirations with small volumes per breath and less pressure than other methods; less incidence of pulmonary complications  Monitor BP (can cause hypotension and/or decreased cardiac output); monitor urine output to monitor organ perfusion 49
  50. 50. Surfactant Therapy (p. 826)  Surfactant: Soap-like substance produced in the lungs; prevents alveoli from collapsing and sticking together during exhalation (produced in adequate quantities after 34 weeks gestation) 50
  51. 51. Nitric Oxide Therapy (p. 826)  Inhaled nitric oxideGas used in babies with pulmonary hypertension; relaxes blood vessels in the lungs without having any effect on the blood vessels of the rest of the body  Neonates > 34 weeks gestation  Indication: hypoxemic respiratory failure  Typically given in tandem with HFOV  Decreases the need for ECMO by acting as a potent pulmonary vasodilator  Benefits:  Improved oxygenation  Less incidence of chronic lung disease (BPD)  Decreased incidence of pulmonary hypertension  Enhanced neurodevelopment  Possible complication:  Methemoglobinemia 51
  52. 52.  Use of a bypass machine to oxygenate the infant’s blood while the infant’s lungs heal  Requires anticoagulation  Intractable hypoxemia due to severe cardiac or respiratory failure  Used with obstructive lung disorders  Persistent pulmonary hypertension of the newborn  Congenital diaphragmatic hernia  Sepsis  Meconium aspiration  Severe pneumonia  Decreases pulmonary hypertension  Given in tandem with HFOV or mechanical ventilation 52 Extra Corporeal Membrane Oxygenation (ECMO) (p. 827)
  53. 53. Extra Corporeal Membrane Oxygenation (ECMO) (p. 827) 53
  54. 54. Nursing Interventions: Monitor Oxygen Levels (pp. 824-825)  Premature baby's blood oxygen can drop fast when agitated  Pulse oximetry (Sp02)  Transcutaneous monitoring (Pa02, PaC02)  Arterial blood gases (Pa02, Sa02, PaC02, pH)  Capillary blood gases are not an accurate way to check Pa02 or Sa02 status  Too much oxygen can cause blindness (retinopathy of prematurity) or eat away lining of lungs (bronchopulmonary dysplasia) 54
  55. 55. Diagnostics Capillary blood gas: Used to estimate acid-base balance (pH) and adequacy of ventilation (PaCO2). Capillary PaO2 measurements are of little value in estimating arterial oxygenation (since there is a mixture of venous and arterial blood) Arterial blood gas: The most accurate way to determine oxygenation status of the baby. Directly measures blood oxygen, carbon dioxide, and acid-base status 55
  56. 56. 56
  57. 57. Diagnostics cont’d….  Pulse oximetry (percentage of hemoglobin that is bound by oxygen): Simple, non-invasive, continuous monitoring of oxygen saturation (Sp02) by sensors attached to the skin  Early warning of hypoxemia  Sp02 for preterm infant in NICU: 88 - 93%.  Not accurate with peripheral vasoconstriction (cold extremities), bright overhead lights, movement, hyperbilirubenemia, methemoglobinemia, or carbon monoxide poisoning  No information about PaCO2  Change probe site q4 hours to promote circulation, avoid skin breakdown and burns 57
  58. 58. Diagnostics cont’d…. Transcutaneous oxygen pressure monitoring (TcP02): Noninvasive, measures oxygen and carbon dioxide  Apply on trunk, abdomen, or lower back  Probe heats the skin, allows estimate of PaO2 and PaCO2  Don't place infants on top of electrode  Monitor closely for skin burns (probe can heat up to 104 F)  Rotate probe sites frequently (q3 hours) 58
  59. 59. Premature baby's first few minutes - NICU Team  59
  60. 60. 60
  61. 61.  Skin is thin  Little insulating subcutaneous fat  Blood vessels close to skin surface  Large skin surface area  Heat more easily lost from internal organs to skin  Poor mechanisms for body temperature regulation during first days of life 61 Problem: Thermoregulation •Flexed position reduces heat loss
  62. 62. Neutral Thermal Environment (NTE)  One in which the infant can maintain a stable body temperature without an increase in 02 consumption or increase in metabolic rate  Goal: infant maintains temperatures and growth using the least amount of energy  Infant’s temperatures maintained at 36.5° – 37.2°C axillary (97.7° – 99°F)  Regulate isolette temperature for preterm infants using skin control with initial set point of 36.5°C (97.7 ° F)  Place infant in open crib/bassinet when infant’s temperature is stable for 8 hours in isolette temperature of 26-27°C (78.8-80.6°F)  For clothed, swaddled infants in open bassinets, need nursery to be 24° C (75° F) 62
