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105 Cards in this Set
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- Back
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Two wayas of causing neonatal withdrawl
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1)Mom addicted to drugs
2) ICU environment, placed on meds such as morphine |
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Neonatal Abstinence Syndrome (withdrawal)
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Degree of drug withdrawal depends on type and duration of addiction and maternal drug levels after delivery.
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Big indicator that mom may be a drug user
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No prenatal care or late prenatal care
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Onset of withdrawal
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Marijuana - 36-72 hours
Methadone - 24-96 hours Heroin - 24-72 hours Cocaine 24-48 hours Ethanol 3-12 hours Methamphetamines 1-14 DAYS Nicotine - unknown |
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Marijuana
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Most common drug ages 18-24 yrs.
Effects on NB: - possible nb tremors - can be subtle. Can tell if they are sz or tremors by holding onto extremity, if a sz, will not stop - LBW <1500g -IUGR - smaller in size, but everything develops normally - could have cognitive delays |
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Methadone
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-Tx of choice for heroin addict
- crosses placenta - signs of w/d: tremors, irratibility, hypertonicity, vomiting, mottling, nasas stuffiness (sneezing not normal, indicative), hyperreflexia Tx - Buprenorphine - sublingual (use pacifier) *Never stop a pg mom cold turkey. W/d causes spontaneous ab* |
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Heroin
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Tx same as mom - methadone or buprenorphrine
Crosses placenta Effects on NB: LBW, SGA, irritability, tachypnea, feeding difficulties, vomiting, high pitched cry, seizures |
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Cocaine
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*Abruptio placentae is an indicator*
5-6 days to get out of system. Effects on NB: Preterm birth, SGA, disturbed sleep patterns, diarrhea (skin excorriation), hypersensitivity to light and noise, developmental delays Use non nutritive sucking, quiet and dim area. Also check skin due to moving around in crib causing abrasions |
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Ethanol
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Effects on Newborn:
Microcephaly Hyperactivity Developmental delays Attention defecits |
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Methamphetamines
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Effects on newborn:
SGA Preterm birth (b4 37 wks) Poor weight gain Lethargy Bx problems later in childhood |
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Nicotine
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Effects on NB:
Preterm birth Low birth weight developmental delays Orofacial clefts (Gestatational ages 3 to 8 weeks) |
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Urine drug screening (done on NB)
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Documents drug use over last 1-14 days.
Very first urine. Can't measure frequency of drug use in mom. |
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Meconium drug screen
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Documents drug use over past 4-5 mos.
First meconiums! Usually sent out, results take up to 1 week. Can also use umbilical cord, as accurate, results faster |
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Finnegan Scoring System
aka NASS |
Measures the degree in which a newborr is experiencing symptoms of substance abuse withdrawal.
Observes CNS, respiratory, GI, vasomotor disturbances |
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How to use Finnegan scoring system
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*Score nb every 3-4 hours - corresponding w/ FREQ. OF FEEDINGS
*Bxs should be assessed throughout 3-4 hours interval *Score all that apply *Try nonpharm. interventions at first - swaddling, paci, soothing voice, dim lights |
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Using Finnegan scoring along w/ tx of w/d
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*tx of w/d w/ meds possible if score 8 or above
*Effective dose maintained fpr 3-5 days amnd then tapering can begin *Is dose therapeutic? Use scoring to see if score number drops* *Scoring continues and tapering should only occur as long as ther is not a marked increase in the score *Tapering by 10% every 1-2 days as tolerated |
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Medications for tx of w/d
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Phenobarb. - CNS depressant
*Monitor for respiratory depression (Norm 30-60) *Monitor drug levels (long term liver effects) Morphine sulfate and Methadone *Monitor for resp. dep. and excessive sedation Narcan is the reversal agent. *Narcan cannot be used if mom was addicted to a narcotic* |
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Nursing care of the narcotic exposed newborn
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Low lights, quiet
May need higher cal formula IV fluids swaddling,hold infant - can use volunteers, non-nutritive sucking Daily wts strict I/O -monitor for 'lyte disturbance keep babies flexed skin assessments for excoriation NASS/Finnegeran |
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Hypoglycemia in NB
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Blood glucose concentration less than adequate to support neurologic, organ and tissue function (usually 50mg/dl or below.)
