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The Premature Infant: Nursing Assessment and Management , 2nd Edition. Lyn E. Vargo, PhD, NNP, RNC Carol Wiltgen Trotter, PhD, NNP, RNC Slides prepared by Margaret Comerford Freda, EdD, RN, CHES, FAAN. March of Dimes Objective. Healthy People Objective. Preterm Births United States.

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the premature infant nursing assessment and management 2nd edition

The Premature Infant:Nursing Assessment and Management,2nd Edition

Lyn E. Vargo, PhD, NNP, RNC

Carol Wiltgen Trotter, PhD,

NNP, RNC

Slides prepared by Margaret Comerford Freda, EdD, RN, CHES, FAAN

preterm births united states

March of Dimes Objective

HealthyPeople Objective

Preterm Births United States

Percent

27 percent increase from 1981 to 2001

slide3

Transition to Extrauterine Life

  • Requires many physiologic changes for the infant
  • Nurses need to understand general principles of delivery-room management, resuscitation and thermoregulation for premature infants.
delivery room management
Delivery-Room Management
  • Certification by the Neonatal Resuscitation Program (NRP) of the American Heart Association (AHA) and the American Academy of Pediatrics (AAP) is essential for all nurses who work with premature infants.
slide5

Delivery-Room Management Risks

  • Tendency to have difficulty with transition
  • Vulnerable to cold stress
  • More lung immaturity and RDS
  • More intracranial hemorrhage
  • More hypoglycemia
  • Potential for oxygen-related injuries
  • High risk of developing NEC
delivery room management precautions
Delivery-Room Management Precautions
  • Follow resuscitation from NRP guidelines.
  • Avoid rough handling during resuscitation.
  • Reduce heat loss even if resuscitation is not required.
  • Preterm infants may require endotracheal intubation and surfactant administration soon after birth.
delivery room management precautions continued
Delivery-Room Management Precautions (Continued)
  • Administer medication slowly as recommended by NRP guidelines.
  • Follow glucose levels carefully. Glycogen stores may be decreased. Infant may experience hypoglycemia secondary to perinatal compromise.
  • Maintain normal oxygen range after resuscitation.
major physiologic problems of the premature infant
Major Physiologic Problems of the Premature Infant
  • RDS, BPD, apnea of prematurity and chronic lung disease
  • PDA and hypotension
  • ROP
  • Immune-system immaturity that increases the risk of infection
  • P-IVH
additional physiologic problems of the premature infant
Additional Physiologic Problems of the Premature Infant
  • Skin immaturity and fragility
  • Thermoregulation
  • GI issues
  • Fluid and electrolyte imbalances related to immature renal function
  • Acid-base disorders
  • Pain management
  • Developmental issues related to the CNS
  • Impact of the NICU environment
slide10
RDS
  • Incidence 10% for all premature infants
  • Incidence 50% for 26 week to 28 weeks
  • Risk factors:
    • Low gestational age
    • Male
    • Born to diabetic mothers
    • Born after an asphyxial insult before birth
    • Born after maternal-fetal hemorrhage
    • Multiple gestation
rds continued
RDS (Continued)
  • Complex respiratory disease characterized by diffuse alveolar atelectasis of the lungs, primarily caused by a deficiency of surfactant. This leads to higher surface tension at the surface of alveoli, which interferes with normal exchange of oxygen and carbon dioxide.
nih recommendations for use of antenatal steroids
NIH Recommendations for Use of Antenatal Steroids
  • Give to all pregnant women 24 to 34 weeks gestation who are at risk for preterm delivery within 7 days:
    • 2 doses of 12 mg of betamethasone IM 24 hours apart OR
    • 4 doses of 6 mg of dexamethasone IM 12 hours apart
  • Repeat courses of corticosteroids should not be given routinely in pregnant women.
signs and symptoms of rds
Signs and Symptoms of RDS
  • Difficulty in establishing normal respiration, especially if infant has risk factors for RDS
  • Expiratory grunting while the infant is not crying
  • Intercostal and sternal retractions due to increased rib cage compliance and decreased lung compliance
signs and symptoms of rds continued
Signs and Symptoms of RDS (Continued)
  • Nasal flaring
  • Cyanosis
  • Tachypnea
rds treatment