  63. 63. Methods of Heat Loss Four methods of heat loss in the neonate: Evaporation Conduction Convection Radiation 63
  64. 64. Methods of Heat Loss—Evaporation Conversion of water to vapor Loss of heat from drying of the skin or insensible water loss (skin, respiratory tract) Bathing; wet linens, clothes, or diapers 64
  65. 65. Conduction Loss of heat from direct contact with cold objects Cold hands, cold stethoscope, cold metal scale 65
  66. 66. Convection Loss of heat from air movement surrounding the infant Drafts, air conditioning, air currents 66
  67. 67. Radiation Loss of heat from being near cold surfaces (not touching) Heat transfer to cooler objects that are not in direct contact with the infant: sides of the incubator, outside walls/windows 67
  68. 68. 68
  69. 69. What Type of Heat Loss Can Occur in Each Situation? Placing the newborn on a cold, unpadded scale Using a cold stethoscope to listen to breath sounds Placing the infant’s crib by a window on a snowy day Partially drying the infant’s hair after the bath Placing the infant’s crib near an air conditioner vent 69
  70. 70. Heat Production in Newborns (pp. 528-529) Nonshivering thermogenesis Vasoconstriction Increase in metabolism Result:   02 and glucose consumption  May cause respiratory distress, hypoglycemia, acidosis, and jaundice 70
  71. 71. Nonshivering Thermogenesis: Brown Fat Oxidation 71
  72. 72. 72 Preterm Infant in Polyethylene Bag to Protect Against Heat Loss
  73. 73. Review Question Brown fat is used to: A. Maintain temperature B. Facilitate digestion C. Metabolize glucose D. Conjugate bilirubin 73
  74. 74. Hypothermia: Temp below 36.5° C (97.7° F) Cold stress (pp. 528-529)  Definition: Excessive loss of heat that results in increased respirations and nonshivering thermogenesis to maintain core body temperature  Temp: 36.0 to 36.4 °C (96.8 to 97.5 °F) Warm the baby and seek to identify cause(s) All newborns at risk for heat loss Newborns at greatest risk: Preterm, postterm, LBW, VLBW, ELBW, SGA, IUGR 74
  75. 75. Indications of Inadequate Thermoregulation  Hypoglycemia and respiratory distress may be the first signs that the infant’s temperature is low  Poor feeding or tolerance  Lethargy  Irritability  Poor muscle tone  Cool skin temp  Mottled skin 75
  76. 76. Reasons for Hypothermia/ Cold Stress  Cold environment  Thin skin with blood vessels near the surface  Little insulating subcutaneous fat  Less heat-producing brown fat  Large surface area  Poor flexion (limp posture)  Hypoglycemia  Infection  CNS (immature temperature control center in hypothalamus) 76
  77. 77. Hazards of Cold Stress  Increased oxygen need  Respiratory distress  Decreased surfactant production  Hypoglycemia  Metabolic acidosis r/t anaerobic metabolism  Jaundice  Return to fetal circulation patterns 77
  78. 78. 78
  79. 79. Identify 4 Consequences of Cold Stress…. Respiratory distress Acidosis Hypoglycemia Hyperbilirubinemia 79
  80. 80. Cold Stress and Temperature Regulation: Nursing Diagnoses Hypothermia Ineffective Thermoregulation Risk for Injury (Cold Stress) Risk for Imbalanced Body Temperature Risk for Unstable Blood Glucose Level Risk for Neonatal Jaundice Risk for Thermal Injury 80
  81. 81. Nursing Interventions: Maintain Body Temperature Provide a neutral thermal environment Place infant in radiant warmer or isolette with portholes closed Monitor temperature continuously by skin probe and axillary temperature Temperature for a preterm infant should remain between 36.5- 37.2 C (97.7-99 F) Prevent evaporation: keep infant dry 81
  82. 82. Nursing Interventions: Maintain Body Temperature cont’d…  Prevent drafts (convection): keep portholes closed, transparent plastic blanket over the radiant warmer bed, blankets or hats when out of the incubator, used warmed oxygen  Prevent conductive heat loss: keep hands warm, warm stethoscope, padding surfaces with warmed blankets  Warming of a hypothermic baby is done over a period of 2-4 hours; Increase by increments of 1 C  When the skin temp reaches 36.5 C, ambient temperature setting is maintained (neutral thermal) 82
  83. 83. Infant in Isolette 83
  84. 84. Infant under Plastic Wrap 84
