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32 Cards in this Set
- Front
- Back
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Gestational Age Variations
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Term
Born from the first day of the 38th week through 42 weeks Preterm Born before completion of 37 weeks Late preterm Born between 34 and 36-6/7 weeks Postterm Born beyond 42 completed weeks |
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Respiratory and Cardiovascular
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Critical factors:
Inability to produce adequate surfactant. Muscular coat of pulmonary blood vessels is incompletely developed. Pulmonary arterioles do not constrict as well in response to decreased oxygen levels. Ductus arteriosus usually responds to rising oxygen levels by vasoconstriction, if more susceptible to hypoxia, the ductus may remain open. Respiratory control centers less developed so they are more prone to apnea |
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Thermal Regulation
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Heat loss occurs due to:
Much larger ratio of body surface to body weight. The infant's ability to produce heat (body weight) is much less than the potential for losing heat (surface area). Little subcutaneous fat. Heat lost from blood vessels that lie close to the skin. A hypotonic, extended posture increases exposed surface area. Strong flexion at 36 weeks helps to prevent heat loss. |
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GI System Immature
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Limited ability to process essential amino acids.
Kidney immaturity makes it difficult to handle certain proteins. Difficulty absorbing saturated fats. Lactose digestion may not be fully functional. Deficiency of calcium and phosphorous mostly laid down in last trimester. |
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Formula Considerations
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Protein ratios with whey/casein ratio of 60/40
Higher calorie 24 cal per ounce Medium chain triglycerides Calcium and vitamin D supplements Breast milk widely used but may have slower weight gain due to high calorie demands |
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Susceptible to Feeding Problems
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Marked danger of aspiration due to poorly developed gag reflex
Small stomach capacity Decreased absorption of essential nutrients Fatigue associated with sucking Feeding intolerance and NEC |
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Methods of Feeding
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Nipple- soft nipple
Gavage feeding If respiratory rate is over 60 risk of aspiration is high so they must be gavage fed |
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Renal
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Problems in the management of fluid and electrolyte balance
Glomerular filtration rate is lower Limited in ability to concentrate urine or to excrete excess amounts Buffering capacity of kidney is less Decreased ability to excrete drugs |
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CNS
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Disorganized in their sleep-wake cycles
Neurological responses are weaker (sucking, muscle tone, states of arousal) |
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Preterm Newborn: Common Problems
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Hypothermia
Hypoglycemia Hyperbilirubinemia |
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Problems related to immaturity of body systems
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Apnea - for periods longer than 20 seconds
PDA – patent ductus arteriosis (shifts blood flow away from the lungs and goes right back into the aorta, baby will show symptoms of hypoperfusion of the lungs), must get oxygen support and possibly ventilator support Periventricular/Intraventricular hemorrhage (PVH/IVH) Respiratory distress syndrome – caused by lack of surfactant, every breath is just as difficult as the first breath, betamethasone may be given to mom who is in preterm labor to help mature the baby’s lungs, artificial surfactant can be given to newborn, stress in utero can help mature lungs earlier, usually seen within first 6 hours of birth Necrotizing enterocolitis (NEC) – acute information leads to nechrosis of the bowel, symptoms occur 4-10 days after birth, will see abdominal distention and lack of peristalsis Anemia Susceptibility to Infection |
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Long-term Complications of Prematurity (Treatment related)
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Retrolental fibroplasia (RLF) or retinopathy of prematurity – secondary to high levels of O2, retinal vessels constrict and lead to blindness
