NEONATAL NURSING

NEONATAL NURSING

Edited by

Doreen Crawford RGN, RSCN, ENB 405, ENB 870, ENB 998

Senior Clinical Nurse

and

Maryke Morris BSc(Hons), RGN, ENB 405

Senior Clinical Nurse

Neonatal Unit Lekester Royal Infirrnary

Leicester, UK

mJ] Springer-Science+Business Media, B.V.

ISBN 978-0-412-48730-9 ISBN 978-1-4899-3101-6 (eBook) DOI 10.1007/978-1-4899-3101-6

First edition 1994

© 1994 Springer Science+Business Media Dordrecht Originally published by Chapman & Hall in 1994.

Typeset in 10/12pt Palatino by Mews Photosetting, Beckenham, Kent

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The publisher makes no representation, express or implied, with regard to the accuracy of the information contained in this book and cannot accept any legal responsibility or liability for any errors or omissions that may be made.

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Charles-Michel Billard (1800-1832) stated that:

During uterine life man can suffer from manY. afflictions . . . the consequences of which are brought wzth 'him into this world . . . children may be born healthy, sick, convalescent, or entirely recovered from former disease.

This amazing perception from a neonatal pioneer still applies today.

Contents

List of contributors xüi About the authors xvii Preface xxi

1 N eonatal care today 1 The neonatal environment 1 Admission to the NNU 3 Response to having a special care baby 4 Caring as a neonatal nurse 7 Family-centred care 8 Some aspects of nursing that enhance family-

centred care 10 Caring for the dying baby 11 Stress and the neonatal unit 12 References 14

2 Nursing models: suitable frameworks for care? 16 Models for nursing 17 Structure of a model 18 The Orem systems-oriented model 18 Roper, Logan and Tierney model 20 Other frameworks 21 A model for neonatal care 22 References 24

3 Prenatal and intranatal care of the fetus, mother and father 25

Prenatal care 25 Intranatal care 29

viii Contents

Midwifery care of the mother 29 Care of the father 35 Conclusion 37 References 38

4 Resuscitation - flying squad transfer 43 Infants most likely to need support 43 Transition from intra- to extrauterine existence 44 Basic emergency resuscitation of the newborn 46 Flying squad transfer 51 References 59

5 Nursing care of babies who are bom too soon or too small 61

Terminology 61 Characteristics of the preterm baby (born

too soon) 63 Characteristics of the light-for-dates baby (born

too small) 64 Factors contributing to a preterm delivery 65 Factors contributing to a light-for-dates baby 66 Nursing care of the baby born too soon

or too small 66 References 79

6 Nursing care of a baby with a disorder of the gastrointestinal system 81

Nursing care of a baby undergoing surgery 82 Nursing care of a baby after surgery 83 Oesophageal atresia and tracheo-oesophageal

fistula 86 Necrotizing enterocolitis 89 Gastroschisis 95 References 101

7 Feeding low birth weight infants in today' s neonatal environment 103

Nutrition-related problems 104 Nutritional requirements 106 Nutritional management 112 References 127

Contents ix

8 Nursing care of a baby with a disorder of the respiratory system 131

Anatomy and physiology of the respiratory system 132 Transition from intrauterine life to independent

existence 134 Structural differences in anatomy between the

infant and the adult 135 Care of the infant with breathing difficulties 136 Common investigations 156 References 158 Further reading 160 Acknowledgement 160

9 Nursing care of a baby with a disorder of the cardiovascular system 161

Anatomy and physiology 161 Causes of congenital heart disease 164 Congestive cardiac failure (CCF) 165 Care of an infant undergoing diagnostic

investigations 168 Care of an infant with an abnormal heart rate,

rhythm or pressure 170 Some common congenital cardiac malformations 174 Acyanotic cardiac malformations 174 Cyanotic cardiac malformations 177 Care of an infant undergoing cardiac

catheterization 180 Care of an infant undergoing cardiac surgery 182 Complications of congenital heart disease 185 Common drugs used in cardiac management 186 The present and the future 188 References 189

10 Infant neurology 191 Anatomy of the central nervous system 191 Neurological conditions seen in the neonatal.

unit 194 lnvestigations used to aid diagnosis 204 Ethical issues 204 References 205 Further reading 206