  85. 85. KangarooCare:mothersorfathersprovideskin-to-skin contactwiththeirpretermbabiesforseveralhourseachday 85
  86. 86. Weaning from Isolette to Open Crib  Stable infant, at least 1500 grams, oral feeder, at least 5 days' weight gain  Dress infant (double thickness cap, cotton shirt, diapers, swaddled)  Incubator temp decreased 1 C each day  Monitor, record temps closely  Infant who can tolerate the incubator setting at 28 C (82.4 F): ready to transfer to open crib  Double wrap with warm blankets 86
  87. 87. From isolette to open crib…. 87
  88. 88. Hyperthermia  Elevated temperature (> 37.5° C / 99.5° F) will cause:   Metabolic rate   02 and glucose consumption   Insensible fluid losses (vasodilation)   Ability to sweat (immature sweat glands)   Risk of hyperthermia  With radiant warmers, warming lights, warmed incubators, too many blankets  Use skin temp probe  Set controls to vary heat according to infant’s skin temp  Alarms: high/low temp  Remove excessive clothing 88
  89. 89. Results of over-heating infant (radiant warmer set too high, too hot bili lights) Increased metabolic rate Increased oxygen needs Increased glucose needs Increased insensible water loss 89
  90. 90. Evaluation Infant expends a minimal amount of extra energy in the production of heat Infant is free from periods of hypothermia or hyperthermia 90
  91. 91. Review Question Becoming cold can lead to respiratory distress primarily because the infant:  A. Needs more oxygen than he or she can supply to generate heat  B. Breathes more slowly and shallowly when hypothermic  C. Reopens fetal shunts when the body temperature reaches 36.1° C (97° F)  D. Cannot supply enough glucose to provide fuel for respirations 91
  92. 92. 92
  93. 93. Problem: Nutrition  Lacks nutrient stores  Needs more nutrients (high metabolism)  Does not absorb nutrients well  Lacks coordination in sucking and swallowing (more than 8 weeks early)  Fatigues easily 93
  94. 94. Fetal nutrient stores are accumulated late in gestation…. At 28 weeks, a fetus has:  20% of term calcium and phosphorus stores  20% of term iron stores  20% of term fat stores  About a quarter of term glycogen stores 75-80% of the nutrient stores in a newborn term infant are accumulated during the third trimester of pregnancy  Infants born prematurely miss this vital placental transfer of nutrients in late pregnancy 94
  95. 95. Nutrition: Nursing Diagnoses  Imbalanced Nutrition: less than body requirements  Fatigue  Impaired Swallowing  Ineffective Infant Feeding Pattern  Ineffective Breastfeeding  Risk for Aspiration  Risk for Unstable Blood Glucose Level  Risk for Electrolyte Imbalance 95
  96. 96. Nursing Interventions: Maintain Nutrition Methods of feeding:  Parenteral (intravenous) –or-  Enteral (uses GI tract): tube feeding, bottle feeding, breast feeding  Need specific knowledge of infant’s physiologic characteristics, the infant’s particular needs, and methods of feeding  At least 32 weeks' gestation for oral feeds (must be able to coordinate sucking, swallowing, and breathing)  Observe for signs of aspiration: coughing, gagging, vomiting, cyanosis, changes in heart rate or respirations, apnea 96
  97. 97. Parenteral Nutrition (Hyperalimentation) (p. 830)  Parenteral: Some route other than through the GI tract, such as by subcutaneous, intramuscular, intrasternal, or intravenous injection  Integral part of clinical management of ELBW/VLBW premature neonates or critically ill infants  Total parenteral nutrition (TPN) or supplemental  Sugar, vitamins, minerals, and other nutrients intravenously (IV)  Change bag and tubing q24 (bacteria can grow in glucose medium) under strict aseptic sterile technique  Check hourly volumes, urinary output, and lung status  Monitor glucose levels 97
  98. 98. Parenteral Nutrition (Hyperalimentation) (p. 830)  Monitor IV site (especially if given peripherally; very irritating to a vein)  Strict asepsis for cleaning IV sites  Weigh daily  Same scales  Weight gain and loss need to be carefully monitored because many factors can impact (such as: asphyxia, increased respiratory effort, cold stress, or insensible water loss)  Strict I & O 98
  99. 99. Dangers of TPN Fluid and electrolyte imbalances Hyperglycemia Blood infection (since infusing through IV line, most often central line) Osteomalacia of the newborn (rickets) Cholestatic jaundice and liver damage/ failure 99
