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

1. 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

2. March of Dimes Objective HealthyPeople Objective Preterm Births United States Percent 27 percent increase from 1981 to 2001

3. 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.

4. 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.

5. 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

6. 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.

7. 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.

8. 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

9. 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

10. 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

11. 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.

12. 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.

13. Chain of Events with Surfactant Delivery

14. 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

15. Signs and Symptoms of RDS (Continued) • Nasal flaring • Cyanosis • Tachypnea

16. RDS Treatment • Thermoregulation • Fluid balance and nutrition • Skin care • Pain assessment • Developmental care • Family care

17. 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.

18. 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.

19. Surfactant Therapy (Continued) • Criteria for identifying at-risk infants who would benefit from prophylactic treatment are unclear. • Multiple doses lead to improved clinical outcomes.

20. 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

21. 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

22. 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

23. 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.

24. 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.

25. 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

26. 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

27. Cascade of Events Occurring in BPD

28. 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.

29. 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).

30. 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.

31. 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.

32. 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.

33. 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.

34. 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

35. 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

36. 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

37. 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

38. Apnea Treatment (Continued) • Attention to gastric tube placement and infusion rate during tube feeding • Nasal CPAP • Methyxanthines (oral to intravenous aminophylline, theophylline and caffeine)

39. 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.

40. 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

41. 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

42. Left-to-Right Shunt Through PDA

43. 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).

44. 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.

45. 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.

46. 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

47. Long-Term Consequences of ROP • Myopia (nearsightedness) • Strabismus (crossed eye) • Amblyopia (lazy eye) • Astigmatism • Glaucoma • Late retinal detachment • Blindness

48. 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

49. 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

50. Characteristics of Neonatal Sepsis M.S. Edwards, 2002a. Reprinted with permission.