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Risk factors for hypoglycemia in the NB
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NB of diabetic mothers.
SGA/LGA Premature Cold stress |
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Signs of hypoglycemia in a NB
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Jitteriness
Irreg. respirations (periodic breathing normal) Apnea (>= 15 sec, color changes, bradycardia) Weak,high pitched cry Feeding difficulties (if baby cold, won't eat) Twitching Eye rolling Seizures Jaundice |
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Assessments/Interventions
hypoglycemia in NB |
BS w/ in 1 hour of birth for high risk newborns
*at birth, bs decreases, after 1/2 hr, body starts to compensate and bs^ - 1 hr is true time to check, not b4* if BS low, FEED!!! Sugar water: Mom is resting, mom had C section |
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Newborns of INSULIN DEPENDENT diabetic mothers
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Perinatal mortality - risk of death is 10% in severe maternal ketoacidosis
Congenital abnormalities: * 7-10% *Mostly involving cardiac, CNS or skeletal systems - spina bifida, transposition of the great vessels |
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Newborns of INSULIN DEPENDENT diabetic mothers
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*Macrosomia - sustained fetal hyperinsulinism and hyperglycemia
*Cardiomyopathy - increased heart size, respiratory systems, CHF *Respiratory distress - surfactant production is diminished *Polycythemia - blood volume and Hct values ^ *hyperbilirubinemia - immature liver cannot metab. ^ bilirubin resulting from polycythemia *Hypocalcemia - possible mothers have hypomagnesemia due to ^urinary calcium excretion w/ causes a hpoparathyroidism |
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Nursing care of NB w/ hypogycemia
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Feeding regularly.
Checking BS prior to feeding (then checking skin integrity from repeated sticks.) |
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Respiratory Distress SYNDROME in NB
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*Results from primary absence, deficiency or alteration in the production of pulmonary surfactant.
*Affects 20k to 30k nb/yr *Occurs more often in caucausion nb (wimpy white boy syndrome) *2x more in males *Pre-term infant |
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Nursing assesesments in RDS
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*Nasal flaring, retractions, apnea
*skin color - blue hands/feet ok (acro), central cyanosis is NOT. Mottling. *Bradycardia *Pulse 02 - remember we do not want nb at 100%, usually <93% |
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Kernicterus
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- brain damage caused by untreated jaundice
- not cognitively impaired |
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Clinical therapy for RDS
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*Surfactant replacemnt therapy
- improves compliance of lungs and decreases work of breathing - improves oxygenation - given via ETT - must check placement *O2 must be humidified *Ventilation therapy: - ventilator - oral aversion isues - CPAP - can give "pig nose" and deteriorate septum - Nasal canula - ideally Get off ventilator asap |
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Jaunidice
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RBC's breakdown, liver cannot keep up w/ breaking down.
Types of bilirubin: Conjugated - excreted by urine/stool - good Unconjugated - can cross blood/brain barrier - bad Jaudice occurs in a CEPHALACAUDAL pattern |
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RH incompatability
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Can cause jaundice.
Tested by direct coombs (on baby) or indirect coombs (on mother |
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Indirect coombs test
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On mother.
Labs drawn at 1st prenatal visit & again at 28 wks. Determines presences of maternal antibodies in maternal blood. Neg. means no antibodies Pos. means presence of antibodies. Negative would receive Rhogam @28 wks, prevents development of antibodies. |
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Direct coombs test
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Uses cord blood.
Determines presence of maternal antibodies in fetal blood. Neg. means no antibodies. Pos. means antibodies present. Positive would have possible need of phototherapy treatment. |
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Hydrops Fetalis
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Severe form of Rh incompatibility.