X Contents

11 Nursing care of a baby in renal failure 207 Homoeostasis and assessment of fluid balance 208 Chemical equilibrium and electrolyte disturbances 211 Acid-base balance 213 Regulation of blood pressure 214 Vitamin D metabolism 216 Erythropoiesis 217 Peritoneal dialysis 217 Nutrition in renal failure 222 Drugs in renal failure 223 Psychosocial aspects 223 Conclusion 224 References 224

12 Neonatal infection 226 Immune response to infection 227 Specific risk factors for infection 227 Detection and diagnosis of infection 228 Bacterial and fungal infection 230 Sites of infection 235 Non-bacterial infections 238 Conclusion 242 References 243 Further reading 244

13 Nursing care of a baby with jaundice 245 Physiology of the bilirubin mechanism 245 Investigations 247 Treatment for jaundice 248 Causes of jaundice 252 References 257 Further reading 258

14 Nursing care of a baby in pain and discomfort 259 Effect of pain and discomfort on the

newborn baby 259 Infant responses to pain and discomfort 260 Categories of environmental disturbance 268 Pain management 272 Summary 275 References 275

Contents xi

15 Enhancing development in the neonatal unit 278 Neonatal infant development 278 Sensory Stimulation and the neonatal unit 280 Role and importance of play 281 Play and the infant in the neonatal unit 282 Play and the sick preterm neonate 286 Play and the geriatric neonate 288 The play specialist 292 References 292

16 Neonatal pharmacology 295 Drug absorption 295 Distribution 299 Metabolism 301 Excretion 301 Drug receptors 302 Therapeutic drug monitaring 302 Drug administration 304 Drug formulation 307 References 308

17 Ethical issues in the neonatal unit 309 Ethical issues in neonatology 310 Aspects of personhood 311 To treat or not to treat? 314 Caring or curing? 316 Balancing the cost of neonatal care 318 Conclusion 320 References 321

18 Horne oxygenation 325 Definitions 325 Pathophysiology 326 Management of BDP/CLD 327 Breathing 329 Medications 331 Positioning 332 Growth and nutrition 332 Feeding problems 333 Gastro-oesophageal reflux and vomiting 334 Environment 335

xii Contents

Development 336 Family 337 Discharge preparation and planning

management at home 338 Criteria for discharge 339 Equipment and Iiaison 340 Continuing management 342 Weaning from oxygen 343 Conclusion 343 References 344

19 Infant statistics 346 Counting births and survivors in Britain

and abroad 346 Infant mortality rates in different places 347 Mortality rates at different times and different

infant ages 348 Effect of birth weight on survival 349 What caused the improved survival of babies? 351 What caused the improved survival of small

babies? 352 Incidence of low birth weight 354 Multiple births 357 Conditions needing neonatal care 358 Cause and effect relationships 360 Congenital malformations 361 Scale of provision for neonatal care 362 Outcomes in the Ionger term 366 References 367

Appendix A 372 Appendix B 373 Index 380

Contributors

Ms Gosia Brykcznska RCN Institute of Advanced Nursing Education 20 Cavendish Square London1 UK WlM OAB

Mr Ian Costello Pharmacy Department St George1 S Hospital Blackshaw Road Tooting London1 UK SW17

Mrs Doreen Crawford Neonatal Nursing Unit Lekester Royal Infirmary Lekester 1 VK LE15WW

Mrs Ann Dooley and Mr Daniel Dooley Paediatrk High Dependency Unit Lekester Public Health Laboratory Lekester Royal lnfirmary Lekester 1 VK LE15WW

xiv

Mrs Helen Gardiner Freelance Nutritionist

Contributors

Formerly Company Nutritionist Scientific Department of Milupa Limited Milupa House Uxbridge Rd Hillingdon Middlesex, UK UBlO ONE

Mrs Claire Thomson Greig Dalgety Bay Fife, UK

Ms Emily Logan Ward SC Hospitals for Siek Children Great Ormond Street London, UK WClN 3JH

Ms Christine Midgley Course Director of Pre-Registration Midwifery Birmingham and Solihull College of Nursing and

Midwifery Midwifery Education Centre Good Hope Hospital Rectory Road Sutton Coldfield Birmingham, UK B75 7RR