  100. 100. Review Question The neonatal nurse should regularly assess the premature infant’s ability to metabolize the total parenteral nutrition (TPN) solution adequately by monitoring the infant for which of the following clinical manifestations:  A. Hyperglycemia  B. Hypoglycemia  C. Hypertension  D. Elevated blood urea nitrogen concentration 100
  101. 101. Assessing Blood Glucose: Warming Infant Foot for Heelstick (p. 577) 101
  102. 102. Assessing Blood Glucose in the Infant (pp. 576-577) Normal blood glucose: 70 – 100 mg/dl 102
  103. 103. Enteral Nutrition (Gavage Feeding) (p. 829) Enteral: Provision of nutrients or drug administration by a tube directly into the GI tract (OG, NGT, GT, jejunostomy tube) Infants unable to coordinate suck and swallow (usually gestation less than 32 weeks) or too high expenditure of energy for sucking (weight loss) Allows infant to conserve energy to heal, grow and develop Babies fed in this manner until 32-34 weeks' gestation Orogastric (1st) or nasogastric tube (2nd) (#5 to #8 Fr) 103
  104. 104. Enteral Nutrition (Gavage Feeding) (p. 829) cont’d…  Measure gavage tube: tip of nose to earlobe and to midpoint between the xiphoid process and umbilicus  Orogastric preferred (obligate nose breathing)  Uses: feed baby, give medicines, remove excess air from stomach  Minimal enteral nutrition (trophic feeding) 104
  105. 105. 105
  106. 106. Gavage Feeding (pp. 829-830)  Before feeding:  Check tube placement  Auscultate bowel sounds  Measure abdominal girth  Check residuals for color, amount, character, mucous.  Return residuals to preserve electrolytes.  Feedings are stopped if residuals are more than 50% of feeding  Start feedings very slowly in small amounts  Feeds: intermittent or continuous  Position after feeding: right side for one hour with head elevated 30 106
  107. 107. Nonnutritive Sucking (p. 831) 107
  108. 108. Gavage Feeding cont’d…. Signs of overfeeding, intolerance, or malabsorption: Abdominal distention High residuals Vomiting, frequent spits Baby is at risk for aspiration, NEC Assess stools for occult blood (screen for NEC) 108
  109. 109. Signs of being ready to nipple feed (strong sucking, swallowing, gag reflexes present): (p. 831)  At least 32 weeks' gestation  Rooting  Sucking on a gavage tube or pacifier  Presence of gag reflex  Respiratory rate less than 60 breaths per minute  In babies that are learning to nipple feed, replace the OG tube with NG (They can't feed well working around the OG tube; NG avoids stimulating the gag reflex)  Start by giving infant a pacifier when gavage feeding (to associate the comfort of fullness with sucking, and to prepare for nipple feeding) 109
  110. 110. Oral Feeding (pp. 828-829) Breast milk: preferred Bottlefeed: soft premature nipple, human milk fortifier added to breast milk, high-calorie formulas (24 kcal/oz) Feed slowly with frequent stops to burp and allow the infant to rest Place the baby on right side after feeding for one hour with head elevated 30 to facilitate the emptying of the stomach into small intestine 110
  111. 111. Nipple-Feeding the Preterm Infant 111
  112. 112. Oral Feeding Stress Cues 112
  113. 113. Breast milk is better than formula because: (p. 616)  Immunities  More easily digested  Less allergies  Enzymes, hormones, and growth factors  Helps prevent NEC  Causes less stress because the baby can better regulate respirations and suckling  Mother’s body keeps the baby warm 113
  114. 114. Preterm Infant Formulas, Human Milk Fortifiers, and Caloric Additives (pp. 827-828)  Cow’s milk-based (NO Soy)  Whey predominant  Higher concentration protein, calcium, and phosphorus  22 or 24 kcal/ ounce for higher energy demands  Exclusive human milk: Human milk fortifier  Supplementation: iron, vitamin D, MVIs, calories 114
  115. 115. Infants: Formula Considerations Nutrient Comparison by Formula Type Formula Types and Indications 115
  116. 116. Evaluation Infant demonstrates a steady weight gain (20 – 30 grams/ day) 116
  117. 117. 117
  118. 118. Facilitate Parent-Infant Attachment 118
  119. 119. 119
  120. 120. 120
