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- 1. Chapter 13 Preterm andPostterm Newborns
- 2. Objectives • Differentiate betweenthe preterm and the low-birth weight newborn. • List three causes of preterm birth. • Describe selected problems of preterm birth and the nursing goals associated with each problem. • Describe the symptoms of cold stress and methods of maintaining thermoregulation. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 2
- 3. Objectives (cont.) • Contrastthe techniques for feeding preterm and full-term newborns. • Discuss two ways to help facilitate maternal- infant bonding for a preterm newborn. • Describe the family reaction to preterm infants and nursing interventions. • List three characteristics of the postterm infant. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 3
- 4. The Preterm Newborn •Preterm birth is the cause of more deaths during the first year of life than any other single factor • Higher percentage of birth defects • The less the preterm weighs at birth, the greater the risks to life during delivery and immediately thereafter Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 4
- 5. Gestational Age • Actualtime from conception to birth that the fetus remains in the uterus • Preterm is less than 38 weeks • Term is 38 to 42 weeks • Postterm is greater than 42 weeks – Standardized method used to determine gestational age is Ballard score • Uses external characteristics and neurological development Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 5
- 6. Level of Maturation •How well-developed the infant is at birth • Ability of organs to function outside of uterus Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 6
- 7. Causes of PretermBirth • Multiple births • Maternal illness • Hazards of actual pregnancy (e.g., GH) • Placental abnormalities – Placenta previa – Premature separation of the placenta from uterine wall Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 7
- 8. Possible Physical Characteristics of a Preterm Infant • Skin transparent or loose • Superficial veins visible on abdomen and scalp • Lack of subcutaneous fat • Lanugo covering forehead, shoulders, and arms • Vernix caseosa abundant • Extremities appear short • Soles of feet have few creases • Abdomen protrudes • Nails are short • Genitalia are small • In the female, the labia majora may be open Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 8
- 9. Related Problems ofPreterm Births Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 9
- 10. Inadequate Respiratory Function • During second half of pregnancy, structural changes occur in the fetal lungs – Alveoli (air sacs) enlarge – Closer to capillaries in the lungs • If born prematurely, the muscles that move the chest are not fully developed • Abdomen is distended, increasing pressure on diaphragm • Stimulation of the respiratory center in the brain is immature • Gag and cough reflexes are weak due to immature nerve supply Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 10
- 11. Respiratory Distress Syndrome (RDS) Type 1 • Also called hyaline membrane disease • Result of immature lungs, leads to decreased gas exchange • Surfactant is a fatty protein that is high in lecithin, its presence is necessary for the lungs to absorb oxygen – Begins to form at 24 weeks gestation and by 34 weeks, if fetus is delivered, should be able to breathe adequately – If infant is premature, the surfactant level is insufficient Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 11
- 12. Manifestations of RDS •Can take up to several hours after birth to be manifested • Respirations increase to 60 breaths/min or higher (tachypnea) • The tachypnea may be accompanied by gruntlike sounds, nasal flaring, cyanosis, as well as intercostal and sternal retractions • Edema, lassitude, and apnea occur as the condition worsens • Mechanical ventilation may be necessary Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 12
- 13. Treatment for RDS •If amniocentesis of mother while fetus is still in utero shows a low L/S ratio, the mother may be given corticosteroids to stimulate lung maturity 1 to 2 days before delivery • In preterm infants, surfactant can be administered via ET tube at birth or when symptoms of RDS occur • Improvement in the neonate’s lung function is generally seen within 72 hours after administration Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 13
- 14. Surfactant Production • Canbe altered – During cold stress – Hypoxia – Poor tissue perfusion Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 14
- 15. Nursing Care ofInfant with RDS • Monitor vital signs • Minimal handling of infant to help conserve energy • Intravenous fluids are prescribed – Observe for signs of under- or overhydration • Oxygen therapy – Monitor pulse oximetry – Infant on supplemental oxygen is at high risk for oxygen toxicity Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 15
- 16. Bronchopulmonary Dysplasia (BPD) • Toxic response of lungs to oxygen therapy • Risks – Atelectasis – Edema – Thickening of membranes, interferes with ventilation • Often a result of prolonged dependence on supplemental oxygen and ventilators • Often has long-term complications Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 16
- 17. Apnea in thePreterm Infant • Cessation of breathing for 20 seconds or longer • Not uncommon in preterms • Believed related to immaturity of nervous system • May be accompanied by – Bradycardia (heart rate <100 beats/min) – Cyanosis Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 17
