Pregnancy & Newborn Screening Developments Newborn Screening for Sickle Cell Disorders.
Unit 4 Newborn Care Chapter 23: Assessment and Management...
Transcript of Unit 4 Newborn Care Chapter 23: Assessment and Management...
4 1 2 MaternalNewbornNursing
Unit4 NewbornCare
Chapter23: AssessmentandManagementofNewbornComplications Contributor:LindaS.Wood,MSN,RN
NCLEX-PN®Connections:Learning Objective:Reviewandapplyknowledgewithin“Assessment and Management of Newborn Complications”inreadinessforperformanceofthefollowingnursingactivitiesasoutlinedbytheNCLEX-PN®testplan:
Checkthenewbornforpossiblecomplications.
Providecaretothenewbornwhoisexperiencingcomplications.
Newborn Complication: Preterm Infant
KeyPoints
Apreterminfantisonewhoisbornafter20weeksgestationandbeforethecompletionof37weeksgestation.
Preterm newborns areat risk fora variety of complications dueto immature organ systems. The degreeofcomplicationsdependsongestationalage.Thecloserthenewbornisto40weeksgestation,thelessthechancesareforcomplications.
Respiratory distress syndrome (RDS)–decreasedsurfactantinthealveoliregardlessofbirthweight.
Bronchopulmonary dysplasia (BPD)–causesthelungstobecomestiffandnoncompliant,requiringaninfanttobeplacedonmechanicalventilationandoxygen.Itissometimesdifficulttoremovetheinfantfromventilationandoxygenafterinitialplacement.
Aspiration–aresultoftheprematureinfantnothavinganintactgagreflexortheabilitytoeffectivelysuckorswallow.
Apnea of prematurity–aresultofimmatureneurologicalandchemicalmechanisms.
Intraventricular hemorrhage–bleedinginoraroundtheventriclesofthebrain.
∆
∆
∆
∆
•
•
•
•
•
CHAPTER 23AssessmentandManagementofNewbornComplications
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 1 3
Retinopathyofprematurity–diseasecausedbyabnormalgrowthofretinalbloodvesselsandisacomplicationassociatedwithoxygenadministrationtotheneonate.Itcancausemildtosevereeyeandvisionproblems.
Patentductusarteriosus (PDA)–occurswhentheductusarteriosusreopensafterbirthduetoneonatalhypoxia.
Necrotizingenterocolitis (NEC)–aninflammatorydiseaseofthegastrointestinalmucosaduetoischemia.NECresultsinnecrosisandperforationofthebowel.Shortgutsyndromemaybetheresultsecondarytoremovalofmostorpartofthesmallintestineduetonecrosis.
Additional complicationsincludeinfection,hyperbilirubinemia,anemia,hypoglycemia,anddelayedgrowthanddevelopment.
KeyFactors
Preterm birthscanbeattributedtomanycausesincluding:
Gestationalhypertension.
Multiplepregnancies.
Adolescentpregnancy.
Lackofprenatalcare.
Substanceabuse.
Smoking.
Previoushistoryofpretermdelivery.
Abnormalitiesoftheuterus.
Cervicalincompetence.
Prematureruptureofthemembranes(PROM).
Placentaprevia.
DiagnosticandTherapeuticProceduresandNursingInterventions
Testsareperformedtomonitorforor treatthemanycomplicationsofpretermbirth.
Completebloodcount(CBC)showsdecreasedhemoglobinandhematocritasaresultoftheslowproductionofredbloodcells
Urinalysisandspecificgravity
Increasedprothrombintimeandpartialthromboplastintimewithanincreasedtendencytobleed
Chestx-ray
•
•
•
•
∆
•
•
•
•
•
•
•
•
•
•
•
∆
•
•
•
•
AssessmentandManagementofNewbornComplications
4 1 4 MaternalNewbornNursing
Arterialbloodgas(ABG)
Headultrasounds
Echocardiography
Eyeexams
Serumglucose
Calcium
Bilirubin
DataCollection
Monitorfor signs and symptoms ofa preterm infant.
Ballard assessmentshowsaphysicalandneurologicalassessmenttotalinglessthan37weeksgestation
Periodic breathingconsistsof5to10secrespiratorypauses,followedby10to15seccompensatoryrapidrespirations
Signsofincreasedrespiratoryeffortand/orrespiratorydistress
Apnea(pauseinrespirationslongerthan10to15sec)
Lowbirthweight
Minimal subcutaneous fat deposits
Headlargeincomparisontobody
Wrinkledfeatures
Skinthatisthin,smooth,shiny,andmaybetranslucent
Veinsclearlyvisibleunderthin,transparentepidermis
Lanugooverthebody
Soft, pliable ear cartilage
Minimal creasesinthesolesandpalms
Skullandribcagefeelsoft
Closedeyesif22to24weeksgestation
Fewscrotalrugae
Undescendedtestes
Prominentlabiaandclitoris
Flatareolawithoutbreastbuds
•
•
•
•
•
•
•
∆
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 1 5
Weakgraspreflex
Heelsfullymovabletotheears, posture extended and frog-like
Inabilityto coordinate suck and swallow,andaweakorabsentgag,suck,andcoughreflex;weakswallow
Hypotonic muscles,decreasedlevelofactivity,weakcryformorethan24hr
Lethargy,tachycardia,andpoorweightgain
Signsofinfection
Observeforsignsofdehydration or overhydration(resultingfromIVnutritionandfluidadministration).
Dehydration
Urineoutputlessthan1mL/kg/hr
Urinespecificgravitymorethan1.015
Weightloss
Drymucousmembranes
Poorskinturgor
Depressedfontanel
Overhydration
Urineoutputgreaterthan3mL/kg/hr
Urinespecificgravitylessthan1.001
Edema
Increasedweightgain
Rales
Intakegreaterthanoutput
Assessmentsforprematureinfantsinclude:
Performingrapidinitialassessment.
Monitoringtheinfant’svitalsignsandtemperature.
Observingforcomplicationsofprematurity.
Assessingtheinfant’sabilitytoconsumeanddigestnutrients.Beforeaprematureinfantcanfeedbybreastornipple,theinfantmusthaveanintactgagreflexandbeabletosuckandswallowtopreventaspiration.
Monitoringtheinfant’sintakeandoutput.
Monitoringeliminationpatternsconsistingoffrequency,amount,color,andconsistency.
•
•
•
•
•
•
∆
•
◊
◊
◊
◊
◊
◊
•
◊
◊
◊
◊
◊
◊
∆
•
•
•
•
•
•
AssessmentandManagementofNewbornComplications
4 1 6 MaternalNewbornNursing
Monitoringtheinfantforweightandfluidlossaswellasmeasuringandrecordingtheinfant’sweightdaily.
Monitoringforbleedingfrompuncturesitesandthegastrointestinaltract.
NANDANursingDiagnoses
Ineffectiveairwayclearancerelatedtoneuromusculardysfunction
Excessfluidvolumerelatedtointravenousnutrition
Suddeninfantdeathsyndromerelatedtoprematurityofinfant
Ineffectivethermoregulationrelatedtoinsufficientsubcutaneousbodyfat
Riskforinfectionrelatedtoimmatureimmunesystem
Riskfordisorganizedinfantbehaviorrelatedtoprematurityofinfant
NursingInterventions
Goalsincludemeetingtheinfant’sgrowthanddevelopmentneedsandanticipatingandmanagingassociatedcomplicationssuchasrespiratorydistresssyndromeandsepsis.
Themainpriorityintreatingpretermnewbornsissupportingthecardiacandrespiratorysystemsasneeded.Mostpreterminfantsarecaredforinaneonatalintensivecareunit(NICU).MeticulouscareandobservationintheNICUisnecessaryuntilthenewborncanreceiveoralfeedings,maintainbodytemperature,andweighsapproximately2kg(4.4lb).
Perform resuscitativemeasuresifneeded.
Ensure thermoregulation(neutralthermalenvironment)tomaintaintheprematureinfant’sbodytemperature
Administerrespiratorysupportmeasuressuchassurfactantand/oroxygenadministration.
Administerparental or enteral nutrition and fluidsasprescribed(mostprematureinfantslessthan34weekswillreceivefluidseitherbyIVorgavagefeedings).
Administermedicationsasprescribed.
Minimize stimulation.Clusternursingcare.Touchthenewbornverysmoothlyandlightly.Keeplightingdimandnoiselevelsreduced.
Positiontheinfantinneutral flexionwiththe extremities close to the bodytoconservebodyheat.Prone and side-lying positions are preferredtosupinewithbodycontainmentusingblanketrolls,swaddling,andsecureholdingtoprovidesecureboundaries.Pronepositionencouragesflexionoftheextremities.
•
•
∆
∆
∆
∆
∆
∆
∆
∆
•
•
•
•
•
•
•
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 1 7
Providefornon-nutritive suckingsuchasusingapacifierwhilegavagefeeding.
Protectagainstinfection.
Keepparentsinformedandeducatedaboutthecareoftheirpretermnewborn.
Newborn Complication: Respiratory Distress Syndrome (RDS)
KeyPoints
Respiratory distress syndrome (RDS)occursasaresultofsurfactantdeficiencyinthelungsandischaracterizedbypoorgasexchangeandventilatoryfailure.
