pediatric nursing

1. Joy A. Shepard, PhD, RN-BC, CNE
Joyce Buck, PhD(c), MSN, RN-BC, CNE
1

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. 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
 http://www.nursingschools.net/profiles/neonatal-intensive-care-nurse/
3

4. 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
4

5. 5

6. 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
6

7. 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
7

8. 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
8

9. 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
9

10. 10

11. 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
11

12. Neuromuscular Maturity: Posture
12

13. Neuromuscular Maturity: Square Window
13

14. Neuromuscular Maturity: Arm Recoil
14

15. Neuromuscular Maturity: Popliteal Angle
15

16. Neuromuscular Maturity: Scarf Sign
16

17. Neuromuscular Maturity: Heel to Ear
17

18. 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
18

19. 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
19

20. 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
20
Preterm infant at 28 weeks'
gestation. Note the flat
smooth sole.
Term gestation. Note
the multiple creases

21. 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
21

22. 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
22
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.

23. 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
23

24. 24

25. Preterm (Premature) (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
25
http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PretermBirth.htm

26. 26

27. 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
27

28. 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
28

29. 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)
29

30. Madeline Mann, once the world's
smallest surviving newborn….
30

31. 31

32. 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
32

33. Prenatal Development of Alveolar Unit
33

34. Respiratory: Nursing Diagnoses
Ineffective Airway Clearance
Risk for Aspiration
Ineffective Breathing Pattern
Impaired Spontaneous Ventilation
Impaired Gas Exchange
34

35. 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
35

36. 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
36

37. 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
37
•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

38. Prone Position
38

39. 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.
39

40. 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 Sa02 (oxygen saturation) of less than 92%
 Oxygen is administered by hood, nasal cannula, 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
40

41. Hood Therapy (p. 824)
41

42. Nasal Cannula (p. 824)
42

43. Continuous Positive Airway Pressure
Therapy (CPAP) (pp. 824-825)
43

44. Mechanical Ventilation (pp. 825-826)
44

45. Premature baby's first few minutes -
NICU Team
https://www.youtube.com/watch?v=EhQxO8pVy0A
45

46. Nursing Interventions:
Monitor Oxygen Levels (pp. 824-825)
 Premature baby's blood oxygen can drop fast when agitated
 Pulse oximetry (Sa02)
 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)
46

47. 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
47

48. 48

49. Diagnostics cont’d….
 Pulse oximetry (percentage of hemoglobin that is bound by oxygen):
Simple, non-invasive, continuous monitoring of oxygen saturation
(Sa02) by sensors attached to the skin
 Early warning of hypoxemia
 Sa02 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
49

50. Diagnostics cont’d….
Transcutaneous oxygen pressure monitoring
(TcP02): Noninvasive, measures oxygen and carbon
dioxide
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 107 F)
Rotate probe sites frequently (q3 hours)
50

51. Oxygen and Additional Therapies
Start out with least invasive and minimal oxygen concentration
 Nasal cannula
 Infant breathes well alone but needs low
amounts of O2 (1/8 LPM to 3 LPM)
 Least invasive way to deliver O2
 Preferred method for home administration
 Hood—
 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
 Continuous positive airway pressure
(CPAP)—
 Application of O2 under a preset
pressure (positive pressure ventilation)
 Prevents alveoli from collapsing at the
end of respiration
 Allows for better perfusion, decreases
pulmonary shunting, and helps resolve
atelectasis
 Can cause pulmonary hypertension
51

52. Oxygen and Additional Therapies cont’d…
 Ventilator
 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
 SurfactantSoaplike substance produced in the lungs; prevents alveoli
from collapsing and sticking together during exhalation (produced in
adequate quantities after 34 weeks gestation)
52

53. Exogenous Surfactant Administration
53

54. Oxygen and Additional Therapies cont’d…
High-frequency oscillatory ventilation
 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
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
54

55. High-Frequency Oscillatory Ventilation
55

56. Oxygen and Additional Therapies cont’d…
Extra corporeal membrane oxygenation (ECMO)
Use of a bypass machine to oxygenate the infant’s
blood while the infant’s lungs heal
Used with obstructive lung disorders
Requires anticoagulation
56