Anemia, cardiac decompensation, cardiomegaly, hepatosplenomegaly. Intrauterine or early neonatal death. |
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Management of Hydrops Fetalis
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Intrauterine transfusion.
O blood type, Rh negative |
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Mangement of jaundice
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Depends on etiology.
Phototherapy treatment. |
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Phototherapy treatment
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*Exposure of NB to high intensity light that decreases serum bilirubin levels by fascilitating exretion of unconjugated bilirubin.
*Bilrubin converted from nonwater soluble form to water soluble byproducts. *Decision to start phototherpay tx. based on GA and age in hours |
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Nursing assessments/interventions r/t phototherapy tx in hospital
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Skin integrity.
Body temp. Eyes covered, assess eye qshift for conjuctivitis Expose as much skin as possible. Assess bilirubin levels - has to be serum. Feeding every 3 hours at least. |
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home care phototherapy tx.
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Biliblanket, takes longer to work.
Usually no more than a week. Eyes are not covered. |
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Exchange transfusion
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*Used to quickly decrease high bilirubin levels.
* W/d and replacement of nb's blood w/ donor blood *Only use rh neg and cmv neg blood |
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How exchange transfusions are performed
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Take out 1ml, put in 1 ml, etc.
Sterile procedure, can take hours. 75-85% of nb blood is exchanged. Warmed whole blood is used. Potential complications: - transfusion reaction - infection - umbilical catheter complications - hypocalcemia |
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Sources of nb infection
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*Transplancental
*perinatal aquisition (vertical) up through vag. canal *Neonatal acquisition (nosocomial, horizonal transmission) |
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Defense mechanisms from infection
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Intact skin and mucous membranes.
Inflammatory response. Immune response - antibodies - immunoglobins IgG, IgM, IgA |
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Portals of entry for infections
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umbilical cord
heel sticks surfactant - ett tube Bulb syringe |
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Immunologic response serves these 3 host functions
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Defense - resistance against infections
Homeostasis - removal of incapacitated host cells Surveillance - perception and destruction of foreign or mutant cells |
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Neonates response to infection
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Bacterial colonization - all infants become colonized at birth
Susceptible host - premature infants have underdeveloped immune systems Bacterial invasion - occurs when breaks in the skin or mucous membranes occur Bacteremia - is the presence of bacteria in the bloodstream - 25-35% of these will go on to develop systemic sepsis (adverse affects) Release of toxins - endotoxins released by the bacteria casue adverse affects |
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Local response to infection
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Vasodilation - areas of high metabolic activity (ie heart and brain) vasodilate to protect oxygenation
Areas of low metabolic activity (gut, kidneys, muscles) vasocontrict to allow preferential perfusion White cell response - mature cells go out first. In s\epsis, white stores are depleted and immature cells are sent out. |
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Microcirculatory changes with infection
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1) more capillaries are opened up to increase surface area for gas exchange.
2)circulation is slowed to allow for more time for gas exchange In sepsis, this response is impaired, so a distrubance in peripheral oxygenation plays a key roll in pathophis. |
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Neonatal neutrophils
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are deficient in adherence, deformability adn chemotaxis. There is a SLOW influx of neutrophils into sites of microbial invasions, resulting in rapidly progressing infections.
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Neonate response to infections - reticuloendothelial response
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Endotoxin is reasled by the bacteria during cell invasion. RES shoudl clear away the endotoxin. This response is not mature in the premature neonate allowing the toxins to circulate and damage cells.
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IgG
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Baby develops antibodies to what mom exposed to in utero - drops off after aprox. 2 wks.
Major immunoglobin of serum and insterstitial fluid. Provides immunity against bacterial and viral pathogens, but limited to viral and gram+ that mom exposed to. Transfer begins at 20wks, but most after 30wks. ^gradually until 40 wks. |
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IgM
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Newborn infants (term/preterm) begins synthesis of IgM at birth in response to antigens in the environment and a rapid ^ in IgM levels occurs by DOL 6. Low at birth unless exposed to infectious agent during pg.