Surfactantisaphospholipidthatassistsinalveoliexpansion. Surfactantkeepsalveolifromcollapsingandallowsgasexchangetooccur.
Atelectasis(collapsingofaportionoflung)increasestheworkofbreathing.Asaresult,respiratoryacidosisandhypoxemiacandevelop.
Birth weight aloneisnotanindicatoroffetal lung maturity.
ComplicationsfromRDSarerelated to oxygen therapy and mechanical ventilation.
Pneumothorax
Pneumomediastinum
Retinopathyofprematurity
Bronchopulmonarydysplasia
Infection
Intraventricularhemorrhage
KeyFactors
Risk factorsthatcontributetoRDSinclude:
Decreasedgestationalage(preterm).
Perinatalasphyxia(e.g.,meconiumstaining,cordprolapse,andnuchalcord).
Maternaldiabetes.
Prematureruptureofmembranes.
Maternaluseofbarbituratesornarcoticsclosetobirth.
•
•
•
∆
∆
∆
∆
∆
•
•
•
•
•
•
∆
•
•
•
•
•
AssessmentandManagementofNewbornComplications
4 1 8 MaternalNewbornNursing
Maternalhypotension.
Cesareanbirthwithoutlabor.
Hydropsfetalis(massiveedemaofthefetuscausedbyhyperbilirubinemia).
Maternalbleedingduringthethirdtrimester.
DiagnosticandTherapeuticProceduresandNursingInterventions
NewbornsdiagnosedwithRDSrequirespecificteststoevaluatetheirlungmaturity,abilitytoexchangegases,andcomplications.
ABGs revealhypercapnia(excessofcarbondioxideintheblood)andrespiratoryormixedacidosis.
Chestx-ray
Cultureandsensitivityoftheblood,urine,andcerebrospinalfluid
Bloodglucoseandserumcalcium
DataCollection
MonitorforsignsandsymptomsofRDS.
Increasedrespiratoryrategreaterthan60/min(tachypnea)
Intercostalandsubsternalretractions
Laboredbreathing
Fineralesonauscultation
Nasalflaring
Expiratorygrunting
Cyanosis
AsRDSworsens,theinfantmaybecomeunresponsive,flaccid,andapneic,withdecreasedbreathsounds.
AssessmentforRDSincludes:
Monitoringpulseoximetry.
Monitoringnutrition.
Monitoringvitalsignsclosely.
MonitoringIV.
•
•
•
•
∆
∆
∆
∆
∆
∆
•
•
•
•
•
•
•
•
∆
•
•
•
•
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 1 9
NANDANursingDiagnoses
Impairedgasexchangerelatedtodeficientsurfactantorunderdevelopedalveoli
Riskforimpairedparent-infantattachmentrelatedtoRDSofinfantrequiringmedicalinterventions
Impairedspontaneousventilationrelatedtodecreasedsurfactantlevelsintheinfant’salveoli
Dysfunctionalventilatoryweaningresponserelatedtoinabilityoftheinfanttobreatheand/orcomplicationsassociatedwithtreatmentofthedisease
IneffectivecardiovasculartissueperfusionrelatedtoRDS
NursingInterventions
Factors that can accelerate lung maturation in the fetus while in utero includeincreasedgestationalage,intrauterinestress,exogenoussteroiduse,andrupturedmembranes.
NursinginterventionsforRDSintheinfantaremostlysupportive.
Suctiontheinfant’smouth,trachea,andnoseasneeded.
Maintainthermoregulation.
Administermedicationsasprescribed(e.g.,exogenoussurfactantinprematurity,naloxone[Narcan]inmaternalnarcoticuse).
Providemouthandskincare.
Correctrespiratoryacidosisbyventilatorysupport.
Correctmetabolicacidosisbyadministeringsodiumbicarbonate.
Maintainadequateoxygenation,preventlacticacidosis,andavoidtoxiceffectsofoxygen.
Decrease stimuli.
Offeremotionalsupporttotheparents.
Newborn Complication: Postterm Infant
KeyPoints
A postterm infant isonewhoisbornafterthecompletionof42weeksofgestation.Postmaturityoftheinfantcanbeassociatedwitheitherofthefollowing:
∆
∆
∆
∆
∆
∆
∆
•
•
•
•
•
•
•
•
•
∆
AssessmentandManagementofNewbornComplications
4 2 0 MaternalNewbornNursing
Dysmaturity from placentaldegenerationanduteroplacentalinsufficiency(placentafunctionseffectivelyforonly40weeks)resultinginchronicfetalhypoxiaandfetaldistressinutero.Thefetalresponseispolycythemia,meconiumaspiration,andneonatalrespiratoryproblems.Perinatalmortalityishigherduetoincreasedoxygendemandsduringlabornotbeingmetbytheinsufficientplacenta.
Continued growth of the fetus in uterobecausetheplacentacontinuestofunctioneffectivelyandtheinfantbecomeslargeforgestationalageatbirth.Thisleadstoadifficultdelivery,cephalopelvic disproportion,aswellashighinsulinreservesandinsufficientglucosereservesatbirth.Theneonatalresponsecanbebirth trauma,perinatalasphyxia,aclaviclefracture,seizures,hypoglycemia,andtemperatureinstability(coldstress).
Apostmature infantmaybeeithersmall for gestational age (SGA) or large for gestational age (LGA)dependingonhowwelltheplacentafunctionsduringthelastweeksofthepregnancy.
Postmatureinfantshaveanincreased risk for aspirating the meconium passedbythefetusinutero.
Persistent pulmonary hypertension (persistent fetal circulation) isacomplicationthatcanresultfrommeconiumaspiration.Thereisaninterferenceinthetransitionfromfetaltoneonatalcirculation,andtheductusarteriosus(connectingmainpulmonaryarteryandtheaorta)andforamenovale(shuntbetweentherightandleftatria)remainopenandfetalpathwaysofbloodflowcontinue.
KeyFactors
Inmostcases,thecauseofaninfantgoingposttermisunknown,butthereisahigherincidenceinfirstpregnanciesandinwomenwhohavehadapreviousposttermpregnancy.
DiagnosticandTherapeuticProceduresandNursingInterventions
Cesareandelivery
Chestx-raytoruleoutmeconiumaspirationsyndrome
Bloodglucoselevelstomonitorforhypoglycemia
Arterialbloodgasessecondarytochronichypoxiainuteroduetoplacentalinsufficiency
Completebloodcountmayshowpolycythemiafromdecreasedoxygenationinutero
Hematocritelevatedfrompolycythemiaanddehydration
•
•
∆
∆
∆
∆
∆
∆
∆
∆
∆
∆
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 2 1
DataCollection
Monitorsigns and symptoms of postterm infant.
Wastedappearance,thinwithlooseskin,havingusedsomeofthesubcutaneousfat
Peeling, cracked, and dry skin;leatheryfromdecreaseinprotectivevernixandamnioticfluid
Long,thinbody
Meconiumstainingoffingernails
Hairandnailsmaybelong
Maydemonstratemorealertnesssimilartoa2-week-oldinfant
Mayhavedifficultyestablishingrespirationssecondarytomeconiumaspiration
Signsandsymptomsofhypoglycemiaduetoinsufficientstoresofglycogen
Signsandsymptomsofcoldstress
Neurologicalsymptomsthatbecomeapparentwiththedevelopmentoffinemotorskills
Macrosomia
Nursing assessmentofthepostterm infantincludes:
Observingforbirthinjuryortrauma.
Respiratorystatus.
Reflexes.
Monitoringvitalsignsandtemperature.
Monitoringintravenousfluids.
NANDANursingDiagnoses
Ineffectiveairwayclearancerelatedtomeconiumaspiration
Riskforaspirationrelatedtothepresenceofmeconium
Ineffectivethermoregulationrelatedtodecreasedsubcutaneousfat
NursingInterventionsNursinginterventionsforthepostterminfantinclude:
Assistingwithsurfactantlavagesduringdeliverytopreventmeconiumaspiration.
∆
•
•
•
•
•
•
•
•
•
•
•
∆
•
•
•
•
•
∆
∆
∆
∆
•
AssessmentandManagementofNewbornComplications
4 2 2 MaternalNewbornNursing
Suctioningmeconiumfromtheneonate’smouthandnaresbeforethefirstbreath.
Usingmechanicalventilationifnecessary.
Administeringoxygenasprescribed.
Administeringintravenous fluids.
Preparingand/orassistingwithexchangetransfusionifhematocritishigh.
Providingthermoregulationinanincubatortoavoidcoldstress.
Providingearlyfeedingstoavoidhypoglycemia.
Identifyingandtreatinganybirthinjuries.
Newborn Complication: Large for Gestational Age Infant (LGA)/Macrosomic
KeyPoints
Large for gestational age (LGA)isaneonatewhoseweightisabove the 90thpercentileorweighing more than 4,000 g (8 lb, 12 oz).LGAneonatesmaybepreterm,postterm,orfullterm.LGAdoesnotnecessarilymeanpostmature.
Macrosomic infantsareatriskforbirthinjuries (e.g.,clavicle fractureoracesareanbirth,hypoglycemia,polycythemia).