57. Extra Corporeal Membrane Oxygenation
(ECMO)
57

58. 58

59.  Skin is thin
 Little insulating Subcut 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
59
Problem: Thermoregulation
•Flexed position reduces heat loss

60. 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)
60

61. Methods of Heat Loss
Four methods of heat
loss in the neonate:
Evaporation
Conduction
Convection
Radiation
61

62. 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
62

63. Conduction
Loss of heat from
direct contact with cold
objects
Cold hands, cold
stethoscope, cold
metal scale
63

64. Convection
Loss of heat from air
movement surrounding
the infant
Drafts, air conditioning,
air currents
64

65. 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
65

66. 66

67. 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
67

68. 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
68

69. Nonshivering Thermogenesis:
Brown Fat Oxidation
69

70. 70
Preterm Infant in Polyethylene Bag to Protect
Against Heat Loss

71. Review Question
Brown fat is used to:
A. Maintain temperature
B. Facilitate digestion
C. Metabolize glucose
D. Conjugate bilirubin
71

72. 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
72

73. 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
73

74. 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)
74

75. 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
75

76. 76

77. Identify 4 Consequences of Cold Stress….
Respiratory distress
Acidosis
Hypoglycemia
Hyperbilirubinemia
77

78. 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
78

79. 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
79

80. 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)
80

81. Infant under Plastic Wrap
81

82. 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
82

83. From isolette to open crib….
83

84. 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
84

85. 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
85

86. Evaluation
Infant expends a minimal amount of extra energy in the
production of heat
Infant is free from periods of hypothermia or
hyperthermia
86

87. 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
87

88. 88

89. 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
89

90. 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
90

91. Nursing Interventions: Maintain Nutrition
Methods of feeding: parenteral (intravenous); enteral (uses GI
tract); 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 (coordination of
sucking and swallowing)
 Observe: coughing, gagging, vomiting, cyanosis, changes in
heart rate or respirations, apnea
91

92. 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)
 Check hourly volumes, urinary output, and lung status
 Monitor glucose levels
92

93. 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
(asphyxia, increased respiratory effort, cold stress,
insensible water loss)
 Strict I & O
93

94. 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
94

95. 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
95

96. Assessing Blood Glucose:
Warming Infant Foot for Heelstick (p. 577)
96

97. Assessing Blood Glucose in the Infant
(pp. 576-577)
Normal blood glucose: 70 – 100 mg/dl
97

98. 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
Nasogastric or orogastric tube (#5 to #8 Fr)
98

99. 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)
99

100. 100

101. 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
101

102. Nonnutritive Sucking (p. 831)
102

103. 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)
103

104. 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)
104

105. Oral Feeding (pp. 828-829)
Breast milk: preferred
Bottlefeed: soft premature nipple, 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
105

106. Nipple-Feeding the Preterm Infant
106

107. Oral Feeding Stress Cues
107

108. 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
108

109. 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
109

110. Infants: Formula Considerations
Nutrient Comparison by Formula Type Formula Types and Indications
110

111. Evaluation
Infant demonstrates a steady weight gain (20 – 30
grams/ day)
111

112. 112

113. Facilitate Parent-Infant Attachment
113

114. 114

115. 115

116. 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
116

117. 117

118. 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
118

119. 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)
119
•Reticulogranular appearance

120. 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
120

121. 121

122. 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
 Sa02 > 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
122

123. 123

124. 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
124

125. 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
125

126. 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
126

127. 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.”
127

128. 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
128

129. IVH: Grades 1 and 2
129

130. IVH: Grades 3 and 4
130

131. 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)
131

132. Ventriculoperintoneal (VP) Shunt
132
• For persistent hydrocephalus: permanent shunt is
placed in the ventricle (ventriculoperitoneal shunt)

133. 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
133

134. 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.
134

135. 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
135

136. 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)
136

137. Swollen, red, and tender
belly
137
Visible bowel loops

138. 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)
138

139.  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)
139
• Center for Advanced
Intestinal Rehabilitation
(CAIR) (Boston Children’s
Hospital)
• Premier program for the
treatment of SBS

140. Serial Transverse Enteroplasty (STEP)
Procedure
140

141. Longitudinal Intestinal Lengthening and
Tailoring (LILT) Procedure
141

142. 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
142

143. Premature Son’s Miraculous First Year
143
https://youtu.be/64zBCIs5tmw

144. 144