RDS Treatment
  • Thermoregulation
  • Fluid balance and nutrition
  • Skin care
  • Pain assessment
  • Developmental care
  • Family care
rds treatment continued
RDS Treatment (Continued)
  • Focus is to prevent and minimize atelectasis.
  • Minimize untoward effects of oxygen and barotrauma or volutrauma.
  • Treat underlying cardiovascular infectious and other physiologic problems.
  • Maintain a balanced physiologic environment.
surfactant therapy
Surfactant Therapy
  • Surfactant coats the inside of the alveoli. It prevents collapse (atelectasis) and keeps alveoli open at the end of expiration.
  • It is given via endotracheal tube.
  • Prophylactic therapy appears more beneficial than rescue therapy.
surfactant therapy continued
Surfactant Therapy (Continued)
  • Criteria for identifying at-risk infants who would benefit from prophylactic treatment are unclear.
  • Multiple doses lead to improved clinical outcomes.
adjunct treatments for rds
Adjunct Treatments for RDS
  • CPAP
    • A method of assisting lung expansion with continuous distending pressure
    • A valuable adjunct when spontaneous breathing is adequate and pulmonary disease is not excessive
    • Increases transpulmonary pressure; improves oxygenation and ventilation
    • Reduces tachypnea and grunting
adjunct treatments for rds continued
Adjunct Treatments for RDS (Continued)
  • HFV
    • Allows the use of small tidal volumes (smaller than anatomic dead space) and high frequencies.
    • Rates of 150 to 3,000 breaths per minute can be used depending on the type of HFV.
    • HFV limits large tidal volumes and wide ventilator pressure swings associated with volutrauma/ barotrauma caused by traditional mechanical ventilation.
  • Oscillation
rds nursing care
RDS Nursing Care
  • Any nurse caring for an infant with RDS must:
    • Be familiar with RDS pathophysiology
    • Recognize symptoms of RDS
    • Initiate interventions as indicated
rds nursing care continued
RDS Nursing Care (Continued)
  • Maintain paO2 and oxygen saturation levels.
  • Recognize importance of weaning oxygen and other ventilator parameters.
  • Recognize complications arising from RDS, intubation and mechanical ventilation.
  • Utilize proper endotracheal suctioning techniques.
rds nursing care continued24
RDS Nursing Care (Continued)
  • Provide mouth and skin care.
  • Maintain proper positioning.
  • Provide adequate fluid and electrolyte balance.
  • Monitor blood glucose levels.
  • Reduce environmental stressors.
  • Provide parental support.
slide25
BPD
  • A significant problem for premature infants
  • Uncommon after 32 weeks gestation
  • A secondary disease that develops in neonates treated with positive pressure ventilation and oxygen for primary lung problems such as RDS
  • 7,500 new cases every year in the United States
  • 10% die by 1 year of age
signs and symptoms of bpd
Signs and Symptoms of BPD
  • Hypoxemia with prolonged oxygen requirement
  • Hypercapnia, tachypnea with increased work of breathing
  • Episodic bronchospasm with wheezing
  • In severe cases, CHF with cor pulmonale
  • Abnormal postures of neck and upper trunk
bpd treatment
BPD Treatment
  • Therapy is preventive and supportive.
  • Preventive measures begin prenatally with preventing prematurity and using a single course of antenatal steroids.
  • Includes early, careful management of RDS, use of low ventilator pressures, and careful use of oxygen and exogenous surfactant treatment.
aap cps summary recommendations on postnatal steroids
AAP/CPS Summary/Recommendations on Postnatal Steroids
  • Systemic administration of dexamethasone to mechanically ventilated premature infants decreases incidence of chronic lung disease and extubation failure. Does not decrease overall mortality.
  • Dexamethasone treatment for VLBW infants is associated with complications (impaired growth and neurodevelopmental delay).
aap cps summary recommendations on postnatal steroids continued
AAP/CPS Summary/Recommendations on Postnatal Steroids (Continued)
  • Use of inhaled corticosteroids to prevent CLD has not shown benefits.
  • Routine use of dexamethasone for the prevention of BPD in VLBW infants is not recommended.
  • Postnatal use of systemic dexamethasone for the prevention of BPD should be limited to carefully designed randomized double-masked controlled trials.
slide31