Uncontrolledhyperglycemiaduringpregnancy(leadingriskfactorforLGA)canleadtocongenitaldefectswiththemostcommonbeingcongenitalheartdefects,tracheoesophagealfistula,andcentralnervoussystemanomalies.
KeyFactors
ContributingfactorsofanLGAinfantinclude:
Postterm infants.
Maternal diabetesduringpregnancy.Highglucoselevelsstimulatecontinuedinsulinproductionbythefetus.
Fetaldisorderoftranspositionofthegreatvessels.
Geneticfactors.
Obesity.
Multiparousmother.
•
•
•
•
•
•
•
•
◊
◊
◊
∆
•
•
•
•
•
•
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 2 3
DiagnosticandTherapeuticProceduresandNursingInterventions
Cesareandeliveryifnecessary
Chest x-raytoruleoutmeconiumaspirationsyndrome
Blood glucose levels tomonitorcloselyforhypoglycemia(lessthan40mg/dL)
Arterialbloodgasesmaybeprescribedduetochronichypoxiainuterosecondarytoplacentalinsufficiency
CBCshowspolycythemia(hematocritgreaterthan65%)frominuterohypoxia
Hyperbilirubinemiaresultingfrompolycythemiaasexcessiveredbloodcellsbreakdownafterbirth
Hypocalcemiamayresultinresponsetoalonganddifficultbirth
DataCollection
MonitorLGAinfantsfor:
Weight above 90th percentile (4,000 g).
Plumpandfull-faced(cushingoidappearance)fromincreasedsubcutaneousfat.
Signsofhypoxia.
Birth trauma(e.g.,fractures,intracranialhemorrhage,andcentralnervoussysteminjury).
Sluggishness,hypotonic muscles,andhypoactivity.
Tremorsfromhypocalcemia.
Signsandsymptomsofhypoglycemia.
Signsandsymptomsofrespiratorydistressfromimmaturelungsormeconiumaspiration.
NursingassessmentforLGAinfantsinclude:
Observingforinjury.
Reflexes.
Earlyandfrequentglucoselevels.
Monitoringvitalsignsandtemperature.
Auscultatinglungsounds.
∆
∆
∆
∆
∆
∆
∆
∆
•
•
•
•
•
•
•
•
∆
•
•
•
•
•
AssessmentandManagementofNewbornComplications
4 2 4 MaternalNewbornNursing
NANDANursingDiagnoses
Riskforinjurysuchasaclaviclefracturerelatedtobirthtrauma
Riskforperipheralneurovasculardysfunctionrelatedtoinjurysustainedduringbirth
Impairedphysicalmobilityrelatedtoparalysisoffacialorbrachialnervesustainedduringbirthinjury
Ineffectivetissueperfusionrelatedtohypoglycemia
NursingInterventions
Nursing interventions foranLGAinfantinclude:
Obtainingearlyandfrequentheelsticks(glucosetesting).
Providingearlyfeedingsorintravenoustherapytomaintainnormalglucoselevels.
Thermoregulationwithincubatorcare.
Administeringsurfactantbyendotrachealtubeifindicated.
Identifyingandtreatinganybirthinjuries.
Newborn Complication: Hypoglycemia
KeyPoints
Hypoglycemiaisaserumglucoselevelofless than 40 mg/dL.Routineassessmentofallnewborns,especiallyLGAinfants,shouldincludeobservingforsymptomsofhypoglycemia.
Hypoglycemia–differsforthepretermandtermnewborn.Hypoglycemiaoccurringinthefirst3daysoflifeinthetermnewbornisdefinedasabloodglucoselevelof<40mg/dL.Inthepretermnewborn,hypoglycemiaisdefinedasthebloodglucoselevelof<25mg/dL.
Untreated hypoglycemiacanresultinmental retardation.
∆
∆
∆
∆
∆
•
•
•
•
•
∆
∆
∆
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 2 5
KeyFactors
Maternaldiabetes
Preterminfant
LGA
Stressatbirthsuchascoldstressandasphyxia
Maternalepiduralanesthesia
DiagnosticandTherapeuticProceduresandNursingInterventions
Twoconsecutivelowplasmaglucoselevelslessthan40mg/dLintheterminfant,lessthan25mg/dLinthepreterminfant
DataCollection
Monitorforsignsandsymptomsofhypoglycemia.
Poorfeeding
Jitteriness/tremors
Hypothermia
Diaphoresis
Weakshrillcry
Lethargy
Flaccidmuscletone
Seizures/coma
Nursing assessmentsforhypoglycemiainclude:
Monitoringbloodglucoselevelclosely.
MonitoringIVifunabletoorallyfeed.
Monitoringforsignsofhypoglycemia.
Monitoringvitalsignsandtemperature.
NANDANursingDiagnosesDisproportionategrowthoftheneonaterelatedtomaternaldiabetes
Imbalancednutrition:Lessthanbodyrequirementsrelatedtopoorfeeding
Riskforinjuryrelatedtocentralnervoussystemcomplicationsofhypoglycemia
∆
∆
∆
∆
∆
∆
∆
•
•
•
•
•
•
•
•
∆
•
•
•
•
∆
∆
∆
AssessmentandManagementofNewbornComplications
4 2 6 MaternalNewbornNursing
NursingInterventions
Nursing interventionsforhypoglycemiainclude:
Obtainingbloodperheelstickforglucosemonitoring.
Frequentoraland/orgavagefeedingsorcontinuosparenteralnutrition isprovidedearlyafterbirthtotreathypoglycemia(untreatedhypoglycemiacanleadtoseizures,braindamage,anddeath).
Newborn Complication: Small for Gestational Age Infant (SGA)/Intrauterine Growth Restriction (IUGR)
KeyPoints
Small for gestational age (SGA) describesaninfantwhosebirthweightisat or below the 10th percentile.
Common complications ofSGAinfantsareperinatalasphyxia,meconiumaspiration,hypoglycemia,polycythemia,andinstabilityofbodytemperature.
KeyFactors
Factors thatcontribute toanewbornbeingSGAinclude:
Congenitalorchromosomalanomalies.
Maternalinfections,disease,ormalnutrition.
Gestationalhypertensionand/ordiabetes.
Smoking,drug,oralcoholuse.
Multiplegestations.
Placentalfactors(e.g.,smallplacenta,placentaprevia,decreasedplacentalperfusion).
Fetalcongenitalinfectionssuchasrubellaortoxoplasmosis.
DiagnosticandTherapeuticProceduresandNursingInterventions
Chestx-raytoruleoutmeconiumaspirationsyndrome
Bloodglucoselevelforhypoglycemia
CBCwillshowpolycythemiaresultingfromfetalhypoxiaandintrauterinestress
ABGsmaybeprescribedduetochronichypoxiainuteroduetoplacentalinsufficiency
∆
•
•
∆
∆
∆
•
•
•
•
•
•
•
∆
∆
∆
∆
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 2 7
DataCollection
MonitorforsignsandsymptomsofSGA/IUGR.
Weight below 10th percentile
Normalskull,butreducedbodydimensions
Reducedsubcutaneousfat
Loose,dryskin
Decreasedmusclemassparticularlyoverthecheeksandbuttocks
Drawnabdomenratherthanwell-rounded
Thin,dry,yellow,anddullumbilicalcordratherthangray,glistening,andmoist
Scalphairsparse
Wideskullsuturesfrominadequatebonegrowth
Signsofrespiratorydistressandhypoxia
Wide-eyed and alert attributed to prolonged fetal hypoxia
Signsofmeconiumaspiration
Signsofhypoglycemia
Signsofhypothermia
Nursing assessmentsforSGA infantsinclude:
Auscultatingbreathsounds.
Pulseoximetry.
Assessingaxillaryskintemperatureevery4hr.
Cardiovascularcirculation.
Signsoffatigueorrespiratorydistress.
Signsofskinbreakdown.
Monitoringvitalsignsandtemperature.
NANDANursingDiagnoses
Impairedgasexchangerelatedtoaspirationofmeconium
Ineffectivethermoregulationrelatedtodecreasedsubcutaneousfat
Imbalancednutrition:Lessthanbodyrequirementsrelatedtoincreasedmetabolicrate
∆
•
•
•
•
•
•
•
•
•
•
•
•
•
•
∆
•
•
•
•
•
•
•
•
•
•
AssessmentandManagementofNewbornComplications
4 2 8 MaternalNewbornNursing
NursingInterventions
Nursing interventionsforSGA/IUGRinfantsinclude:
Supporting respiratory effortsandsuctioning asnecessarytomaintainanopenairway.
Providinganeutralthermalenvironment(isoletteorradiantheatwarmer)toprevent cold stress.
Initiatingearly feedings (SGAwillhavemorefrequentfeedings).
Parenteralnutritionifnecessary.
Administeringapartial exchange transfusion toreduceviscosityofthebloodifprescribed.
Maintainingadequate hydration.
Conservinganewborn’senergylevel.
Preventingskinbreakdown.
Protectingfrominfection.
Providingsupporttoparentsandextendedfamilyandencouragingthemtoparticipateinnewborncare.
Newborn Complication: Hyperbilirubinemia
KeyPoints
Hyperbilirubinemiaisanelevation of serum bilirubin levelsresultinginjaundice.Jaundicenormallyappearsinacephalocaudalmanner,firstbeingnoticedinthehead(especiallythescleraandmucousmembranes),andthenprogressesdownthethorax,abdomen,andextremities.