- 18. Neonatal Hypoxia • Inadequateoxygenation at the cellular level • Degree can be measured via pulse oximetry – Oxygen on Hgb in circulating blood divided by the oxygen capacity of the hemoglobin • Saturation levels 92% or above is normal • Severely anemic infant may have severe hypoxia and not manifest clinical symptoms • Abnormal fetal Hgb can also cause hypoxia because fetal Hgb does not readily release oxygen to the tissues and end organs Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 18
- 19. Sepsis in thePreterm Infant • Generalized infection • Body enzymes are of the bloodstream inefficient • At risk due to • Some symptoms immaturity of many include body systems – Low temperature • Liver is immature, – Lethargy or irritability poor formation of – Poor feeding antibodies – Respiratory distress Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 19
- 20. Treatment of Sepsis •Administration of intravenous antimicrobials • Maintenance of warmth and nutrition • Close monitoring of vital signs • Care should be organized to help infant conserve as much energy as possible • Following Standard Precautions, including strict hand hygiene, is essential Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 20
- 21. Poor Control ofBody Temperature • Lack of brown fat (body’s own “insulation”) • Radiation from a surface area that is large in proportion to body weight • Heat-regulating center of brain is immature • Sweat glands are not functioning to capacity • Preterm is inactive, has muscles that are weak/less resistant to cold; unable to shiver • Preterm body position is one of leg extension • High metabolism, prone to low blood glucose levels • Can result in cold stress Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 21
- 22. Safety Alert • Signsand symptoms of cold stress – Decreased skin temperature – Increased respiratory rate with periods of apnea – Bradycardia – Mottling of skin – Lethargy Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 22
- 23. Hypoglycemia • Plasma glucoselevels <40 mg/dL in a term infant and <30 mg/dl in preterm infant • Preterm infants have not remained in utero long enough to build up stores of glycogen and fat – Aggravated by increased need for glycogen in the brain, heart, and other tissues • Any condition that increases metabolism increases glucose needs • Energy requirements place more stress on the already deficient stores Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 23
- 24. Hypocalcemia • Calcium transportedacross placenta in higher quantities in third trimester • Early hypocalcemia occurs when the parathyroid fails to respond to the preterm infant’s low calcium levels • Late hypocalcemia occurs about 1 week in infants who are fed cow’s milk, as it increases serum phosphate levels causing serum calcium levels to fall Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 24
- 25. Increased Tendency toBleed • Blood is deficient in prothrombin • Fragile capillaries of the head are susceptible to injury during birth, which can lead to intracranial hemorrhage • Nursing care includes – Monitoring neurological status – Report bulging fontanels, lethargy, poor feeding, seizures – Slight Fowler’s position – Unnecessary stimulation can increase intracerebral pressure Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 25
- 26. Retinopathy of Prematurity(ROP) • Separation and fibrosis of the retina, can lead to blindness • Damage to immature retinal blood vessels thought to be caused by high oxygen levels in arterial blood • Leading cause of blindness in infants weighing <1500 grams • Has several stages • Maintaining sufficient levels of vitamin E and avoiding excessively high concentrations of oxygen may help prevent ROP from occurring • Cryosurgery may reduce long-term complications Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 26
- 27. Poor Nutrition • Stomachcapacity is small • Sphincters at either end of stomach are immature • Increased risk of regurgitation and vomiting • Sucking and swallowing reflexes are immature • Ability to absorb fat is poor • Increased need for glucose and other nutrients to promote growth and prevent brain damage are contributing factors • Parenteral or gavage feedings may be needed until infant’s systems are more mature Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 27
- 28. Necrotizing Enterocolitis (NEC) •Acute inflammation of the bowel that leads to bowel necrosis • Factors include – Diminished blood supply to bowel lining • Leads to hypoxia or sepsis • Causes a decrease in protective mucus – Results in bacterial invasion – Source of bacterial growth if receiving milk formula or hypertonic gavage feedings Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 28
- 29. Signs of NEC • Abdominal distention • Bloody stools • Diarrhea • Bilious vomitus Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 29
- 30. Nursing Care ofInfant with NEC • Observing vital signs – Measuring abdomen – Auscultating for bowel sounds • Carefully resuming fluids as ordered • Maintaining infection prevention and control techniques • Surgical removal of the necrosed bowel may be indicated Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 30
- 31. Immature Kidneys • Cannoteliminate body wastes effectively • Contributes to electrolyte imbalance and disturbed acid-base relationships • Dehydration occurs easily • Tolerance to salt is limited • Susceptibility to edema is increased Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 31