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IgA
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Common in respiratory tract, GI tract, human colostrum, and human milk. Receive from BF, but doesn't secrete IgA until 2-5 wks after birth.
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Patterns of sepsis
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Early onset/congenital - occuring w/ in 48hrs after birth, such as GBS.
Late onset - occuring after 7 days of birth. Usually nosocomial, environmental. |
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Early onset sepsis
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Occur from direct contact w/ mom GI/GU.
GBS most common infecting organism. Other organisms: H. influenzae Coagulase-neg. staph Strep viridians HSV Chlamydia Gonococci Chorio symptoms - fetal tachycardia, uterine tenderness, purulent amniotic fluid, elevated WBC count, temp - infant at risk for sepsis |
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Early onset risk factors
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Maternal:
ROM >18 hrs Maternal > 38 C/100.4 F Maternal UTI Vaginal colonization w GBS Presense of chorioamnionitis Give Penicilian G Neonatal risk factors -Prematurity -low birth weight -Low apgars - multiple gestation -meconium aspiration |
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Incidence of early onset sepsis
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Term infants 1-3/1000
Pre-term infants - increased rate w/ decreasing GA The more premature an infant, the longer the delay between ROM and delivery, the higher the incidence of neonatal sepsis. |
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Lab studies w/ sepsis
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CBC
- Total WBC <6000 or >30,000 - Platelet count <100,000 Cultures - blood - 2x, lots of false + - CSF - Tracheal Chest X-ray - looking for infiltrates C-reactive protein - inflammatory response |
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Preventing sepsis
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Effective handwashing.
Standard precautions. Thorough cleaning of contaminated equipment. Frequent replacement of used equipment. Avoid overcrowding. No artificial or long fingernails. Instiallation of erythromycin. Cord care. Combined use of alcohol, hand hygeine and gloves. |
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Perinatally Acquired Infections
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TORCH
T - toxoplasmosis O - other (gonorrhea, syphilis, hep b, varicella-zoster, HIV) R - rubella C - Cytomegalovirus H - Herpes simplex virus |
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Toxoplasmosis
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*Infection follows hand-to-mouth contact
- handling cat litter - handling or ingesting raw meat from sheep/cattle - eating unwashed/unpeeled fruits or veggies *First trimester exposure more serious than 3rd trimester More than 70% affected nb are symptom free |
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Toxoplasmosis mortality and morbidity
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10-15% die
85% have severe psychomotor problems or congenital impairment by age 2 to 4 years. Cognitive issues start to appear 2-4 yrs. 50% have visual problems by age 1 Some symptoms develop early, some not until later inlife IUGR, Microcephaly/hydrocephaly, CNS calcification, Thrombocytopenia, Petechiae NO TREATMENT |
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Gonorrhea
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*Contamination occurs during pass through birth canal
*can become infected through mouth, conjunctiva, rectum, pharynx *Erythromycin w/in 1st hr of birth *Mild infections - recover completely - single dose of ceftriaxone *Serious infections -can lead to death |
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Syphillis
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Re-emergence as a sig. health problem - long dormancy period, usually goes untreated
- 40-50% of neonates born to pg. women w/ syphilis will have symptomatic congenital syphilis Target of HP 2010 - 1 new case per 100,000 live births |
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Syphilis
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Untreated infections - miscarriage or stillbirth
All neonates affected if infections occurs b$ 7th month Only 60% affected in infection occurs later in pg. If treated b4 18th wk,,, seldom demonstrate signs of disease if treated after 18th wk, pathologic charges may not be prevented. |
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Syphillis and development
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*Organs develop normally
*Organs affected - liver - spleen -kidneys - adrenal glands - bone covering -marrow |
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Signs of congenital syphilis
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Poor feeding
Slight hyperthermia. "Snuffles" sneezing, runny nose Copper covered maculopapular rash - palms, then soles of feet, diaper area, mouth and anus Elevated wart-like lesions around anus Lesions of lips. |
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Treatment of Syphillis
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No treatment necessary if motehr adequately treated and serologic testing of newborn negative.