Miss Maryke Morris Neonatal Unit Lekester Royal Infirmary Leicester, UK LE15WW

Ms Kathy Sleath Hammersmith Hospital Du Cane Road London, UK W12

Contributors

Miss Margaret Sparshott Tamerton Plymouth Devon, UK

Mrs Marjorie Tew Wollaton Nottingham, UK

Mrs Marie-Claire Turrall Therwil Switzerland

XV

About the authors

Gosia Brykczyliska BA, BSc, Cert Ed, RGN, RSCN, RNT ENB 273 is currently a lecturer in ethics and philosophy at the Institute of Advanced Nursing Education, Royal College of Nursing. She is a humanities graduate who has specialized in paediatric nursing. She has written numerous articles and chapters and edited several books, including a book on health care ethics. She is the nurse representative on the British Paediatric Association Ethics Advisory Committee, and is a member of the RCN Ethics Committee. She is currently enrolled as an MPhil/PhD candidate.

Ian Costello BPharm (Hons), MSc, MRPharmS is Senior Pharmacist (Neonatal and Paediatric Services) at St. George's Hospital in Tooting, London, a post he has held for the past year. His research interests include parenteral nutrition, pharmaco­kinetics and therapeutic drug monitoring in neonates.

Doreen Crawford RGN, RSCN, ENB 405, ENB 870 is currently a Senior Oinical Nurse on the Neonatal Unitat the Leicester Royal lnfirmary, where she has worked for the last 5 years. She is also doing a BSc (Hons) degree at King's College, University of London. Doreen is a member of the Association of British Paediatric Nurses, Society of Paediatric Nurses and a member of the Neonatal Nurses Association. Her special interests include teaching neonatal nursing care, the enhance­ment and promotion of neonatal nursing by writing for various nursing publications, and undertaking speaking engagements. She is currently doing research into the benefits of teaching resuscitation skills to the parents of new babies.

xviii About the authors

Ann Dooley RGN, ENG 405 is currently undertaking postregistra­tion RSCN training in Lekester. She has previously worked as a Staff Nurse in both the Neonatal Unit and the Paediatric High Dependency Unit at the Lekester Royal Infirmary. She has a special interest in the implementation of family-centred care.

Daniel Dooley, BSc (Hons), State Registered Medical Laboratory Scientific

Officer is a mkrobiologist currently working for the Publk Health Labaratory Service at the Lekester Royal Infirmary. He has a special interest in foodborne infection, particularly when caused by Listeria monocytogenes. He is undertaking post­graduate study leading to an MSc in biomedkal sciences.

Helen Gardiner BSc(Hons) SRD is a freelance nutritionist. She was previously the Company Nutritionist in the Scientifk Department of Milupa Limited.

Claire Thomson Greig RGN, SCM, Neonatal Certificate, ADM, BN,

MSc (Nursing Education) has wide clinkal experience of neo­natal nursing in Scotland and Canada. She is currently a midwifery teacher in Lothian College of Health, where she coordinates Professional Studies II modules in Neonatal Care. Claire is a member of the Royal College of Midwives and the Neonatal Nurses Association. She is also the educational representative for the Scottish Neonatal Nurses Group.

Emily Logan RSCN, RGN, ENB 136 has been Sister on the Paediatrk Nephrology Unitat Great Ormond Street Hospital for the past 3 years. She is presently undertaking an MSc in Health Psychology.

Christine Midgley, MEd, RGN, RM, MTD is the Course Director for Pre-Registration Midwifery education at the Birmingham and Solihull College of Nursing and Midwifery. Christine has occupied this post since its inception in August 1990. Pre­viously she worked as a midwife teacher at the Lekester Royal Infirmary, where she was responsible for the ENB 405 Course. An interest in frameworks for nursing and midwifery stems from studying for her bachelor' s degree.

About the authors xix

Maryke Morris BSc(Hons), RGN, ENG 405 was a Senior Clinical Nurse on the Neonatal Unitat the Lekester Royal Infirmary, where she has worked for 4 years since graduating from the University of Surrey. Maryke is a member of the University of Surrey Nurses' Association and a member of the Neo­natal Nurses Association. Her special interests include teaching and research into the extended role of the neonatal nurse.

Kathy Sleath RSCN, ENB 402 is currently Senior Nurse Specialist on the Neonatal Unit at Hammersmith Hospital, London. Kathy was an award winner in the Nursing Times/3M com­petition for innovative and pioneering work with oxygen­dependent infants. Kathy currently holds a jointpost involv­ing both her interests, in research and clinical practice.

