Post on 13-Dec-2014
description
Marcelo Q. Buenavista Jr.Marcelo Q. Buenavista Jr.
HIGH RISK NEWBORNHIGH RISK NEWBORN
High Risk NeonatesHigh Risk Neonates a newborn a newborn regardless of gestational age or birth regardless of gestational age or birth weight, who has a greater-than-average weight, who has a greater-than-average chance of morbidity or mortality because chance of morbidity or mortality because of conditions or circumstances of conditions or circumstances superimposed on the normal course of superimposed on the normal course of events associated with birth and the events associated with birth and the adjustment to extrauterine existence.adjustment to extrauterine existence.
HIGH RISK NEWBORNSHIGH RISK NEWBORNS
Encompasses human growth and development Encompasses human growth and development from the time of viability – 28 days following birth from the time of viability – 28 days following birth and includes threat to life and health that occur and includes threat to life and health that occur during the prenatal, perinatal, and postnatal during the prenatal, perinatal, and postnatal periods.periods.
Viability – gestational age at which survival Viability – gestational age at which survival outside the uterus is believed to be possible, or outside the uterus is believed to be possible, or as early as 23 weeks of gestation.as early as 23 weeks of gestation.
CLASSIFICATION OF HIGH-RISK CLASSIFICATION OF HIGH-RISK NEWBORNNEWBORN
Birth WeightBirth WeightGestational AgeGestational Age – preterm/post term – preterm/post termPredominant Physiologic FactorsPredominant Physiologic Factors – –
associated with state of maturity; chemical associated with state of maturity; chemical disturbances (hypoglycemia, disturbances (hypoglycemia, hypocalcemia); consequences of hypocalcemia); consequences of immature organ systems (hypothermia, immature organ systems (hypothermia, Respiratory Distress Syndrome, Respiratory Distress Syndrome,
CLASSIFICATION ACCORDING CLASSIFICATION ACCORDING TO SIZETO SIZE
Low Birth WeightLow Birth Weight – less than 2500g – less than 2500g regardless of gestational ageregardless of gestational age
Moderately Low Birth WeightModerately Low Birth Weight – birth – birth weight is between 1501g to 2500g.weight is between 1501g to 2500g.
Very Low Birth WeightVery Low Birth Weight – birth weight is – birth weight is less than 1500g.less than 1500g.
Extremely Low Birth WeightExtremely Low Birth Weight – birth weight – birth weight less than 1000g.less than 1000g.
CLASSIFICATION ACCORDING CLASSIFICATION ACCORDING TO SIZETO SIZE
Appropriate for Gestational Age (AGA)Appropriate for Gestational Age (AGA) – – birth weight falls between the 10birth weight falls between the 10thth and 90 and 90thth percentilepercentile
Small for Gestational Age (SGA)Small for Gestational Age (SGA) – birth – birth weight falls below the 10weight falls below the 10thth percentile percentile
Large for Gestational Age (LGA)Large for Gestational Age (LGA) – birth – birth weight falls above the 90weight falls above the 90thth percentile percentile
CLASSIFICATION ACCORDING CLASSIFICATION ACCORDING TO GESTATIONAL AGETO GESTATIONAL AGE
Premature InfantPremature Infant – born before the – born before the completion of 37 weeks of gestation, completion of 37 weeks of gestation, regardless of birth weightregardless of birth weight
Full-Term InfantFull-Term Infant – born between the – born between the beginning of the 38 weeks and the beginning of the 38 weeks and the completion of the 42 weeks of gestationcompletion of the 42 weeks of gestation
Postmature InfantPostmature Infant – born after 42 weeks of – born after 42 weeks of gestational age, regardless of birth weightgestational age, regardless of birth weight
PRETERM INFANTSPRETERM INFANTSAn infant born before term (</=36 weeks); An infant born before term (</=36 weeks);
premature or pretermpremature or pretermA low birth weight infant: </=1300-2000g A low birth weight infant: </=1300-2000g
(Philippine Standards) (,2.5kg)(Philippine Standards) (,2.5kg)Born before complete maturity; born Born before complete maturity; born
before body and organ system have before body and organ system have completely matured.completely matured.
PRETERM: refers to pregnancy (PT PRETERM: refers to pregnancy (PT labor); PREMATURE: to describe a babylabor); PREMATURE: to describe a baby
PRETERM INFANTSPRETERM INFANTS
INCIDENCE:INCIDENCE:Highest among low socio economic classHighest among low socio economic classLargest # of admission to NICULargest # of admission to NICU12% of all pregnancies12% of all pregnanciesMultiple pregnanciesMultiple pregnanciesPIHPIHPlacental problemsPlacental problems
PRETERM INFANTSPRETERM INFANTS
CAUSES:CAUSES:UNKNOWNUNKNOWNMATERNAL FACTORMATERNAL FACTOR
MalnutritionMalnutrition Preeclampsia (toxemia of pregnancy)Preeclampsia (toxemia of pregnancy) Chronic Medial illness (Cardiac/kidney disease/DM)Chronic Medial illness (Cardiac/kidney disease/DM) Infection (UTI, vaginal infection)Infection (UTI, vaginal infection) Drug Use (coccaine, tobacco, alcohol)Drug Use (coccaine, tobacco, alcohol) Abnormal structure of the uterusAbnormal structure of the uterus Previous PT BirthsPrevious PT Births
PRETERM INFANTSPRETERM INFANTSCAUSES:CAUSES:
PREGNANCYPREGNANCY HypertensionHypertension Incompetent CervixIncompetent Cervix Placental Previa/ Abruptio PlacentaPlacental Previa/ Abruptio Placenta PP.OM, poly/oligohydramniosPP.OM, poly/oligohydramnios
FETUSFETUS Chromosomal abnormalitiesChromosomal abnormalities Intrauterine InfectionIntrauterine Infection Anatomic AbnormalitiesAnatomic Abnormalities IUGR, multiple gestationsIUGR, multiple gestations
PRETERM INFANTSPRETERM INFANTSDIAGNOSTIC EVALUATION:DIAGNOSTIC EVALUATION:
Appraisal is made as soon as possible after Appraisal is made as soon as possible after admission to the nursery.admission to the nursery.
HEAD – head circumference is large in comparison HEAD – head circumference is large in comparison with chest (reflects cephalocaudal direction of growth)with chest (reflects cephalocaudal direction of growth)
The fontanels are small and bones are softThe fontanels are small and bones are soft Soft cranium subject to characteristic nonintentional Soft cranium subject to characteristic nonintentional
deformation, “preemie head”deformation, “preemie head”
Absent eyebrows, eyes closed, and ears are poorly Absent eyebrows, eyes closed, and ears are poorly supported by cartilage (soft and pliable)supported by cartilage (soft and pliable)
Bones of skull and ribs – softBones of skull and ribs – soft Very small and appear scrawny – less subcutaneous Very small and appear scrawny – less subcutaneous
fat (skin is wrinkled)fat (skin is wrinkled)
PRETERM INFANTSPRETERM INFANTS
DIAGNOSTIC EVALUATION:DIAGNOSTIC EVALUATION: SKIN – bright pink (often transluscent) with small SKIN – bright pink (often transluscent) with small
blood vesselsblood vessels Smooth and shiny (may be edematous) with small blood Smooth and shiny (may be edematous) with small blood
vessels clearly visible underneath thin epidermisvessels clearly visible underneath thin epidermis
Fine lanugo hair abundant over body, sparse, fine & Fine lanugo hair abundant over body, sparse, fine & fuzzy on headfuzzy on head
Soles and palms – minimal creasesSoles and palms – minimal creases Harlequin color – Skin color changes when preterm Harlequin color – Skin color changes when preterm
infant is moved; upper half or one side of the body is infant is moved; upper half or one side of the body is pale or one side of the body is red.pale or one side of the body is red.
Small breast bud size with underdeveloped nipplesSmall breast bud size with underdeveloped nipples Male Infants – few scrotal rugae, undescended testesMale Infants – few scrotal rugae, undescended testes
PRETERM INFANTSPRETERM INFANTSDIAGNOSTIC EVALUATION:DIAGNOSTIC EVALUATION:
Labia and clitoris are prominent in femalesLabia and clitoris are prominent in females Posture - complete relaxation with marked flexion and abduction Posture - complete relaxation with marked flexion and abduction
of the thighs; random movements are common with slightest of the thighs; random movements are common with slightest stimulusstimulus
Activity – Inactive and listlessActivity – Inactive and listless Extremities maintain an attitude of extension and remain in any Extremities maintain an attitude of extension and remain in any
position in which they are placed.position in which they are placed. Reflexes – partially developedReflexes – partially developed
Sucking absent, weak or ineffectual; swallow, gag, cough reflexes – Sucking absent, weak or ineffectual; swallow, gag, cough reflexes – ABSENTABSENT
Temperature instability – Heat regulation poorly developed in the Temperature instability – Heat regulation poorly developed in the preterm infant because of poor development of CNSpreterm infant because of poor development of CNS
Increased susceptibility to infectionIncreased susceptibility to infection
PRETERM INFANTSPRETERM INFANTSDIAGNOSTIC EVALUATION:DIAGNOSTIC EVALUATION:
Respirations are not efficient because of muscular weakness of Respirations are not efficient because of muscular weakness of lungs and rib cage and limited surfactant production;lungs and rib cage and limited surfactant production;
Retraction at xiphoid is evidence of air hungerRetraction at xiphoid is evidence of air hunger Infants should be stimulated if apnea occursInfants should be stimulated if apnea occurs HMD/RDS, chronic lung disease, BPD, apnea of prematurityHMD/RDS, chronic lung disease, BPD, apnea of prematurity
Greater tendency toward capillary fragility in the preterm infantGreater tendency toward capillary fragility in the preterm infant Red and white blood cell counts are low with resulting anemia Red and white blood cell counts are low with resulting anemia
during first few months of life.during first few months of life. Neuro – Higher incidence of intracranial hemorrhage in the Neuro – Higher incidence of intracranial hemorrhage in the
preterm infantpreterm infant Muscle twitching, convulsions, cyanosis, abnormal respirations, and Muscle twitching, convulsions, cyanosis, abnormal respirations, and
a short shrill crya short shrill cry Cerebral palsy, visual-motor deficits, altered intellectual functionsCerebral palsy, visual-motor deficits, altered intellectual functions
PRETERM INFANTSPRETERM INFANTSDIAGNOSTIC EVALUATION:DIAGNOSTIC EVALUATION:
GIT: Nutrition is difficult to maintain – because of weak sucking GIT: Nutrition is difficult to maintain – because of weak sucking and swallowing reflexes, small capacity of stomach, and slow and swallowing reflexes, small capacity of stomach, and slow emptying time of the stomachemptying time of the stomach
Renal: Reduced glomerular filtration rate results in decreased Renal: Reduced glomerular filtration rate results in decreased ability to concentrate urine and conserve fluid.ability to concentrate urine and conserve fluid.
Higher ECF – vulnerable to fluid and electrolyte imbalanceHigher ECF – vulnerable to fluid and electrolyte imbalance Cardio: (+) murmurCardio: (+) murmur More susceptible to biochemical alterations – hyperbilirubinemia, More susceptible to biochemical alterations – hyperbilirubinemia,
hypoglycemiahypoglycemia The greater degree of immaturity, the greater the degree of The greater degree of immaturity, the greater the degree of
potential disability.potential disability.
PRETERM INFANTSPRETERM INFANTSTHERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT:
Team approach: neonatologist, advance Team approach: neonatologist, advance practice nurse, nurse staff, respiratory practice nurse, nurse staff, respiratory therapisttherapist
Incubator, IV lines, Oxygen therapyIncubator, IV lines, Oxygen therapyPREVENTION:PREVENTION:
PRENATAL CARE: key factorPRENATAL CARE: key factorGood nutrition and educationGood nutrition and educationID mothers at riskID mothers at riskEducate on symptoms of PT laborEducate on symptoms of PT laborAvoid heavy/repetitive work or standing long Avoid heavy/repetitive work or standing long
periods of timeperiods of time
PRETERM INFANTSPRETERM INFANTS
THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT:TREATMENT:TREATMENT:
Oxygen, IVFOxygen, IVFUmbilical catheterization – IVF, meds, bld Umbilical catheterization – IVF, meds, bld
extractionextractionX-rayX-raySpecial feedings of breastmilk/formulaSpecial feedings of breastmilk/formulaMedicationsMedicationsKangaroo care – shorter stay in NICUKangaroo care – shorter stay in NICU
PRETERM INFANTSPRETERM INFANTSTHERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT:
DISCHARGE:DISCHARGE:Usually stay in hospital until reach pregnancy due Usually stay in hospital until reach pregnancy due
date depending on their conditiondate depending on their conditionGOALS:GOALS:
Serious illness resolvedSerious illness resolved Stable temperatureStable temperature Taking all feedings by breast/bottleTaking all feedings by breast/bottle No recent apnea/bradycardiaNo recent apnea/bradycardia Parents are able to provide care (meds and feedings)Parents are able to provide care (meds and feedings) Prior to discharge: eye examination, follow up visitsPrior to discharge: eye examination, follow up visits
PRETERM INFANTSPRETERM INFANTSNURSING CARE:NURSING CARE:
IMPLEMENTATION:IMPLEMENTATION: Maintain airway; check respirator function if employed; Maintain airway; check respirator function if employed;
position to promote ventilation; suction when necessary; position to promote ventilation; suction when necessary; maintain temperature of environment; administer oxygen only maintain temperature of environment; administer oxygen only if necessaryif necessary
Observe for changes in respirations, color, and vital signsObserve for changes in respirations, color, and vital signs Check efficacy of Isolette: maintain heat, humidity, and Check efficacy of Isolette: maintain heat, humidity, and
oxygen concentration; monitor oxygen carefully to prevent oxygen concentration; monitor oxygen carefully to prevent retrolental fibroplasiasretrolental fibroplasias
Maintain aseptic technique to prevent infectionMaintain aseptic technique to prevent infection Adhere to the techniques of gavages feeding for safety of the Adhere to the techniques of gavages feeding for safety of the
infantinfant
PRETERM INFANTSPRETERM INFANTSNURSING CARE:NURSING CARE:
IMPLEMENTATION:IMPLEMENTATION:Observe weight-gain patternsObserve weight-gain patternsDetermine blood gases frequently to prevent Determine blood gases frequently to prevent
acidosisacidosisInstitute phototherapy by letting them verbalize and Institute phototherapy by letting them verbalize and
ask questions to relieve anxietyask questions to relieve anxietyProvide flexible and liberal visiting hours for Provide flexible and liberal visiting hours for
parents as soon as possibleparents as soon as possibleAllow parents to do as much as possible for the Allow parents to do as much as possible for the
infant after appropriate teachinginfant after appropriate teachingArrange follow-up before and after discharge by a Arrange follow-up before and after discharge by a
visiting nurse or a Barangay Health Workervisiting nurse or a Barangay Health Worker
POST MATURE INFANTSPOST MATURE INFANTS
After 42 weeks AOG/ 294 days past 1After 42 weeks AOG/ 294 days past 1stst day of day of mother’s LMP; regardless of birth weightmother’s LMP; regardless of birth weight
Post term, post maturity, prolonged pregnancy, Post term, post maturity, prolonged pregnancy, post datismpost datism
INCIDENCE:INCIDENCE: 7% (3.5-15%) OF ALL PREGNANCIES7% (3.5-15%) OF ALL PREGNANCIES
CAUSES:CAUSES: unknown unknown History of >/= 1 previous post term pregnancies & History of >/= 1 previous post term pregnancies &
miscalculated due date (not sure of LMP)miscalculated due date (not sure of LMP)
POST MATURE INFANTSPOST MATURE INFANTSFETAL RISK:FETAL RISK:
Progressive placental dysfunction – placenta Progressive placental dysfunction – placenta (supplies nutrient & oxygen) ages toward the end of (supplies nutrient & oxygen) ages toward the end of pregnancy --- may not function efficientlypregnancy --- may not function efficiently
Amniotic fluid volume decreases, fetus may stop Amniotic fluid volume decreases, fetus may stop gaining weight/ weight lossgaining weight/ weight loss
Decreased amniotic fluid may lead to cord compression Decreased amniotic fluid may lead to cord compression during laborduring labor
Increased risk of MAS and hypoglycemiaIncreased risk of MAS and hypoglycemia Increasing size (mainly length) & hardening of skull Increasing size (mainly length) & hardening of skull
may contribute to CPDmay contribute to CPD GREATEST RISK: during stresses of labor & delivery GREATEST RISK: during stresses of labor & delivery
especially in infants of primigravidas.especially in infants of primigravidas.
POST MATURE INFANTSPOST MATURE INFANTSCHARACTERISTICS OF INFANTS (1-3wks of CHARACTERISTICS OF INFANTS (1-3wks of
AGE):AGE): Absent lanugo, little if any vernix caseosa, abundant Absent lanugo, little if any vernix caseosa, abundant
scalp hair, overgrown nailsscalp hair, overgrown nails Dry, peeling skin (cracked, parchmentlike & Dry, peeling skin (cracked, parchmentlike &
desquamating)desquamating) Wasted physical appearance (reflects intrauterine Wasted physical appearance (reflects intrauterine
deprivation)deprivation) Minimal fat deposit (depleted subcutaneous fat) – Minimal fat deposit (depleted subcutaneous fat) –
thin, elongated appearancethin, elongated appearance Meconium staining – seen in skin folds w/ vernix Meconium staining – seen in skin folds w/ vernix
caseosacaseosa Visible creases palms/ solesVisible creases palms/ soles
POST MATURE INFANTSPOST MATURE INFANTSDIAGNOSIS: P.EDIAGNOSIS: P.E
UTZ, non-stress testing, estimate amniotic fluid UTZ, non-stress testing, estimate amniotic fluid volumevolume
MANAGEMENT:MANAGEMENT: Check respiratory problems related to meconiumCheck respiratory problems related to meconium Blood test for hypoglycemiaBlood test for hypoglycemia PREVENTION: PREVENTION:
Accurate due date and UTZAccurate due date and UTZ
Cesarean section/ induction of labor - recommendedCesarean section/ induction of labor - recommended
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIA
Refers to excessive level of accumulated Refers to excessive level of accumulated Bilirubin in the bloodBilirubin in the blood
JAUNDICE or ICTERUS – yellowish JAUNDICE or ICTERUS – yellowish discoloration of skin, sclera, nailsdiscoloration of skin, sclera, nails
Relatively benign but it can also be Relatively benign but it can also be pathologicpathologic
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIA
PATHOPHYSIOLOGY:PATHOPHYSIOLOGY:
RBC DESTRUCTION
Globin Heme
Unconjugated Bilirubin
liver
Bilirubin detched from albumin through enzyme glucoronyl transferase + glucoronic acid
Conjugated Bilirubin
Excreted into Bile (feces and urine)
Protein (used by the body)
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIA
PATHOPHYSIOLOGY:PATHOPHYSIOLOGY:Result from increased unconjugated/ Result from increased unconjugated/
conjugated bilirubinconjugated bilirubinBilirubin – one of the breakdown products of Bilirubin – one of the breakdown products of
hgb from RBC destructionhgb from RBC destructionUnconjugated Bilirubin – insoluble, bound to Unconjugated Bilirubin – insoluble, bound to
albuminalbumin Intestines – (+) bacterial action – reduces Intestines – (+) bacterial action – reduces
conjugated bilirubinconjugated bilirubinUrobilinogen – pigment that gives stool its Urobilinogen – pigment that gives stool its
characteristic odor.characteristic odor.