10-day course of Penicillin G if mom not treated. Newborn may be completely asymptomatic until after discharge. Standard precautions apply. |
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Hepatitis B
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Blood transmission.
Infection during pg. not associated w/ malformations, stillbirths or IUGR. Increased risk for preterm birth. Most commonly infected during birth or in first few days of life. If mom is positive - nb Hep B immunization plus immunoglobulin |
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Signs of Hep B infection and treatment
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May be asymptomatic or show signs of acute hepatitis.
Give Hep B injection w/ in 1 hr of birth. Give hepatitis immune globulin w/in 12 hrs of birth Give concurrently, but at DIFFERENT SITES May breastfeed after BOTH are received. |
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Varicella Zoster
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Transmission to fetus may occur across the placenta when contracted in 1st half of pregnancy.
Fetal effects - *limb atrophy *neurologic abnormalities *eye abnormalities *IUGR If maternal infection occurs w/ in last few days of pg, 20% develop conginetal varicella. Severity increases if maternal infection occurs w/ in 5 days b4 or 2 days after birth |
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Treatement of varicella
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Varicella immune globulin at birth.
Acyclovir for generalized involvement and pnuemonia. |
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HIV in nb
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Majority of pediatric AIDs results from maternal to fetal transmission.
Universal counseling and screening recommended. Mom can deny testing. |
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HIV transmission in nob
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Occurs transplacentally at various gestational ages.
Risk of infection to newborn of HIV + mother: 13-39% Incidence of neonatal infection decreased due to education Delivery must be C-Section Postpartum trasmission occurs from vaginal birth. |
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HIV signs and symptoms in NB
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HIV infected nb - asymptomatic at birth.
Early onset illness - opportunistic infections - rapid progression of immunodeficiency - death w/ in one year Remainder seroconvert over a period of months to years |
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Treatment for HIV in nb
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Highly active antiretroviral therapy (HAART)
Agressive ATB tx of opportunistic infections |
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Rubella in the nob
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Congenital rubella can be reduced b/c we now immunize.
Risk for anomalies varies w/ fetus's GA at time of infections. Wks 3-8 most severe. |
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Signs and symptoms of rubella in the NB
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2/3 asymptomatic at birth.
Sequelae may develop years later. S/S that may be present: *Hearing loss *Hepatosplenomegaly *IUGR *Jaundice *Characteristic BLUEBERRY MUFFIN lesions *Cataracts *Glaucoma *Diabetes type 1 |
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Cytomegalovirus (CMV)
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CMV during pregnancy can result in miscarriage, stillbirth or congetnital illness
Most common cause of congital viral infections. 90& of adults & 70% kids test positive. |
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S/S of CMV
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90 -95% asymptomatic at birth.
10% will display severe involvement: - IUGR - Microcephaly -Rash - Jaundice -hepatosplenomegaly - long term neurologic sequelae |
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Treatment of CMV
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- no breastfeeding if mother experiencing acute CMV syndrome.
- treat infected nb w ganciclovir. Effective in decreasing neurologic sequelae,esp. hearing loss. Prevention? Handwashing! Esp. pg. mom w/ other kids in daycare/school. |
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Herpes simplex virus in NB
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-Congenital infection rare
- Usually IUGR, more likely to be born preterm. -Severe psychomotor restriction *intercranial calcification *seizures -eye involvement *Cataracts *Blindness |
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Herpes Simplex Virus infection & presentatiuon
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*Most infected during vag. birth if mother has active lesions - C-section
Presentation: Disseminated localized infection. Symptoms usually w/in 1st wk of life. 1/3 have skin vessicles. *25% mortality rate w/ out antivrial therapy.* |
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HSV treatment
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*Culture mouth, eyes and any lesions
*Prophylactic eye ointment 5 days for nb at risk *Acyclovir is standard therapy (14-21 days.) IV in hospital. |
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Group B Strep
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Most common cause of sepsis and meningitis and is a frequent cause of nb pneumonia.