Bronchopulmonary Dysplasia (BPD)- secondary to mechanical ventilation, causes lung damages due to lung immaturity, delays lung and body growth, long term dependence on diuretics, steroids, bronchodilators, chronic hypoxia problem can lead to psychomotor and developmental delays Sensorineural hearing loss – ototoxic drugs such as gentamycin and lasix |
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Common Preterm Newborn Assessment Characteristics :
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Weight <5.5 lb
Scrawny appearance Poor muscle tone Minimal subcutaneous fat Undescended testes Plentiful lanugo Poorly formed ear pinna Fused eyelids – 22-24 weeks Soft spongy skull bones Matted scalp hair Absent to few creases in soles and palms Minimal scrotal rugae; prominent labia and clitoris Thin transparent skin Abundant vernix |
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Preterm Newborns: Nursing Management
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Oxygenation
Thermal regulation Infection prevention Stimulation Pain management Growth and development Parental support: high-risk status; possible perinatal loss Discharge preparation |
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Planning/Interventions for Preterm Infants
Maintenance of respiratory function |
Impaired gas exchange r/t insufficient surfactant production immature pulmonary and neurologic development
Ineffective breathing pattern r/t immaturity and fatigue Assist with intubation/surfactant administration Positioning – avoid supine position, prone is better because it facilitates chest expansion Judicious suctioning – oxygenate well prior to and after suctioning Monitor for respiratory distress (page 730) Tactile stimulation during periods of apnea |
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Planning/Interventions for Preterm Infants
Maintenance of thermoneutral environment |
Ineffective Thermoregulation r/t immaturity, lack of subcutaneous and brown fat, and hypotonia
Place infant in isolette or radiant warmer with temp probe Warm and humidify O2, blood, etc Cap on infant’s head Skin to skin with parents Avoid placing infant on cold surfaces |
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Planning/Interventions for Preterm Infants
Maintaining fluid and electrolyte status |
Risk for deficient fluid volume r/t inadequate intake and excessive losses
Evaluate hydration status – strict I&O, loss of weight is most sensitive indicator of fluid loss Daily weights Accurate I&O (hourly) Monitor IV (infusion pumps) |
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Planning/Interventions for Preterm Infants
Preventing infection |
Risk for Infection r/t immature immunologic defenses and invasive procedures
Wash hands (staff and family) Limit visitors Designated equipment Risk for impaired skin integrity r/t thin fragile skin, less subcutaneous fat Position on pressure-reducing mattress; change position Monitor skin and mucus membranes – lubricate if necessary Minimize chemical skin prep and tape; special electrodes |
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Planning/Interventions for Preterm Infants
Nutritional needs |
Imbalanced nutrition: less than body requirements r/t high metabolic rate and inability to ingest adequate nutrients
Assess suck, swallow, and gag reflexes Advance strength of feedings Listen for bowel sounds, check for residuals, and measure abdominal girth before feeds; observe for diarrhea and occult blood in stools Gradually progress to nipple feeds Position after feeds to prevent aspiration Decrease metabolic needs |
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Planning/Interventions for Preterm Infants
Promote parent-infant attachment |
Risk for impaired parent- infant attachment r/t NICU care
Provide anticipatory guidance Draw attention to their unique infant Encourage visits – touching, talking Provide updates (esp if at another facility) Assess knowledge of infant condition and provide info from consistent source Encourage expression of feelings Reassure about competence as parents Teach about developmental response – behavioral assessments Information about resources and support groups |
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Planning/Interventions for Preterm Infants
Promote sensory stimulation/ prevent CNS injury |
Risk for disorganized infant behavior r/t immature CNS
Developmentally supportive care Assess individual newborn behaviors Help parents identify infant cues Monitor environmental stimuli / cluster activity Risk for injury r/t immature CNS, increased ICP, increased bilirubin, or stress Assess prenatal and birth history Minimize procedures that increase ICP such as suctioning, position, fluid balance, oxygenation Monitor for signs of increased ICP or injury |
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Post-term Pregnancy