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIACOMPARISON OF MAJOR TYPES OF COMPARISON OF MAJOR TYPES OF
UNCONJUGATED HYPERBILIRUBINEMIAUNCONJUGATED HYPERBILIRUBINEMIA
PHYSIOLOGIC PHYSIOLOGIC JAUNDICEJAUNDICE
BREAST-BREAST-FEEDING-FEEDING-
ASSOCIATED ASSOCIATED JAUNDICEJAUNDICE
(EARLY ONSET)(EARLY ONSET)
BREAST MILK BREAST MILK JAUNDICEJAUNDICE
(LATE ONSET)(LATE ONSET)
HEMOLYTIC HEMOLYTIC DISEASEDISEASE
CAUSE:CAUSE:
Immature hepatic Immature hepatic function + increased function + increased bilirubin load from bilirubin load from RBC hemolysisRBC hemolysis
Decreased milk Decreased milk intake related to intake related to fewer calories fewer calories consumed by infant consumed by infant before mother’s milk before mother’s milk is well established; is well established; enterohepatic enterohepatic shuntingshunting
Possible factors is Possible factors is breast milk that breast milk that prevent bilirubin prevent bilirubin conjugationconjugation
Less frequent Less frequent stoolingstooling
Blood antigen Blood antigen incompatibility incompatibility causes hemolysis of causes hemolysis of large # of RBCs.large # of RBCs.
Liver unable to Liver unable to conjugate & excrete conjugate & excrete excess bilirubin excess bilirubin from hemolysisfrom hemolysis
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIACOMPARISON OF MAJOR TYPES OF UNCONJUGATED COMPARISON OF MAJOR TYPES OF UNCONJUGATED
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIA
PHYSIOLOGIC PHYSIOLOGIC JAUNDICEJAUNDICE
BREAST-BREAST-FEEDING-FEEDING-
ASSOCIATED ASSOCIATED JAUNDICEJAUNDICE
(EARLY ONSET)(EARLY ONSET)
BREAST MILK BREAST MILK JAUNDICEJAUNDICE
(LATE ONSET)(LATE ONSET)
HEMOLYTIC HEMOLYTIC DISEASEDISEASE
ONSET:ONSET:
After 24 hours After 24 hours (preterm infants, (preterm infants, prolonged)prolonged)
22ndnd – 4 – 4thth day day 55thth – 7 – 7thth day day During 1During 1stst 24 hrs 24 hrs (levels increase (levels increase faster than faster than 5mg/ml/day)5mg/ml/day)
PEAK:PEAK:
75 – 90 hours75 – 90 hours 33rdrd – 5 – 5thth day day 1010thth – 15 – 15thth day day VariableVariable
DURATION:DURATION:
Declines on 5Declines on 5thth-7-7thth dayday
VariableVariable May remain May remain jaundiced x 3-12 jaundiced x 3-12 weeks or moreweeks or more
Dependent on Dependent on severity & severity & treatmenttreatment
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIACOMPARISON OF MAJOR TYPES OF UNCONJUGATED COMPARISON OF MAJOR TYPES OF UNCONJUGATED
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIA
PHYSIOLOGIC PHYSIOLOGIC JAUNDICEJAUNDICE
BREAST-BREAST-FEEDING-FEEDING-
ASSOCIATED ASSOCIATED JAUNDICEJAUNDICE
(EARLY ONSET)(EARLY ONSET)
BREAST MILK BREAST MILK JAUNDICEJAUNDICE
(LATE ONSET)(LATE ONSET)
HEMOLYTIC HEMOLYTIC DISEASEDISEASE
THERAPY:THERAPY:
Increase frequency Increase frequency of feedings & avoid of feedings & avoid supplements.supplements.
Evaluate stooling Evaluate stooling pattern.pattern.
Monitor Monitor Transcutaneous Transcutaneous Bilirubin (TcB)/ Bilirubin (TcB)/ Total Serum Total Serum Bilirubin (TSB)Bilirubin (TSB)
Frequent Frequent (10-12x/day) (10-12x/day) breastfeeding, avoid breastfeeding, avoid glucose water, glucose water, water supplements water supplements or formula.or formula.
Evaluate stooling Evaluate stooling pattern; stimulate as pattern; stimulate as needed.needed.
Increase frequency Increase frequency of breast feeding; of breast feeding; use no use no supplementations supplementations (glucose water); (glucose water); cessation of cessation of breastfeeding not breastfeeding not recommended.recommended.
Perform risk Perform risk assessment.assessment.
Monitor TcB/TSB Monitor TcB/TSB level.level.
Perform risk Perform risk assessmentassessment
POST NATALPOST NATAL – – phototherapy; phototherapy; administer IVIG per administer IVIG per protocol; if severe, protocol; if severe, perform exchange perform exchange transfusion.transfusion.
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIACOMPARISON OF MAJOR TYPES OF UNCONJUGATED COMPARISON OF MAJOR TYPES OF UNCONJUGATED
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIA
PHYSIOLOGIC PHYSIOLOGIC JAUNDICEJAUNDICE
BREAST-BREAST-FEEDING-FEEDING-
ASSOCIATED ASSOCIATED JAUNDICEJAUNDICE
(EARLY ONSET)(EARLY ONSET)
BREAST MILK BREAST MILK JAUNDICEJAUNDICE
(LATE ONSET)(LATE ONSET)
HEMOLYTIC HEMOLYTIC DISEASEDISEASE
THERAPY:THERAPY:
Perform risk Perform risk assessment.assessment.
Use phototherapy if Use phototherapy if bilirubin level bilirubin level increases increases significantly significantly (>5mg/dl/day) or (>5mg/dl/day) or significant significant hemolysis is hemolysis is present.present.
Use phototherapy if Use phototherapy if bilirubin level bilirubin level increases increases significantly (17-significantly (17-22mg/dl) or 22mg/dl) or significant significant hemolysis is hemolysis is present.present.
Consider Consider performing performing additional additional evaluations: G6PD, evaluations: G6PD, direct and indirect direct and indirect serum bilirubin, serum bilirubin, family history & family history & others as others as necessary.necessary.
PRENATAL PRENATAL – – transfusion (fetus)transfusion (fetus)
Prevent sensitization Prevent sensitization (Rh Incompatibility) (Rh Incompatibility) of Rh-negative of Rh-negative mother with Rhig mother with Rhig (Rhogam)(Rhogam)
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIACOMPARISON OF MAJOR TYPES OF UNCONJUGATED COMPARISON OF MAJOR TYPES OF UNCONJUGATED
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIA
BREAST-FEEDING-BREAST-FEEDING-ASSOCIATED JAUNDICEASSOCIATED JAUNDICE
(EARLY ONSET)(EARLY ONSET)
BREAST MILK BREAST MILK JAUNDICEJAUNDICE
(LATE ONSET)(LATE ONSET)
HEMOLYTIC DISEASEHEMOLYTIC DISEASE
THERAPY:THERAPY:
If phototherapy is instituted, If phototherapy is instituted, evaluate benefits & harm of evaluate benefits & harm of temporarily discontinuing temporarily discontinuing breastfeeding; additional breastfeeding; additional assessments may be required.assessments may be required.
Assist mother with maintaining Assist mother with maintaining milk supply, feed expressed milk milk supply, feed expressed milk as appropriate.as appropriate.
After discharge, follow up After discharge, follow up according to hour of discharge.according to hour of discharge.
May include home phototherapy May include home phototherapy with a temporary (10-12hr) with a temporary (10-12hr) discontinuation of a discontinuation of a breastfeeding; a subsequent breastfeeding; a subsequent TSB may be drawn to evaluate a TSB may be drawn to evaluate a drop in serum levels.drop in serum levels.
Assist mother with maintenance Assist mother with maintenance of milk supply & reassurance of milk supply & reassurance regarding her milk supply and regarding her milk supply and therapy.therapy.
Use formula supplements only at Use formula supplements only at practitioner’s discretion.practitioner’s discretion.
PRENATAL PRENATAL – If mother is – If mother is breastfeeding, assist with breastfeeding, assist with maintenance & storage of milk; maintenance & storage of milk; may bottle-feed expressed milk may bottle-feed expressed milk as appropriate to therapy.as appropriate to therapy.
Minimize maternal-infant Minimize maternal-infant separation & encourage separation & encourage contact as appropriate.contact as appropriate.
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIAPOSSIBLE CAUSES:POSSIBLE CAUSES:
PHYSIOLOGIC (DEVELOPMENTAL) PHYSIOLOGIC (DEVELOPMENTAL) FACTORS (PREMATURITY):FACTORS (PREMATURITY):Physiologic Jaundice / Icterus Neonatorum – most Physiologic Jaundice / Icterus Neonatorum – most
common cause; no pathologic processcommon cause; no pathologic process2 PHASES: term infants2 PHASES: term infants
11STST phase – Bilirubin: 6mg/dl on 3 phase – Bilirubin: 6mg/dl on 3rdrd DOL DOL decreased to 2-3mg/dl by 5decreased to 2-3mg/dl by 5thth day day
22ndnd phase – Steady plateau without phase – Steady plateau without increase/decrease level increase/decrease level 12 12thth-14-14thth day: levels day: levels decresed to normal (1mg/dl)decresed to normal (1mg/dl)
Pattern varies according to racial group, method of Pattern varies according to racial group, method of feeding, gestational agefeeding, gestational age
PRETERM: Bilirubin – 10-12mg/dl at 4-5days PRETERM: Bilirubin – 10-12mg/dl at 4-5days slowly decrease by 2-4 weeks.slowly decrease by 2-4 weeks.
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIAPOSSIBLE CAUSES:POSSIBLE CAUSES:
PHYSIOLOGIC (DEVELOPMENTAL) PHYSIOLOGIC (DEVELOPMENTAL) FACTORS (PREMATURITY):FACTORS (PREMATURITY):Mechanisms Involved:Mechanisms Involved:
NB produce 2x as much bilirubin as do adults due to NB produce 2x as much bilirubin as do adults due to higher concentrations of circulating RBC & shorter life higher concentrations of circulating RBC & shorter life span of RBC (70-90days)span of RBC (70-90days)
Liver’s ability to conjugate bilirubin reduced – due to Liver’s ability to conjugate bilirubin reduced – due to limited production of glucoronyl transferaselimited production of glucoronyl transferase
Lower plasma binding capacity for bilirubin because of Lower plasma binding capacity for bilirubin because of lower albumin concentrations than other children.lower albumin concentrations than other children.
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIA
POSSIBLE CAUSES:POSSIBLE CAUSES:PHYSIOLOGIC (DEVELOPMENTAL) PHYSIOLOGIC (DEVELOPMENTAL)
FACTORS (PREMATURITY):FACTORS (PREMATURITY):Primary Mechanism : enterohepatic Primary Mechanism : enterohepatic
circulation/shuntingcirculation/shunting Normally: Conjugated bilirubin Normally: Conjugated bilirubin urobilinogen (excreted) urobilinogen (excreted) Sterile & less motile NB bowel is less effective in Sterile & less motile NB bowel is less effective in
excreting urobilinogenexcreting urobilinogen Conjugated bilirubin Conjugated bilirubin thru B-glucoronidasethru B-glucoronidase
converted back to unconjugated bilirubin converted back to unconjugated bilirubin reabsorbed by intestinal mucosa reabsorbed by intestinal mucosa liver liver
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIAPOSSIBLE CAUSES:POSSIBLE CAUSES:
An association with breast feeding or breast milkAn association with breast feeding or breast milk BREASTFEEDING JAUNDICE – early onsetBREASTFEEDING JAUNDICE – early onset
Begins at 2-4days of age; 12-13% of Breastfeeding infantsBegins at 2-4days of age; 12-13% of Breastfeeding infants Related to process of breastfeeding, results from decreased Related to process of breastfeeding, results from decreased
caloric & fluid intake by Breastfeeding infants before milk supply caloric & fluid intake by Breastfeeding infants before milk supply is well-established (fasting is associated with decrease hepatic is well-established (fasting is associated with decrease hepatic clearance of bilirubin)clearance of bilirubin)
Feeding (+) peristalsis Feeding (+) peristalsis more rapid passage of meconium more rapid passage of meconium decreased amount of reabsorption of unconjugated decreased amount of reabsorption of unconjugated bilirubinbilirubin
Feeding introduces bacteria to aid in reduction of bilirubin Feeding introduces bacteria to aid in reduction of bilirubin to urobilinogento urobilinogen
Colostrums, natural cathartic, facilitates meconium Colostrums, natural cathartic, facilitates meconium evacuationevacuation
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIAPOSSIBLE CAUSES:POSSIBLE CAUSES:
An association with breast feeding or breast An association with breast feeding or breast milkmilkBREAST MILK JAUNDICE – late onsetBREAST MILK JAUNDICE – late onset
Onset: 4Onset: 4thth-7-7thth day of age; 12-13% of Breastfeeding day of age; 12-13% of Breastfeeding infantsinfants
Rising levels peak at 2Rising levels peak at 2ndnd week week gradually diminish gradually diminish May remain jaundiced x 3-12 weeks or more May remain jaundiced x 3-12 weeks or more infants infants
are wellare well May be caused by factors in BM (pregnanediol, fatty May be caused by factors in BM (pregnanediol, fatty
acids, B-glucorinidase) that either inhibit conjugation or acids, B-glucorinidase) that either inhibit conjugation or decrease excretion of bilirubindecrease excretion of bilirubin
Less frequent stooling by Breastfeeding infants may Less frequent stooling by Breastfeeding infants may allow for extended time for reabsorption of bilirubin from allow for extended time for reabsorption of bilirubin from stoolsstools
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIAPOSSIBLE CAUSES:POSSIBLE CAUSES:
Excess production of bilirubin – Hemolytic Excess production of bilirubin – Hemolytic disease, biochemical defects, bruisesdisease, biochemical defects, bruisesHemolytic disease – blood antigen incompatibility – Hemolytic disease – blood antigen incompatibility –
hemolysis of RBC ; liver unable to conjugate & hemolysis of RBC ; liver unable to conjugate & excrete excess bilirubin from hemolysisexcrete excess bilirubin from hemolysis
Onset: 1Onset: 1stst 24 hours (levels increase faster than 24 hours (levels increase faster than 5mg/dl/day)5mg/dl/day)
Treatment: Postnatal – phototherapy ; exchange Treatment: Postnatal – phototherapy ; exchange transfusion – severetransfusion – severe
Prenatal – transfusion (fetus) ; RhogamPrenatal – transfusion (fetus) ; Rhogam
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIA
POSSIBLE CAUSES:POSSIBLE CAUSES:Disturbed capacity of liver to secrete Disturbed capacity of liver to secrete
conjugated bilirubin – enzyme deficiency, bile conjugated bilirubin – enzyme deficiency, bile duct obstructionduct obstruction
Combined overproduction & undersecretion – Combined overproduction & undersecretion – sepsissepsis
Some disease states – hypothyroidism, Some disease states – hypothyroidism, galactosemia, infant of a diabetic mothergalactosemia, infant of a diabetic mother
Genetic predisposition to increase production Genetic predisposition to increase production – Native Americans, Asians – Native Americans, Asians
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIACLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS
Jaundice – most obvious signJaundice – most obvious signYellowish discoloration: sclera, nails, skinYellowish discoloration: sclera, nails, skinIf it appears within 1If it appears within 1stst 24 hours: hemolytic disease 24 hours: hemolytic disease
of Newborn, sepsis, maternally-derived diseases of Newborn, sepsis, maternally-derived diseases (DM, infections)(DM, infections)
Appears on 2Appears on 2ndnd or 3 or 3rdrd day, peaks on 3 day, peaks on 3rdrd – 4 – 4thth day, day, declines on 5declines on 5thth – 7 – 7thth day: physiologic jaundice day: physiologic jaundice (varies according to ethnicity)(varies according to ethnicity)
Intensity of jaundice is not always related to Intensity of jaundice is not always related to the degree of hyperbilirubinemiathe degree of hyperbilirubinemia
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIADIAGNOSTIC EVALUATIONDIAGNOSTIC EVALUATION
Serum Bilirubin (B1: 0.2-1.4mg/dl)Serum Bilirubin (B1: 0.2-1.4mg/dl) Jaundice appears at >5mg/dlJaundice appears at >5mg/dl Evaluation based on:Evaluation based on:
Timing of appearance of clinical jaundiceTiming of appearance of clinical jaundice Gestational age at birthGestational age at birth Age in days since birthAge in days since birth Family history including maternal Rh factorFamily history including maternal Rh factor Evidence of hemolysisEvidence of hemolysis Feeding methodFeeding method Infant’s physiologic statusInfant’s physiologic status Progression of serum bilirubin levelsProgression of serum bilirubin levels
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIADIAGNOSTIC EVALUATIONDIAGNOSTIC EVALUATION
Indicators of physiologic jaundice – warrants further Indicators of physiologic jaundice – warrants further investigation as to the cause of jaundiceinvestigation as to the cause of jaundice
Clinical jaundice within 24 hrs. of birthClinical jaundice within 24 hrs. of birth Persistent jaundice over 2 weeks in full-term, formula fed Persistent jaundice over 2 weeks in full-term, formula fed
infantinfant Total serum bilirubin levels 12.9mg/dl (term infant) or over Total serum bilirubin levels 12.9mg/dl (term infant) or over
15mg/dl (preterm); upper limit for breastfeeding infant – 15mg/dl (preterm); upper limit for breastfeeding infant – 15mg/dl15mg/dl
Increase serum bilirubin >5mg/dl/dayIncrease serum bilirubin >5mg/dl/day Direct bilirubin (B2) 1.5-2mg/dlDirect bilirubin (B2) 1.5-2mg/dl Total serum Bilirubin – over 95Total serum Bilirubin – over 95thth percentile for age (in hours) percentile for age (in hours)
on hour-specific risk nomogramon hour-specific risk nomogram
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIADIAGNOSTIC EVALUATIONDIAGNOSTIC EVALUATION
Transcutaneous Bilirubinometry – noninvasive Transcutaneous Bilirubinometry – noninvasive monitoring of bilirubin via cutaneous monitoring of bilirubin via cutaneous reflectance mechanisms; allow for repetetive reflectance mechanisms; allow for repetetive estimations of bilirubinestimations of bilirubin
Hour-specific Serum Bilirubin Levels – predict Hour-specific Serum Bilirubin Levels – predict newborn at risk for rapidly rising levelsnewborn at risk for rapidly rising levelsRecommended by AAP for monitoring healthy Recommended by AAP for monitoring healthy
Newborn >35wks AOG before discharge from Newborn >35wks AOG before discharge from hospitalhospital
Carbon monoxide indices in exhaled breath – Carbon monoxide indices in exhaled breath – CO is produced when RBC is broken downCO is produced when RBC is broken down
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIACOMPLICATIONSCOMPLICATIONS
BILIRUBIN ENCEPHALOPATHY/ BILIRUBIN ENCEPHALOPATHY/ KERNICTERUS – unconjugated bilirubin KERNICTERUS – unconjugated bilirubin highly toxic to the neuronshighly toxic to the neuronsSyndrome of severe brain damage due to Syndrome of severe brain damage due to
deposition of unconjugated bilirubin in brain cells deposition of unconjugated bilirubin in brain cells (extremely high B1 level increase crosses the (extremely high B1 level increase crosses the blood-brain barrier)blood-brain barrier)
KERNICTERUS – yellow staining of brain KERNICTERUS – yellow staining of brain cells that may result in bilirubin cells that may result in bilirubin encephalopathyencephalopathy
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIACOMPLICATIONSCOMPLICATIONS
FACTORS THAT CONTRIBUTE TO FACTORS THAT CONTRIBUTE TO BILIRUBIN NEUROTOXICITY:BILIRUBIN NEUROTOXICITY:Serum bilirubin alone do not predict the risk of Serum bilirubin alone do not predict the risk of
brain injurybrain injuryMetabolic acidosisMetabolic acidosisLow serum albumin levelLow serum albumin levelIntracranial infections (meningitis)Intracranial infections (meningitis)Abrupt increase in BPAbrupt increase in BPConditions that increase metabolic demands for Conditions that increase metabolic demands for
oxygen and glucose – fetal distress, hypoxia, oxygen and glucose – fetal distress, hypoxia, hypothermia, hypoglycemiahypothermia, hypoglycemia
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIACOMPLICATIONSCOMPLICATIONS
SIGNS OF CNS DEPRESSION/ SIGNS OF CNS DEPRESSION/ EXCITATION:EXCITATION:Prodrome: decreased activity, lethargy, irritability, Prodrome: decreased activity, lethargy, irritability,
hypotonia, seizureshypotonia, seizuresAthetoid CP, mental retardation, deafnessAthetoid CP, mental retardation, deafnessThose who survived: NEUROLOGIC DAMAGEThose who survived: NEUROLOGIC DAMAGE
Mental retardation, ADHD, delayed/ abnormal motor Mental retardation, ADHD, delayed/ abnormal motor movements (ataxia, athetosis), behavior disorders, movements (ataxia, athetosis), behavior disorders, perceptual problems, sensorineural hearing lossperceptual problems, sensorineural hearing loss
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIATHERAPEUTIC MANAGEMENTTHERAPEUTIC MANAGEMENT
Phototherapy – main formPhototherapy – main form Exchange transfusion – reduce high bilirubin levels Exchange transfusion – reduce high bilirubin levels
that occur with hemolytic diseasethat occur with hemolytic disease Phenobarbital – hemolytic disease; effective when Phenobarbital – hemolytic disease; effective when
given to mother several days before deliverygiven to mother several days before delivery Promotes hepatic glucoronyl transferase synthesis Promotes hepatic glucoronyl transferase synthesis
increases bilirubin conjugation & hepatic clearance of increases bilirubin conjugation & hepatic clearance of pigment in bilepigment in bile
Promotes protein synthesis – increase albumin for more Promotes protein synthesis – increase albumin for more bilirubin binding sitesbilirubin binding sites
Heme-oxygenase inhibitors – decrease bilirubin Heme-oxygenase inhibitors – decrease bilirubin productionproduction
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIA
THERAPEUTIC MANAGEMENTTHERAPEUTIC MANAGEMENTEarly initiation of feedings & frequent Early initiation of feedings & frequent
breastfeeding – promotes increased intestinal breastfeeding – promotes increased intestinal motility, decreases enterohepatic shunting, motility, decreases enterohepatic shunting, establish normal bacterial flora in the bowel establish normal bacterial flora in the bowel excrete B2excrete B2Frequent breastfeeding every 2 hrsFrequent breastfeeding every 2 hrsAvoid glucose water, formula or water Avoid glucose water, formula or water
supplementationsupplementation
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIATHERAPEUTIC MANAGEMENTTHERAPEUTIC MANAGEMENT
Phototherapy – application of fluorescent light Phototherapy – application of fluorescent light (bili light) to infant’s exposed skin(bili light) to infant’s exposed skinLight Light promotes bilirubin excretion by promotes bilirubin excretion by
photoisomerizationphotoisomerization (alters structure of bilirubin to a (alters structure of bilirubin to a soluble form – soluble form – lumirubinlumirubin) for easier excretion) for easier excretion
Blue Light – more effective in reducing bilirubin but Blue Light – more effective in reducing bilirubin but alters the color of the infantalters the color of the infant
Fluorescent bulbs with spectrum 420-460nm Fluorescent bulbs with spectrum 420-460nm preferredpreferred
Infant skin is fully exposedInfant skin is fully exposed
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIATHERAPEUTIC MANAGEMENTTHERAPEUTIC MANAGEMENT
Phototherapy – application of fluorescent light (bili light) to Phototherapy – application of fluorescent light (bili light) to infant’s exposed skininfant’s exposed skin
Rapidly rising bilirubin/ critical level – double intensive phototherapyRapidly rising bilirubin/ critical level – double intensive phototherapy Conventional overhead lamps while infant is lying on fiber optic blanketConventional overhead lamps while infant is lying on fiber optic blanket BEST RESULT: occur within 1BEST RESULT: occur within 1stst 24-48hrs of treatment 24-48hrs of treatment
Fiberoptic blanket/panelFiberoptic blanket/panel – light generating illuminator – light generating illuminator blanket delivers therapeutic light consistently & continuously to infant & blanket delivers therapeutic light consistently & continuously to infant &
achieve same photoisomerization as conventional phototherapyachieve same photoisomerization as conventional phototherapy For home phototherapy, permits more infant-parent interaction, better For home phototherapy, permits more infant-parent interaction, better
temperature controltemperature control Eliminates the need for eye patchesEliminates the need for eye patches SPECIAL CAUTION: plastic pad must completely be covered to SPECIAL CAUTION: plastic pad must completely be covered to
prevent exposing fragile skin of extremely immature/compromised prevent exposing fragile skin of extremely immature/compromised infant to fiberoptic blanket (dermal injury)infant to fiberoptic blanket (dermal injury)
When blood is drawn, phototherapy lights are turned off, blood is When blood is drawn, phototherapy lights are turned off, blood is transported in covered tube to avoid false reading as a result of transported in covered tube to avoid false reading as a result of bilirubin destruction in test tube.bilirubin destruction in test tube.
