Chapter 15 The Newborn at Risk: Conditions Associated with Gestational Age and Development Copyright...
-
Upload
alvin-doyle -
Category
Documents
-
view
215 -
download
1
Transcript of Chapter 15 The Newborn at Risk: Conditions Associated with Gestational Age and Development Copyright...
Chapter 15
The Newborn at Risk:
Conditions Associated with Gestational Age and Development
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1
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 May incur birth trauma
Often sluggish, hypotonic, hypoactive at birth 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 Decreased bile salts and pancreatic lipase
May have weak suck-swallow reflexes 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 Careof 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. Large for gestational age
B. Symmetric
C. Asymmetric
D. Small for gestational age
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 26
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 bowelCopyright © 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