  121. 121. Neonatal Respiratory Distress Syndrome (RDS) (p. 836)  Insufficient production of surfactant; atelectasis (collapse of lung alveoli), hypoxemia (decreased Pa02), hypercarbia (increased PaC02); acidemia (decreased pH); and difficulty maintaining adequate respiratory function  Manifestations: Crackles, poor air exchange, pallor, retractions, apnea, grunting while breathing  Incidence:  Most before 34th week of pregnancy  Most common problem in premature infants  Incidence increases as gestational age decreases 121
  122. 122. 122
  123. 123. Neonatal Respiratory Distress Syndrome (RDS) (p. 836)  Etiology: The premature infant with immature lungs does not have enough surfactant to keep air sacs in the lungs open; lungs stiff and noncompliant, increasing amount of energy necessary for breathing  Birth before 34 weeks—critical period  Surfactant is first produced in the alveoli at 22 weeks gestation; by 34 – 36 weeks gestation, production of surfactant is usually mature enough to enable the infant to breathe normally outside the uterus  Lecithin, sphingomyelin, and phosphatidylglycerol: components of surfactant that can be detected by tests of amniotic fluid  Can predict whether fetal lungs are mature enough for survival outside the uterus  LS ratio of 2-to-1: the baby’s lungs are mature and the baby is ready to be born 123
  124. 124. RDS: Diagnostic Tests (p. 837)  Chest x-rays:  “Ground glass appearance”  Atelectasis  Arterial blood gases (respiratory acidosis):  Decreased pH (acidosis)  Decreased Pa02 (hypoxemia)  Increased PaC02 (hypercapnia) 124 •Reticulogranular appearance
  125. 125. RDS: Treatment (p. 837) Surfactant replacement therapy Supportive treatment: mechanical ventilation, correction of the acidosis, parenteral feedings (protein, fats) Complications: patent ductus arteriosus, bronchopulmonary dysplasia, sepsis Monitor blood gases and respiratory status closely Monitor electrolytes, urinary output, weight 125
  126. 126. 126
  127. 127. Retinopathy of Prematurity (ROP)(p. 837)  Developing blood vessels in a premature infant's retina constrict and become permanently occluded in response to high oxygen concentrations; damages retina and may cause decreased vision, myopia, or blindness  Most cases in babies who weigh less than 1,500 gm  Associated with high arterial blood oxygen levels  Sp02 > 95% should be avoided  Premature babies: screened routinely (at 4 – 6 weeks after birth) by an ophthalmologist to detect retinal changes  Mild: no treatment  Severe: laser treatment, freezing treatment (cryotherapy), medication eye injections 127
  128. 128. 128
  129. 129. Bronchopulmonary Dysplasia (BPD) (pp. 837-838)  Most common chronic lung disease of infancy  Lower airway: inflamed & scarred lungs  Premature lungs (≤ 30 wks; < 2 lbs)  RDS at birth  Supplemental O2, mechanical ventilation  Need long-term breathing support & O2 Defined & classified by gestational age & O2 requirement: mild, moderate, severe 129
  130. 130. BPD: Clinical Manifestations (p. 838)  Irritability  Tachypnea, retractions, coughing  Crackles, rhonchi, wheezing  Decreased breath sounds  Grunting, nasal flaring  Circumoral cyanosis  Clubbing of fingers  Failure to thrive; delayed growth & development  Barrel chest  Pulmonary HTN; manifestations of right-sided heart failure 130
  131. 131. BPD: Collaborative Care (p. 838)  Supplemental O2  Chest percussion  Bronchodilators  Diuretics (pulmonary hypertension)  Synagis® (palivizumab) monthly injections– monoclonal antibody to RSV  Planned rest periods to decrease respiratory effort & conserve energy  Small frequent meals to prevent over-distention of stomach  Nutritional support: PO formula + NG supplement 131
  132. 132. BPD: Review Question An 11-month-old child is being discharged home for the first time after being diagnosed with bronchopulmonary dysplasia (BPD). She will require home oxygen therapy. Which statement by the mother indicates that discharge teaching is incomplete? A. “We will not allow any smoking at our home.” B. “We have several fire extinguishers, and we know how to use them.” C. “Her brother will blow out the birthday candles at her party.” D. “We will return to the hospital if she seems irritable and won’t play.” 132
  133. 133. Intraventricular Hemorrhage (IVH) (pp. 838-839)  Immature, fragile blood vessels within the brain burst and bleed into the hollow chambers (ventricles) normally reserved for cerebrospinal fluid  Diagnosed: ultrasound, graded from 1 to 4 according to severity:  Grades 1 to 2Usually no symptoms or long-term damage  Grades 3 to 4Symptoms and long-term problems  Grade 4 bleedsextension into brain tissue; 50% mortality rate; 90% neurologic disabilities 133