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIAMANAGEMENT OF HYPERBILIRUBINEMIA IN HEALTHY TERM MANAGEMENT OF HYPERBILIRUBINEMIA IN HEALTHY TERM
NEWBORNNEWBORNTSB LEVEL (mg/dl/mmol/L)TSB LEVEL (mg/dl/mmol/L)
AGE AGE (HOURS)(HOURS)
CONSIDER CONSIDER PHOTOTHERAPYPHOTOTHERAPY
PHOTOTHERAPYPHOTOTHERAPY EXCHANGE EXCHANGE TRANSFUSION IF TRANSFUSION IF
INTENSIVE INTENSIVE PHOTOTHERAPY PHOTOTHERAPY
FAILSFAILS
EXCHANGE EXCHANGE TRANSFUSION TRANSFUSION AND INTENSIVE AND INTENSIVE
PHOTOTHERAPYPHOTOTHERAPY
2424 ------ ------ ------ ------
25-4825-48 >/= 12 (170)>/= 12 (170) >/= 15 (260)>/= 15 (260) >/= 20 (340)>/= 20 (340) >/= 25 (430)>/= 25 (430)
48-7248-72 >/= 15 (260)>/= 15 (260) >/= 18 (310)>/= 18 (310) >/= 25 (430)>/= 25 (430) >/= 30 (510)>/= 30 (510)
>72>72 >/= 17 (290)>/= 17 (290) >/= 20 (340)>/= 20 (340) >/= 25 (430)>/= 25 (430) >/= 30 (510)>/= 30 (510)
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIA
PROGNOSIS:PROGNOSIS:Early recognition prevents brain damageEarly recognition prevents brain damageBilirubin encephalopathy: athetosis, Bilirubin encephalopathy: athetosis,
sensorineural hearing loss, paralytic gaze sensorineural hearing loss, paralytic gaze palsy, gaze abnormalities, delayed motor palsy, gaze abnormalities, delayed motor skills, dental enamel hypoplasiaskills, dental enamel hypoplasia
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIANURSING CONSIDERATIONSNURSING CONSIDERATIONS
ASSESSMENTASSESSMENTObserve for evidence of jaundice at regular Observe for evidence of jaundice at regular
intervalsintervals Observe color from head-toe, color of sclera & mucous Observe color from head-toe, color of sclera & mucous
membranesmembranes Apply direct pressure to skin especially bony Apply direct pressure to skin especially bony
prominences (tip of nose or sternum) prominences (tip of nose or sternum) blanching blanching allow yellow stain to be more pronouncedallow yellow stain to be more pronounced
Dark-skinned – color of sclera, conjunctiva, oral mucosaDark-skinned – color of sclera, conjunctiva, oral mucosa Observe natural daylightObserve natural daylight
Evidence of jaundice that appears before infant is Evidence of jaundice that appears before infant is 24 hrs of age – indication for assessing bilirubin 24 hrs of age – indication for assessing bilirubin levelslevels
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIA
NURSING CONSIDERATIONSNURSING CONSIDERATIONSPhototherapy – nude under light source, Phototherapy – nude under light source,
repositioned frequently to expose all body surface repositioned frequently to expose all body surface areas to lightareas to light
Frequent bilirubin determination – every 6-12hrs (visual Frequent bilirubin determination – every 6-12hrs (visual assessment is no longer considered valid)assessment is no longer considered valid)
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIANURSING CONSIDERATIONSNURSING CONSIDERATIONS
PHOTOTHERAPY:PHOTOTHERAPY: PRECAUTIONS: PRECAUTIONS:
Eye Shield – opaque mask to prevent exposure to lightEye Shield – opaque mask to prevent exposure to light Properly sized, correctly positioned without occluding the naresProperly sized, correctly positioned without occluding the nares Infant’s eyelids are closed before mask is applied, corneas may Infant’s eyelids are closed before mask is applied, corneas may
become excoriatedbecome excoriated Eyes checked every shift for discharge, excessive pressure on lids, Eyes checked every shift for discharge, excessive pressure on lids,
corneal irritationcorneal irritation Removed during feedingsRemoved during feedings
Infants in open crib must have a protective plexiglass shield Infants in open crib must have a protective plexiglass shield between them & fluorescent lights to minimize amount of between them & fluorescent lights to minimize amount of undesirable UV lights reaching skin & protect them from undesirable UV lights reaching skin & protect them from accidental bulb breakageaccidental bulb breakage
Temperature monitoredTemperature monitored Maintain in flexed position w/ rolled blankets alongside bodyMaintain in flexed position w/ rolled blankets alongside body
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIANURSING CONSIDERATIONSNURSING CONSIDERATIONS
PHOTOTHERAPY:PHOTOTHERAPY:ACCURATE CHARTING:ACCURATE CHARTING:
Times that phototherapy is started and stoppedTimes that phototherapy is started and stopped Proper shielding of the eyesProper shielding of the eyes Type of fluorescent lampType of fluorescent lamp Number of lampsNumber of lamps Distance between surface of lamps & infant (not <18 in)Distance between surface of lamps & infant (not <18 in) Use of phototherapy in combination with an incubator or Use of phototherapy in combination with an incubator or
open bassinetopen bassinet Photometer measurement of light intensityPhotometer measurement of light intensity Occurrence of side effectsOccurrence of side effects
Side effects: loose greenish stools transient skin Side effects: loose greenish stools transient skin rashes, hypothermia, Increase BMR, DHN, rashes, hypothermia, Increase BMR, DHN, electrolyte imbalance (hypocalcemia), priapismelectrolyte imbalance (hypocalcemia), priapism
HYPERBILIRUBINEMIAHYPERBILIRUBINEMIANURSING CONSIDERATIONSNURSING CONSIDERATIONS
PHOTOTHERAPY:PHOTOTHERAPY: Informed consent prior to treatmentInformed consent prior to treatment Oily lubricants/lotions not used – “frying effect”Oily lubricants/lotions not used – “frying effect” Full-term newborn – additional fluid volume to compensate Full-term newborn – additional fluid volume to compensate
for fluid lossfor fluid loss Meticulous skin careMeticulous skin care Rebound effect – after phototherapy is permanently Rebound effect – after phototherapy is permanently
discontinued discontinued subsequent increase in serum bilirubin level; subsequent increase in serum bilirubin level; transienttransient
““Bronze Baby Syndrome” – serum, urine, skin turn grayish Bronze Baby Syndrome” – serum, urine, skin turn grayish brown hours after infant is placed under lightbrown hours after infant is placed under light
Due to retention of bilirubin breakdown product of phototherapy Due to retention of bilirubin breakdown product of phototherapy (copper prophyrin)(copper prophyrin)
Infants with elevated B2 level & some degree of cholestasisInfants with elevated B2 level & some degree of cholestasis Resolves after discontinuation of phototherapyResolves after discontinuation of phototherapy
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
Condition of surfactant deficiency & physiologic immaturity of thoraxCondition of surfactant deficiency & physiologic immaturity of thorax Seen almost exclusively in preterm infants; seen in infants <32 wks Seen almost exclusively in preterm infants; seen in infants <32 wks
AOGAOG A disease related to developmental delay in lung maturation A disease related to developmental delay in lung maturation Also associated with multifetal pregnancies, infants of diabetic Also associated with multifetal pregnancies, infants of diabetic
mothers, Caesarean Section delivery, delivery before 37 weeks mothers, Caesarean Section delivery, delivery before 37 weeks AOG, low birth weight, precipitous delivery, cold stress, asphyxia, AOG, low birth weight, precipitous delivery, cold stress, asphyxia, history of previous RDShistory of previous RDS
Rare in drug-exposed infants or those who have been exposed to Rare in drug-exposed infants or those who have been exposed to chronic intrauterine stress (HPN, preeclampsia)chronic intrauterine stress (HPN, preeclampsia)
RDS of nonpulmonary origin in Newborn: sepsis, cardiac defects, RDS of nonpulmonary origin in Newborn: sepsis, cardiac defects, exposure to cold, airway obstruction, IVH, hypoglycemia, metabolic exposure to cold, airway obstruction, IVH, hypoglycemia, metabolic acidosis, acute blood loss, drugs.acidosis, acute blood loss, drugs.
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
PATHOPHYSIOLOGYPATHOPHYSIOLOGYDeficient Surfactant
Collapse of Alveoli
Great deal of effort to reexpand the alveoli with each breath
Exhaustion
Fewer and fewer alveoli opens
Atelectasis
Hypoperfusion to the lung tissue
Hypoxemia and hypercapnia
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
PATHOPHYSIOLOGYPATHOPHYSIOLOGYPreterm – born before lungs are fully Preterm – born before lungs are fully
prepared for gas exchange (critical factor in prepared for gas exchange (critical factor in RDS)RDS)
Combination of structural and functional Combination of structural and functional immaturity of lungsimmaturity of lungs
(+) fetal respiratory activity before birth: lungs (+) fetal respiratory activity before birth: lungs have feeble respiratory movements, fluid have feeble respiratory movements, fluid excreted thru alveoliexcreted thru alveoli
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
PATHOPHYSIOLOGYPATHOPHYSIOLOGYFinal unfolding of alveolar septa (increase Final unfolding of alveolar septa (increase
surface area of the lungs) occurs on last surface area of the lungs) occurs on last trimester of pregnancytrimester of pregnancyPreterms are born with underdeveloped and uninflatable alveoli
Limited pulmonary blood flow
Collapsed lungs
Increased pulmonary vascular resistance
Fetal blood shunted from lungs by ductus arteriosus and foramen ovale
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
PATHOPHYSIOLOGYPATHOPHYSIOLOGY Rib Cage: weak and compliantRib Cage: weak and compliant
Fetal chest highly compliant because of predominance of Fetal chest highly compliant because of predominance of cartilage; diaphragm is prone to fatiguecartilage; diaphragm is prone to fatigue
Fetal Lungs deficient in surfactant due to immaturity Fetal Lungs deficient in surfactant due to immaturity of surfactant producing type 2 alveolar cellsof surfactant producing type 2 alveolar cells
Surfactant – 1Surfactant – 1stst produced at 24 wks AOG, type 2 cells do not produced at 24 wks AOG, type 2 cells do not fully mature until about 36 wks AOGfully mature until about 36 wks AOG
Reduces surface tension of fluids that line the alveoli & Reduces surface tension of fluids that line the alveoli & respiratory passages respiratory passages uniform expansion and maintains lung uniform expansion and maintains lung expansionexpansion
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
PATHOPHYSIOLOGYPATHOPHYSIOLOGYDeficient surfactant – unequal inflation of alveoli on Deficient surfactant – unequal inflation of alveoli on
inspiration, collapse of alveoli of end expirationinspiration, collapse of alveoli of end expiration Without surfactant – infants unable to keep lungs Without surfactant – infants unable to keep lungs
inflated, exerts great effort to reexpand the alveoli inflated, exerts great effort to reexpand the alveoli exhaustion exhaustion atelectasis atelectasis
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
PATHOPHYSIOLOGYPATHOPHYSIOLOGYInadequate pulmonary perfusion and ventilation
Hypoxemia and hypercapnia
Markedly reactive pulmonary arterioles and thickMuscular layer decreased oxygen concentration
Decreased oxygen tension + decreased blood pH
Vasospasm in pulmonary arterioles
Increased PVR
Intrapulmonary shunting
Anaerobic glycolysis
Metabolic acidosis, cyanosis
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
PATHOPHYSIOLOGYPATHOPHYSIOLOGY (+) pulmonary edema – impaired gas exchange(+) pulmonary edema – impaired gas exchange (+) pulmonary interstitial emphysema – (+) pulmonary interstitial emphysema –
overdistention of distal airwaysoverdistention of distal airways
MAJOR FACTORS IN RDSMAJOR FACTORS IN RDS
CAUSECAUSE EFFECTEFFECT
Increased surface tension of alveoli Increased surface tension of alveoli (surfactant deficiency)(surfactant deficiency)
Alveolar collapse, atelectasis, increased Alveolar collapse, atelectasis, increased difficulty in breathingdifficulty in breathing
Impaired gas exchangeImpaired gas exchange Hypoxemia, and hypercapnia with Hypoxemia, and hypercapnia with respiratory acidosisrespiratory acidosis
Increased pulmonary vascular resistanceIncreased pulmonary vascular resistance Hypoperfusion of pulmonary circulationHypoperfusion of pulmonary circulation
Hypoperfusion (with hypoxemia)Hypoperfusion (with hypoxemia) Tissue hypoxia & metabolic acidosisTissue hypoxia & metabolic acidosis
Increased transudation of fluid into lungsIncreased transudation of fluid into lungs Hyaline membrane formation; impaired gas Hyaline membrane formation; impaired gas exchangeexchange
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
CLINICAL MANIFESTATIONS:CLINICAL MANIFESTATIONS: Respiratory Signs and Symptoms:Respiratory Signs and Symptoms:
Tachypnea (80-120/min) initially : dyspneaTachypnea (80-120/min) initially : dyspnea Pronounced intercostals and/or substernal retractionsPronounced intercostals and/or substernal retractions Fine inspiratory crackles ; audible expiratory gruntFine inspiratory crackles ; audible expiratory grunt Flaring of external naresFlaring of external nares Cyanosis / pallorCyanosis / pallor
As disease progressesAs disease progresses Apnea ; flaccidity ; absent spontaneous movementApnea ; flaccidity ; absent spontaneous movement Unresponsive ; diminished breath sounds ; mottlingUnresponsive ; diminished breath sounds ; mottling
Severe disease: shock-like stateSevere disease: shock-like state Decreased cardiac output and bradycardiaDecreased cardiac output and bradycardia Low systemic BPLow systemic BP
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
EVALUATION:EVALUATION:Blood glucose testBlood glucose testChest x-ray with fine, diffuse, recticogranular Chest x-ray with fine, diffuse, recticogranular
or “ground glass appearance and air or “ground glass appearance and air bronchogrambronchogram
Arterial blood gas (ABGs) ; pulse oximetry Arterial blood gas (ABGs) ; pulse oximetry and carbon dioxide monitoring, pulmonary and carbon dioxide monitoring, pulmonary function testsfunction tests
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
EVALUATION:EVALUATION: Prenatal diagnosis:Prenatal diagnosis:
Problems like maternal diabetes – delay fetal lung maturationProblems like maternal diabetes – delay fetal lung maturation Antenatal administration of glucocorticoids – enhance fetal lung Antenatal administration of glucocorticoids – enhance fetal lung
maturationmaturation Lecithin / sphingomyelin ratio (L:S ratio) : relationship Lecithin / sphingomyelin ratio (L:S ratio) : relationship
between these 2 lipids during gestationbetween these 2 lipids during gestation L:S = 2:1L:S = 2:1
““Shake/ bubble test” – stable foam bubbles form when Shake/ bubble test” – stable foam bubbles form when amniotic fluid is shaken in presence of ethanolamniotic fluid is shaken in presence of ethanol
Tap Test – abundant bubbles appear in test tube of amniotic Tap Test – abundant bubbles appear in test tube of amniotic fluid with 6N – HCL and diethyl etherfluid with 6N – HCL and diethyl ether
TDx fetal lung maturity assay TDx fetal lung maturity assay
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT: Immediate establishment of adequate oxygen and ventilation Immediate establishment of adequate oxygen and ventilation
and supportive measures required for a preterm, prevent further and supportive measures required for a preterm, prevent further complicationscomplications
SUPPORTIVE MEASURES:SUPPORTIVE MEASURES: Maintain adequate ventilation and oxygenMaintain adequate ventilation and oxygen Maintain acid-base balanceMaintain acid-base balance Maintain neutral thermal environmentMaintain neutral thermal environment Maintain adequate tissue perfusion and oxygenMaintain adequate tissue perfusion and oxygen Prevent hypotensionPrevent hypotension Maintain adequate hydration and electrolyte statusMaintain adequate hydration and electrolyte status
NUTRITION: parenteral therapy during 1NUTRITION: parenteral therapy during 1stst phase of disease phase of disease Nipple and gavage feedings are contraindicated – causes increase Nipple and gavage feedings are contraindicated – causes increase
RR, prone to aspirationRR, prone to aspiration Enteral substrate to infant with transient hypoxia – increase risk Enteral substrate to infant with transient hypoxia – increase risk
Necrotizing EnterocolitisNecrotizing Enterocolitis
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT: EXOGENOUS SURFACTANT REPLACEMENT (via ET Tube)EXOGENOUS SURFACTANT REPLACEMENT (via ET Tube)
Decrease oxygen requirements and mean airway pressure (MAP)Decrease oxygen requirements and mean airway pressure (MAP) Improves blood gas values & ventilator settingsImproves blood gas values & ventilator settings Decrease incidence of pulmonary air leaksDecrease incidence of pulmonary air leaks Decrease deaths from RDSDecrease deaths from RDS Decrease mortality rateDecrease mortality rate COMPLICATIONS: pulmonary hemorrhage, mucous pluggingCOMPLICATIONS: pulmonary hemorrhage, mucous plugging Given at birth via endotracheal (ET) tube directly into infants tracheaGiven at birth via endotracheal (ET) tube directly into infants trachea NURSING RESPONSIBILITIES:NURSING RESPONSIBILITIES:
Assist in delivery of the product, collection, and monitoring of ABG’s, Assist in delivery of the product, collection, and monitoring of ABG’s, scrupulous monitoring of oxygen with pulse oximetryscrupulous monitoring of oxygen with pulse oximetry
Assess infant’s tolerance of procedureAssess infant’s tolerance of procedure Delay suctioning for an hour or so to allow maximum effects to occurDelay suctioning for an hour or so to allow maximum effects to occur
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT: OXYGEN THERAPYOXYGEN THERAPY
Aggressive respiratory support: Oxygen, continuous positive Aggressive respiratory support: Oxygen, continuous positive airway pressure (CPAP), intubation, mechanical ventilationairway pressure (CPAP), intubation, mechanical ventilation
Goals of Oxygen therapy: provide adequate oxygen to Goals of Oxygen therapy: provide adequate oxygen to tissuestissues
Prevent lactic acidosis resulting from hypoxiaPrevent lactic acidosis resulting from hypoxia Avoid negative effects of oxygen barotrauma / toxicityAvoid negative effects of oxygen barotrauma / toxicity
Gas should be warmed before entering respiratory tractGas should be warmed before entering respiratory tract Oxygen can be supplied via plastic hoodOxygen can be supplied via plastic hood If oxygen saturation of blood cannot be maintained at If oxygen saturation of blood cannot be maintained at
satisfactory level and PaO2 rises satisfactory level and PaO2 rises ventilatory assistance ventilatory assistance
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT:
METHODMETHOD DESCRIPTIONDESCRIPTION HOW PROVIDEDHOW PROVIDED
CONVENTIONAL CONVENTIONAL METHODSMETHODS
Continuous Positive Airway Continuous Positive Airway Pressure (CPAP)Pressure (CPAP)
Provides contrast distending Provides contrast distending pressure to airway in pressure to airway in spontaneously breathing spontaneously breathing infant.infant.