AAP/CPS Summary/Recommendations on Postnatal Steroids (Continued)

Outside the context of a randomized controlled trial, the use of postnatal corticosteroids should be limited to exceptional clinical circumstances (an infant on maximal ventilatory support). Parents should be fully informed about the short- and long-term risks and agree to treatment.

bpd nursing care
BPD Nursing Care
  • Prevent further lung damage.
  • Wean ventilator and oxygen support slowly.
  • Recognize that stressful situations can minimize hypoxemia-inducing events.
  • Use sucrose with nonnutritive sucking before painful procedures to decrease pain.
bpd nursing care continued
BPD Nursing Care (Continued)
  • Preoxygenation (increasing FiO2 just before suctioning) may help prevent hypoxemia with suctioning.
  • A consistent caregiver is helpful to parents.
  • Use fortified breastmilk or premature specialty formula for a consistent weight gain of 10 g to 30 g per day.
  • Kangaroo care promotes bonding.
kangaroo care
Kangaroo Care
  • Improvement in gas exchange and temperature in premature infants
  • No adverse affect on physiologic stability
  • Improvement in lactation outcomes in mothers wishing to breastfeed premature infants
  • Positive impact on the parenting process
apnea of prematurity
Apnea of Prematurity
  • 50% of NICU infants
  • Periods of cessation of respiration for longer than 10 seconds to 15 seconds
  • Apneic episodes frequently accompanied by cyanosis, bradycardia, pallor or hypotonia
  • Exact cause unknown but thought to be due to immature CNS
types of apnea in premature infants
Central: Absent breathing movements/ effort

Obstructive: Breathing movements but no air flow

Mixed: Mixture of obstructive and central apnea

Types of Apnea in Premature Infants
apnea treatment
Apnea Treatment
  • Cardiac and respiratory monitoring until no apnea episodes for 5 to 7 days
  • Neutral thermal environment
  • Careful positioning; avoid flexion and hyperextension of the neck
apnea treatment continued
Apnea Treatment (Continued)
  • Attention to gastric tube placement and infusion rate during tube feeding
  • Nasal CPAP
  • Methyxanthines (oral to intravenous aminophylline, theophylline and caffeine)
apnea nursing care
Apnea Nursing Care
  • Assess infant’s color, perfusion, respiratory rate, heart rate, position and oxygen saturation.
  • Document frequency and severity of episodes and type and amount of stimulation required to interrupt the event.
  • Ensure bag and mask set-ups with oxygen available at infant bedside.
slide40
PDA
  • The most common cardiac complication in premature infants
  • Incidence inversely related to gestational age
  • Occurs in 45% of infants with a birthweight <1,750 g
  • Occurs in 80% of infants with a birthweight <1,200 g
signs and symptoms of pda
Signs and Symptoms of PDA
  • Signs and symptoms of congestive heart failure, increased need for oxygen and inability to wean from ventilator
  • Widened pulse pressure, an active precordium, bounding peripheral pulses and tachycardia with or without a gallop
  • Echocardiogram most useful to evaluate PDA
pda treatment
PDA Treatment
  • Treatment is controversial.
  • Medical management with fluid restriction and diuretics may be the initial approach.
  • Indomethacin has been effective in closing PDAs (dosage depends on weight, gestation and renal function).
pda nursing care
PDA Nursing Care
  • Continually assess high-risk infants for pulse, heart rate, pulse pressure, perfusion, and auscultation for the presence of a murmur.
  • Know dosage and contraindications for indomethacin.
  • Assess infant after indomethacin for ductal closure, decreased urine output and thrombocytopenia.
  • Teach and reassure parents.
slide45
ROP
  • A significant cause of blindness in children initiated by delay in retinal vascular growth
  • The more premature the infant, the more likely the infant is to have ROP.
  • 82% of infants weighing <1,000 g at birth develop ROP.
rop continued
ROP (Continued)
  • 47% of infants weighing 1,000 g to 1,500 g at birth develop ROP.
  • Other risk factors: prolonged mechanical ventilation and oxygen administration, hyperoxia, hypoxia, sepsis, acidosis, shock
long term consequences of rop
Long-Term Consequences of ROP
  • Myopia (nearsightedness)
  • Strabismus (crossed eye)
  • Amblyopia (lazy eye)
  • Astigmatism
  • Glaucoma
  • Late retinal detachment
  • Blindness
aap screening premature infants for rop
AAP: Screening Premature Infants for ROP
  • First exam occurs 4 to 6 weeks after birth or 31 to 33 weeks postconceptional age.
  • Two exams after pupillary dilation using indirect ophthalmoscopy if:
    • Weight at birth <1,500 g or gestational age <28 weeks
    • High-risk event and weight at birth 1,501 g to 2000 g or gestational age 29 to 36 weeks
rop treatment
ROP Treatment
  • ROP progresses at different rates in different infants.
  • The goal of treatment for ROP is prevention of blindness.
  • Surgical therapies—Laser photocoagulation and cryotherapy
characteristics of neonatal sepsis
Characteristics of Neonatal Sepsis