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Definition – 42+ weeks
Incidence - Etiology – perinatal mortality doubles at 43wks, placenta gives out, usually due to lack of prenatal care, history of post-term pregnancies, fetal abnormalities |
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Post-term Pregnancy
Assessment |
Fetal Movement test – “Kick counts” (page 324-325), same time everyday, preferably after a meal
Weight loss, decreased fondus height, placental insufficiency, decreased fat stores, hypoglycemia, hypothermia Biophysical profile – amniotic fluid volume, tone, breathing movements Non-stress test (up at least 15 beats and last at least 15 seconds, 2 within 20mins) |
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Post-term Pregnancy
Treatment |
Favorable cervix (Bishop score) - induce
Unfavorable - continue monitoring Start 2 X/ wk NST at 41 weeks Kick counts At 42 wks or oligohydramnios or fetal distress Ripen cervix and induce with pitocin |
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Post-term Pregnancy
Postterm Labor |
Nursing Assessment: estimated date of birth (verified by ultrasound?); daily fetal movement counts, nonstress tests twice weekly, amniotic fluid analysis, weekly cervical examinations
Nursing Management: fetal surveillance; decision for labor induction; support; education, intrapartal care Nursing Concerns with postterm delivery Maternal Risks Risk for injury (pitocin, LGA delivery) Fear / Anxiety / Fatigue Fetal Risks Impaired gas exchange Aging placenta Oligohydramnios Cord compression Risk for injury Fetal macrosomia / possible shoulder dystocia Newborn risk Risk for injury Birth trauma Hypoglycemia Risk for aspiration Meconium |
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Post-term Pregnancy
Post-term Infants Assessment |
Assessment
Most babies of prolonged pregnancy are of normal size and health. Can be small for age depending on the placenta. Some keep growing and are over 4000 g. Some lose muscle mass and subq fat due to unfavorable uterine environment Inability of placenta to provide adequate oxygen and nutrients to fetus after 42 weeks gestation |
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Post-term Pregnancy
Signs of Postmaturity Syndrome |
Wide-eyed, alert, may indicate chronic intrauterine hypoxia
Dry, cracking parchment like skin without vernix or lanugo Long, thin extremities; creases cover entire soles of feet Fingernails are long, scalp hair is profuse Wasting of subcutaneous tissue, fat layers almost non-existent Frequent meconium staining of nails, skin and umbilical cord Thin umbilical cord |
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Postterm Newborn: Common Problems
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Perinatal asphyxia
Hypoglycemia Hypothermia Polycythemia Meconium aspiration |
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Postterm Newborn
Nursing Interventions |
Antenatal evaluation- NST, CST
Deliver if placental depletion Intrapartally - might do amnioinfusion to decrease risk of meconium aspiration At delivery - if meconium stained fluid, special airway suctioning might be necessary |
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Amnioinfusion
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Indications
Severe variable decelerations due to cord compression Oligohydramnios due to placental insufficiency Postmaturity or rupture of membranes Preterm labor with premature rupture of membranes Thick meconium fluid Nursing management: teaching, maternal and fetal assessment, preparation for possible cesarean birth |
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Postterm Newborn: Nursing Management
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Resuscitation
Blood glucose level monitoring Serial dextrostix Initiation of early feedings; IV dextrose 10% Prevention of heat loss Evaluation for polycythemia Parental support |
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Meconium Aspiration Syndrome-
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Asphyxia causes increased peristalsis and relaxation of the anal sphincter
After inhaled into lungs, it produces a ball-valve action (air can come in but can’t go out and alveoli rupture, pneumothorax) Chemical pneumonitis commonly leads to a secondary bacterial pneumonia Nursing Assessment Fetal: Observe for signs of fetal hypoxia and meconium staining of amniotic fluid Newborn: Signs of distress Low Apgar scores (anything less than 7) Pallor, cyanosis Respiratory distress: flaring, grunting, retracting, tachypnea, apnea Planning Impaired Gas Exchange r/t meconium obstruction of airway Resuscitation protocol if necessary Surfactant administration – decrease surface tension of alveoli Mechanical ventilation High ambient oxygenation and controlled ventilation Low positive end-expiratory pressures (PEEP) Chest physiotherapy Prophylactic antibiotics |