Nasal prongs, endotracheal Nasal prongs, endotracheal tube, face mask, nasal tube, face mask, nasal cannulacannula
Positive End-Expiratory Positive End-Expiratory Pressure (PEEP)Pressure (PEEP)
Provides increase end-Provides increase end-expiratory pressure during expiratory pressure during expiration and between expiration and between Mandatory breaths which Mandatory breaths which prevents alveolar collapse; prevents alveolar collapse; maintains residual airway maintains residual airway pressurepressure
Endotracheal intubation, and Endotracheal intubation, and either volume-limited or either volume-limited or pressure-limited ventilatorpressure-limited ventilator
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT:METHODMETHOD DESCRIPTIONDESCRIPTION HOW PROVIDEDHOW PROVIDED
Intermittent Mandatory Intermittent Mandatory Ventilation (IMV)Ventilation (IMV)
Allows infant to breath Allows infant to breath spontaneously at own rate but spontaneously at own rate but provides mechanical cycled provides mechanical cycled respirations and pressure at respirations and pressure at regular preset intervalsregular preset intervals
Endotracheal Endotracheal intubation and intubation and ventilatorventilator
Synchronized Intermittent Synchronized Intermittent Mandatory Ventilation Mandatory Ventilation (SIMV)(SIMV)
Mechanically delivered breaths Mechanically delivered breaths are synchronized to the onset of are synchronized to the onset of spontaneous patient breaths; spontaneous patient breaths; assist/control mode facilities full assist/control mode facilities full inspiratory synchrony; involves inspiratory synchrony; involves signal detection of onset of signal detection of onset of spontaneous respiration from spontaneous respiration from abdominal movement, thoracic abdominal movement, thoracic impedance, airway pressure, or impedance, airway pressure, or flow changesflow changes
Patient-triggered infant Patient-triggered infant ventilator with signal ventilator with signal detector and detector and assist/control mode; assist/control mode; endotracheal tubeendotracheal tube
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT:
METHODMETHOD DESCRIPTIONDESCRIPTION HOW PROVIDEDHOW PROVIDED
Volume Guarantee Volume Guarantee VentilationVentilation
Delivers predetermined volume Delivers predetermined volume of gas using an inspiratory of gas using an inspiratory pressure that varies according pressure that varies according to infant’s lung compliance to infant’s lung compliance (often used in conjunction with (often used in conjunction with SIMV)SIMV)
Volume guarantee Volume guarantee ventilator with flow ventilator with flow sensor; endotracheal sensor; endotracheal tubetube
ALTERNATIVE ALTERNATIVE METHODSMETHODS
High frequency Oscillation High frequency Oscillation (HFO)(HFO)
Application of high-frequency, Application of high-frequency, low-volume, sine wave flow low-volume, sine wave flow oscillations to airway at rates oscillations to airway at rates between 480 and 1200 between 480 and 1200 breaths/minbreaths/min
Variable-speed piston Variable-speed piston pump (or loudspeaker, pump (or loudspeaker, fluidic oscillator) ; fluidic oscillator) ; endotracheal tubeendotracheal tube
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT:
METHODMETHOD DESCRIPTIONDESCRIPTION HOW PROVIDEDHOW PROVIDED
High-Frequency Jet High-Frequency Jet Ventilation (HFJV)Ventilation (HFJV)
Uses separate, parallel, Uses separate, parallel, low compliant circuit and low compliant circuit and injector port to deliver injector port to deliver small pulses or jets of small pulses or jets of fresh gas deep into airway fresh gas deep into airway at rates between 250 and at rates between 250 and 900 breaths/min900 breaths/min
May be used alone or with May be used alone or with low-rate IMV; endotracheal low-rate IMV; endotracheal tubetube
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT: COMPLICATIONS OF POSITIVE PRESSURE COMPLICATIONS OF POSITIVE PRESSURE
VENTILATION:VENTILATION: Increased incidence of air leaks that produce complications:Increased incidence of air leaks that produce complications:
Pulmonary Interstitial EmphysemaPulmonary Interstitial Emphysema PneumothoraxPneumothorax PneumomediastinumPneumomediastinum
Associated with Intubation:Associated with Intubation: Nasal/tracheal/pharyngeal perforationNasal/tracheal/pharyngeal perforation Stenosis; inflammationStenosis; inflammation Palatal grooves; subglottic stenosisPalatal grooves; subglottic stenosis Tube obstruction and infectionTube obstruction and infection
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT: INHALED NITRIC OXIDE (NO): for newborn with conditions that INHALED NITRIC OXIDE (NO): for newborn with conditions that
cause persistent pulmonary HPN, pulmonary vasoconstriction, cause persistent pulmonary HPN, pulmonary vasoconstriction, subsequent acidosis, and severe hypoxiasubsequent acidosis, and severe hypoxia
Colorless, highly diffusible gas: cause smooth muscle relaxation and Colorless, highly diffusible gas: cause smooth muscle relaxation and reduce pulmonary vasoconstriction and subsequent pulmonary HPN reduce pulmonary vasoconstriction and subsequent pulmonary HPN when inhaled into lungswhen inhaled into lungs
Administered through ventilator circuit and blended with oxygenAdministered through ventilator circuit and blended with oxygen Attaches readily to hemoglobin and deactivated so that systemic Attaches readily to hemoglobin and deactivated so that systemic
vasculature is not affectedvasculature is not affected Toxic in large quantitiesToxic in large quantities Mucus may collect I respiratory tract as a result of infant’s Mucus may collect I respiratory tract as a result of infant’s
pulmonary condition pulmonary condition interferes with gas flow and obstruct interferes with gas flow and obstruct passagespassages
Catheter inserted gently but quickly; intermittent suctioning (limited Catheter inserted gently but quickly; intermittent suctioning (limited to <5secs)to <5secs)
FiO2 increased by 10% before suctioningFiO2 increased by 10% before suctioning
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
TREATMENT / MANAGEMENT:TREATMENT / MANAGEMENT:Most advantageous position for facilitating an Most advantageous position for facilitating an
infant’s open airway are on the side with head infant’s open airway are on the side with head supported in alignment by small folded supported in alignment by small folded blanketblanketBack position – keep neck slightly extendedBack position – keep neck slightly extended
Head in “sniffing” positionHead in “sniffing” position
Inspection of skin – position changes and use Inspection of skin – position changes and use of water pillows (prevents skin breakdown)of water pillows (prevents skin breakdown)
Mouth careMouth care
RESPIRATORY DISTRESS RESPIRATORY DISTRESS SYNDROME (RDS)SYNDROME (RDS)
TRANSIENT TACHYPNEA OF THE TRANSIENT TACHYPNEA OF THE NEWBORN (RDS TYPE 2)NEWBORN (RDS TYPE 2)Delayed resorption of fetal lung fluid; Delayed resorption of fetal lung fluid;
decrease lung compliancedecrease lung complianceManagement: Oxygen therapyManagement: Oxygen therapySigns and symptoms similar to RDS 1 Signs and symptoms similar to RDS 1
(hyaline membrane disease) but resolves 48-(hyaline membrane disease) but resolves 48-72 hrs.72 hrs.
SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA Generalized bacterial infection in the Generalized bacterial infection in the
bloodstreambloodstream Newborns are highly susceptible to infection as Newborns are highly susceptible to infection as
a result of diminished nonspecific (inflammatory) a result of diminished nonspecific (inflammatory) & specific (humoral) immunity: impaired & specific (humoral) immunity: impaired phagocytosis, delayed chemotactic response, phagocytosis, delayed chemotactic response, minimal/absent IgA & IgM, decreased minimal/absent IgA & IgM, decreased complement levelscomplement levels
High-Risk Infant 4x greater chance; males > High-Risk Infant 4x greater chance; males > femalesfemales
SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA
RISK FACTORS:RISK FACTORS: PrematurityPrematurity Congenital AnomaliesCongenital Anomalies Acquired injuries that disrupt the skin, mucous Acquired injuries that disrupt the skin, mucous
membranesmembranes Invasive procedures – IV lines, ET tubesInvasive procedures – IV lines, ET tubes Administration of TPNsAdministration of TPNs Nosocomial exposures – NICUNosocomial exposures – NICU Infant born after a difficult or traumatic labor & Infant born after a difficult or traumatic labor &
deliverydelivery
SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA
PATHOPHYSIOLOGY:PATHOPHYSIOLOGY:Premature withdrawal of placental barrier – Premature withdrawal of placental barrier –
leaves infants vulnerable to viral, fungal, leaves infants vulnerable to viral, fungal, bacterial, parasitic infectionsbacterial, parasitic infections
Early birth interrupts transplacental Early birth interrupts transplacental transmission of passive immunity (IgG)transmission of passive immunity (IgG)Preterms – low IgG; IgA & IgM not transferred to Preterms – low IgG; IgA & IgM not transferred to
fetusfetus
SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA
SOURCES OF INFECTION:SOURCES OF INFECTION:Acquired prenatally across placenta from Acquired prenatally across placenta from
maternal blood stream or during labor from maternal blood stream or during labor from ingestion or aspiration of infected amniotic ingestion or aspiration of infected amniotic fluidfluidProlonged rupture of membranes – maternal-fetal Prolonged rupture of membranes – maternal-fetal
transfer of pathogenic organismstransfer of pathogenic organismsTransplacental transfer of CMV, toxoplasmosis, Transplacental transfer of CMV, toxoplasmosis,
syphilis can occursyphilis can occur
SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA
SOURCES OF INFECTION:SOURCES OF INFECTION: Early Sepsis (< 3days) – acquired in perinatal periodEarly Sepsis (< 3days) – acquired in perinatal period
Direct contact with organisms from maternal GIT & GUTDirect contact with organisms from maternal GIT & GUT Group B streptococcus (GBS), E. ColiGroup B streptococcus (GBS), E. Coli H. influenza, coagulase-negative staphylococci – Very Low H. influenza, coagulase-negative staphylococci – Very Low
Birth Weight infantsBirth Weight infants Gonococci, Candida albicans, Herpes Simplex Virus II, Gonococci, Candida albicans, Herpes Simplex Virus II,
Listeria organism, ChlamydiaListeria organism, Chlamydia
Late Sepsis (1-3 weeks after birth) – nosocomialLate Sepsis (1-3 weeks after birth) – nosocomial Staphylococci, Kleibsiella, enterococci, PseudomonasStaphylococci, Kleibsiella, enterococci, Pseudomonas Coagulase-negative staphylococci – Extremely Low Birth Coagulase-negative staphylococci – Extremely Low Birth
Weight, Very Low Birth Weight InfantsWeight, Very Low Birth Weight Infants
SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA
SOURCES OF INFECTION:SOURCES OF INFECTION:Bacterial Invasion: umbilical stump, mucous Bacterial Invasion: umbilical stump, mucous
membranes of the eyes, nose, pharynx, ear; membranes of the eyes, nose, pharynx, ear; internal systems (respiratory, nervous, internal systems (respiratory, nervous, urinary, GIT)urinary, GIT)
Postnatal Infection: cross-contamination from Postnatal Infection: cross-contamination from other infants, personnel, object in the other infants, personnel, object in the environmentenvironment
SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA
SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS: Systemic InfectionsSystemic Infections – subtle, vague, nonspecific – subtle, vague, nonspecific General:General: Fever, Temperature instability; “not doing Fever, Temperature instability; “not doing
well”; poor feeding, edemawell”; poor feeding, edema GI System:GI System: poor feeding, abdominal distention; poor feeding, abdominal distention;
vomiting; diarrhea/ decreased stooling; vomiting; diarrhea/ decreased stooling; Hepatomegaly, hemoccult-positive stoolsHepatomegaly, hemoccult-positive stools
Respiratory System:Respiratory System: irregular respirations, irregular respirations, Apnea/tachypnea; dyspnea, retractions; flaring, Apnea/tachypnea; dyspnea, retractions; flaring, grunting; cyanosisgrunting; cyanosis
Renal System:Renal System: Oliguria Oliguria
SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA
SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS: Cardiovascular System/ Circulatory: Pallor/ cyanosis/ Cardiovascular System/ Circulatory: Pallor/ cyanosis/
mottling, cold clammy skin; hypotension; irregular mottling, cold clammy skin; hypotension; irregular heartbeat : Tachycardia/ Bradycardia, edemaheartbeat : Tachycardia/ Bradycardia, edema
CNS: diminished activity – lethargy, hyporeflexia, CNS: diminished activity – lethargy, hyporeflexia, comacoma
Increased activity – irritability, tremors, seizuresIncreased activity – irritability, tremors, seizures Full fontanelle, High-pitched cry, increased/ decreased tone, Full fontanelle, High-pitched cry, increased/ decreased tone,
abnormal eye movementsabnormal eye movements
Hematologic System: Jaundice, splenomegaly, pallor, Hematologic System: Jaundice, splenomegaly, pallor, petechiae, purpura, ecchymosis petechiae, purpura, ecchymosis
SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA
DIAGNOSIS:DIAGNOSIS: Based on suspicion of presenting clinical signs and Based on suspicion of presenting clinical signs and
symptomssymptoms Laboratory and radiographic examination – definitive Laboratory and radiographic examination – definitive
diagnosisdiagnosis Blood/ urine/ CSF cultures – 10% will have negative culturesBlood/ urine/ CSF cultures – 10% will have negative cultures CBC: anemia, leukocytosis/ leucopeniaCBC: anemia, leukocytosis/ leucopenia
Leucopenia – ominous signLeucopenia – ominous sign C-reactive protein serial measurementsC-reactive protein serial measurements Chest x-rayChest x-ray Lumbar puncture if < 28 days old, and if with altered mental Lumbar puncture if < 28 days old, and if with altered mental
status or meningeal signsstatus or meningeal signs
SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT:
SUPPORTIVE THERAPY: Circulatory, respiratorySUPPORTIVE THERAPY: Circulatory, respiratory Respiratory distress/ hypoxia : Oxygen therapyRespiratory distress/ hypoxia : Oxygen therapy IVF regulationIVF regulation Correct electrolytes and acid-base balanceCorrect electrolytes and acid-base balance NPO temporarilyNPO temporarily Blood transfusions for anemia and shockBlood transfusions for anemia and shock Vital signs, thermoregulationVital signs, thermoregulation
Aggressive administration of antibiotics, Aggressive administration of antibiotics, immunotherapyimmunotherapy
Antibiotics X7-10 days if cultures are positive, discontinue in Antibiotics X7-10 days if cultures are positive, discontinue in 3 days if culture is negative & infant is asymptomatic (thru IV 3 days if culture is negative & infant is asymptomatic (thru IV infusion)infusion)
Antifungal/ antiviral therapies Antifungal/ antiviral therapies
SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA
PROGNOSISPROGNOSISVariableVariableELBW/ VLBW infants: Early onset sepsis ELBW/ VLBW infants: Early onset sepsis
severe neurologic & respiratory sequelaesevere neurologic & respiratory sequelaeLate-onset sepsis & meningitis: poor outcomeLate-onset sepsis & meningitis: poor outcome
SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA
NURSING CONSIDERATIONS:NURSING CONSIDERATIONS: Recognize existing problem: “something is wrong”Recognize existing problem: “something is wrong” Awareness of potential modes of infection Awareness of potential modes of infection
transmissiontransmission Knowledge of the side effects of specific antibiotic & Knowledge of the side effects of specific antibiotic &
proper regulation & administration of drug are vitalproper regulation & administration of drug are vital Prolonged antibiotic therapy – (+) growth of resistant Prolonged antibiotic therapy – (+) growth of resistant
organisms & superinfection from fungal/ mycotic agents organisms & superinfection from fungal/ mycotic agents (Candida albicans) (Candida albicans)
Nystatin oral suspension swabbed on oral mucosa – Nystatin oral suspension swabbed on oral mucosa – prophylaxisprophylaxis
Avoid fully flexed position for obtaining spinal fluid.Avoid fully flexed position for obtaining spinal fluid.