Typically exposed to GBS in labor and delivery. GBS +mom needs 2 doses of PCN before delivery. GBS colonized in 15-35% of all women. |
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GBS Early onset
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Occurs w/in 1st 7 days of life.
Results from vertical transmission. NB have respiratory illness. Significant mortality rate. Can rapidly develop into septic shock. presents like pneumonia/meningitis:RDS, lethargy, poor feeding, abd distention, shcok, seizures |
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GBS Late onset
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7-10 days after birth. 1wk to 3 mos.
85% of these will have meningitis. Mortality rate 5% 50% of survivors have neurologic damage. Fever, lethargy, bulging AF. Long term sequelae - 25-50% have mental retardation, spastc quardrapelgia, deafness, hydrocephalus |
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GBS intrapartum ATB prophalaxis
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If patient is not known to be allergic to PCN, give PCN G 5 million units IVPB asap.
Then, PCN G 2.5 million unitls IVPB q4h until infant is delivered. |
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Candidiasis
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Yeast like substance.
Aquired orally. Candidal diaper dermatitis: *appears on perineal area, inguinal fold, and lower portion of abd. *Intensely erythematous *Topical application of antifungal |
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Oral candidiasis
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Aka Thrush.
*characterized by white plaques on oral mucosa, gums and tongue. *tends to BLEED when touched. |
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Nursing care mangement of candidiasis
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*Good handwashing
*cleanliness to prevent infection/reinfection *treat w/ topical fungicide *expose perineal area to dry air for diaper dermatitis |
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Nursing care treatment of oral candidiasis
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*Rinse mouth w/ plain water after each feeding b4 applying medication.
*Boil reusable nipples and bottles, pacifiers for 20 minutes *Treat nipples of breastfeeding mothers w/ topical antifungal - can still breastfeed |
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Grief
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Total response to the emotional experience r/t loss, manifested emotionally, somatically, and cognitively, assoc. w/ overwhelming distress or sorrow
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Bereavement
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Subjective responses experienced by a survivor of loss
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Mourning
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Behavioral process through which grief is eventually resolved, influenced by culture, religeon and customs.
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Somatic (physiologic) signs of grief
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GI:anorexia, wt. loss, N/V, overating
Respiratory: sighing, hyperventilation Cardiovascular: palpations, chest heaviness Neuromuscular: vertigo, HA |
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Behavioral signs of grief
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Feelings:
*guilt over somehow having caused death *sadness, may be overwhelming *anger and hostility towards othrs *Apathy, inability to make decisions *Helplessness *Preoccupation - daydreams or fantasizes about nb, nightmares, longing to hold nb *Interpersonal relationships - decreased sexual interest, w/d from social activities, public or private crying, unable to perform ADLs |
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Siblings and grief
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*Child's reaction to deat of sibling depends on childs developmental level and parental response to loss
*Universal fear - fear of separation &abandonment; fear that parents may die |
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How children view death
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Up to age 6 - view death as temporary and reversible; may feel guilty that their neg. thoughts may have caused death.
Age 6 - 12 View death as inevitible and irreversible. 12 and older Think abstractly like an adult. |
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Acute distress
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*state of shock and numbness
*sense of unreality, loss of innocence, powerlessness *Disbelief and denial *Sadness,devastation, depression, intense outbursts of emotion, crying |
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Intense Grief
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Many difficult emotions as parents work through pain and adjust to life w/ out their child
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Reorganization
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*Occurs when parent is better able to function at home and at work
*Experience a return of self esteem and confidence *Can cope w new challenges *Has placed the loss in perspective *Peaks sometime after the first year |
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Non helpful responses to grief
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*Maintaining state of denial
*Isolation *Prohibiting contact btwn nbs and parents |
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Helpful responses
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*Supportive relationship
*Encouraging expression of emotions *Seeing and touching *Offering time alone |
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Decision making and grief
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*20 weeks is viability
*Autopsy *Organ donation usually not possible *Spiritual needs- also for yourself *Final dispostion of the body - private funerals -burial of ashes during acommunal burial |
