Transcript Chapter 16
Chapter 15 The Newborn at Risk: Conditions Associated with Gestational Age and Development Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1 Risks for the Newborn Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 2 Objectives Define key terms listed. Describe how gestational age is determined. Review the causes of intrauterine growth restriction. Compare and contrast the preterm newborn, the term newborn, and the postterm newborn. Describe the care of the preterm newborn. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 3 At-Risk Newborn Susceptible to illness as a result of Immaturity Physical disorders Complications during or after birth Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 4 New Ballard Score Maturational assessment of gestational age Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 5 Classification of Newborns at Birth Preterm or premature: before 37 weeks Term or full term: 38 to 42 weeks Postterm: after 42 weeks Low birth weight: less than 2500 g (5.5 lbs) Small for gestational age (SGA): < 10th % Appropriate for gestational age (AGA) Large for gestational age (LGA): > 90th % Intrauterine growth restriction (IUGR): failure to grow as expected in utero Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 6 Small for Gestational Age Weight less than the 10th percentile Contributing factors may be Genetic Maternal factors or disease Environmental Malnutrition Placental Fetal Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 7 Types of Growth Restriction Symmetric: growth interference during organ development; all parts of body are small, including brain Chronic maternal hypertension Severe malnutrition Intrauterine infection Substance abuse Anemia Asymmetric: growth interference begins later in pregnancy Compromised uteroplacental blood flow most common cause Gestational hypertension Smoking Maternal drug use Uncontrolled diabetes mellitus Placental infarcts Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 8 Physical Appearance of SGA Newborn Physical characteristics suggest IUGR Long and thin Head may appear large, but circumference is usually normal Sutures wide apart due to impaired bone growth Face is thin Chest and abdominal circumference reduced due to decreased subcutaneous fat Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 9 Behavior of SGA Newborn More active than expected for size Cry is vigorous Strong suck, eats well and gains weight Wide-eyed, alert facial expression may be caused by chronic hypoxia Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 10 Assessment and Management of SGA Newborns Careful examination for congenital anomalies Monitor for hypoglycemia Higher caloric needs Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 11 LGA Newborn Typically weighs 4000 g (8 lbs, 13 oz) or more Mechanical problems for vaginal delivery Often sluggish, hypotonic, hypoactive at birth May incur birth trauma Hypoglycemia or polycythemia Prone to hypoglycemia Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 12 Postterm Newborn Born after 42 weeks gestation Placental insufficiency may develop Fetus does not receive adequate oxygen or nutrients Fetus at risk for meconium aspiration May use subcutaneous fat in utero and appears thin at birth Skin is cracked and dry due to lack of vernix caseosa Little lanugo Long fingernails Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 13 Risks for Postterm Newborn Hypoxia Meconium aspiration Could lead to airway obstruction Hypoglycemia Polycythemia Cold stress Asphyxia Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 14 Preterm Newborn Prematurity most common factor associated with neonatal death Birth before 37 weeks gestation Skin often wrinkled, covered with lanugo Thin, little subcutaneous fat Prominent fontanelles and sutures of skull Cry could be weak Body appears limp with poor muscle tone Extremities in extension, not flexion Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 15 Limitations of the Body Systems in the Preterm Newborn Depends on weeks of gestation at birth May require Supplemental oxygen • Mechanical ventilation Specialized incubators to maintain warmth and prevent infection Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 16 Respiratory System of the Preterm Newborn Not fully mature until after 35th week Surfactant is usually present in sufficient amounts to keep alveoli of lungs from collapsing If born before 35th week, increased risk of alveolar collapse Exchange of oxygen and carbon dioxide is reduced Leads to hypoxia and decreased pulmonary blood flow; depletes newborn’s energy Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 17 Breathing of the Preterm Newborn Irregular patterns, called periodic breathing At risk for apnea If lasts longer than 20 seconds, newborn at risk for bradycardia and cyanosis At risk for gastroesophageal reflux due to weak gag reflex Laryngospasms and apnea Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 18 Respiratory Distress in the Preterm Newborn Retractions of chest wall Expiratory grunting Nasal flaring Changes in respiratory and heart rate Tiny nasal and respiratory passages easily occluded by mucous plugs High concentrations of oxygen Long-term ventilatory therapy Can lead to bronchopulmonary dysplasia (BPD) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 19 Circulatory System and the Preterm Newborn Tendency toward persistent fetal circulation Low surfactant contributes to hypoxia Can reopen ductus arteriosus Blood bypasses lungs, worsening hypoxia Fragile blood vessels can rupture Increased risk for intraventricular hemorrhage Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 20 Gastrointestinal System and the Preterm Newborn May not be able to digest saturated fats, proteins high in casein May have weak suck-swallow reflexes Decreased bile salts and pancreatic lipase Limited stomach capacity Subject to gastroesophageal reflux and aspiration Nonnutritive sucking (i.e., pacifier) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 21 Liver and Metabolic Function and the Preterm Newborn Have reduced glycogen, fat, vitamin, and mineral stores Increases risk of Hypoglycemia • Blood glucose of 30 mg/dL or less • Glycogen stores deplete more rapidly Hypocalcemia • Twitching, seizures, high-pitched cry Poor clearance of bilirubin More susceptible to cold stress, which releases free fatty acids Fatty acids compete for albumin-binding sites, displace bilirubin Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 22 Renal System and the Preterm Newborn Immature kidneys contribute to fluid and electrolyte imbalances Limited ability to concentrate urine or handle large amounts