M.S. Edwards, 2002a. Reprinted with permission.

deficiencies in neonatal host defenses that predispose to infection
Deficiencies in Neonatal Host Defenses that Predispose to Infection
  • Anatomic barriers—Injuries during delivery (skin abrasions)
  • Invasive procedures in the nursery (umbilical artery catheters, endotracheal tubes)
deficiencies in neonatal host defenses that predispose to infection continued
Deficiencies in Neonatal Host Defenses that Predispose to Infection, Continued
  • Phagocytic cells
    • Small PMN leukocyte storage pool
    • Decreased PMN leukocyte adherence
    • Decreased PMN leukocyte and monocyte chemotaxis
    • Decreased phagocytosis in stressed neonates
    • Decreased PMN leukocyte intracellular killing in stressed neonates
deficiencies in neonatal host defenses that predispose to infection continued53
Deficiencies in Neonatal Host Defenses that Predispose to Infection, Continued
  • Complement
    • Decreased levels of complement
    • Decreased expression of complement receptors
  • Cellular immunity
    • Possible defects in T-cell immunoregulation
deficiencies in neonatal host defenses that predispose to infection continued54
Deficiencies in Neonatal Host Defenses that Predispose to Infection, Continued
  • Humoral immunity
    • Decreased IgA, IgM
    • Decreased IgG in premature neonates
    • Impaired antibody function
    • Decreased levels of fibronectin
    • Decreased levels of cytokine (interferon, tumor necrosis factor)
slide55