  134. 134. IVH: Grades 1 and 2 134
  135. 135. IVH: Grades 3 and 4 135
  136. 136. IVH: Clinical Manifestations (pp. 838-839) Rising intracranial pressure: lethargy, poor muscle tone, decreased reflexes, irregular respirations (cyanosis, apnea), bradycardia, and bulging fontanels Developmental problems, mental disability, cerebral palsy Seizures if the bleeding is severe Hydrocephalus (abnormal accumulation of cerebrospinal fluid in the ventricles of the brain) because the blood plugs up the brain's fluid pathways (the ventricles) 136
  137. 137. Ventriculoperintoneal (VP) Shunt 137 • For persistent hydrocephalus: permanent shunt is placed in the ventricle (ventriculoperitoneal shunt)
  138. 138. To avoid increasing intracranial pressure (ICP): Keep infant calm (decrease crying) Minimum stimulation: gentle handling; cluster care; no sudden turning or jerking; dim lights; low noise Head slightly elevated (15) Avoid suctioning (increases blood pressure) Avoid Trendelenburg position Measure head circumference daily Be alert for subtle neurologic changes 138
  139. 139. IVH: Review Question Nursing care that reduces the risk for intraventricular hemorrhage includes: A. Assessing for abnormal heart rhythms or murmurs. B. Minimal and gentle handling of the infant. C. Limit the duration of parental visits. D. Examining the eyes at 4 weeks and 8 weeks. 139
  140. 140. Necrotizing Enterocolitis (NEC) (pp. 839-840)  Life-threatening inflammatory disease of intestinal tract  Premature infants (90% of cases)  Intestines partially destroyed from hypoxia and bacterial infection  First 7-14 days after birth (but can occur anytime)  Immature bowel damaged when blood supply decreased; bacteria then invade damaged area  Enteral formulas  Breast milk protective effect 140
  141. 141. NEC: Clinical Manifestations (p. 839)  Nonspecific: lack of energy; unstable body temperature; signs of infection such as lethargy (sluggishness) and apnea (cessation of breathing); bradycardia; hypotension; low urinary output  GI symptoms: increased abdominal girth (bloated or distended stomach); bile-colored (green) vomiting or gastric drainage; decreased or absent bowel sounds; poor feeding; bloody stools; loops of bowel seen through the abdominal wall  Diagnosis: clinical findings; X-ray (free peritoneal gas, dilated bowel loops, bowel distention) 141
  142. 142. Swollen, red, and tender belly 142 Visible bowel loops
  143. 143. NEC: Collaborative Care (p. 840)  Oral/tube feeds stopped immediately  Relieving gas in the bowel by inserting a tube in the stomach  Parenteral (intravenous) therapy  Antibiotic therapy  Checking stools for blood  Most cases treated successfully without surgery  Surgery if there is a hole in the intestines or inflammation of the abdominal wall (peritonitis)  If the full thickness of a portion of the intestines dies, the damaged sections must be removed surgically (a colostomy may be required) 143
  144. 144.  Decreased ability to digest and absorb a regular diet because of shortened small intestine  Diarrhea, dehydration, malnutrition, FTT  TPN; Neocate (enteral)  Serial transverse enteroplasty (STEP) procedure  Nursing care: monitor F & E, monitor growth/ development; minimize complications; meticulous CVL care; prepare family for home therapy Short Bowel Syndrome (SBS) (p. 748, Ball & Bindler) 144 • Center for Advanced Intestinal Rehabilitation (CAIR) (Boston Children’s Hospital) • Premier program for the treatment of SBS
  145. 145. Serial Transverse Enteroplasty (STEP) Procedure 145
  146. 146. Longitudinal Intestinal Lengthening and Tailoring (LILT) Procedure 146
  147. 147. Review Question  The father of a premature infant asks why oxygen concentrations are not higher to help his son breathe better. The nurse’s best response is based on an understanding of the following conditions: (Select all that apply)  A. Bronchopulmonary dysplasia  B. Intraventricular hemorrhage  C. Necrotizing enterocolitis  D. Retinopathy of prematurity  E. Respiratory distress syndrome 147
  148. 148. Premature Son’s Miraculous First Year 148
  149. 149. 149