Jaundice can be either physiologic or pathologic
Physiologicjaundice isconsideredbenign(resultingfromnormalnewbornphysiologyofincreasedbilirubinproductionduetotheshortenedlifespanandbreakdownoffetalRBCsandliverimmaturity).Theinfantwithphysiologicaljaundicehasnoothersymptomsandshowssignsofjaundice after 24 hr of age.
Pathologicjaundiceisaresultofanunderlyingdisease.Pathologicjaundiceappearsbefore 24 hr of ageorispersistent after day 7.Intheterminfant,bilirubinlevelsincreasemorethan0.5mg/dL/hr,peaksatgreater than 13 mg/dL,orisassociatedwithanemiaandhepatosplenomegaly.Pathologicjaundiceisusuallycausedbyabloodgroupincompatibilityoraninfection,butmaybetheresultofRBCdisorders.
∆
•
•
•
•
•
•
•
•
•
•
∆
∆
•
•
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 2 9
Kernicterus(bilirubinencephalopathy)canresultfromuntreatedhyperbilirubinemiawithbilirubin levels at or higher than 25 mg/dL.Itisaneurologicalsyndromecausedbybilirubindepositinginbraincells.Survivorsmaydevelopcerebralpalsy,epilepsy,ormentalretardation.Theymayhaveminoreffectssuchaslearningdisordersorperceptual-motordisabilities.
KeyFactors
Factors that affect development of hyperbilirubinemiainclude:
IncreasedRBCproductionorbreakdown.
Rh or ABO incompatibility.
Decreasedliverfunction.
Maternalenzymesinbreastmilk.
Ineffectivebreastfeeding.
Certainmedications(aspirin,tranquilizers,andsulfonamides).
Hypoglycemia.
Hypothermia.
Anoxia.
DiagnosticandTherapeuticProceduresandNursingInterventions
Laboratorytestingincludes:
Elevated serum bilirubin level(directandindirectbilirubin).Monitortheinfant’sbilirubinlevelsevery4hruntillevelreturnstonormal.
Bloodgroupincapabilitybetweenthemotherandnewborn.
Hemoglobinandhematocrit.
Direct Coombs’ testrevealsthepresenceofantibody-coated(sensitized)Rh-positiveRBCsinthenewborn.
Electrolytelevelsfordehydrationfromphototherapy.
Phototherapyistheprimarytreatmentofhyperbilirubinemia.
DataCollection
Monitorforsignsandsymptomsofjaundicedifferentiatingbetweenpathologicandphysiologicjaundice.
Noteyellowishtinttoskin,sclera,andmucousmembranes.
∆
∆
•
•
•
•
•
•
•
•
•
∆
•
•
•
•
•
∆
∆
•
AssessmentandManagementofNewbornComplications
4 3 0 MaternalNewbornNursing
Toverifyjaundice,presstheinfant’sskinonthecheekorabdomenlightlywithonefinger,thenreleasepressureandobserveskincolorforyellowishtintastheskinisblanched.
Notetimeofjaundiceonsettodistinguishbetweenphysiologicandpathologicjaundice.
Assesstheunderlyingcausebyreviewingthematernalprenatal,family,andnewbornhistory.
Signsofhypoxia,hypothermia,hypoglycemia,andmetabolicacidosiscanoccurasaresultofhyperbilirubinemiaandincreasetheriskofbraindamage.
Monitorforsignsandsymptomsofkernicterus.
Yellowishskin
Lethargy
Hypotonic
Poorsuck
Ifuntreated,theinfantwillbecomehypertonicwithbackwardarchingoftheneckandtrunk
High-pitchedcry
Fever
Nursing assessments forhyperbilirubinemiainclude:
Observingskinandmucousmembranesforsignsofjaundice.
Monitoringvitalsigns.
Observeforside effects of phototherapy.
Bronzediscoloration,notaseriouscomplication
Maculopapularskinrash,notaseriouscomplication
Developmentofpressure areas
Dehydration(e.g.,poorskinturgor,drymucousmembranes,decreasedurinaryoutput)
Elevated temperature
Nursing assessments duringphototherapyinclude:
Monitoringeliminationandweighingdaily,watchingforsignsofdehydration.
Checkingaxillarytemperatureevery4hrduringphototherapybecausetemperaturemaybecomeelevated.
•
•
•
•
∆
•
•
•
•
•
•
•
∆
•
•
∆
•
•
•
•
•
∆
•
•
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 3 1
NANDANursingDiagnoses
Riskforinjuryrelatedtohemolyticdiseaseandeffectsofphototherapy
Deficientknowledge(parents)relatedtohyperbilirubinemiaandtreatment
NursingInterventions
Nursing interventionsforhyperbilirubinemiainclude:
Feedingearlyandfrequently – every3to4hr.Thiswillpromotebilirubinexcretioninthestools.
Maintainingadequatefluidintaketopreventdehydration.
Reassuringtheparentsthatmostnewbornsexperiencesomedegreeofjaundice.
Explaininghyperbilirubinemia,causes,diagnostictests,andtreatmenttoparents.
Explainingthatthenewborn’sstoolcontainssomebilethatwillbeloose andgreen.
Settingupphototherapyifprescribed.
Maintainingeye maskoverthenewborn’seyesforprotectionofcorneasandretinas.
Keepingthenewborn undressedwiththeexceptionofamalenewborn.Asurgicalmaskshouldbeplaced(makelikeabikini)overthegenitaliatopreventpossibletesticulardamagefromheatandlightwaves.Besuretoremovethemetalstripfromthemasktopreventburning.
Not applying lotions or ointmentstotheinfantbecausetheyabsorbheatandcancauseburns.
Removing the newborn from phototherapy every 4 hr andunmaskingthenewborn’seyesandcheckingforsignsofinflammationorinjury.
Repositioning the newborn every 2 hrtoexpose all of the body surfacestothephototherapylightsandprevent pressure sores.
Turningoffphototherapylightsbeforedrawingbloodfortesting.
Administeringanexchange transfusionforinfantsatriskforkernicterus.
∆
∆
∆
•
•
•
•
•
•
◊
◊
◊
◊
◊
◊
∆
AssessmentandManagementofNewbornComplications
4 3 2 MaternalNewbornNursing
Newborn Complications: Congenital Anomalies
KeyPoints
Newbornscanbebornwithamultitudeofcongenital anomaliesinvolvingallsystems.Theseareoftendiagnosedprenatally.Anurseshouldprovideemotionalsupporttotheparentswhoarefacingproceduresorsurgeriestocorrectthedefects.
Congenital anomaliesarepresentatbirthandcaninvolveanyofthebodysystems.Majoranomaliescausingseriousproblemsinclude:
Congenital heart disease(atrialseptaldefects,ventricularseptaldefects,coarctationoftheaorta,tetralogyofFallot,transpositionofthegreatvessels,stenosis,atresiaofvalves).
Neurological defects(neuraltubedefects,hydrocephalus,anencephaly,encephalocele,meningocele,ormyelomeningocele).
Gastrointestinal problems(cleftlip/palate,diaphragmatichernia,imperforateanus,tracheoesophagealfistula/esophagealatresia,omphalocele,gastroschisis,umbilicalhernia,orintestinalobstruction).
Musculoskeletal deformities(clubfoot,polydactyly,developmentaldysplasiaofthehip).
Genitourinary deformities(hypospadias,epispadias,exstrophyofthebladder).
Metabolic disorders(phenylketonuria,galactosemia,hypothyroidism).
Chromosomal abnormalities (e.g.,Downsyndrome,whichisthemostcommontrisomicabnormalitywith47chromosomesineachcell).
KeyFactors
Risk factorsforcongenital anomaliesincludegeneticand/orenvironmentalfactors.
Maternalagegreaterthan40years
ChromosomeabnormalitiessuchasDownsyndrome
Viralinfectionssuchasrubella
Excessivebodyheatexposureduringthefirsttrimester(neuraltubedefects)
Medicationsandsubstanceabuseduringpregnancy
Radiationexposure
Maternalmetabolicdisorders(e.g.,phenylketonuria,diabetesmellitus)
∆
∆
•
•
•
•
•
•
•
∆
•
•
•
•
•
•
•
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 3 3
Poormaternalnutritionsuchasfolicaciddeficiency(neuraltubedefects)
Prematureinfants
SGAinfants
Oligohydramniosorpolyhydramnios
DiagnosticandTherapeuticProceduresandNursingInterventions
Prenatal diagnoses of congenitalanomaliesareoftenmadebyamniocentesis,chorionicvillisampling,ultrasound,andalphafetalprotein.
Routine testingofnewbornsformetabolicdisorders(inbornerrorsofmetabolism)
Guthrietestforphenylketonuria(PKU)showingelevationsofphenylalanineinbloodandurine.Notreliableuntiltheinfanthasingestedsufficientamountsofprotein.
Bloodandurinelevelsofgalactose(galactosemia)
Thyroxinemeasurement(hypothyroidism)
Cytologic studies(karyotypingofchromosomes)suchasabuccalsmearusescellsscrapedfromthemucosafrominsideofthemouth.