SEPSIS / SEPTICEMIASEPSIS / SEPTICEMIA NURSING CONSIDERATIONS:NURSING CONSIDERATIONS:
Continual cardiorespiratory & pulse oximetry Continual cardiorespiratory & pulse oximetry monitoring provides an ongoing assessment of monitoring provides an ongoing assessment of infant’s conditioninfant’s condition
Decrease additional physiologic or environmental Decrease additional physiologic or environmental stressstress
Thermoregulated environmentThermoregulated environment Anticipate potential problems – dehydration, hypoxiaAnticipate potential problems – dehydration, hypoxia
Precautionary measures: proper hand washing, use Precautionary measures: proper hand washing, use disposable equipmentdisposable equipment
Proper disposal of excretions (vomitus, stool)Proper disposal of excretions (vomitus, stool) Adequate housekeepingAdequate housekeeping
Observe for signs of complications – meningitis, Observe for signs of complications – meningitis, septic shockseptic shock
NECROTIZING ENTEROCOLITISNECROTIZING ENTEROCOLITISAcute inflammatory disease of the bowelAcute inflammatory disease of the bowelSeen primarily in premature infants, Seen primarily in premature infants,
although, described in full-term neonates although, described in full-term neonates as wellas well
Occurs several weeks after birthOccurs several weeks after birth
ETIOLOGY:ETIOLOGY:Precise Cause: unknownPrecise Cause: unknownPrematurity: risk factorPrematurity: risk factor
NECROTIZING ENTEROCOLITISNECROTIZING ENTEROCOLITISETIOLOGY:ETIOLOGY:
3 FACTORS THAT PLAY ROLE IN 3 FACTORS THAT PLAY ROLE IN DEVELOPMENT OF NEC:DEVELOPMENT OF NEC:Intestinal Ischemia – vascular compromise on GITIntestinal Ischemia – vascular compromise on GIT
Diminished Blood Supply
Cell death
No secretion of protective, lubricating mucus
Thin unprotected wall attacked by proteolytic enzyme
Bowel wall swell and break down
Unable to synthesize IgM, mucosa permeable to toxins
Gas-forming bacteria invasion
(+) pneumatosis intestinalis (air in submucosa / subserosa)
NECROTIZING ENTEROCOLITISNECROTIZING ENTEROCOLITIS
ETIOLOGY:ETIOLOGY: 3 FACTORS THAT PLAY ROLE IN DEVELOPMENT 3 FACTORS THAT PLAY ROLE IN DEVELOPMENT
OF NEC:OF NEC: Colonization by pathogenic bacteriaColonization by pathogenic bacteria Substrate (formula feeding) in intestinal lumen – stress on Substrate (formula feeding) in intestinal lumen – stress on
ischemic bowelischemic bowel
SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS: Nonspecific Clinical Signs:Nonspecific Clinical Signs:
Lethargy, poor feeding, hypotensionLethargy, poor feeding, hypotension Vomiting, oliguria, hypotensionVomiting, oliguria, hypotension Unstable temperature, jaundiceUnstable temperature, jaundice
NECROTIZING ENTEROCOLITISNECROTIZING ENTEROCOLITIS
SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS: Specific Signs:Specific Signs:
Distended (often shiny) abdomen; blood in stools/gastric Distended (often shiny) abdomen; blood in stools/gastric contentcontent
Gastric retention; bilious vomitusGastric retention; bilious vomitus Localized abdominal wall erythema/ indurationLocalized abdominal wall erythema/ induration
DIAGNOSIS:DIAGNOSIS: Abdominal x-ray: Sausage-shaped dilation of intestine Abdominal x-ray: Sausage-shaped dilation of intestine
distended loops of bowel; “pneumatosis distended loops of bowel; “pneumatosis intestinalis” --- “soapsuds” or bubbly appearance of intestinalis” --- “soapsuds” or bubbly appearance of thickened bowel wall & ultralumina;thickened bowel wall & ultralumina;
Air in portal vein; free air under the diaphragm (perforation)Air in portal vein; free air under the diaphragm (perforation)
NECROTIZING ENTEROCOLITISNECROTIZING ENTEROCOLITIS
DIAGNOSIS:DIAGNOSIS: Occult blood in the stoolOccult blood in the stool Blood culture – bacteremia / septicemiaBlood culture – bacteremia / septicemia CBC: anemia, leucopenia/ leukocytosisCBC: anemia, leucopenia/ leukocytosis Metabolic acidosis, electrolyte imbalanceMetabolic acidosis, electrolyte imbalance
TREATMENT: TREATMENT: Begins with preventionBegins with prevention
NPO x 24-48 hours – infants who have suffered birth NPO x 24-48 hours – infants who have suffered birth asphyxia, ELBW, VLBW infantsasphyxia, ELBW, VLBW infants
Breast milkBreast milk Minimal enteral feedings – trophic feeding, GIT priming Minimal enteral feedings – trophic feeding, GIT priming
NECROTIZING ENTEROCOLITISNECROTIZING ENTEROCOLITIS
TREATMENT: TREATMENT: Confirmed NEC:Confirmed NEC:
Discontinue all oral feedingsDiscontinue all oral feedings Place NGT – for decompressionPlace NGT – for decompression IV fluids; IV antibioticsIV fluids; IV antibiotics Surgery in extreme casesSurgery in extreme cases
PROGNOSIS:PROGNOSIS: Sequelae of surgical intervention: shirt-gut syndrome, Sequelae of surgical intervention: shirt-gut syndrome,
colonic stricture with obstruction, fat malabsorption, colonic stricture with obstruction, fat malabsorption, failure to thrivefailure to thrive
NECROTIZING ENTEROCOLITISNECROTIZING ENTEROCOLITIS
NURSING CONSIDERATIONS:NURSING CONSIDERATIONS: Prompt recognition of early warning signs of NEC: abdominal Prompt recognition of early warning signs of NEC: abdominal
distention, absent bowel soundsdistention, absent bowel sounds Measure abdominal girth, residual gastric contents before feedings, Measure abdominal girth, residual gastric contents before feedings,
listen for presence of bowel soundslisten for presence of bowel sounds Vital signs including blood pressureVital signs including blood pressure
Avoid rectal temperatures (danger of perforation)Avoid rectal temperatures (danger of perforation) Avoid pressure on distended abdomenAvoid pressure on distended abdomen
Infants are left undiapered & positioned supine or on the sideInfants are left undiapered & positioned supine or on the side Conscientious attention to nutritional and hydration needs, Conscientious attention to nutritional and hydration needs,
administration of antibioticsadministration of antibiotics Oral feedings: started 7-10 days after diagnosis & treatment using Oral feedings: started 7-10 days after diagnosis & treatment using
human milk, elemental formulahuman milk, elemental formula Sterile water may be given initiallySterile water may be given initially Strict hand washingStrict hand washing
FAILURE TO THRIVEFAILURE TO THRIVE Sign of inadequate growth resulting from inability Sign of inadequate growth resulting from inability
to obtain or use calories required for growthto obtain or use calories required for growth No universal definitionNo universal definition Common parameter: WEIGHT, sometimes Common parameter: WEIGHT, sometimes
height that falls below 5height that falls below 5thth percentile for child’s percentile for child’s ageage
Weight for age (height) Weight for age (height) z z value of less than -2.0value of less than -2.0 Weight curve (loss) that crosses >2 percentile Weight curve (loss) that crosses >2 percentile
lines on National Center for Health Statistics lines on National Center for Health Statistics (NCHS) growth (NCHS) growth after previous achievement of a after previous achievement of a stable growth pattern.stable growth pattern.
FAILURE TO THRIVEFAILURE TO THRIVE 3 GENERAL CATEGORIES:3 GENERAL CATEGORIES:
Organic Failure to Thrive Organic Failure to Thrive Physical CausePhysical Cause
Congenital heart defects, neurologic lesions, cerebral palsy, Congenital heart defects, neurologic lesions, cerebral palsy, microcephalymicrocephaly
Chronic renal failure, gastroesophageal refluxChronic renal failure, gastroesophageal reflux Malabsorption syndrome, endocrine dysfunction Malabsorption syndrome, endocrine dysfunction Cystic fibrosis, acquired immunodeficiency syndrome (AIDS)Cystic fibrosis, acquired immunodeficiency syndrome (AIDS)
Nonorganic Failure to Thrive (NFTT)Nonorganic Failure to Thrive (NFTT) Unrelated to diseaseUnrelated to disease Result of psychosocial factors – inadequate nutritional information by Result of psychosocial factors – inadequate nutritional information by
parentparent Deficiency of maternal care of disturbance in maternal-child attachmentDeficiency of maternal care of disturbance in maternal-child attachment Disturbance in child’s ability to separate from parent leading to food Disturbance in child’s ability to separate from parent leading to food
refusal to maintain attentionrefusal to maintain attention Idiopathic Failure to Thrive – unexplained by usual organic and Idiopathic Failure to Thrive – unexplained by usual organic and
environmental etiologies but may also be classified as NFTT.environmental etiologies but may also be classified as NFTT.
FAILURE TO THRIVEFAILURE TO THRIVE
Some experts suggest that classifications are Some experts suggest that classifications are too simplistic because most cases of growth too simplistic because most cases of growth failure have mixed causes.failure have mixed causes. FTT be classified according to pathophysiology for the FTT be classified according to pathophysiology for the
following categories:following categories: Inadequate Caloric IntakeInadequate Caloric Intake
Incorrect formula preparationsIncorrect formula preparations Neglect, food fadsNeglect, food fads Excessive juice consumptionExcessive juice consumption PovertyPoverty Behavioral problems affecting eatingBehavioral problems affecting eating CNS problems affecting intakeCNS problems affecting intake
FAILURE TO THRIVEFAILURE TO THRIVE
Inadequate absorptionInadequate absorption Cystic fibrosis, celiac disease, vitamin/ mineral Cystic fibrosis, celiac disease, vitamin/ mineral
deficiencies, biliary atresia, hepatic diseasedeficiencies, biliary atresia, hepatic disease
Increase metabolismIncrease metabolism Hyperthyroidism, congenital heart defects, chronic Hyperthyroidism, congenital heart defects, chronic
immunodeficiency immunodeficiency
Defective utilizationDefective utilization Trisomy 21 or 18, congenital infection, metabolic storage Trisomy 21 or 18, congenital infection, metabolic storage
diseasesdiseases
FAILURE TO THRIVEFAILURE TO THRIVE
ETIOLOGY – multifactorialETIOLOGY – multifactorial Infant organic diseaseInfant organic diseaseDysfunctional parenting behaviorsDysfunctional parenting behaviorsSubtle neurologic/ behavioral problemsSubtle neurologic/ behavioral problemsDisturbed parent-child interactionsDisturbed parent-child interactions
FACTORS LEADING TO INADEQUATE FACTORS LEADING TO INADEQUATE FEEDING OF INFANTFEEDING OF INFANTPoverty – dilute formula to extend available Poverty – dilute formula to extend available
supply; no insurancesupply; no insuranceNo primary care practitioner; homelessness No primary care practitioner; homelessness
FAILURE TO THRIVEFAILURE TO THRIVE Health or childbearing beliefs – fad diets, excessive concern with Health or childbearing beliefs – fad diets, excessive concern with
obesity, hypercholesterolemia, nursing caries obesity, hypercholesterolemia, nursing caries Strict use of scheduled feedingsStrict use of scheduled feedings Inappropriate food source; excessive juice intakeInappropriate food source; excessive juice intake
Inadequate nutritional knowledge – cultural confusion (immigrant Inadequate nutritional knowledge – cultural confusion (immigrant to USA); cognitive impairmentsto USA); cognitive impairments
Family Stress – overwhelming involvement with another Family Stress – overwhelming involvement with another chronically ill childchronically ill child
Financial, marital, excessive parenting & employment Financial, marital, excessive parenting & employment responsibilitiesresponsibilities
Single parent employed full time, depression, substance abuse, Single parent employed full time, depression, substance abuse, acute griefacute grief
FAILURE TO THRIVEFAILURE TO THRIVE
Psychosocial factors – maternal depression, Psychosocial factors – maternal depression, Munchausen syndrome by proxy, child temperamentMunchausen syndrome by proxy, child temperament
Feeding resistance – oral tactile hypersensitivityFeeding resistance – oral tactile hypersensitivity Infant receiving nonoral nutritional therapy early in life or Infant receiving nonoral nutritional therapy early in life or
exclusively fed with feeding tubesexclusively fed with feeding tubes
Insufficient breast milk – fatigue, poor release of milk, Insufficient breast milk – fatigue, poor release of milk, breast surgery augmentation, lack of maternal breast surgery augmentation, lack of maternal confidence / support. confidence / support.
FAILURE TO THRIVEFAILURE TO THRIVE CLINICAL MANIFESTATIONS:CLINICAL MANIFESTATIONS:
Growth Failure – 5Growth Failure – 5thth percentile in weight only or weight and percentile in weight only or weight and heightheight
Developmental delays – social, motor, adaptive, languageDevelopmental delays – social, motor, adaptive, language ApathyApathy Poor hygienePoor hygiene Withdrawn behaviorWithdrawn behavior Feeding/ eating disorder: vomiting, anorexia, pica, ruminationFeeding/ eating disorder: vomiting, anorexia, pica, rumination No fear of strangers (stage when stranger anxiety is normal)No fear of strangers (stage when stranger anxiety is normal) Avoidance of eye contactAvoidance of eye contact Wide-eyed gaze & continual scan of environment (radar gaze)Wide-eyed gaze & continual scan of environment (radar gaze) Stiff & unyielding or flaccid & unresponsiveStiff & unyielding or flaccid & unresponsive Minimal smilingMinimal smiling
FAILURE TO THRIVEFAILURE TO THRIVE DIAGNOSTIC EVALUATION:DIAGNOSTIC EVALUATION:
Evidence of growth retardation & caloric deprivationEvidence of growth retardation & caloric deprivation Anthropometric measurementsAnthropometric measurements
Onset of FTT is fairly recent: weigh (not height) is below accepted Onset of FTT is fairly recent: weigh (not height) is below accepted standards (5standards (5thth percentile) percentile)
Long standing FTT: height and weight depressed; chronic Long standing FTT: height and weight depressed; chronic malnutritionmalnutrition
Complete health and dietary history --- history of food consumed Complete health and dietary history --- history of food consumed over 3-5 day periodover 3-5 day period
Child’s activity level, perceived food allergies, dietary restrictionsChild’s activity level, perceived food allergies, dietary restrictions P.E for evidence of organic causes, developmental assessmentP.E for evidence of organic causes, developmental assessment Family assessment – parental height, household organizations & Family assessment – parental height, household organizations &
mealtime behaviors & ritualsmealtime behaviors & rituals Rule out organic causesRule out organic causes
Lead toxicity, anemia, stool-reducing substance, occult blood, ova, Lead toxicity, anemia, stool-reducing substance, occult blood, ova, parasitesparasites
Alkaline phospatase, zinc levelsAlkaline phospatase, zinc levels
FAILURE TO THRIVEFAILURE TO THRIVE
THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT: Directed as reversing the malnutrition & underlying Directed as reversing the malnutrition & underlying
causecause Goal: provide sufficient calories to support “catch up” Goal: provide sufficient calories to support “catch up”
growthgrowth Treat any coexisting problemsTreat any coexisting problems Multidisciplinary team: physician, nurse, dietitian, Multidisciplinary team: physician, nurse, dietitian,
gastroenterologist, child-life specialist, social worker gastroenterologist, child-life specialist, social worker or mental health professionalor mental health professional
Relieve any additional stresses on family – referrals to Relieve any additional stresses on family – referrals to welfare agencies or supplemental food programswelfare agencies or supplemental food programs
FAILURE TO THRIVEFAILURE TO THRIVE
THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT: Family therapyFamily therapy Behavior modificationBehavior modification Hospitalization indications:Hospitalization indications:
Evidence (anthropometric) of severe acute malnutritionEvidence (anthropometric) of severe acute malnutrition Child abuse / neglectChild abuse / neglect Significant dehydrationSignificant dehydration Caretaker substance abuse or psychosisCaretaker substance abuse or psychosis Outpatient management that does not result in weight gainOutpatient management that does not result in weight gain
FAILURE TO THRIVEFAILURE TO THRIVE
NURSING CONSIDERATIONS:NURSING CONSIDERATIONS:Accurate assessment of initial weight & height Accurate assessment of initial weight & height
and daily weight & recording of all food intakeand daily weight & recording of all food intakeFeeding behavior is documented & parent-Feeding behavior is documented & parent-
child interaction during feedingchild interaction during feedingFeeding checklistFeeding checklistShould be placed in a room with noninfectious Should be placed in a room with noninfectious
children of similar age children of similar age Structure feeding environment to encourage Structure feeding environment to encourage
eatingeating
FAILURE TO THRIVEFAILURE TO THRIVE NURSING CONSIDERATIONS:NURSING CONSIDERATIONS:
The childThe child May exhibit altered behavioral interactionsMay exhibit altered behavioral interactions Display intense interest in inanimate objects (toys) but less in Display intense interest in inanimate objects (toys) but less in
social interactionssocial interactions Watchful of people at a distance but become distressed as Watchful of people at a distance but become distressed as
others come closerothers come closer Dislike being touched or held & avoid face-to-face contact; Dislike being touched or held & avoid face-to-face contact;
when held they protest briefly on being put down& apathetic when held they protest briefly on being put down& apathetic when left alonewhen left alone
History of difficulty in feeding, vomiting, sleep disturbance, History of difficulty in feeding, vomiting, sleep disturbance, excessive irritabilityexcessive irritability
Crying during feedings, hoarding food in mouth, rumination Crying during feedings, hoarding food in mouth, rumination after feeding, refusing to switch from liquids to solids, after feeding, refusing to switch from liquids to solids, aversion behaviors (turning from food, spitting)aversion behaviors (turning from food, spitting)
Difficult temperament or passive, sleepy, lethargic infant who Difficult temperament or passive, sleepy, lethargic infant who does not wake up for feedingsdoes not wake up for feedings
FAILURE TO THRIVEFAILURE TO THRIVE
NURSING CONSIDERATIONS:NURSING CONSIDERATIONS:The parentThe parent
Increased risk for altered parent-infant interactions Increased risk for altered parent-infant interactions because:because:
Isolation and social crisisIsolation and social crisis Inadequate support systemsInadequate support systems Poor / absent parenting role models when they were Poor / absent parenting role models when they were
childrenchildrenLack of education, physical/ mental health Lack of education, physical/ mental health
problemsproblems Physical and sexual abuse, depression, drug Physical and sexual abuse, depression, drug
dependence, immaturitydependence, immaturity
FAILURE TO THRIVEFAILURE TO THRIVE
NUTRITIONAL MANAGEMENT:NUTRITIONAL MANAGEMENT:4 Primary Goals in Nutritional management of 4 Primary Goals in Nutritional management of
FTT:FTT:Correct nutritional deficiencies & achieve ideal Correct nutritional deficiencies & achieve ideal
weight for heightweight for height Increase caloric intake in formula fed infants: Increase caloric intake in formula fed infants:
supplements like Polycose, medium chain triglycerides supplements like Polycose, medium chain triglycerides may be added slowly – in 2kcal/oz increments q2-3 days may be added slowly – in 2kcal/oz increments q2-3 days to yield up 28-30 kcal/ozto yield up 28-30 kcal/oz
Carbohydrate additives (8 kcal/tsp)Carbohydrate additives (8 kcal/tsp)
FAILURE TO THRIVEFAILURE TO THRIVE
NUTRITIONAL MANAGEMENT:NUTRITIONAL MANAGEMENT: Rice cereal & vegetable oilRice cereal & vegetable oil Multivitamin supplementation – zinc and ironMultivitamin supplementation – zinc and iron Breast-fed infants: add 1 tsp of 24 kcal/oz formula to 3 oz Breast-fed infants: add 1 tsp of 24 kcal/oz formula to 3 oz
breast milkbreast milk Toddlers: high caloric milk (PediaSure)Toddlers: high caloric milk (PediaSure) Fruit juices – minimized in infants < 6 monthsFruit juices – minimized in infants < 6 months Extreme cases: tube feedings or IV therapyExtreme cases: tube feedings or IV therapy
Allow for catch up growthAllow for catch up growthRestore optimum body compositionRestore optimum body composition
FAILURE TO THRIVEFAILURE TO THRIVE
NUTRITIONAL MANAGEMENT:NUTRITIONAL MANAGEMENT:Educate parents/ primary caregivers regarding Educate parents/ primary caregivers regarding
child’s nutritional requirements & appropriate child’s nutritional requirements & appropriate feeding methodsfeeding methods
Step-by-step directions for formula preparations, written Step-by-step directions for formula preparations, written schedule of feeding timesschedule of feeding times
Juices should be avoided in children with growth failure Juices should be avoided in children with growth failure until adequate weight gain has been achieved (should until adequate weight gain has been achieved (should not exceed 4oz/day)not exceed 4oz/day)
Family-system approachFamily-system approach
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
Erythroblastosis fetalisErythroblastosis fetalisHyperbilirubinemia in 1Hyperbilirubinemia in 1stst 24 hrs of life 24 hrs of lifeAbnormally rapid rate of RBC destructionAbnormally rapid rate of RBC destructionAnemia caused by this destruction (+) Anemia caused by this destruction (+)
production of RBCs production of RBCs increased # cells increased # cells for hemolysisfor hemolysis
Major causes: isoimmunization (primarily Major causes: isoimmunization (primarily Rh) & ABO incompatibilityRh) & ABO incompatibility
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
Blood IncompatibilityBlood Incompatibility Antigen / Agglutinogens – substance capable of Antigen / Agglutinogens – substance capable of
producing an immune response if recognized by the producing an immune response if recognized by the body as foreignbody as foreign
Antigens + Antibodies = agglutination (clumping)Antigens + Antibodies = agglutination (clumping) Antibodies in plasma of 1 blood group (except AB Antibodies in plasma of 1 blood group (except AB
group – no antibodies) produce agglutination when group – no antibodies) produce agglutination when mixed with antigens of a different blood groupmixed with antigens of a different blood group
ABO blood group system – antibodies occur naturallyABO blood group system – antibodies occur naturally Rh system - isoimmunizationRh system - isoimmunization
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
1. Rh Incompatibility1. Rh Incompatibility The presence of naturally occurring Rh The presence of naturally occurring Rh
factor determines the blood type.factor determines the blood type. Rh (+) – presence of antigenRh (+) – presence of antigen Rh (-) – absence of antigenRh (-) – absence of antigen No problems occur when Rh blood type are No problems occur when Rh blood type are
same in both mother and fetus or if mother same in both mother and fetus or if mother is Rh (+) and infant is Rh (-).is Rh (+) and infant is Rh (-).