Margaret Sparshott RGN, RM, ENB 405 is a Senior Staff Nurse on the Neonatal Intensive Care Unit at Derriford Hospital, Plymouth where she has worked since 1986. Her previous experience in Neonatal Nursing includes 6 years on the Premature Baby Unit at the Aghia Sophia Children' s Hospital in Athens and 6 years on the Neonatal Unit at the Cantonal

· University Hospital in Geneva. She is a member of the Neonatal Nurses Association and is particularly interested in the environmental problems of the newborn, writing and lecturing on the subject.

Marjorie Tew MAis a Research Statistician at Nottingham Medical School. When Marjorie became a statistician to medical research she observed that the available statistics, when analysed, did not support the widely held theory that the great decrease in matemal and infant mortality after 1950 was caused by the great increase in hospitalization and obstetric manage­ment of childbirth. The findings of her wider and deeper researches confirmed her early conclusions and, despite strong opposition from the obstetric profession and its supporters, she succeeded in having these reported in many articles in medical joumals or as chapters in books. In 1990 her book Safer Childbirth? A Critical History of Maternity Care was published. Its importance was acknowledged in the House of Commons Health Committee's report in 1992 of the findings of its

XX About the authors

Inquiry into the Maternity Service. She is a member of the steering committee of the Royal Society of Medicine' s Forum on Maternity and the Newborn.

Marie-Claire Turrall RGN, RSCN, ENB 405, Diploma Professional Studies

in Nursing qualified in 1985 and has held a number of posts caring for children and infants in theatres, intensive care and cardiology wards. Most recently she worked as a Senior Clinical Nurse on the Neonatal Unit at Lekester Royal Infir­mary. Marie-Claire currently resides in Switzerland and is actively involved in the local childbirth trust, counselling mothers with breastfeeding problems and helping those who have children in neonatal intensive care.

Preface

There are many books on the care of the sick infant and some are excellent. Most, however, are written with medicine in mind. This book is written mainly by experienced neonatal nurses, although some chapters have been written by the appropriate specialists. lt is intended primarily for nurses who Iook after sick infants and is not intended to be an exhaustive reference but to address some of the issues and concepts of neonatal care in the 1990s. Nursing models are an important part of neonatal care in the 1990s but this book has not been written within this framework. There are several reasons for this: arguably no current model is ideally suited to neonates and the favouring of one particular model might restriet the book's applicability. Also, as contributors from other disciplines were invited to contribute we were anxious that these chapters did not stand out as oddities. Additionally, much neonatal care overlaps and were a framework to be used in its entirety for each nursing care chapter we feit that there could be some repeti­tion; conversely, if a framework was fragmented in some chap­ters to cover specific areas of care, we were concemed that the overall effect would have been 'bitty'. We feit that such treat­ment of nursing models would have been unjustifiable.

In this book, the terms 'infant' and 'baby' are used inter­changeably and where the term 'he' is used, the term 'she' is equally appropriate. The term 'neonatal nurse' applies to any person who is professionally involved in the nursing care of a sick baby, be he or she a nurse, midwife or student.

As long ago as 1907, Pierre Buddin, one of the founders of the art and science which we now call neonatology, wrote that 'the lives of the little ones have been saved but at the

xxü Preface

cost of the mother's'. Today nurses and doctors are partners, with the parents, in the care of the sick infant.

We have moved forward, away from the fairground exhibi­tion of tiny and premature babies to the curious. It is not that the fascination for the small no Ionger exists, nor that we are reticent to display the hi-tech environment in which we work; nor even that these babies are so vulnerable that a passing stranger is a fearsome infection risk. The reason for our low profile is that these babies, like any other sick human beings, are entitled to privacy, peace and dignity in which to either recover or to die.

We wish to express our thanks and gratitude to family and friends who tolerated the stress and strain of writing this book and never gave up hope.

ACKNOWLEDGEMENTS

Maryke Morris and Doreen Crawford wish to acknowledge Karen Allyene, Play Specialist, for her advice on the developmental needs of a baby in a neonatal unit; Dennis Crawford for his computer skills, patience during indexing and for printing all the numerous drafts; Mr and Mrs Hayes for their personal account as parents of baby Joshua who was resi­dent on the NNU; Margaret Sparshott for allowing us to use her drawing for the front cover.