Dermatoglyphicsexaminesthepatternsformedbytheridgesintheskinonthedigits,palms,andsoles(Downsyndrome).
Congenitalanomaliesaregenerallyidentified soon after birthbyApgarscoringandabriefassessmentindicatingtheneedforfurtherinvestigation.Onceidentified,congenitalanomaliesaretreated in a pediatric setting.
DataCollection
Monitorforsignsandsymptomsofcongenital anomaliesincluding:
Cleft lip/palate –failureoftheliporhardorsoftpalatetofuse.
Tracheoesophageal atresia–failureoftheesophagustoconnecttothestomach,excessivemucoussecretionsanddrooling,periodiccyanoticepisodesandchoking,abdominaldistentionafterbirth,andimmediateregurgitationafterbirth.
Phenylketonuria (PKU)–theinabilitytometabolizetheaminoacidphenylalanine;canresultinmentalretardationifuntreated.
Galactosemia –inabilitytometabolizegalactoseintoglucose.Canresultinfailuretothrive,cataracts,jaundice,cirrhosisoftheliver,sepsis,andmentalretardationifuntreated.
•
•
•
•
∆
∆
•
•
•
∆
∆
∆
∆
•
•
•
•
AssessmentandManagementofNewbornComplications
4 3 4 MaternalNewbornNursing
Hypothyroidism – slowmetabolismcausedbymaternaliodinedeficiencyormaternalantithyroidmedicationsduringpregnancy.Canresultinhypothermia,poorfeeding,lethargy,jaundice,andcretinismifuntreated.
Neurologic anomalies (spina bifida) –aneuraltubedefectinwhichthevertebralarchfailstocloseandtheremaybeaprotrusionofthemeningesand/orspinalcord.
Hydrocephalus–excessivespinalfluidaccumulationintheventriclesofthebraincausingtheheadtoenlargeandthefontanelstobulge.Sun-settingsigniscommoninwhichthewhitesoftheeyesarevisibleabovetheiris.
Patent ductus arteriosus (PDA)–noncyanoticheartdefectinwhichtheductusarteriosusconnectingthepulmonaryarteryandtheaortafailstocloseafterbirth.Signsandsymptomsconsistofmurmurs,abnormalheartrateorrhythm,breathlessness,andfatiguewhilefeeding.
Tetralogy of Fallot–cyanoticheartdefectcharacterizedbyaventricularseptaldefect,theaortapositionedovertheventricularseptaldefect,stenosisofthepulmonaryvalve,andhypertrophyoftherightventricle.Observeforsignsofrespiratorydifficulties,cyanosis,tachycardia,tachypnea,anddiaphoresis.
Down syndrome–obliquepalpebralfissuresorupwardslantofeyes,epicanthalfolds,flatfacialprofilewithadepressednasalbridgeandasmallnose,protrudingtongue,smalllow-setears,shortbroadhandswithafifthfingerthathasoneflexioncreaseinsteadoftwo,adeepcreaseacrossthecenterofthepalmfrequentlyreferredtoasasimiancrease,hyperflexibility,andhypotonicmuscles.
Nursing assessmentsofinfantswithcongenital anomaliesinclude:
Newborn’sabilitytotakeinadequatenourishment.
Newborn’sabilitytoeliminatewasteproducts.
Vitalsignsandaxillarytemperature.
Infant-parentalbonding,observingtheparent’sresponsetothediagnosisofacongenitaldefect,andencouragingtheparentstoverbalizeconcerns.
NANDANursingDiagnoses
Riskforimpairedparentingrelatedtocongenitalanomalyofinfant
Riskforinjuryordeathrelatedtocongenitalanomaly
Riskforinfectionrelatedtocongenitalanomalyoritstreatment
Dysfunctionalgrievingrelatedtothebirthofaninfantwithacongenitalanomaly
Deficientknowledgerelatedtocongenitalanomalyanditstreatment
•
•
•
•
•
•
∆
•
•
•
•
∆
∆
∆
∆
∆
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 3 5
NursingInterventions
Nursinginterventionsforcongenitalanomaliesaredependentuponthetypeandextentoftheanomaly.
Neurologic anomalies (spina bifida)
Protectmembranewithsterilecoveringandplastictopreventdrying.
Observeforleakageofcerebrospinalfluid.
Handlenewborngentlybypositioningproneortothesidetopreventtrauma.
Preventinfectionbykeepingfreefromcontaminationbyurineandfeces.
Measurethecircumferenceoftheheadtoidentifyhydrocephalus.
Assessforincreasedintracranialpressure.
Hydrocephalus
Frequentlyrepositiontheinfant’sheadtopreventsores.
Measuretheinfant’sheadcircumferencedaily.
Assesstheinfantforsignsofincreasedintracranialpressuresuchasvomitingandashrillcry.
PDA
Educatetheparentsaboutthetreatmentofsurgery.
Tetralogy of Fallot
Conservetheinfant’senergytoreducetheworkloadontheheart.
Administergavagefeedingsorgiveoralfeedingswithaspecialnipple.
Elevatetheinfant’sheadandshoulderstoimproverespirationsandreducethecardiacworkload.
Preventinfection.
Placetheinfantinaknee-chestpositionduringrespiratorydistress.
Nursinginterventionsforcongenitalanomaliesinclude:
Establishingandmaintainingadequaterespiration.
Establishingextrauterinecirculation.
Establishinggoodthermoregulation.
Providingadequatenutrition.
Cleft lip/palate–determinethemosteffectivenippleforfeeding.Feedtheinfantintheuprightpositiontodecreaseaspirationrisk.Feedslowly,burpingfrequentlysecondarytotendencytoswallowair.Cleansethemouthwithwaterafterfeedings.
∆
•
◊
◊
◊
◊
◊
◊
•
◊
◊
◊
•
◊
•
◊
◊
◊
◊
◊
∆
•
•
•
•
◊
AssessmentandManagementofNewbornComplications
4 3 6 MaternalNewbornNursing
Tracheoesophageal atresia–withholdfeedingsuntilthedeterminationofesophagealpatency.Elevatetheheadofthecribtopreventgastricjuicereflux.Supervisethefirstfeedingofallnewbornstoobserveforthisanomaly.
PKU –specialsyntheticformulainwhichphenylalanineisremovedorreduced.Restrictionofmeat,dairyproducts,dietdrinks,andprotein.Aspartamemustbeavoided.
Galactosemia –giveinfantamilksubstancebecausegalactoseispresentinmilk.
Administeringmedicationsasprescribedsuchasthyroidreplacementforhypothyroidism.
Educatingtheparentsregardingpreoperativeandpostoperativetreatmentprocedures.
Encouragingtheparentstohold,touch,andtalktotheirnewborn.
Ensuringthattheparentsprovideconsistentcaretothenewborn.
Newborn Complication: Birth Trauma or Injury
KeyPoints
Birth injury consistsofaphysicalinjurysustainedbyanewbornduringlaboranddelivery.Mostinjuriesareminorandresolverapidly.Otherinjuriesmayrequiresomeintervention.Afewareseriousenoughtobefatal.
Types of birth injuries include:
Scalp(e.g.,caputsuccedaneum,cephalohematoma).
Skull(e.g.,linearfracture,depressedfracture).
Intracranial(e.g.,epiduralorsubduralhematoma,cerebralcontusion).
Spinalcord(e.g.,spinalcordtransactionorinjury,vertebralarteryinjury).
Plexus(e.g.,totalbrachialplexusinjury,Klumpkeparalysis).
Cranialandperipheralnerve(e.g.,radialnervepalsy,diaphragmaticparalysis).
KeyFactors
Maternal, intrapartum, obstetric birth techniques, and newborn factors maypredispose the newborn to injuries.Theseinclude:
Fetalmacrosomia.
Abnormalordifficultpresentations.
◊
◊
◊
•
•
•
•
∆
∆
•
•
•
•
•
•
∆
•
•
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 3 7
Uterinedysfunctionleadingtoprecipitateorprolongedlabor.
Cephalopelvicdisproportion.
Multifetalgestation.
Congenitalabnormalities.
InternalFHRmonitoring.
Forcepsorvacuumextraction.
Externalversion.
Cesareanbirth.
DiagnosticandTherapeuticProceduresandNursingInterventions
BirthinjuriesarenormallydiagnosedbyCTscan,x-rayofsuspectedareaoffracture,orneurologicalexamtodetermineparalysisofnerves.
DataCollection
Monitorthenewbornforsignsandsymptomsofbirthinjuries,whichinclude:
Irritability,seizures,anddepression.Theseareallsignsofasubarachnoidhemorrhage.
Facialflatteningandunresponsivenesstogrimacethataccompaniescryingorstimulation,andtheeyeremainingopenaresymptomstoassessforfacialparalysis.
Weakorhoarsecry,whichischaracteristicoflaryngealnervepalsyfromexcessivetractionontheneck.
Flaccidmuscletone,whichmaysignaljointdislocationsandseparationduringbirth.
Flaccidmuscletoneoftheextremities,whichissuggestiveofnerveplexusinjuriesorlongbonefractures.
Limitedmotionofanarm,crepitusoveraclavicle,andabsenceofMororeflexontheaffectedside,whicharesymptomsofclavicularfractures.