Mother Rh (-) and Infant Rh (+) : problemMother Rh (-) and Infant Rh (+) : problem
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
Isoimmunization – no effect on 1Isoimmunization – no effect on 1stst pregnancy pregnancyInitial sensitization to Rh antigens rarely occurs Initial sensitization to Rh antigens rarely occurs
before the onset of laborbefore the onset of laborWith increased risk of fetal blood transferred to With increased risk of fetal blood transferred to
maternal circulation during placental separation, maternal circulation during placental separation, maternal antibody production is stimulated.maternal antibody production is stimulated.
Fetal RBCs (with antigens foreign to mother)
Enters maternal circulation
Mother produces anti-Rh antibodies
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
Factors that increase incidence of Factors that increase incidence of transpalcental hemorrhage & subsequent transpalcental hemorrhage & subsequent isoimmunization:isoimmunization:Multiple gestation, abruptio placenta, placenta Multiple gestation, abruptio placenta, placenta
previa, manual removal of placenta, cesarean previa, manual removal of placenta, cesarean deliverydelivery
Subsequent pregnancy with Rh (+) fetus
Previously formed maternal antibodies to Rh (+) blood cells enter fetal circulation
Attack and destroy fetal RBCs
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
Sensitization may occur during 1Sensitization may occur during 1stst pregnancy pregnancy if woman had previously received an Rh (+) if woman had previously received an Rh (+) blood transfusionblood transfusion
Fetus compensate for hemolysis and anemia
Increase rate of erythropoiesis
(+) erythroblasts in circulation
Erythroblastosis fetalis
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
No sensitization: if there’s strong placental barrier No sensitization: if there’s strong placental barrier which prevents transfer of fetal blood into maternal which prevents transfer of fetal blood into maternal circulationcirculation
10-15% of sensitized mothers: no hemolytic reaction in 10-15% of sensitized mothers: no hemolytic reaction in NewbornNewborn
Some Rh (-) women even though exposed to Rh (+) fetal Some Rh (-) women even though exposed to Rh (+) fetal blood are unable to produce antibodies to foreign antigenblood are unable to produce antibodies to foreign antigen
Most severe form: hydrops fetalisMost severe form: hydrops fetalis Fetal hypoxia, cardiac failure, anasarca, effusions (pleural, Fetal hypoxia, cardiac failure, anasarca, effusions (pleural,
pericardial, peritoneal)pericardial, peritoneal) Stillborn or in severe respiratory distressStillborn or in severe respiratory distress
Early intrauterine detection: ultrasound, fetal blood Early intrauterine detection: ultrasound, fetal blood samplingsampling
Management: fetal blood transfusionsManagement: fetal blood transfusions
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
2. ABO Incompatibility2. ABO Incompatibility Major blood group antigens of fetus are Major blood group antigens of fetus are
different from those of the motherdifferent from those of the mother Major blood groups: A, B, AB, OMajor blood groups: A, B, AB, O Presence / absence of antibodies & antigens Presence / absence of antibodies & antigens
determines whether agglutination will occurdetermines whether agglutination will occur
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
ABO RELATIONSHIP OF ANTIGENS / ANTIBODIES & ABO RELATIONSHIP OF ANTIGENS / ANTIBODIES & DONOR- RECIPIENT COMPATIBILITYDONOR- RECIPIENT COMPATIBILITY
RBC RBC COMPATIBILITYCOMPATIBILITY
BLOOD GROUP BLOOD GROUP (PHENOTYPE)(PHENOTYPE)
GENOTYPEGENOTYPE RBC RBC ANTIGENSANTIGENS
PLASMA PLASMA ANTIBODIESANTIBODIES
AS DONOR AS DONOR TO TYPETO TYPE
AS AS RECIPIENT RECIPIENT
FROM FROM TYPETYPE
AA
BB
ABAB
OO
AA, AOAA, AO
BB, BOBB, BO
ABAB
OOOO
AA
BB
A & BA & B
NONENONE
BB
AA
NONENONE
A & BA & B
AB, AAB, A
AB, BAB, B
ABAB
AB, A, B, OAB, A, B, O
O, AO, A
O, BO, B
O, A, B, ABO, A, B, AB
OO
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
Antibodies in plasma of 1 blood group (except type AB) + Antigens of a different blood group
= agglutination (clumping)
hemolysis
Release large amounts of bilirubin into circulation
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
Most common: mother – type O and infant – Most common: mother – type O and infant – type A or Btype A or B
May occur in 1May occur in 1stst pregnancy and subsequent pregnancy and subsequent pregnancy.pregnancy.
Naturally occurring anti-A or anti-B antibodiesPresent in maternal circulation cross placenta
Attack fetal RBC
Hemolysis (less severe than Rh incompatibility)
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
POTENTIAL MATERNAL-FETAL ABO POTENTIAL MATERNAL-FETAL ABO INCOMPATIBILITIESINCOMPATIBILITIES
MATERNAL BLOOD MATERNAL BLOOD GROUPGROUP
INCOMPATIBLE FETAL INCOMPATIBLE FETAL BLOOD BROUPBLOOD BROUP
OO
BB
AA
A or BA or B
A or ABA or AB
B or ABB or AB
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
CLINICAL MANIFESTATIONS:CLINICAL MANIFESTATIONS: Anemia (hemolysis of RBCs) Anemia (hemolysis of RBCs) jaundice on 1 jaundice on 1stst 24 hours; serum bilirubin 24 hours; serum bilirubin
elevated (result from liver’s inability to conjugate & excrete excess elevated (result from liver’s inability to conjugate & excrete excess bilirubin)bilirubin)
Hepatosplenomegaly, varying degrees of hydrops, sign of hypovolemic Hepatosplenomegaly, varying degrees of hydrops, sign of hypovolemic shockshock
Hypoglycemia – due to pancreatic cell hyperplasiaHypoglycemia – due to pancreatic cell hyperplasia
DIAGNOSTIC EVALUATION:DIAGNOSTIC EVALUATION: Genetic testingGenetic testing Chorionic Villus Sampling – determine fetal group and type Chorionic Villus Sampling – determine fetal group and type can lead can lead
to abortionto abortion Amniocentesis – fetal blood type Amniocentesis – fetal blood type can lead to infection or leaking can lead to infection or leaking Ultrasonography – allow early treatment; used to check amniotic fluid Ultrasonography – allow early treatment; used to check amniotic fluid
and condition of the placentaand condition of the placenta Indirect Coombs Test – evaluate rising anti Rh antibody titers in maternal Indirect Coombs Test – evaluate rising anti Rh antibody titers in maternal
circulation; done Rh (-) mothers; 1circulation; done Rh (-) mothers; 1stst prenatal visit prenatal visit Direct Coombs Test – detect antibodies attached to the circulating Direct Coombs Test – detect antibodies attached to the circulating
erythrocytes of affected infants ; done to baby; to determine how erythrocytes of affected infants ; done to baby; to determine how extensive is the hemolysisextensive is the hemolysis
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT: Postnatal therapy: phototherapy for mild cases, Postnatal therapy: phototherapy for mild cases,
exchange transfusion for severe casesexchange transfusion for severe cases Prevention of Rh isoimmunization: Rho immune Prevention of Rh isoimmunization: Rho immune
globulin (Rhogam)globulin (Rhogam) Human gamma globulin concentrate of anti-D to all Human gamma globulin concentrate of anti-D to all
unsensitized Rh (-) mothers after delivery or abortion of an unsensitized Rh (-) mothers after delivery or abortion of an Rh-positive infant or fetusRh-positive infant or fetus
Destroys (by phagocytosis & agglutination) fetal RBCs Destroys (by phagocytosis & agglutination) fetal RBCs passing into maternal circulation before they can be passing into maternal circulation before they can be recognized by mother’s immune system recognized by mother’s immune system immune immune response is blocked, anti-D antibodies & memory cells not response is blocked, anti-D antibodies & memory cells not formedformed
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT: Must be administered to unsensitized mothers within 72 Must be administered to unsensitized mothers within 72
hours (possibly as long as 3-4 weeks) after the 1hours (possibly as long as 3-4 weeks) after the 1stst delivery or delivery or abortion & repeated after subsequent onesabortion & repeated after subsequent ones
Administration of RhIg at 26-28 weeks AOG reduces risk of Administration of RhIg at 26-28 weeks AOG reduces risk of Rh isoimmunizationRh isoimmunization
Administered thru IM to Rh (-) sensitized women, never to Administered thru IM to Rh (-) sensitized women, never to newborn or fathernewborn or father
Intravenous immunoglobulin (IVIG) – decreased Intravenous immunoglobulin (IVIG) – decreased severity of RBC destruction (hemolysis) in HDN & severity of RBC destruction (hemolysis) in HDN & subsequent development of jaundicesubsequent development of jaundice
Attacks maternal cells that destroy neonatal RBCs, slows Attacks maternal cells that destroy neonatal RBCs, slows down the progression of bilirubin production down the progression of bilirubin production
Used in conjunction with phototherapy; decreased necessity Used in conjunction with phototherapy; decreased necessity for exchange transfusionfor exchange transfusion
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT: Intrauterine transfusion – infuse blood into umbilical Intrauterine transfusion – infuse blood into umbilical
vein of fetusvein of fetus Infuse Rh O-negative packed RBCs to raise fetal hematocrit Infuse Rh O-negative packed RBCs to raise fetal hematocrit
to 40-50% every 2 weeks until fetus reaches 37-38 weeksto 40-50% every 2 weeks until fetus reaches 37-38 weeks
Exchange transfusion – infant’s blood removed in Exchange transfusion – infant’s blood removed in small amounts (5-10ml at a time) & replaced with small amounts (5-10ml at a time) & replaced with compatible blood (Rh – negative blood) compatible blood (Rh – negative blood)
Removes sensitized RBCs, lowers serum bilirubin, corrects Removes sensitized RBCs, lowers serum bilirubin, corrects anemia, prevents cardiac failureanemia, prevents cardiac failure
Indications:Indications: Rapidly increasing bilirubin level, hemolysis despite intensive Rapidly increasing bilirubin level, hemolysis despite intensive
phototherapyphototherapy Infant born with hydrops fetalis or sign or cardiac failureInfant born with hydrops fetalis or sign or cardiac failure
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT:Fresh whole blood typed & crossmatched to Fresh whole blood typed & crossmatched to
mother’s serummother’s serumAmount of donor blood is double the blood volume Amount of donor blood is double the blood volume
of infant (85ml/kgBW) but not >500mlof infant (85ml/kgBW) but not >500mlSterile surgical procedure: catheter Sterile surgical procedure: catheter umbilical umbilical
vein vein inferior vena cava inferior vena cava 5-10 ml withdrawn within 15-20 secs 5-10 ml withdrawn within 15-20 secs same volume x same volume x
60-90 secs60-90 secs
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
THERAPEUTIC MANAGEMENT:THERAPEUTIC MANAGEMENT:ABO INCOMPATIBILITYABO INCOMPATIBILITY
Early detection & implementation of phototherapyEarly detection & implementation of phototherapy(+) jaundice within 1(+) jaundice within 1stst 24 hours, increased serum 24 hours, increased serum
bilirubin levels, RBC spherocytosis, increased bilirubin levels, RBC spherocytosis, increased ESR: diagnostic of ABO incompatibilityESR: diagnostic of ABO incompatibility
IVIG + phototherapyIVIG + phototherapyExchange transfusion – not commonly required Exchange transfusion – not commonly required
except when phototherapy fails to decrease except when phototherapy fails to decrease bilirubin concentration bilirubin concentration
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
PROGNOSIS:PROGNOSIS:Severe anemia: result in stillbirth, shock, Severe anemia: result in stillbirth, shock,
congestive heart failure, pulmonary/ cerebral congestive heart failure, pulmonary/ cerebral complications (cerebral palsy)complications (cerebral palsy)
With early detection & intrauterine treatment – With early detection & intrauterine treatment – erythroblastic Newborn rare, exchange erythroblastic Newborn rare, exchange transfusions for the conditions less commontransfusions for the conditions less common
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
NURSING CONSIDERATIONS: NURSING CONSIDERATIONS: Initial nursing responsibility – recognizing jaundiceInitial nursing responsibility – recognizing jaundice
Thru prenatal & perinatal history Thru prenatal & perinatal history
Exchange transfusion: prepare infant and family Exchange transfusion: prepare infant and family assist practitioner with procedureassist practitioner with procedure
Document blood volume exchanged: amount of blood Document blood volume exchanged: amount of blood volume withdrawn & infused, time of each procedure, volume withdrawn & infused, time of each procedure, cumulative record of total volume exchangedcumulative record of total volume exchanged
Vital signs monitoredVital signs monitored (+) signs of cardiac/ respiratory problems: procedure stopped (+) signs of cardiac/ respiratory problems: procedure stopped
temporarily & resumed once stabletemporarily & resumed once stable Observe for transfusion reactionObserve for transfusion reaction
HEMOLYTIC DISEASE OF THE HEMOLYTIC DISEASE OF THE NEWBORNNEWBORN
NURSING CONSIDERATIONS: NURSING CONSIDERATIONS: Attention on thermoregulationAttention on thermoregulation
Hypothermia – increase oxygen and glucose Hypothermia – increase oxygen and glucose consumption consumption metabolic acidosis; (-) binding capacity metabolic acidosis; (-) binding capacity of albumin & bilirubin & hepatic enzyme reaction of albumin & bilirubin & hepatic enzyme reaction kernicteruskernicterus
Hyperthermia – damages donor’s RBC, increase free K+, Hyperthermia – damages donor’s RBC, increase free K+, predisposes infant to cardiac arrestpredisposes infant to cardiac arrest
Performed with infant under radiant warmer, with Performed with infant under radiant warmer, with sterile drapes, blood is warmedsterile drapes, blood is warmed
After procedure: nurse inspects umbilical vein (for After procedure: nurse inspects umbilical vein (for bleeding), catheter may remain in placebleeding), catheter may remain in place
SUDDEN INFANT DEATH SUDDEN INFANT DEATH SYNDROME (SIDS)SYNDROME (SIDS)
Sudden death of infant < 1 years oldSudden death of infant < 1 years old Unexplained after a complete mortem examination, Unexplained after a complete mortem examination,
including an investigation of death scene & review of including an investigation of death scene & review of case historycase history
33rdrd leading cause of death in children between 1 month – leading cause of death in children between 1 month – 1 year ; increased incidence in winter1 year ; increased incidence in winter
Incidence: 0.65:1000 live births (1999); males > femalesIncidence: 0.65:1000 live births (1999); males > females Peak age: 2-4 months; 95% occur by 6 monthsPeak age: 2-4 months; 95% occur by 6 months Time of death: during sleepTime of death: during sleep Racial: Native Americans, African Americans, HispanicsRacial: Native Americans, African Americans, Hispanics Lower socioeconomic classLower socioeconomic class
SUDDEN INFANT DEATH SUDDEN INFANT DEATH SYNDROME (SIDS)SYNDROME (SIDS)
Risks: Preterm especially low birth weight; Risks: Preterm especially low birth weight; multiple births (2multiple births (2ndnd twin, male twin & small- twin, male twin & small-for-date twin)for-date twin)Newborn with low APGAR scoreNewborn with low APGAR score Infants with CNS disturbances & respiratory Infants with CNS disturbances & respiratory
disorder (bronchopulmonary dysplasia/ disorder (bronchopulmonary dysplasia/ chronic lung disease) chronic lung disease)
Increased birth order (subsequent siblings as Increased birth order (subsequent siblings as opposed to 1opposed to 1stst born child) born child)
Infants with recent history of mild illnessInfants with recent history of mild illness
SUDDEN INFANT DEATH SUDDEN INFANT DEATH SYNDROME (SIDS)SYNDROME (SIDS)
Sleep in prone positionSleep in prone position Cause oropharyngeal obstruction or affect thermal balance Cause oropharyngeal obstruction or affect thermal balance
or arousal stateor arousal state Rebreathing of carbon dioxide by prone infant & impaired Rebreathing of carbon dioxide by prone infant & impaired
arousal from active & quiet sleeparousal from active & quiet sleep Side-lying position no longer recommended – tends to turn to Side-lying position no longer recommended – tends to turn to
prone positionprone position Use of soft bedding – not able to move their heads to Use of soft bedding – not able to move their heads to
the side the side suffocation and lethal rebreathing suffocation and lethal rebreathing Overheating (thermal stress); co-sleeping with adult Overheating (thermal stress); co-sleeping with adult
especially on sofaespecially on sofa Adult beds/ sofas are not designed for infants & may carry Adult beds/ sofas are not designed for infants & may carry
risk of accidental entrapment & suffocationrisk of accidental entrapment & suffocation
SUDDEN INFANT DEATH SUDDEN INFANT DEATH SYNDROME (SIDS)SYNDROME (SIDS)
Lower incidence in breast-fed infants – pacifier Lower incidence in breast-fed infants – pacifier may be protective against SIDSmay be protective against SIDS
Maternal risk: young age, cigarette smoking Maternal risk: young age, cigarette smoking especially during pregnancyespecially during pregnancy Poor prenatal care, substance abuse (heroin, Poor prenatal care, substance abuse (heroin,
methadone, cocaine)methadone, cocaine) 12% of all SIDS death could be prevented with 12% of all SIDS death could be prevented with
prenatal smoking cessationprenatal smoking cessation Maternal smoking decreases infant’s ability to arouse to Maternal smoking decreases infant’s ability to arouse to
auditory stimuli in mothers who smoke prenatally. auditory stimuli in mothers who smoke prenatally.