of fluid Risk for fluid retention and overhydration Metabolic acidosis can occur due to excessive bicarbonate loss Poor drug clearance Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 23 Immune System and the Preterm Newborn Receive limited passive immunity from mother, mostly in third trimester Meticulous adherence to infection prevention and control protocols is essential Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 24 Management and Nursing Care of the Preterm Newborn Temperature regulation Ability to produce own heat is limited Immature temperature regulation in brain Vessels near surface of skin Decreased glucose stores Skin care Place on back with mattress slightly elevated Frequent repositioning Feeding Methods available Needs 110 to 130 kcal/day Requires more whey protein than term newborn Breast milk 20 to 30 g/day weight gain Fluid volume Assess for underhydration or overhydration Monitor I&O 1 g = 1 mL of fluid Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 25 Audience Response System Question 1 Chronic maternal hypertension, severe malnutrition, intrauterine infection, and substance abuse can cause what type of growth restriction? A. B. C. D. Large for gestational age Symmetric Asymmetric Small for gestational age Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 26 The Compromised Newborn Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 27 Objectives Explain the factors that predispose the newborn to necrotizing enterocolitis. Discuss developmentally supportive care of preterm newborns. Outline the needs of parents who have a preterm newborn. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 28 Common Problems of the Compromised Newborn Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 29 Retinopathy of Prematurity Prolonged periods of hyperoxygenation produce oxygen toxicity Cause vasoconstriction in vessels of retina • Retrolental fibroplasia Can lead to loss of vision or blindness Monitor pulse oximeter Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 30 Bronchopulmonary Dysplasia (BPD) Prolonged supplemental oxygen causes thickening of alveolar sacs Leads to atelectasis and scarring Can result in long-term oxygen dependence Interventions include Apnea monitoring Cutaneous stimulation Suctioning, positioning, and chest physiotherapy Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 31 Patent Ductus Arteriosus (PDA) Underdeveloped musculature or hypoxia If ductus arteriosus remains open Left-to-right shunting occurs Increases workload on left ventricle Results in pulmonary congestion and hypoxia Administration of prostaglandin synthesis inhibitor can constrict ductus and cause it to close May require surgical intervention to close Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 32 Necrotizing Enterocolitis (NEC) Acute inflammatory process of bowel Multifactorial disorder Asphyxia reduces circulation Causes ischemia and necrosis of bowel Feeding precedes onset of symptoms Organisms invade Abdominal distention Diminished or absent bowel sounds Diarrhea Occult blood X-ray shows free air in peritoneum, perforated bowel Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 33 Management of NEC Discontinue all oral feedings Nasogastric suction IV fluid Broad-spectrum antimicrobials Measure abdominal girth Auscultate bowel sounds Surgery if perforation of bowel occurs or to remove necrotic bowel tissue Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 34 Intraventricular Hemorrhage Potential causes Capillary fragility Increased cerebral blood flow Unstable blood gas levels During birth process Trauma Hypoxia Asphyxia Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 35 Pain and Irritability Signs of pain Intense cry Tightly closed eyes Grimaces Changes in vital signs Lower oxygen saturation levels Increased movement of extremities Interventions Swaddling Nesting Kangaroo care Provide pacifier Soft voice Music Rocking in vertical position Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 36 Sedation Does not relieve pain Often reduces infant’s ability to express pain Usually used in intubated preterms to prevent pneumothorax Organizational phase of brain development occurs in second trimester Drugs can influence outcome of brain development Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 37 Developmentally Supportive Care Integration of technology with sensitive, family-centered, hands-on nursing care Promote growth and development based on needs of newborn Protect quiet sleep state of newborn Organize care to conserve newborn’s energy Maintain flexibility of care when newborn indicates the need for rest Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 38 Developmentally Supportive Care (cont.) Keep parents informed Encourage and support bonding Cover isolette to protect newborn’s eyes from bright lights and to provide circadian rhythm Encourage self-consoling by placing infant’s hand near mouth, using pacifier, and using nesting position Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 39 Developmentally Supportive Care (cont.) Support family; encourage visitation and participation in care Allow for grieving; help work through emotions and feelings of guilt Nurse prepares family for newborn’s limited ability to respond because of all the medical equipment Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 40 CAM Therapy and the Preterm Newborn Aromatherapy can be used to alter behavior Kangaroo care is skin-to-skin contact between parent and newborn Music therapy is soothing and helps with nonnutritive sucking Massage can regulate sleep patterns and reduce motor activity Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 41 Home Care Before discharge, parents should be given opportunity to care for newborn Rooming-in at night helps parents learn nighttime behaviors Reviewing feeding techniques, breast pumping, and milk storage is important Bathing, diapering, dressing, and wrapping Bonding behaviors CPR techniques are essential Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 42 Mother-Newborn Interaction The two components of the mother-newborn interaction that are most affected by having the preterm newborn in the high-risk nursery are sensory (touch) and caring for her infant. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 43 Audience Response System Question 2 Which is the least life threatening to a preterm newborn? A. Necrotizing enterocolitis (NEC) B. Patent ductus arteriosus (PDA) C. Retinopathy of Prematurity (ROP) D. Intraventricular hemorrhage (IVH) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 44 Review Key Points Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 45