Flaccidarmwiththeelbowextendedandthehandrotatedinward,absenceoftheMororeflexontheaffectedside,sensorylossoverthelateralaspectofthearm,andintactgraspreflex,whicharesymptomsofErb-Duchenneparalysis(brachial paralysis).
Localizeddiscoloration,ecchymosis,petechiae,andedemaoverthepresentingpart.Theseareseenwithsofttissueinjuries.
•
•
•
•
•
•
•
•
∆
∆
•
•
•
•
•
•
•
•
AssessmentandManagementofNewbornComplications
4 3 8 MaternalNewbornNursing
Nursingassessmentsforbirthinjuriesinclude:
Reviewingmaternalhistoryandlookingforfactorsthatmaypredisposethenewborntoinjuries.
Apgarscoring thatmightindicateapossibilityofbirthinjury.Neonatesinneedofimmediateresuscitationshouldbeidentified.
Initial head to toe physical assessment andcontinued assessment uponeachcontactwiththeneonate.
Vital signsandtemperature.
NANDANursingDiagnoses
Injuryrelatedtobirthtrauma
Impairedphysicalmobilityrelatedtobrachialplexusinjury
Impairedgasexchangerelatedtodiaphragmaticparalysis
Acutepainrelatedtoinjury
NursingInterventions
Nursing interventionsforbirth injuriesinclude:
Administeringtreatmenttothenewbornbasedontheinjuryandaccordingtotheprimarycareprovider’sprescriptions.
Preventingfurthertraumabydecreasingstimuliandmovement.
Educatingtheinfant’sparentsandfamilyregardingtheinjuryandthemanagementoftheinjury.
Promotingparent-newbornbonding.
Newborn Complication: Neonatal Infection/Sepsis (Sepsis Neonatorum)
KeyPoints
Infectionmaybecontractedbythenewbornbefore,during,orafterdelivery.Newbornsaremoresusceptibletomicro-organismsbecauseoftheirlimitedimmunityandinabilitytolocalizeinfection.Theinfectioncanthereforespreadrapidlyintothebloodstream.
Neonatal sepsisisthepresenceofmicro-organismsortheirtoxinsinthebloodortissuesoftheinfantduringthefirstmonthafterbirth.Signsofsepsisaresubtleandmayresembleotherdiseases;thenurseoftennoticesthemduringroutinecareoftheinfant.
∆
•
•
•
•
∆
∆
∆
∆
∆
•
•
•
•
∆
∆
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 3 9
Prevention of infectionand neonatal sepsisstartsperinatallywithmaternalscreeningforinfections,prophylacticinterventions,andtheuseofsterileandaseptictechniquesduringdelivery.Prophylacticantibiotictreatmentoftheeyesofallnewbornsandappropriateumbilicalcordcarealsohelptopreventneonatalinfectionandsepsis.
KeyFactors
Risk factorsforinfection/sepsisofthenewborninclude:
Prematureruptureofthemembranes.
TORCH(toxoplasmosis,rubella,cytomegalovirus,andherpes).
Chorioamnionitis.
Prematurebirth.
Lowbirthweight.
Substanceabuse.
Maternalurinarytractinfection.
Meconium.
Humanimmunodeficiencyvirus(HIV)transmittedfromthemothertothenewbornperinatallythroughtheplacentaandpostnatallythroughthebreastmilk.
DiagnosticandTherapeuticProceduresandNursingInterventions
Complete septic workupincludes:
CBC.
Blood,urine,andcerebrospinalfluidculturesandsensitivities.
Positive blood cultures,usuallypolymicrobial(morethanonepathogen)indicatesthepresenceofinfection/sepsis.
Organismsfrequentlyresponsibleforneonatalinfectionsinclude:Staphylococcus aureus,S. epidermidis, Escherichia coli, Haemophilus influenza, and group B Streptococcus.
Chemical profileshowsafluid and electrolyte imbalance.
∆
∆
•
•
•
•
•
•
•
•
•
∆
•
•
∆
•
∆
AssessmentandManagementofNewbornComplications
4 4 0 MaternalNewbornNursing
DataCollection
Monitorforsignsandsymptomsofneonatal infection/sepsis, whichinclude:
Temperatureinstability.
Suspiciousdrainage(e.g.,eyes,umbilicalstump).
Poorfeedingpattern,suchasaweaksuckordecreasedintake.
Vomitinganddiarrhea.
Poorweightgain.
Abdominaldistention,largeresidualiffeedingbygavage.
Apnea,sternalretractions,grunting,andnasalflaring.
Decreasedoxygensaturation.
Colorchangessuchasjaundice,pallor,andpetechiae.
Tachycardiaorbradycardia.
Poormuscletoneandlethargic.
Nursing assessmentsforneonatal infection/sepsisinclude:
Assessinginfectionrisks(reviewmaternalrecord).
Monitoringforsignsofopportunisticinfection.
Monitoringvitalsignscontinuously.
Axillarytemperature.
Pulseoximetry.
Assessingforweightloss.
Monitoringfluidandelectrolytestatus.
Monitoringvisitorsforinfection.
NANDANursingDiagnoses
Infectionrelatedtomaternalinfection,needforindwellingintrauterinedevices,orneonatalcontactwithpathogen
Ineffectivethermoregulationrelatedtoinfection
Impairedtissueintegrityrelatedtoinvasiveprocedures
∆
•
•
•
•
•
•
•
•
•
•
•
∆
•
•
•
•
•
•
•
•
∆
∆
∆
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 4 1
NursingInterventions
Nursing interventionsforneonatal infections/sepsisinclude:
Obtaining specimens(blood,urine,andstool)toassistinidentifyingthecausativeorganism.
InitiatingandmaintainingIV therapyasprescribedtoadministerelectrolytereplacements,fluids,andmedications.
Administeringmedicationsasprescribed(e.g.,broad-spectrumantibioticspriortoculturesbeingobtained).
Initiatingandmaintainingrespiratory supportasneeded.
Providingnewborncaretomaintain temperature.
Maintainingstandardprecautions.
Cleaningandsterilizingallequipmenttobeused.
Providingfamilyeducationoninfectioncontrol,whichincludes:
Instructingthefamilyontheuseofcleanbottlesandnipplesforeachfeeding.
Notstoringleftoverformula.
Supervisinghandwashing.
Providingemotionalsupporttothefamily.
Newborn Complication: Maternal Substance Abuse During Pregnancy
KeyPoints
Maternal substance abuse during pregnancyconsistsofanyuseofalcoholordrugsduringpregnancy.Intrauterinedrugexposurecancauseanomalies,neurobehavioralchanges,andsignsofwithdrawal.Thesechangesdependonspecificdrugorcombinationofdrugsused,dosage,routeofadministration,metabolismandexcretionbymotherandfetus,timingofdrugexposure,andlengthofdrugexposure.
Substance withdrawalinthenewbornoccurswhenthemotherusesillicitdrugswhilepregnant.
Fetal alcohol syndrome (FAS)resultsfromthechronicorperiodicintakeofalcoholduringpregnancy.Alcoholisconsideredteratogenic,sothedailyintakeofalcoholincreasestheriskofFAS.
∆
•
•
•
•
•
•
•
•
◊
◊
◊
•
∆
∆
∆
AssessmentandManagementofNewbornComplications
4 4 2 MaternalNewbornNursing
NewbornswithFASareatriskforspecificcongenitalphysicaldefects,alongwithlong-termcomplicationsincluding:
Feedingproblems.
Centralnervoussystemdysfunction(e.g.,mentalretardation,cerebralpalsy).
Behavioraldifficultiessuchashyperactivity.
Languageabnormalities.
Futuresubstanceabuse.
Delayedgrowthanddevelopment.
Poormaternal-infantbonding.
KeyFactors
Risk factorsformaternal substance abuse during pregnancyinclude:
Motherusingsubstancespriortoknowingsheispregnant.
Maternalsubstanceabuseandaddiction.
DiagnosticandTherapeuticProceduresandNursingInterventions
Drug screenofurineormeconiumtorevealtheagentabusedbythemother.
Chest x-rayforFAStoruleoutcongenitalheartdefects.
Blood testsshouldbedonetodifferentiatebetweenneonataldrugwithdrawalandcentralnervoussystemirritability.Testsshouldinclude:
CBC.
Bloodglucose.
Calcium.
Magnesium.
TSH,T4,T3.
ABS.
∆
•
•
•
•
•
•
•
∆
•
•
∆
∆
∆
•
•
•
•
•
•
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 4 3
DataCollection
Monitorforsignsandsymptomsofneonatal abstinence syndrome(withdrawal)intheneonateusingtheneonatal abstinence scoring systemthatassessesforandscoresthefollowing:
Central nervous systems–irritability,tremors,high-pitched,shrillcry,incessantcrying,hyperactivewithincreasedMororeflex,increaseddeeptendonreflexes,increasedmuscletone,increasedwakefulness,excoriationsonthekneesandface,andconvulsions.
Metabolic, vasomotor, and respiratory–nasalcongestionwithflaring,tachypnea,sweating,frequentyawning,skinmottling,tachypneagreaterthan60/min,temperaturegreaterthan37.2°C(99°F).
Gastrointestinal–poorfeeding,vomiting,regurgitation(projectilevomiting),diarrhea,andexcessive,uncoordinated,andconstantsucking.