- 32. Nursing Care ofInfant with Immature Kidneys • Accurate measurement of intake and output • Weigh diapers per hospital procedures • Urine output should be between 1 and 3 mL/kg/hr • Observe for signs of dehydration or overhydration • Document status of fontanels, tissue turgor, weight, and urinary output Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 32
- 33. Jaundice • Immature liver,contributes to condition called icterus • Causes skin and whites of eyes to assume a yellow-orange cast • Liver unable to clear blood of bile pigments which result from the normal postnatal destruction of RBCs • The higher the serum bilirubin level, the higher the jaundice and the greater the risk for neurological damage Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 33
- 34. Jaundice (cont.) • An increase of >5 • Breastfed infants can mg/dl in 24 hours or a show signs of bilirubin level above jaundice about 4 days 12.9 mg/dl requires after birth careful investigation • Total serum bilirubin • Pathological jaundice levels typically peak – If occurs within 24 about 3 to 5 days hours of birth, may be after birth related to an abnormal condition such as ABO incompatibility Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 34
- 35. Goals of TreatingJaundice • Prevent kernicterus by preventing the rising bilirubin levels from staining the basal nuclei of the brain • Nursing care goals should be to – Observe skin, sclera, and mucous membranes for signs of jaundice – Report the progression of jaundice from the face to the abdomen and feet – Monitor and report any abnormal lab results – Response to phototherapy Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 35
- 36. Special Needs ofthe Preterm Infant Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 36
- 37. Nursing Goals for the Preterm Newborn • Improve respiration • Maintain body heat • Conserve energy • Prevent infection • Provide proper nutrition and hydration • Give good skin care • Observe infant carefully and record observations • Support and encourage the parents Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 37
- 38. Incubators • It isimportant for the nurse to know how to use the various types of incubators available in their health care facility in order to provide safe and effective care to the infant who is in one Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 38
- 39. Radiant Heat Warmers •Supplies overhead heat • Allows easier access to infant Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 39
- 40. Kangaroo Care •Uses skin-to-skin contact • Infant wears only a diaper (and sometimes a cap) and is placed on the parent’s naked chest • The skin warms and calms the child • Promotes bonding Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 40
- 41. Providing Nutrition tothe Preterm Infant • May require – Parenteral feedings – Gavage feedings • May use bottles for – Breast milk – Formula • Early initiation of feedings reduces the risk of hypoglycemia, hyperbilirubinemia, and dehydration Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 41
- 42. Nursing Care Relatedto Nutrition • Observe and record bowel sounds and passage of meconium stools • For gavage feeding, aspiration of gastric contents prior to feeding is important • If no residual received, it’s safe to start the feeding • If a higher-than-ordered limit of gastric contents is received, feeding may need to be held and the health care provider notified Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 42
- 43. Positioning and NursingCare • Preterm is placed on the side or prone with head of mattress slightly elevated – Decreases respiratory effort, improves oxygenation – Promotes more organized sleep pattern and lessens physical activity that burns up energy needed for growth and development • Should be compatible with drainage of secretions and prevention of aspiration • Do not leave infant in one position for a long period of time, as it increases the risk of skin breakdown Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 43
- 44. Prognosis for PretermInfant • Growth rate nears the term infant’s about the second year of life, but very-low-birth weight infants may not catch up, especially if chronic illness, insufficient nutritional intake, or inadequate caregiving has occurred • Growth and development of the preterm infant are based on – Current age minus the number of weeks before term the infant was born – This calculation helps prevent unrealistic expectations for the infant Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 44
- 45. Family Reaction toa Preterm Infant • Parents will need guidance throughout the infant’s hospitalization • May believe they are to blame for infant’s condition • May be concerned about their ability to care for such a small infant • Parents are taught how to provide appropriate stimulation without overtiring their infant Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 45
- 46. Discharge Planning of the Preterm Infant • Begins at birth • Parents will need to demonstrate and practice routine and/or specialized care • Home nursing visits may be required to assess home, infant, and family Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 46
- 47. The Postterm Newborn •Born beyond 42 weeks gestation • Placenta does not function well after a certain point • Can result in fetal distress • Mortality rate of later-term infants is higher than that of term newborns – Morbidity rates also higher Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 47