Meningitis

  • Severely debilitating illness in VLBW infants
  • Caused by the same pathogens that cause sepsis
  • Incidence of culture-proven meningitis: 1.8%
  • Occurs in neonates with lower mean birth-weights and gestational ages
  • Residual major neurologic abnormalities and subnormal scores on MDI on the Bayley Scales of Infant Development
meningitis continued
Meningitis (Continued)
  • Most common etiology is hematogenous spread from the bloodstream to the meninges.
  • Can be early- or late-onset
  • Mortality is usually higher with early onset disease.
signs and symptoms of meningitis
Signs and Symptoms of Meningitis
  • Lethargy
  • Hypotonia
  • Temperature instability
  • Increased oxygen requirements
  • Apnea
  • Bradycardia
  • Feeding intolerance
  • Seizures
pneumonia
Pneumonia
  • Developed:
    • In utero through transplacental transfer of organisms and aspiration of pathogens from amniotic fluid of mothers with chorioamnionitis
    • During/After delivery through aspiration of infected materials
    • Postdelivery through inhalation of particles from individuals or equipment; through contaminated endotracheal tubes; through hematogenous spread from pathogens in the bloodstream
  • Most common cause is GBS.
signs and symptoms of pneumonia
Signs and Symptoms of Pneumonia
  • Early signs are the same as for sepsis:
    • Lethargy or irritability
    • Poor feeding
    • Temperature instability
    • Poor color
    • Respiratory signs--tachypnea, apnea, cyanosis, retractions, grunting, nasal flaring and retractions
treatment of sepsis meningitis and pneumonia
Treatment of Sepsis, Meningitis and Pneumonia
  • Early identification of neonate at risk is essential for prevention of morbidity and mortality.
  • Develop a culture of prevention of infection in NICU.
  • Eradicate the pathogen with medications.
  • Minimize sequelae.
nursing care of sepsis meningitis and pneumonia
Nursing Care of Sepsis, Meningitis and Pneumonia
  • Monitor respiratory status, oxygen support, mechanical ventilation.
  • Watch for worsening apnea/bradycardia.
  • Suctioning PRN
  • Volume replacements PRN with isotonic solutions
nursing care of sepsis meningitis and pneumonia continued
Nursing Care of Sepsis, Meningitis and Pneumonia, Continued
  • Blood products PRN
  • Minimal handling to avoid extra stress
  • Watch for seizures.
slide65
NEC
  • The most common neonatal intestinal emergency
  • Characterized by intestinal ischemia, most often involving the terminal ileum
  • Pathogenesis is uncertain.
  • Three major factors: bowel wall ischemia; bacterial invasion of the bowel wall; enteral feedings
three stages of nec
Three Stages of NEC
  • Generalized symptoms of early sepsis, including temperature instability, lethargy, apnea and bradycardia, feeding intolerance, abdominal distention, and stools that test positive for occult blood
  • Severe abdominal distention and tenderness, visible bowel loops, grossly bloody stools, metabolic acidosis, poor perfusion and a mottled skin color
  • Fulminant signs of SIRS, including shock, mixed acidosis, DIC and neutropenia
nec treatment
NEC Treatment
  • Goals:
    • Stabilize the neonate.
    • Treat the infection.
    • Rest the intestinal tract.
  • Discontinue feedings.
  • Initiate IV access for fluids and antibiotics.
  • NG tube to decompress GI tract
nec nursing care
NEC Nursing Care
  • Monitor vital signs.
  • Monitor blood gases and pH.
  • Examine for abdominal distention, tenderness, emesis, bloody stools, temperature instability, metabolic acidosis, apnea, bradycardia.
  • Support parents.
  • Encourage mother to pump breasts and freeze breastmilk.
intrapartum antibiotic prophylaxis to prevent perinatal gbs
Intrapartum prophylaxis not indicated

Previous pregnancy with positive GBS screening culture (unless a culture was also positive during the current pregnancy)

Planned cesarean delivery performed in the absence of labor or membrane rupture (regardless of maternal GBS culture status)

Negative vaginal and rectal GBS screening culture in late gestation during the current pregnancy, regardless of intrapartum risk factors

Intrapartum prophylaxis indicated

Previous infant with invasive GBS disease

GBS bacteriuria during current pregnancy

Positive GBS screening culture during current pregnancy (unless a planned cesarean delivery, in the absence of labor or amniotic membrane rupture, is performed)

Unknown GBS status (culture not done, incomplete or results unknown) and any of the following:

Delivery at <37 weeks gestation

Amniotic membrane rupture ≥18 hours

Intrapartum temperature ≥100.4°F (≥38.0°C)†

Intrapartum Antibiotic Prophylaxis to Prevent Perinatal GBS

Vaginal and rectal GBS screening cultures at 35 to 37 weeks gestation for all pregnant women (unless patient had GBS bacteriuria during the current pregnancy or a previous infant with invasive GBS disease).