Opiatewithdrawalcanlastfor2to3weeks.
Signsandsymptomsofneonatalabstinencesyndrome includerapidchangesinmood,hypersensitivitytonoiseandexternalstimuli,dehydration,andpoorweightgain.
Heroin withdrawal
SignsandsymptomsofneonatalabstinencesyndromeincludelowbirthweightandSGA,decreasedMororeflexes(ratherthanincreased),andhypothermiaorhyperthermia.
Methadone withdrawal
Signsandsymptomsofneonatalabstinencesyndromeincludeanincreasedincidenceofseizures,higherbirthweights,andhigherriskofsuddeninfantdeathsyndrome.
Marijuana withdrawal
Signsandsymptomsincludepretermbirthandmeconiumstaining.
Amphetamine withdrawal
PretermorSGA,drowsiness,jitters,respiratorydistress,frequentinfections,poorweightgain,emotionaldisturbances,anddelayedgrowthanddevelopment.
∆
•
•
•
∆
•
∆
•
∆
•
∆
•
∆
•
AssessmentandManagementofNewbornComplications
4 4 4 MaternalNewbornNursing
Fetal alcohol syndrome
Facialanomaliesincludeeyeswithepicanthalfolds,strabismus,andptosis;mouthwithapoorsuck,cleftliporpalate,andsmallteeth
Deafness
Abnormalpalmarcreasesandirregularhair
Manyvitalorgananomaliessuchasheartdefectsincludingatrialandventricularseptaldefects,teratologyofFallot,andpatentductusarteriosus
Developmentaldelaysandneurologicabnormalities
Prenatalandpostnatalgrowthretardation
Sleepdisturbances
Tobacco
Prematurity,lowbirthweight,increasedriskforsuddeninfantdeathsyndrome,increasedriskforbronchitis,pneumonia,anddevelopmentaldelays
Nursing assessments formaternal substance abuse andneonatal effects or withdrawal include:
Apgarscoring.
Headtotoephysicalassessment.
Elicitingandassessingreflexes.
Monitoringinfant’sabilitytofeedanddigestintake.
Monitoringfluidsandelectrolytessuchasskinturgor,mucousmembranes,fontanels,andI&O.
Observingtheinfant’sbehavior.
Vitalsignsandtemperature.
Measuringandweighingoftheneonate.
Observingparent-infantbonding.
NANDANursingDiagnoses
Riskforinjuryrelatedtohyperactivityorseizures
Alterednutrition:Lessthanbodyrequirementsrelatedtopoorsuckreflex
Riskfordeficientfluidvolumerelatedtovomitinganddiarrhea
∆
•
•
•
•
•
•
•
∆
•
∆
•
•
•
•
•
•
•
•
•
∆
∆
∆
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 4 5
NursingInterventions
Nursing interventionsfortheeffects on the neonate of substance abuse during pregnancyorsubstance withdrawal include:
Administeringmedicationsasprescribedtodecrease central nervous systemirritabilityandcontrolseizures.
Reducing external stimulation.
Swaddlingthenewbornsnugglytoreduceselfstimulationandprotecttheskinfromabrasions.
Frequent, small feedingsofhigh-calorieformula–mayneedgavagefeedings.
Elevating theinfant’s headduringandfollowingfeedings,andburping the infantwelltoreducevomitingandaspiration.
Tryingvariousnipplestocompensateforapoorsuckreflex.
Havingsuctionavailabletoreducetheriskforaspiration.
Forcocaine addicted infants, avoiding eye contactandusingvertical rockingandapacifier.
Preventinginfection.
Referringmothertoadrugand/oralcoholtreatmentcenter.
PrimaryReference:Lowdermilk,D.L.&Perry,S.E.(2004).Maternity & women’s health care(8thed.).St.
Louis,MO:Mosby.
AdditionalResources:NANDAInternational(2004).NANDA nursing diagnoses: Definitions and
classification 2005-2006.Philadelphia:NANDA.
Pillitteri,A.(2003).Maternal & child health nursing: Care of the childbearing and childrearing family(5thed.).Philadelphia:Lippincott.
Springhouse(2003). Maternal-neonatal nursing made incredibly easy! (1sted.).Philadelphia:Lippincott,Williams,&Wilkins.
∆
•
•
•
•
•
•
•
•
•
•
AssessmentandManagementofNewbornComplications
4 4 6 MaternalNewbornNursing
Chapter23:AssessmentandManagementofNewbornComplications
ApplicationExercises
Scenario:Anurseiscalledtothebirthingroomtoassistwiththeassessmentofa32-weekgestationnewbornandtoprovidecaretothemotherpostpartum.Theinfant’sbirthweightis1,100g.Theinfant’sApgarscoresare3at1minand7at5min.Theinfantisexperiencingnasalflaring,grunting,andsubsternalandintercostalretractions.Heisflaccidandlyinginafrog-likeposition.Theinfantiscoveredwithathick,cheesysubstance(vernixcaseosa),andlanugoiswidelydistributedoverhisbody.
1.Whichofthefollowingarecharacteristicsofapreterminfantthatthenursemayseeatthisbirth?(Selectallthatapply.)
_____ Largeheadincomparisontobody
_____ Lanugo
_____ Longhair
_____ Longnails
_____ Weakgraspreflex
_____ Translucentskin
_____ Plumpface
2.Whatassessmentfindingsindicatethatacomplicationmaybedevelopingforthisnewborn?
3.Whyisthisinfantatriskforineffectivethermoregulation?
4.Anurseiscaringforaninfantwithahighbilirubinlevelwhoisreceivinghighintensitylighttreatments(phototherapy).Thenurse’shighestassessmentpriorityinmonitoringthisinfantistocheckfrequentlyandcarefullyforsignsofwhichofthefollowingcommonandpotentialseriouscomplicationsofphototherapy?
A.Retinaldamage
B.Bronzeskindiscoloration
C.Dehydration
D.Maculopapularskinrash
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 4 7
5.Anurseassessesatermnewborndeliveredlessthan1hrago.Thenursesuspectsaproblembasedontheinfant’s
A.relaxedposture.
B.clenchedfists.
C.startlereaction.
D.steppingmovements.
6.Amultiparouswomanat40weeksofgestationhasjustgivenbirthtohernewborn.Afterprolongedpushinginthesecondstage,aforceps-assistedbirthwasnecessary.Thenewbornweighs9lb,8oz(4,318g).Thenewbornhasmarkedcaputsuccedaneumandmarkedbruisingabouttheface,head,andshoulders.Howwouldanursecharacterizethisinfant?(Selectallthatapply.)
_____ Preterm
_____ Term
_____ Postterm
_____ LGA
_____ SGA
_____ AGA
7.Anurseisexamininganinfantwhowasjustdeliveredtoawomanat41weeksgestation.Whichofthefollowingcharacteristicsindicatesthatthisinfantispostterm?
A.Abundantlanugo
B.Flatareolawithoutbreastbuds
C.Heelsmovablefullytotheears
D.Leathery,cracked,wrinkledskin
AssessmentandManagementofNewbornComplications
4 4 8 MaternalNewbornNursing
8.ToevaluatetheefficacyofsyntheticsurfactantgiventoapreterminfantdiagnosedwithRDS,thenurse’sfirstpriorityinassessmentismonitoringtheinfant’s
A.oxygensaturation.
B.bodytemperature.
C.bilirubinlevels.
D.heartrate.
9.Anurseshouldconsiderthepossibilityofneonatalwithdrawalsyndromeifanewborn
A.hasdecreasedmuscletone.
B.hasacontinuoushigh-pitchedcry.
C.sleepsfor2hrafterfeeding.
D.hasmildtremorswhendisturbed.
10.Theparentofapostterminfantisconcernedbecausehisinfant’sskinisdryandpeeling.Whichofthefollowingresponsesbythenurseismostappropriate?
A.“Thistypeofskinisanexpectedfindinginbabiesbornafter42weeksofgestation.”
B.“Itwouldbebestforyoutoaskthepediatricianabouttheconditionofyourbaby’sskin.”
C.“Peelingskiniscommoninsomefamilies.Haveyouseenthisinotherinfantsinyourfamily?”
D.“Don’tworry.Wehaveseveralskinpreparationswecanapplytohelpresolvethiscondition.”
11.Anewbornisdeliveredat39weeks.Theneonatalnurseplotstheinfant’sweightandfindsittobeinthe8thpercentileforweight.Thisinfantwouldbeclassifiedas
A.termandAGA.
B.pretermandLGA.
C.termandSGA.
D.posttermandSGA.
12.Whichofthefollowingnutritionalproblemsshouldthenurseobserveforinapretermneonate?
A.Hypoglycemia
B.Hyperglycemia
C.Anemia
D.Galactosemia
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 4 9
Chapter23:AssessmentandManagementofNewbornComplications
ApplicationExercisesAnswerKey
Scenario:Anurseiscalledtothebirthingroomtoassistwiththeassessmentofa32-weekgestationnewbornandtoprovidecaretothemotherpostpartum.Theinfant’sbirthweightis1,100g.Theinfant’sApgarscoresare3at1minand7at5min.Theinfantisexperiencingnasalflaring,grunting,andsubsternalandintercostalretractions.Heisflaccidandlyinginafrog-likeposition.Theinfantiscoveredwithathick,cheesysubstance(vernixcaseosa),andlanugoiswidelydistributedoverhisbody.