- 48. Problems Associated with Postterm Delivery • Asphyxia • Difficult delivery due to • Meconium aspiration increased size of fetus • Poor nutritional • Birth defects status • Seizures • Increase in red blood cell production Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 48
- 49. Physical Characteristics ofthe Postterm Newborn • Long and thin – Weight may have been lost – Skin is loose (especially around buttocks and thighs) • Little lanugo or vernix caseosa – Skin is dry, cracks and peels – Nails are long and may be stained from meconium • Thick head of hair and looks alert Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 49
- 50. Nursing Care ofthe Postterm Newborn • Careful observation for – Respiratory distress – Hypoglycemia – Hyperbilirubinemia – Cold stress Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 50
- 51. Transporting the High-Risk Newborn • Stabilization of the newborn prior to transport is essential • Baseline data such as vital signs and blood work should also be obtained and provided to the transport team members • Copies of all medical records are made, including the mother’s prenatal history and how the delivery progressed Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 51
- 52. Transporting the High-Risk Newborn (cont.) • Ensure infant is properly identified and that the mother has the same identification number band • Provide parents with name and location of the NICU the infant is being transported to, including telephone numbers • If possible, allow parents a few moments with their infant prior to transporting • If possible, take a picture of the baby and give to parents Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 52
- 53. Discharge of theHigh-Risk Newborn • Parents must be familiar with infant’s care • The newborn’s behavioral patterns are discussed and realistic expectations are reviewed • Communication can be maintained with the hospital through “warm lines” • Social services may be of help in ensuring the home environment is satisfactory and special needs of the infant can be met • Support group referrals are given • Newborn CPR techniques are reviewed Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 53
- 54. Question for Review •What are the differences in the appearance of a preterm infant and a postterm infant? Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 54
- 55. Review • Objectives • Key Terms • Key Points • Online Resources • Question for Review • Review Questions Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 55
Editor's Notes
- #7 Discuss physical examination, observation of behavior, and family history as they apply to levels of maturation.
- #8 What maternal illnesses and hazards could cause preterm birth?
- #9 Discuss Figure 13-3 on page 308 and the physical characteristics listed.
- #12 How would you describe hyaline membrane disease?
- #13 Describe intercostal and sternal retractions and the pathophysiology regarding the use of these accessory muscles.
- #14 What is the nurse’s role in monitoring the neonate during the management of RDS?
- #15 Discuss the pathophysiology regarding these effects of surfactant production.
- #16 What are the signs of under- and overhydration? Discuss the nurse’s role in monitoring the neonate for oxygen toxicity.
- #17 Describe atelectasis.
- #18 What are nursing interventions for a neonate who has periods of apnea? Discuss using an apnea monitor for these neonates. Audience Response Question #1 Complete the analogy. Preterm bradycardia : less than 100 bpm as preterm tachypnea : ____________. 1. Greater than or equal to 60 breaths/min 2. Less than 60 breaths/min 3. Greater than 30 breaths/min, but less than 60 4. Less than 50 breaths per minute
- #20 Discuss how maternal infection or illness at delivery can cause sepsis in the preterm infant.
- #21 Which methods provide warmth and nutrition? Give an example of organized care to minimize energy expenditure. Discuss how standard precautions may protect the preterm neonate.
- #25 Discuss the treatment for the preterm neonate with hypocalcemia.
- #26 Describe assessment of the preterm neonate’s neurological status. Discuss the pathophysiology regarding bulging fontanels and the rationale for a slight Fowler’s position.
- #28 What is the nurse’s role in providing parenteral and/or gavage feedings?
- #30 Describe bilious vomitus.
- #31 What infection control techniques should be used for an infant with NEC?
- #33 Give an example of a situation in which the nurse must determine whether the infant’s output is adequate.
- #34 Describe icterus.
- #35 Should breastfeeding continue for infants with jaundice? Discuss the pathophysiology regarding peaked levels 3 to 5 days postbirth. Audience Response Question #2 Physiologic jaundice occurs within 48 hours after birth. 1. True 2. False
- #36 Discuss the pathophysiology of phototherapy and the treatment of jaundice.
- #38 In what ways can the nurse support and encourage the parents?
- #39 Discuss Figure 13-6 on page 313.
- #41 Discuss Skill 13-2 on page 315.
- #43 Why must gastric contents be aspirated prior to gavage feedings?
- #46 In what ways could a parent overtire an infant? What nursing interventions would assist the family in managing a preterm infant?
- #49 Discuss the pathophysiology of each complication listed.
- #51 How does the nurse assess each of these conditions?
- #54 What is the nurse’s role in the discharge process of a high-risk newborn?