SUDDEN INFANT DEATH SUDDEN INFANT DEATH SYNDROME (SIDS)SYNDROME (SIDS)
ETIOLOGY:ETIOLOGY: UnknownUnknown Hypothesis: related to brainstem abnormality in Hypothesis: related to brainstem abnormality in
neurologic regulation of cardiorespiratory controlneurologic regulation of cardiorespiratory control Abnormalities: prolonged sleep apnea, increased frequency Abnormalities: prolonged sleep apnea, increased frequency
of brief inspiratory pauses, excessive periodic breathing, of brief inspiratory pauses, excessive periodic breathing, impaired arousal responsiveness to increase carbon dioxide impaired arousal responsiveness to increase carbon dioxide or decrease oxygenor decrease oxygen
Sleep apnea is not the cause of SIDS; genetic predisposition Sleep apnea is not the cause of SIDS; genetic predisposition has been postulated as the causehas been postulated as the cause
Autopsies: pulmonary edema & intrathoracic Autopsies: pulmonary edema & intrathoracic hemorrhageshemorrhages
Should be performed on all infants suspected of dying of Should be performed on all infants suspected of dying of SIDSSIDS
SUDDEN INFANT DEATH SUDDEN INFANT DEATH SYNDROME (SIDS)SYNDROME (SIDS)
INFANTS AT RISK FOR SIDS:INFANTS AT RISK FOR SIDS: Infants with 1 or more ALTEs requiring Infants with 1 or more ALTEs requiring
cardiopulmonary resuscitation (CPR) or vigorous cardiopulmonary resuscitation (CPR) or vigorous stimulationstimulation
Preterm infants who continue to have apnea at the Preterm infants who continue to have apnea at the time of hospital dischargetime of hospital discharge
Siblings of 2 or more SIDS victimSiblings of 2 or more SIDS victim Infants with certain types of disease or conditions – Infants with certain types of disease or conditions –
central hypoventilationcentral hypoventilation Home monitoring and/or use of respiratory stimulant drugs Home monitoring and/or use of respiratory stimulant drugs
recommendedrecommended No diagnostic tests exist to predict which infants will survive No diagnostic tests exist to predict which infants will survive
SUDDEN INFANT DEATH SUDDEN INFANT DEATH SYNDROME (SIDS)SYNDROME (SIDS)
NURSING CONSIDERATIONS:NURSING CONSIDERATIONS: Educate families in prevention of SIDSEducate families in prevention of SIDS
Risk of prone sleeping position in infant births – 6 monthsRisk of prone sleeping position in infant births – 6 months Use of appropriate beddings, parental smoking around infant Use of appropriate beddings, parental smoking around infant
and dangers of sharing an adult bed with infantand dangers of sharing an adult bed with infant
Post partum discharge planning, newborn discharge Post partum discharge planning, newborn discharge teaching and newborn-care classesteaching and newborn-care classes
Follow-up visits, well-baby clinic visits, immunization Follow-up visits, well-baby clinic visits, immunization visitsvisits
Discuss infant sleep positionDiscuss infant sleep position
SUDDEN INFANT DEATH SUDDEN INFANT DEATH SYNDROME (SIDS)SYNDROME (SIDS)
NURSING CONSIDERATIONS:NURSING CONSIDERATIONS:Psychologic intervention – loss of childPsychologic intervention – loss of childPractices that may reduce the risk of SIDSPractices that may reduce the risk of SIDS
Avoid smoking during pregnancy and near the Avoid smoking during pregnancy and near the infantinfant
Encouraging supine sleeping positionEncouraging supine sleeping position ““back to sleep”back to sleep”
Avoid soft, moldable mattresses, blankets, pillowsAvoid soft, moldable mattresses, blankets, pillows No pillows/ quilts, stuffed toys, towelsNo pillows/ quilts, stuffed toys, towels
Discouraging bed sharingDiscouraging bed sharingEncourage breastfeedingEncourage breastfeeding
SUDDEN INFANT DEATH SUDDEN INFANT DEATH SYNDROME (SIDS)SYNDROME (SIDS)
NURSING CONSIDERATIONS:NURSING CONSIDERATIONS: Avoid overheating during sleepAvoid overheating during sleep
Infants should wear light-clothing, comfortable room Infants should wear light-clothing, comfortable room temperaturetemperature
Infant’s head position should be varied to prevent flattening Infant’s head position should be varied to prevent flattening of the skullof the skull
Use of pacifier – protective against occurrence of SIDS; Use of pacifier – protective against occurrence of SIDS; naptime and bedtime, no sweetened coatingnaptime and bedtime, no sweetened coating
Finding the infantFinding the infant it’s always the mother who finds child dead in cribit’s always the mother who finds child dead in crib Child is in disheveled bed w/ blankets over head, huddled in Child is in disheveled bed w/ blankets over head, huddled in
1 corner1 corner
SUDDEN INFANT DEATH SUDDEN INFANT DEATH SYNDROME (SIDS)SYNDROME (SIDS)
NURSING CONSIDERATIONS:NURSING CONSIDERATIONS:Frothy, blood-tinged fluid fills the mouth & nostrils, Frothy, blood-tinged fluid fills the mouth & nostrils,
lying face down in secretions (bled to death)lying face down in secretions (bled to death)Diaper is wet and full of stool – cataclysmic type of Diaper is wet and full of stool – cataclysmic type of
deathdeathParents must deal with his/her initial shock, panic, Parents must deal with his/her initial shock, panic,
griefgriefCompassionate, sensitive approach to familyCompassionate, sensitive approach to family
SUDDEN INFANT DEATH SUDDEN INFANT DEATH SYNDROME (SIDS)SYNDROME (SIDS)
NURSING CONSIDERATIONS:NURSING CONSIDERATIONS:Arriving at emergency departmentArriving at emergency department
No attempt at resuscitationNo attempt at resuscitationParents are asked only factual questions – when Parents are asked only factual questions – when
they found the infant, how he/she lookedthey found the infant, how he/she looked No misguided statements: “this looks like suffocation” No misguided statements: “this looks like suffocation”
(guilt)(guilt)
Discuss possible autopsyDiscuss possible autopsyCompassionate care – allow them to say good-bye Compassionate care – allow them to say good-bye
to their childto their child
APNEA OF PREMATURITY (AOP)APNEA OF PREMATURITY (AOP)
Preterm infants; rare: full-termPreterm infants; rare: full-term Apneic spells increase in prevalence the younger the gestational Apneic spells increase in prevalence the younger the gestational
ageage 1/3 infants <33 weeks AOG, >1/2 healthy infants < 30 weeks AOG1/3 infants <33 weeks AOG, >1/2 healthy infants < 30 weeks AOG Resolves as infant reaches 37 weeks postmenstrual ageResolves as infant reaches 37 weeks postmenstrual age Preterms are periodic breathers – periods of rapid respirations Preterms are periodic breathers – periods of rapid respirations
separated by periods of very slow breathing, often short periods with separated by periods of very slow breathing, often short periods with no visible or audible respirationsno visible or audible respirations
Apnea – extension of periodic breathingApnea – extension of periodic breathing Lapse of spontaneous breathing for 20 seconds or longer, that may Lapse of spontaneous breathing for 20 seconds or longer, that may
or may not be followed by bradycardia, oxygen desaturation and or may not be followed by bradycardia, oxygen desaturation and color changecolor change
Temporary apnea - <15-20 secondsTemporary apnea - <15-20 seconds Pathologic apnea - > 20 secondsPathologic apnea - > 20 seconds
APNEA OF PREMATURITY (AOP)APNEA OF PREMATURITY (AOP)
Classification according to origin:Classification according to origin: Central Apnea – absence of diaphragmatic and other Central Apnea – absence of diaphragmatic and other
respiratory effortrespiratory effort Occurs when CNS does not transmit signals to the Occurs when CNS does not transmit signals to the
respiratory musclerespiratory muscle
Obstructive Apnea – air flow ceases because of upper Obstructive Apnea – air flow ceases because of upper airway obstruction yet chest or abdominal wall airway obstruction yet chest or abdominal wall movement is presentmovement is present
Mixed Apnea: combination of central and obstructive Mixed Apnea: combination of central and obstructive apneaapnea
Most common apnea seen in preterm infantsMost common apnea seen in preterm infants
APNEA OF PREMATURITY (AOP)APNEA OF PREMATURITY (AOP)
PATHOPHYSIOLOGY:PATHOPHYSIOLOGY: Reflects the immature and poorly refined neurologic Reflects the immature and poorly refined neurologic
and chemical respiratory control mechanism in and chemical respiratory control mechanism in premature infantspremature infants
Not responsive to hypercarbia and hypoxemia, have Not responsive to hypercarbia and hypoxemia, have fewer dendritic associations than those of more fewer dendritic associations than those of more mature infantsmature infants
Respiratory reflexes less mature – contributing factor Respiratory reflexes less mature – contributing factor in etiologyin etiology
Weakness of muscles of thorax, diaphragm and upper Weakness of muscles of thorax, diaphragm and upper airway – contribute to apneic episodes airway – contribute to apneic episodes
APNEA OF PREMATURITY (AOP)APNEA OF PREMATURITY (AOP)
PATHOPHYSIOLOGY:PATHOPHYSIOLOGY: Apnea – observed during periods of REM sleepApnea – observed during periods of REM sleep Precipitated/ worsened by a variety of factors:Precipitated/ worsened by a variety of factors:
InfectionInfection Intracranial hemorrhageIntracranial hemorrhage PDAPDA
Secondary causes: investigated in infants with new-Secondary causes: investigated in infants with new-onset apnea or when there’s significant change in onset apnea or when there’s significant change in frequency or severity of apneic episodesfrequency or severity of apneic episodes
Apnea in full-term: consider secondary causeApnea in full-term: consider secondary cause
APNEA OF PREMATURITY (AOP)APNEA OF PREMATURITY (AOP) POSSIBLE CAUSES OF APNEA OF PREMATURITY:POSSIBLE CAUSES OF APNEA OF PREMATURITY:
PrematurityPrematurity Airway obstruction with mucus or milk, or poor positioningAirway obstruction with mucus or milk, or poor positioning Anemia, polycythemiaAnemia, polycythemia DehydrationDehydration Cooling / overheatingCooling / overheating HypoxemiaHypoxemia Hypercapnia / hypocapniaHypercapnia / hypocapnia Hypoglycemia, hypocalcemia, hyponatremiaHypoglycemia, hypocalcemia, hyponatremia Sepsis, meningitisSepsis, meningitis SeizuresSeizures Increased vaga tone (in response to suctioning nasopharynx, gavage Increased vaga tone (in response to suctioning nasopharynx, gavage
tube insertion, reflux of gastric contents, endotracheal intubation)tube insertion, reflux of gastric contents, endotracheal intubation) CNS depression – pharmacologic agentsCNS depression – pharmacologic agents Intraventricular hemorrhage (IVH)Intraventricular hemorrhage (IVH) Patent ductus arteriosus (PDA), congestive heart failure (CHF)Patent ductus arteriosus (PDA), congestive heart failure (CHF) Depression following maternal obstetric sedationDepression following maternal obstetric sedation Respiratory distress – pnemonia, inborn errors of metabolism Respiratory distress – pnemonia, inborn errors of metabolism
(hyperammonemia), congenital defects of upper airways(hyperammonemia), congenital defects of upper airways
APNEA OF PREMATURITY (AOP)APNEA OF PREMATURITY (AOP)
CLINICAL MANIFESTATIONS:CLINICAL MANIFESTATIONS: Persistent apneic spellsPersistent apneic spells
TREATMENTTREATMENT Observe for apneaObserve for apnea Check for thermal stabilityCheck for thermal stability Administration of methylxanthines (theophylline, aminophylline Administration of methylxanthines (theophylline, aminophylline
or caffeine)or caffeine) Reduce frequency of primary apnea-bradycardia spells in newbornReduce frequency of primary apnea-bradycardia spells in newborn CNS stimulants to breathingCNS stimulants to breathing Observe for symptoms of toxicityObserve for symptoms of toxicity Caffeine – fewer side effects ; once daily dosingCaffeine – fewer side effects ; once daily dosing Monitor weight and urine outputMonitor weight and urine output
APNEA OF PREMATURITY (AOP)APNEA OF PREMATURITY (AOP)
TREATMENT:TREATMENT:Nasal continuous positive airway pressure Nasal continuous positive airway pressure
(NCPAP) and intermittent positive pressure (NCPAP) and intermittent positive pressure ventilationventilationCPAP acts to maintain airway patencyCPAP acts to maintain airway patencyMore effective for obstructive/ mixed apneaMore effective for obstructive/ mixed apnea
APNEA OF PREMATURITY (AOP)APNEA OF PREMATURITY (AOP)
NURSING CONSIDERATION:NURSING CONSIDERATION: Monitor respiration and heart rate routinely in all preterm infantsMonitor respiration and heart rate routinely in all preterm infants Observe for presence of respirationsObserve for presence of respirations Observe colorObserve color Provide gentle tactile stimulation – rubbing the back/ chest Provide gentle tactile stimulation – rubbing the back/ chest
gently, turning infant to supine positiongently, turning infant to supine position If tactile stimulation fails to reinstitute respiration – flow by If tactile stimulation fails to reinstitute respiration – flow by
oxygen and suctioning of nose and mouthoxygen and suctioning of nose and mouth Apply artificial ventilation with bag-valve mask and with sufficient Apply artificial ventilation with bag-valve mask and with sufficient
pressure to lift rib cagepressure to lift rib cage If breathing does not beginIf breathing does not begin Raise chin gently to open airwayRaise chin gently to open airway Infant is never shakenInfant is never shaken
APNEA OF PREMATURITY (AOP)APNEA OF PREMATURITY (AOP)
NURSING CONSIDERATION:NURSING CONSIDERATION: After breathing is restored: assess for and manage any After breathing is restored: assess for and manage any
precipitating factors (temperature instability, abdominal precipitating factors (temperature instability, abdominal distention, ambient oxygen) – use pulse oximetrydistention, ambient oxygen) – use pulse oximetry
Record episodes of apnea - # apneic spells, appearance during Record episodes of apnea - # apneic spells, appearance during and after the episode, did infant self-recover or whether tactile and after the episode, did infant self-recover or whether tactile stimulation or other measures were done to restore breathing.stimulation or other measures were done to restore breathing.