1.Whichofthefollowingarecharacteristicsofapreterminfantthatthenursemayseeatthisbirth?Selectallthatapply.
__X__ Large head in comparison to body
__X__ Lanugo
_____ Longhair
_____ Longnails
__X__ Weak grasp reflex
__X__ Translucent skin
_____ Plumpface
Characteristics of a preterm infant include large head in comparison to body, lanugo over the body, a weak grasp reflex, and skin that is thin, smooth, shiny, and may be translucent. Long hair and nails are signs of a postterm infant. A plump face would be seen in a macrosomic infant.
2.Whatassessmentfindingsindicatethatacomplicationmaybedevelopingforthisnewborn?
Nasal flaring, grunting, and substernal and intercostal retractions indicate that the infant is experiencing respiratory distress. The frog-like position, vernix caseosa, and lanugo are the usual assessment findings for a premature newborn at 32 weeks gestation.
AssessmentandManagementofNewbornComplications
4 5 0 MaternalNewbornNursing
3.Whyisthisinfantatriskforineffectivethermoregulation?
The infant’s low birth weight and gestational age mean that it has little glycogen stored in its liver and little brown fat available for producing heat. The preterm infant lacks subcutaneous fat to insulate his body and his flaccid muscle tone does not allow him to take a flexed position to prevent heat loss.
4.Anurseiscaringforaninfantwithahighbilirubinlevelwhoisreceivinghighintensitylighttreatments(phototherapy).Thenurse’shighestassessmentpriorityinmonitoringthisinfantistocheckfrequentlyandcarefullyforsignsofwhichofthefollowingcommonandpotentialseriouscomplicationsofphototherapy?
A.Retinaldamage
B.Bronzeskindiscoloration
C. Dehydration
D.Maculopapularskinrash
Infants receiving phototherapy lose more water and have loose stools due to increased bilirubin excretion. This increases their risk of dehydration, a serious and sometimes life-threatening complication in an infant. Supplemental oral or intravenous fluids are given as needed to prevent this complication. It is not known whether or not phototherapy causes retinal damage; nevertheless, it is standard procedure to protect the infant’s eyes by closing them and then covering them with eye patches while the infant is exposed to phototherapy. Due to the confinement of the patches, it is important for the nurse to assess the infant’s eyes between therapy sessions for signs of conjunctivitis. However, the nurse would not be able to detect signs of retinal damage during routine assessments. Some infants who have elevated direct serum bilirubin levels develop a bronze discoloration as a side effect of phototherapy. This is not a serious complication. Infants can also develop a maculopapular skin rash as a side effect of phototherapy. Again, this is not a serious complication. Because the infant’s opportunities to be held are limited, the nurse must assess the infant’s skin carefully for development of pressure areas and must change the infant’s position at least every 2 hr.
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 5 1
5.Anurseassessesatermnewborndeliveredlessthan1hrago.Thenursesuspectsaproblembasedontheinfant’s
A. relaxed posture.
B.clenchedfists.
C.startlereaction.
D.steppingmovements.
A relaxed position indicates hypotonia, which is a possible result of hypoxia in utero or medications received by the mother. The nurse would expect to find fist clenching in a newborn. Straightened legs that are not flexed at the knees are an expected finding following a breech presentation. The nurse should review the delivery record before concluding that this finding represents a problem. It is expected that a newborn’s legs would move one at a time as though the infant were pedaling a bicycle.
6.Amultiparouswomanat40weeksofgestationhasjustgivenbirthtohernewborn.Afterprolongedpushinginthesecondstage,aforceps-assistedbirthwasnecessary.Thenewbornweighs9lb,8oz(4,318g).Thenewbornhasmarkedcaputsuccedaneumandmarkedbruisingabouttheface,head,andshoulders.Howwouldanursecharacterizethisinfant?(Selectallthatapply.)
______ Preterm
__X__ Term
______ Postterm
__X__ LGA
______ SGA
______ AGA
The infant is term (40 weeks) and LGA (greater than 90th percentile in weight). Preterm is prior to 37 weeks gestation and postterm is after the completion of the 42nd week of gestation. SGA is an infant that is at or below the 10th percentile in weight. AGA is between the 10th and 90th percentile for weight.
AssessmentandManagementofNewbornComplications
4 5 2 MaternalNewbornNursing
7.Anurseisexamininganinfantwhowasjustdeliveredtoawomanat41weeksgestation.Whichofthefollowingcharacteristicsindicatesthatthisinfantispostterm?
A.Abundantlanugo
B.Flatareolawithoutbreastbuds
C.Heelsmovablefullytotheears
D. Leathery, cracked, wrinkled skin
Leathery, cracked, and wrinkled skin is seen in a postterm newborn due to placental insufficiency. Abundant lanugo, flat areolas without breast buds, and heels movable fully to ears are found in preterm newborns.
8.ToevaluatetheefficacyofsyntheticsurfactantgiventoapreterminfantdiagnosedwithRDS,thenurse’sfirstpriorityinassessmentismonitoringtheinfant’s
A. oxygen saturation.
B.bodytemperature.
C.bilirubinlevels.
D.heartrate.
Surfactant contains surface-active phospholipids, specifically lecithin and sphingomyelin, that are critical for alveolar stability. Surfactant therapy stabilizes the alveoli and prevents collapse, thereby increasing lung compliance and maintaining or improving oxygen saturation. Surfactant would not have a direct effect on body temperature, thus it would not reflect the efficacy of this treatment. However, cold stress increases the amount of oxygen the newborn needs. Hypothermia in a newborn can lead to metabolic acidosis, hypoxia, and shock. The nurse must provide a neutral thermal environment for this infant and monitor body temperature continuously. Surfactant does not have a direct effect on bilirubin levels; however, preterm infants are prone to hyperbilirubinemia and so this parameter must be monitored and treated as needed. However, serum bilirubin level is not a reflection of the efficacy of surfactant. It is important to monitor the heart rate of any preterm infant, as well as any infant who has RDS. Since surfactant can cause bradycardia, this is an especially important assessment parameter for this infant. However, heart rate is not a reflection of the efficacy of surfactant therapy.
AssessmentandManagementofNewbornComplications
MaternalNewbornNursing 4 5 3
9.Anurseshouldconsiderthepossibilityofneonatalwithdrawalsyndromeifanewborn
A.hasdecreasedmuscletone.
B. has a continuous high-pitched cry.
C.sleepsfor2hrafterfeeding.
D.hasmildtremorswhendisturbed.
Symptoms of withdrawal from maternal substance abuse include central nervous system disturbances such as an excessive or continuous high-pitched cry and a markedly hyperactive Moro reflex. An infant withdrawing from narcotics or other substances abused maternally is likely to have an increased muscle tone along with other central nervous system disturbances. Most newborns sleep for varying amounts of time after feeding. Symptoms of withdrawal from maternal substance abuse include difficulty moving through various sleep stages. These infants might only sleep for very short periods of time. This sleep pattern disturbance is related to central nervous system excitation secondary to drug or alcohol withdrawal. Many newborns have mild tremors when they are disturbed. What distinguishes infants who have neonatal abstinence syndrome from this normal pattern is that they have moderate to severe tremors when they are undisturbed.
10.Theparentofapostterminfantisconcernedbecausehisinfant’sskinisdryandpeeling.Whichofthefollowingresponsesbythenurseismostappropriate?
A. “This type of skin is an expected finding in babies born after 42 weeks of gestation.”
B.“Itwouldbebestforyoutoaskthepediatricianabouttheconditionofyourbaby’sskin.”
C.“Peelingskiniscommoninsomefamilies.Haveyouseenthisinotherinfantsinyourfamily?”
D.“Don’tworry.Wehaveseveralskinpreparationswecanapplytohelpresolvethiscondition.”
Peeling skin is a normal condition seen in postterm newborns due to dehydration from placental insufficiency. There is no need to ask the primary care provider as this is a normal finding in postterm newborns. A condition of peeling skin in the family would not show up as early as the newborn period. Lotions will not help with the peeling because it is due to lack of nutrition. The peeling will resolve once the newborn receives adequate nutrition and fluids.
AssessmentandManagementofNewbornComplications
4 5 4 MaternalNewbornNursing
11.Anewbornisdeliveredat39weeks.Theneonatalnurseplotstheinfant’sweightandfindsittobeinthe8thpercentileforweight.Thisinfantwouldbeclassifiedas
A.termandAGA.
B.pretermandLGA.
C. term and SGA.
D.posttermandSGA.
This newborn is term, between 37 and 42 weeks gestation, SGA, and below the 10th percentile.
12.Whichofthefollowingnutritionalproblemsshouldthenurseobserveforinapretermneonate?
A. Hypoglycemia
B.Hyperglycemia
C.Anemia
D.Galactosemia
A preterm neonate is at risk for hypoglycemia because it has not built up glycogen reserves yet. A preterm infant will have polycythemia and excessive red blood cells rather than anemia. Galactosemia is the inability of the neonate to convert galactose to glucose and is an inborn error of metabolism.