Complications of the Neonate

1. Complications of the Neonate Assessment Thermoregulation Nutrition Skin care Pain Growth & Development Parental involvement

2. COMPLICATIONS OF THE NEONATE • Classifications of high-risk neonates: <2500gm = LBW <1500gm = VLBW <1000gm = ELBW (also called “micropremie”) • Infant Mortality Rates & LBW: The lower the birthweight the greater the mortality • Ethical Isssues: Survival vs Quality of life Hospital Ethics Committee

3. Assessment Guidelines: • General: Weigh daily, or qod if unstable • Respiratory: • note retractions-- grade & location • pneumothorax--diminished sounds on one side • vent settings, size of ET tube, pulseox

4. Assessment Guidelines: (continued) • Cardiovascular: • note murmurs--location & amplitude. • PMI-if on wrong side may indicate diaphragmatic hernia. • Assess Peripheral pulses. • Note mottling if poor peripheral perfusion • Monitors-  every hour for positioning and accuracy.

5. Assessment Guidelines: • Gastrointestinal: • Abd. Distention, loops of bowel seen. • Feeding tolerance- regurge, gastric aspirate ac. Blood in stools( + hemoccult test) • Genitourinary: • daily weight for hydration. • Weigh diapers on gram scale for output. • Assess for Ambiguous genitalia, preterm genitalia

6. Assessment Guidelines: • Neurological:jittery-- immature CNS or hypoglycemia. Reflexes, head circumference,fontanels soft & flat • Temperature: skin temp vs air temp in isolette weaning baby from isolette, axillary vs rectal • Skin: irritation from all monitoring equipment/probes/IV’s/heel sticks; preterm “look” of skin: translucent, waxy

7. Maintaining Thermoneutrality • Goal is to keep axillary temp. 36.5 - 37.5 C. • Types of beds in NICU: *Radiant Warmer *Double-walled isolette *Open crib

8. Maintaining Thermoneutrality (cont’d) • Other options: * bubblewrap * saran wrap * Kangaroo Care • Essential to watch for signs of INFECTION: *lethargy, poor feeding, Temp  or  *most babes are on Ampicillin & Gentamycin

9. HYDRATION • Preterm infant is at great risk for dehydration because of large body surface area, 90% extracellular body water content, & underdeveloped kidneys • Ways to provide Hydration Parenterally: • Peripheral: hands, feet scalp, antecubital • UAC-- umbilical artery catheter • UVC -- umbilical venous catheter • PICC or PCVC -- Peripheral Intravenous Central Catheter or Percutaneous Central Venous Catheter

10. NUTRITION • Suck reflex: appears 32-34 weeks gestation, but cannot coordinate suck, swallow, breathe until 36 wks. • Premies have poor muscle tone in lower esophageal sphincter so regurge a lot, which may lead to aspiration or vagal response of apnea • Premies need calories to GROW, KEEP WARM, & to HEAL

11. Nutrition (cont’d) • “Minimal enteral feedings” also called priming the gut: 0.5cc/hr of premie formula or breastmilk per infusion pump to stimulate GI tract, even though most nutrition still given parenterally • Breastmilk is still STRONGLY advocated with added fortifier

12. NUTRITION (cont’d) • Gavage feeding- • NG interferes with nasal breathing, but OG interferes with oral intake. • Depends on infant status & NICU protocol. • May be administered by gravity, or pump- intermittent or continuous • Nursing Assessments: • need to always  aspirate and placement ac • non-nutritive sucking often advocated during gavage feedings to foster cognitive association of sucking with nourishment and sense of satiation.

13. Nutrition (cont’d) • Bottlefeeding- signs of readiness: • strong suck; • can coordinate suck, swallow, breathe; • gag reflex present; • sucking motions; • rooting & wakefulness ac and sleeping pc. • May need to do partial feeding nippled & the rest via NG/OG tube to  stress on babe

14. NUTRITION (cont’d) • Speech Therapists- often used to teach special exercises to foster sucking. • Nutritionists calculate daily caloric needs • Positioning: preterm infants digest better in a PRONE position. They use less energy when prone, and have improved oxygenation.

15. NEONATAL SKIN CARE • Preterm skin is thinner, delicate, and lacks”RETE PEGS” which anchor epidermis to dermis. Puts premies at great risk for skin tears. • Limit use of adhesivie tape, bandaids. • Use Stomahesive under tape. • Do NOT use adhesive remover! Rather use warm water to remove sticky tape. • Warm heels before heelsticks.

16. ACUTE PAIN IN THE PREMATURE INFANT • Look for symptoms of distress: * grimacing * thrashing * flaccidity * fussiness * desaturations * HR/RR increase • CNS is developed enough for babies to feel pain!

17. FOSTERING GROWTH & DEVELOPMENT • Need to foster normal G & D by establishing some kind of daily routine for baby. • Get nursing care done, then let baby rest. • Infant massage may relax baby. • Cover isolettes with blankets to create “day & night” environment • Make tapes of parents talking, or have soft music and play in isolette if parents cannot be present

18. FOSTERING GROWTH & DEVELOPMENT • Kangaroo Care- once baby is stable. Skin-to-skin contact has been proven through research to •  SaO2, •  rate of weight gain, •  HR •  # of apneic episodes • Encourage parents to put black & white mobiles around crib for visual stimulation

19. PARENT INFANT INTERACTION • Parents are often scared to touch the premie because of his size and apparent fragility.Fear of loss and fear of attachment are conflicting emotions all parents go through. • Parents feel overwhelmed by the amount of technical equipment being used to keep their baby alive & by the number of people it takes to coordinate his care. • The NURSE needs to serve as the parent advocate by clarifying what the doctors say on rounds, explaining the purpose behind all the diagnostic testing and equipment, and emphasizing the attributes of THEIR BABY.

20. PARENT INFANT INTERACTION (cont’d) • Let parents do as much of the care as is safe and they can handle. Encourage visits whenever possible. Point out personality characteristics seen in their baby! • Sibling visits are encouraged but still mostly at specific times. Siblings must have their temps taken, answer questions about exposure to communicable dzs, and wash their hands before visiting with premie.

21. NEONATAL LOSS • If the premature infant dies, it is important to support the family through this loss. • Photos of the baby dressed in doll clothes are routinely taken and saved on the unit if the parents are not ready to take the photos with them. • Parents are given the option of holding their baby when he is dying when all the machines have been turned off. • Nurse or chaplain may baptize baby before death.

22. Neonatal Loss (cont’d) • A “Memory Book” is made for the family with armbands, footprints & handprints, lock of hair, hat and booties and any other memorabilia belonging to the baby. • Referral is made to support groups for parents who have experienced such a loss.

23. That’s It!! • Be sure to review all the pathophysiology discussed in the content outline in your syllabus re: • RDS • Hypoglycemia • Hyperbilirubinemia • Complications as NEC, ROP • Meconium Aspiration Syndrome