Investigate possible cause of apneic episodeInvestigate possible cause of apneic episode Observe for signs of theophylline or caffeine toxicity; tachycardia Observe for signs of theophylline or caffeine toxicity; tachycardia
(rate 180-190/ min) and later, vomiting, restlessness, irritability(rate 180-190/ min) and later, vomiting, restlessness, irritability Assess skin (with NCPAP) for breakdown, irritation, and nasal Assess skin (with NCPAP) for breakdown, irritation, and nasal
septumseptum
AUTISTIC SPECTRUM AUTISTIC SPECTRUM DISORDER (AUTISM)DISORDER (AUTISM)
Complex developmental disorder of brain Complex developmental disorder of brain function accompanied by intellectual and function accompanied by intellectual and behavioral deficitsbehavioral deficits
Manifested during early childhood: 18-36 Manifested during early childhood: 18-36 months of agemonths of age
1-2 in 500 children; males > females 1-2 in 500 children; males > females (females more severely affected)(females more severely affected)
Not related to socioeconomic level, race, Not related to socioeconomic level, race, parenting styleparenting style
AUTISTIC SPECTRUM AUTISTIC SPECTRUM DISORDER (AUTISM)DISORDER (AUTISM)
ETIOLOGYETIOLOGY UnknownUnknown Multiple biologic causesMultiple biologic causes Abnormal EEG, epileptic seizures, delayed development of hand Abnormal EEG, epileptic seizures, delayed development of hand
predominance, persistence of primitive reflexes, metabolic predominance, persistence of primitive reflexes, metabolic abnormalities (increased serotonin), hypoplasia of vermis of abnormalities (increased serotonin), hypoplasia of vermis of cerebellumcerebellum
Increased in twinsIncreased in twins High risk of recurrence of ASD in families with one affected childHigh risk of recurrence of ASD in families with one affected child Not caused by thimerosal-containing vaccinesNot caused by thimerosal-containing vaccines Associated with fragile X syndrome, tuberous sclerosis, Associated with fragile X syndrome, tuberous sclerosis,
metabolic disorder, fetal rubella syndrome, H. influenza metabolic disorder, fetal rubella syndrome, H. influenza meningitis, structural brain anomaliesmeningitis, structural brain anomalies
Perinatal events: higher incidence of maternal uterine bleeding Perinatal events: higher incidence of maternal uterine bleeding during pregnancyduring pregnancy
Lower incidence of maternal vaginal infections during pregnancyLower incidence of maternal vaginal infections during pregnancy Decreased maternal use of contraceptivesDecreased maternal use of contraceptives Higher incidence of neonatal hyperbilirubinemiaHigher incidence of neonatal hyperbilirubinemia
AUTISTIC SPECTRUM AUTISTIC SPECTRUM DISORDER (AUTISM)DISORDER (AUTISM)
CLINICAL MANIFESTATIONS AND CLINICAL MANIFESTATIONS AND DIAGNOSTIC EVALUATION:DIAGNOSTIC EVALUATION: Hallmark: inability to maintain eye contact with Hallmark: inability to maintain eye contact with
another personanother person Display limited functional play and may interact with Display limited functional play and may interact with
toys in an unusual mannertoys in an unusual manner Deficits in social development: primary feature of Deficits in social development: primary feature of
illnessillness Majority have some degree of mental retardationMajority have some degree of mental retardation
Females tend to have very low intelligence scoresFemales tend to have very low intelligence scores Savants – children with ASD who excel in particular Savants – children with ASD who excel in particular
areas: art, music, memory, mathematics, perceptual areas: art, music, memory, mathematics, perceptual skills (puzzle building)skills (puzzle building)
AUTISTIC SPECTRUM AUTISTIC SPECTRUM DISORDER (AUTISM)DISORDER (AUTISM)
Speech and language delaysSpeech and language delaysImmediate evaluation of any child who does not Immediate evaluation of any child who does not
display such language skills as babbling or display such language skills as babbling or gesturing by 12 months, single word by 16 months, gesturing by 12 months, single word by 16 months, 2-word phrases by 24 months2-word phrases by 24 months
Sudden deterioration in extant expressive speech Sudden deterioration in extant expressive speech is also a red-flag event for further evaluationis also a red-flag event for further evaluation
AUTISTIC SPECTRUM AUTISTIC SPECTRUM DISORDER (AUTISM)DISORDER (AUTISM)
DIAGNOSTIC CRITERIA FOR ASD:DIAGNOSTIC CRITERIA FOR ASD: Total of 6 (or more) items from (1), (2), (3) with at Total of 6 (or more) items from (1), (2), (3) with at
least two from (1), and one each from (2) & (3)least two from (1), and one each from (2) & (3)(1) Qualitative impairment in social interaction, as manifested (1) Qualitative impairment in social interaction, as manifested
by at least 2 of the following:by at least 2 of the following: Marked impairment in use of multiple nonverbal behaviors such Marked impairment in use of multiple nonverbal behaviors such
as eye-to-eye gaze, facial expression, body postures, & as eye-to-eye gaze, facial expression, body postures, & gestures to regulate social interactiongestures to regulate social interaction
Failure to develop peer relationships appropriate to Failure to develop peer relationships appropriate to developmental leveldevelopmental level
A lack of spontaneous seeking to share enjoyment, interests, or A lack of spontaneous seeking to share enjoyment, interests, or achievements w/ other people (ex. By a lack of showing, achievements w/ other people (ex. By a lack of showing, bringing, or pointing out objects of interest)bringing, or pointing out objects of interest)
Lack of social/ emotional reciprocityLack of social/ emotional reciprocity
AUTISTIC SPECTRUM AUTISTIC SPECTRUM DISORDER (AUTISM)DISORDER (AUTISM)
(2) Qualitative impairments in communication as (2) Qualitative impairments in communication as manifested by at least 1 of the following:manifested by at least 1 of the following:
Delay in, or total lack, of the development of spoken Delay in, or total lack, of the development of spoken language (not accompanied by an attempt to language (not accompanied by an attempt to compensate through alternative modes of compensate through alternative modes of communication such as gesture or mime)communication such as gesture or mime)
In individuals w/ adequate speech, marked impairment in In individuals w/ adequate speech, marked impairment in the ability to initiate or sustain a conversation with othersthe ability to initiate or sustain a conversation with others
Stereotyped and repetitive use of language or Stereotyped and repetitive use of language or idiosyncratic languageidiosyncratic language
Lack of varied, spontaneous, make-believe play or social Lack of varied, spontaneous, make-believe play or social imitative play appropriate to developmental levelimitative play appropriate to developmental level
AUTISTIC SPECTRUM AUTISTIC SPECTRUM DISORDER (AUTISM)DISORDER (AUTISM)
(3) Restricted repetitive and stereotyped patterns of behavior, interests (3) Restricted repetitive and stereotyped patterns of behavior, interests & activities, as manifested by at least 1 of the following:& activities, as manifested by at least 1 of the following:
Encompassing preoccupation with one or more stereotyped and Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focusrestricted patterns of interest that is abnormal either in intensity or focus
Apparently inflexible adherence to specific, nonfunctional routines or Apparently inflexible adherence to specific, nonfunctional routines or ritualsrituals
Stereotyped & repetitive motor mannerisms (ex. Hand or finger flapping Stereotyped & repetitive motor mannerisms (ex. Hand or finger flapping or twisting, or complex whole-body movements)or twisting, or complex whole-body movements)
Persistent preoccupation w/ parts of objectsPersistent preoccupation w/ parts of objects Delays or abnormal functioning in at least 1 of the following Delays or abnormal functioning in at least 1 of the following
areas with onset before age 3 yearsareas with onset before age 3 years Social interactionSocial interaction Language as used in social communicationLanguage as used in social communication Symbolic or imaginative playSymbolic or imaginative play
The disturbance is not better accounted for by Rett disorder or The disturbance is not better accounted for by Rett disorder or childhood disintegrative disorderchildhood disintegrative disorder
AUTISTIC SPECTRUM AUTISTIC SPECTRUM DISORDER (AUTISM)DISORDER (AUTISM)
PROGNOSIS:PROGNOSIS: Severely disabling conditionSeverely disabling condition Some improve with acquisition of language skills & Some improve with acquisition of language skills &
communication w/ otherscommunication w/ others Some achieve independence, but most require Some achieve independence, but most require
lifelong adult supervisionlifelong adult supervision Aggravation of psychiatric symptoms – ½ children Aggravation of psychiatric symptoms – ½ children
during adolescence, w/ girls having tendency for during adolescence, w/ girls having tendency for continued deteriorationcontinued deterioration
Most favorable for children who develop Most favorable for children who develop communicative speech by age, years & have an IQ communicative speech by age, years & have an IQ higher than 50 at time of diagnosishigher than 50 at time of diagnosis
AUTISTIC SPECTRUM AUTISTIC SPECTRUM DISORDER (AUTISM)DISORDER (AUTISM)
NURSING CARE MANAGEMENT:NURSING CARE MANAGEMENT: No cure for ASD but there are numerous therapiesNo cure for ASD but there are numerous therapies Highly structured & intensive behavior modification Highly structured & intensive behavior modification
programsprograms Promote positive reinforcement, increase social Promote positive reinforcement, increase social
awareness of others, teach verbal communication awareness of others, teach verbal communication skills and decrease unacceptable behaviorskills and decrease unacceptable behavior
Provide a structured routine for the child to follow – Provide a structured routine for the child to follow – key management in ASDkey management in ASD
AUTISTIC SPECTRUM AUTISTIC SPECTRUM DISORDER (AUTISM)DISORDER (AUTISM)
NURSING CARE MANAGEMENT:NURSING CARE MANAGEMENT: Hospitalized child with ASD: dcrease stimulationHospitalized child with ASD: dcrease stimulation
Place child in private roomPlace child in private room Avoid extraneous auditory & visual distractionAvoid extraneous auditory & visual distraction Encourage parents to bring in possessions to which child is Encourage parents to bring in possessions to which child is
attachedattached Minimum holding & eye contactMinimum holding & eye contact Care must be taken when performing procedures, Care must be taken when performing procedures,
administering meds, feeding these children – may swallow administering meds, feeding these children – may swallow thermometer, gags when eatingthermometer, gags when eating
Family support - counselingFamily support - counseling
MAJOR STRESSORS OF MAJOR STRESSORS OF HOSPITALIZATIONHOSPITALIZATION
SEPARATION ANXIETYSEPARATION ANXIETYMiddle infancy – preschool ageMiddle infancy – preschool ageSTAGES:STAGES:
PROTEST PHASE:PROTEST PHASE: Cry and screamCry and scream Cling to parentCling to parent Avoids/ rejects contact with strangersAvoids/ rejects contact with strangers Verbally and physically attack strangersVerbally and physically attack strangers Attempts to escape and find parentsAttempts to escape and find parents
MAJOR STRESSORS OF MAJOR STRESSORS OF HOSPITALIZATIONHOSPITALIZATION
DESPAIR PHASE:DESPAIR PHASE: Crying stops, evidence of depressionCrying stops, evidence of depression Less activeLess active Uninterested in foodUninterested in food Withdraws from othersWithdraws from others Child’s physical condition may deteriorate from refusal to Child’s physical condition may deteriorate from refusal to
eat, drink, or moveeat, drink, or move
DETACHMENT PHASE:DETACHMENT PHASE: Denial; resignation and not contentmentDenial; resignation and not contentment Child becomes more interested in the surroundingsChild becomes more interested in the surroundings Forms new but superficial relationshipForms new but superficial relationship May have serious attachment to parent after separationMay have serious attachment to parent after separation
MAJOR STRESSORS OF MAJOR STRESSORS OF HOSPITALIZATIONHOSPITALIZATION
LOSS OF CONTROLLOSS OF CONTROL INFANTSINFANTS
TrustTrust Consistent, loving caregiversConsistent, loving caregivers Attempts to control their environment through emotional Attempts to control their environment through emotional
expressionsexpressions
TODDLERSTODDLERS AutonomyAutonomy When their egocentric pleasures meet with obstacles, they When their egocentric pleasures meet with obstacles, they
react with negativismreact with negativism Results from altered routines and ritualsResults from altered routines and rituals
MAJOR STRESSORS OF MAJOR STRESSORS OF HOSPITALIZATIONHOSPITALIZATION
PRESCHOOLERSPRESCHOOLERSSuffer loss of control by physical restriction, altered Suffer loss of control by physical restriction, altered
routines, and enforced dependencyroutines, and enforced dependencyEgocentric and magical thinking typical of ageEgocentric and magical thinking typical of ageMay view illness and hospitalization as punishment May view illness and hospitalization as punishment
for misdeedfor misdeedPREOPERATIONAL THOUGHT – explanations PREOPERATIONAL THOUGHT – explanations
are understood only in terms of real eventsare understood only in terms of real eventsTRANSDUCTIVE REASONING – deduct from the TRANSDUCTIVE REASONING – deduct from the
particular to particular, rather than from the specific particular to particular, rather than from the specific to the generalto the general
MAJOR STRESSORS OF MAJOR STRESSORS OF HOSPITALIZATIONHOSPITALIZATION
SCHOOL AGESCHOOL AGE Striving for independence and productivityStriving for independence and productivity Altered family roles, physical disability, fears of death, Altered family roles, physical disability, fears of death,
abandonment, permanent injury, loss of peer acceptance, abandonment, permanent injury, loss of peer acceptance, lack of productivitylack of productivity
BoredomBoredom
ADOLESCENTSADOLESCENTS Struggle for independence, self assertion and liberation – Struggle for independence, self assertion and liberation –
personal identitypersonal identity Separation from peer groupSeparation from peer group May respond with anger, frustrationMay respond with anger, frustration Voluntarily isolate themselves from age mates until they can Voluntarily isolate themselves from age mates until they can
feel they can competefeel they can compete Need for information about their conditionNeed for information about their condition
MAJOR STRESSORS OF MAJOR STRESSORS OF HOSPITALIZATIONHOSPITALIZATION
FEARS OF BODILY INJURY AND PAINFEARS OF BODILY INJURY AND PAIN Common fear among childrenCommon fear among children May persist into adulthood and result in avoidance of May persist into adulthood and result in avoidance of
needed careneeded care
YOUNG INFANT’S RESPONSE TO PAIN: <6 monthsYOUNG INFANT’S RESPONSE TO PAIN: <6 months Generalized response of rigidity, thrashingGeneralized response of rigidity, thrashing Loud cryingLoud crying Facial expressions of discomfort – most consistent indicator Facial expressions of discomfort – most consistent indicator
of stressof stress No understanding of the relationship between stimuli and No understanding of the relationship between stimuli and
subsequent pain.subsequent pain.
MAJOR STRESSORS OF MAJOR STRESSORS OF HOSPITALIZATIONHOSPITALIZATION
OLDER INFANT’S RESPONSE TO PAIN: (6months – 1year)OLDER INFANT’S RESPONSE TO PAIN: (6months – 1year) Withdrawal from painful stimuliWithdrawal from painful stimuli Loud cryingLoud crying Facial grimaceFacial grimace Physical resistancePhysical resistance
YOUNG CHILD’S RESPONSE TO PAIN: (toddlers)YOUNG CHILD’S RESPONSE TO PAIN: (toddlers) Loud crying; screamingLoud crying; screaming Verbalization, “ow”, “ouch”, “it hurts”Verbalization, “ow”, “ouch”, “it hurts” Thrashing of limbsThrashing of limbs Attempts to push away stimulusAttempts to push away stimulus Uncooperative; needs restraintsUncooperative; needs restraints Clings to parent, nurse, or other significant personClings to parent, nurse, or other significant person Request emotional supportRequest emotional support
MAJOR STRESSORS OF MAJOR STRESSORS OF HOSPITALIZATIONHOSPITALIZATION
SCOOL-AGE CHILD’S RESPONSE TO PAINSCOOL-AGE CHILD’S RESPONSE TO PAINStalling behavior – “wait a minute”, “I’m not ready”Stalling behavior – “wait a minute”, “I’m not ready”Muscle rigidityMuscle rigidityMay use all behaviors of young childMay use all behaviors of young child
ADOLESCENT’S RESPONSE TO PAINADOLESCENT’S RESPONSE TO PAINLess vocal protest, less motor activityLess vocal protest, less motor activityIncreased muscle tension and body controlIncreased muscle tension and body controlMore verbalization (“It hurts”, You’re hurting me!”)More verbalization (“It hurts”, You’re hurting me!”)
INDIVIDUAL RISK FACTORS THAT INDIVIDUAL RISK FACTORS THAT INCREASE VULNERABILITY TO INCREASE VULNERABILITY TO
STRESSES OF STRESSES OF HOSPITALIZATIONHOSPITALIZATION
““Difficult” temperamentDifficult” temperament Lack of fit between child and parentLack of fit between child and parent Age (especially between 6 months and 5 years Age (especially between 6 months and 5 years
old)old) Male genderMale gender Below average intelligenceBelow average intelligence Multiple and continuing stresses (ex. Frequent Multiple and continuing stresses (ex. Frequent
hospitalizations)hospitalizations)
BENEFICIAL EFFECT OF BENEFICIAL EFFECT OF HOSPITALIZATIONHOSPITALIZATION
Recovery from illnessRecovery from illness
Increase coping skillsIncrease coping skills
Master stress and feel competent in Master stress and feel competent in copingcoping
New socialization experiencesNew socialization experiences
PREVENTING OR MINIMIZING PREVENTING OR MINIMIZING SEPARATIONSEPARATION
Primary nursing goalPrimary nursing goal
Especially for children < 5 years oldEspecially for children < 5 years old
Family-centered careFamily-centered care
Parents are not “visitors”Parents are not “visitors”
Familiar items from homeFamiliar items from home
NORMALIZING THE HOSPITAL NORMALIZING THE HOSPITAL ENVIRONMENTENVIRONMENT
Maintain child’s routine, if possibleMaintain child’s routine, if possible
Time structuringTime structuring
Self-care (age appropriate)Self-care (age appropriate)
School workSchool work
Friends and visitorsFriends and visitors
PREVENTING OR MINIMIZING PREVENTING OR MINIMIZING FEAR OF BODILY INJURYFEAR OF BODILY INJURY
All children fear bodily injury from mutation, All children fear bodily injury from mutation, bodily intrusion, body-image change, disability, bodily intrusion, body-image change, disability, or death.or death.
Preparation of children for painful procedures Preparation of children for painful procedures decreases their fears.decreases their fears.
Use of bandagesUse of bandages Repeatedly stress the reason for a procedureRepeatedly stress the reason for a procedure Adolescents may express concern about the Adolescents may express concern about the
actual procedure but more anxious about the actual procedure but more anxious about the resulting scar.resulting scar.
PAIN FACTS AND FALLACIESPAIN FACTS AND FALLACIES
FACT: Children are under treated for pain.FACT: Children are under treated for pain.
FACT: Analgesia is withheld for fear of the child FACT: Analgesia is withheld for fear of the child becoming addictedbecoming addicted
FALLACY: Analgesia should be withheld FALLACY: Analgesia should be withheld because it may cause respiratory depression in because it may cause respiratory depression in childrenchildren
FALLACY: Infants do not feel pain.FALLACY: Infants do not feel pain.
PRINCIPLE OF PAIN PRINCIPLE OF PAIN ASSESSMENT IN CHILDREN: ASSESSMENT IN CHILDREN:
QUESTTQUESTT Question the child.Question the child. Use pain rating scale.Use pain rating scale. Evaluate behavioral & physiologic changes.Evaluate behavioral & physiologic changes. Secure parent’s involvement.Secure parent’s involvement. Take the cause of pain into account.Take the cause of pain into account. Take action and evaluate result.Take action and evaluate result.
Question the child – verbal & description of pain. Ask child to Question the child – verbal & description of pain. Ask child to point where it hurts.point where it hurts.
Use of Pain Rating Scale – provide a quantitative self-reporting Use of Pain Rating Scale – provide a quantitative self-reporting measure of pain.measure of pain.
PAIN RATING SCALESPAIN RATING SCALES
Not all pain rating scale are reliable or Not all pain rating scale are reliable or appropriate for childrenappropriate for children
Should be age appropriateShould be age appropriate
Consistent use of same scale by all staff.Consistent use of same scale by all staff.
Familiarize child with scaleFamiliarize child with scale
PAIN RATING SCALEPAIN RATING SCALE
F.L.A.C.C (FACE, LEGS, ACTIVITY, CRY, CONSOLABILITYF.L.A.C.C (FACE, LEGS, ACTIVITY, CRY, CONSOLABILITY
00 11 22
FACEFACE No particular No particular expression or smileexpression or smile
Occasional grimace Occasional grimace or frown, withdrawn, or frown, withdrawn, disinteresteddisinterested
Frequent to constant Frequent to constant frown, clenched jaw, frown, clenched jaw, quivering chinquivering chin
LEGSLEGS
ACTIVITYACTIVITY
Normal, relaxed Normal, relaxed position, moves position, moves easilyeasily
Uneasy, restless, Uneasy, restless, tense, shifting back tense, shifting back and forthand forth
Arched, rigid or Arched, rigid or jerkingjerking
CRYCRY No cry (awake or No cry (awake or asleep)asleep)
Moans, whimpers, Moans, whimpers, occasional occasional complaintcomplaint
Crying steadily, Crying steadily, screams or sobs, screams or sobs, frequent complaintsfrequent complaints
CONSOLABILITYCONSOLABILITY Content, relaxedContent, relaxed Reassured by Reassured by occasional touching, occasional touching, hugging or talking tohugging or talking to
Difficult to console Difficult to console or comfortor comfort
CHILDREN’S DEVELOPMENTAL CHILDREN’S DEVELOPMENTAL CONCEPT OF ILLNESSCONCEPT OF ILLNESS
PREOPERATIONAL THOUGHT PREOPERATIONAL THOUGHT
(2-7years)(2-7years)PHENOMENISM – perceives an external, PHENOMENISM – perceives an external,
unrelated, concrete phenomenon as cause of unrelated, concrete phenomenon as cause of illnessillness
CONTAGION – perceives cause of illness as CONTAGION – perceives cause of illness as proximity between 2 events that occur by proximity between 2 events that occur by magicmagic
CHILDREN’S DEVELOPMENTAL CHILDREN’S DEVELOPMENTAL CONCEPT OF ILLNESSCONCEPT OF ILLNESS
CONCRETE OPERATIONAL THOUGHTCONCRETE OPERATIONAL THOUGHT
(7-10years)(7-10years)CONTAMINATION – perceives cause as a CONTAMINATION – perceives cause as a
person, object, or action external to the child person, object, or action external to the child that is “bad” or “harmful” to the bodythat is “bad” or “harmful” to the body
INTERNALIZATION – perceives illness as INTERNALIZATION – perceives illness as having an external cause but as being located having an external cause but as being located inside the bodyinside the body
CHILDREN’S DEVELOPMENTAL CHILDREN’S DEVELOPMENTAL CONCEPT OF ILLNESSCONCEPT OF ILLNESS
FORMAL OPERATIONAL THOUGHTFORMAL OPERATIONAL THOUGHT (13yrs & above)(13yrs & above)
PHYSIOLOGIC – perceives cause as PHYSIOLOGIC – perceives cause as malfunctioning or nonfunctioning organ or malfunctioning or nonfunctioning organ or process; can explain illness in sequence of process; can explain illness in sequence of eventsevents
PSYCHOPHYSIOLOGIC – realizes that PSYCHOPHYSIOLOGIC – realizes that psychologic actions and attitudes affect health psychologic actions and attitudes affect health and illness. and illness.