pbps for prevention of nosocomial infections in nicus
PBPs for Prevention of Nosocomial Infections in NICUs
  • Increased compliance with hand-hygiene standards
  • Improved accuracy of the diagnosis of bacteremia
  • Reduced line and line connection (hub) bacterial contamination
pbps for prevention of nosocomial infections in nicus continued
PBPs for Prevention of Nosocomial Infections in NICUs(Continued)
  • Maximal barrier precautions for central line placement
  • Decreased
    • Number of skin punctures
    • Duration of IV lipid infusion
    • Duration of central venous line use
ivh pvh
IVH/PVH
  • 50% will die.
  • Occurs in 25% to 30% of all VLBW infants discharged from Level III NICUs
  • Associated primarily with prematurity
  • Infants <28 weeks gestation are at greatest risk.
ivh pvh continued
IVH/PVH (Continued)
  • Small (Grades I and II)
    • Grade I hemorrhage is an isolated germinal matrix hemorrhage.
    • Grade Il is an IVH with normal ventricular size.
  • Moderate (Grade III) is an IVH with acute ventricular dilation.
  • Severe (Grade IV) is an IVH with parenchymal hemorrhage.
signs and symptoms of ivh pvh
Signs and Symptoms of IVH/PVH
  • Can be subtle; sometimes only decreased hematocrit or hemoglobin levels
  • May evolve over several hours and include decreased activity, hypotonia, altered consciousness, respiratory disturbances
  • Can develop rapidly, with seizures, decerebrate posturing, fixed pupils
ivh pvh treatment and nursing care
IVH/PVH Treatment and Nursing Care
  • Optimal treatment is prevention.
  • Minimize brain tissue destruction.
  • Minimize pain and stress.
  • Minimize crying, suctioning, rapid bolus infusions.
ivh pvh treatment and nursing care continued
IVH/PVH Treatment and Nursing Care (Continued)
  • Maintain neutral thermal environment.
  • Elevate head 30º.
  • Use sucrose pacifiers, topical anesthetics for procedures.
  • Provide parental support.
pbps for prevention of ivh and pvl
PBPs for Prevention of IVH and PVL
  • Administer antenatal steroids.
  • Optimize peripartum management.
  • Administer antenatal antibiotics for preterm rupture of the membranes.
  • Delivery-room resuscitation by neonatologists and an experienced team
pbps for prevention of ivh and pvl continued
PBPs for Prevention of IVH and PVL (Continued)
  • Maintain the baby’s temperature >36° centigrade.
  • Maintain cardiorespiratory stability while administering surfactant.
  • Optimize direct clinical management by neonatologists.
  • Implement measures to minimize pain and stress responses.
pbps for prevention of ivh and pvl continued83
PBPs for Prevention of IVH and PVL (Continued)
  • Use developmental care.
  • Judiciously use narcotic sedation (low dose, continuous).
  • Avoid early lumbar puncture (72 hours old).
  • Use optimal positioning.
pbps for prevention of ivh and pvl continued84
PBPs for Prevention of IVH and PVL (Continued)
  • In terms of fluid volume treatment of hypotension, there is no evidence demonstrating benefit of using MAP 30 rather than MAP > estimated gestational age weeks.
  • Use postnatal indomethacin judiciously.
  • Optimize respiratory management.
  • Use postnatal dexamethasone judiciously.
goals of nursing care to promote parental attachment
Goals of Nursing Care to Promote Parental Attachment
  • Opening the intensive care nursery to parents
  • Transporting the mother to be near her infant
  • Maternal day care for premature infants
  • Rooming in for parents
  • Individualized nursing care plans
  • Early discharge
goals of nursing care to promote parental attachment continued
Goals of Nursing Care to Promote Parental Attachment (Continued)
  • Listening to parents during the infant’s hospitalization and after discharge
  • Parent support groups
  • Programmed contact and reciprocal interaction
  • Transporting the healthy premature infant to the mother
goals of nursing care to promote parental attachment continued87
Goals of Nursing Care to Promote Parental Attachment (Continued)
  • Home-based interventions for young parents
  • Discussion with parents after discharge
  • Kangaroo care
  • Nurse home visitation
march of dimes prematurity campaign
March of Dimes Prematurity Campaign
  • Multi-year, multimillion-dollar campaign to help families have healthier babies by:
    • Funding research to find causes of premature birth
    • Educating women about risk reduction
    • Providing support to families
march of dimes prematurity campaign continued
March of Dimes Prematurity Campaign (Continued)
  • Expanding access to health care coverage for prenatal care
  • Helping providers learn ways to help reduce risk of early delivery
  • Advocating for access to insurance to improve maternity care and infant health outcomes
march of dimes nicu family support sm
March of Dimes NICU Family Supportsm
  • Provides emotional and informational resources to families with a newborn in the NICU
  • In more than 50 NICUs in the United States by 2007
  • marchofdimes.com/prematurity/nicu
march of dimes share your story
March of DimesShare Your Story
  • Online community for families with a child in the NICU
  • Users share NICU experiences, participate in online discussions and meet other NICU families.
  • More than 10,000 registered members
  • marchofdimes.com/share