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31The Newborn at Risk:

Birth-Related StressorsCHAPTER

We watched him breathe every precious breath. He was covered with wiresand tubes. The rhythmic tides of his sleeping and feeding spaciouslymeasured his days and nights.We kept watch. He was special to us and wewould say over and over, “Daddy and mommy are here and we love you.”

—Alan and Claudia, parents of a baby with RDS

LEARNING OBJECTIVES

813

■ Discuss how to identify infants in need ofresuscitation and the appropriate method ofresuscitation based on the labor record andobservable physiologic indicators.

■ Based on clinical manifestations, differentiatebetween the various types of respiratory distress(respiratory distress syndrome, transient tachypnea ofthe newborn, and meconium aspiration syndrome) inthe newborn and their related nursing care.

■ Discuss selected metabolic abnormalities(including cold stress and hypoglycemia), theireffects on the newborn, and the nursingimplications.

■ Differentiate between physiologic and pathologicjaundice based on onset, cause, possiblesequelae, and specific management.

■ Explain how Rh incompatibility or ABOincompatibility can lead to the development ofhyperbilirubinemia.

■ Identify nursing responsibilities in caring for thenewborn receiving phototherapy.

■ Discuss selected hematologic problems such asanemia and polycythemia and the nursingimplications associated with each one.

■ Describe the nursing assessments that would leadthe nurse to suspect newborn sepsis.

■ Relate the consequences of selected maternallytransmitted infections, such as maternal syphilis,gonorrhea, herpesvirus, and chlamydia, to themanagement of the infant in the neonatal period.

■ Describe the interventions to facilitate parentalattachment with the at-risk newborn.

■ Identify the special initial and long-term needs ofparents of at-risk infants.

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Infant Respiratory Distress SyndromeThinking Critically

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Marked homeostatic changes happen during the transition from fe-tal to neonatal life. The most rapid anatomic and physiologicchanges of this period occur in the cardiopulmonary system, so

the newborn’s major problems are usually related to this system. Theseproblems include asphyxia, respiratory distress, cold stress, jaundice, he-molytic disease, and anemia. Ideally, problems are anticipated and identifiedprenatally, and appropriate intervention measures are begun at or immedi-ately after birth.

CARE OF THE NEWBORN AT RISK DUE TO ASPHYXIANeonatal asphyxia results in circulatory, respiratory, and biochemicalchanges. Circulatory patterns that accompany asphyxia indicate the new-born’s inability to make the transition to extrauterine circulation—in effect,a return to fetal circulatory patterns. Failure of lung expansion and estab-lishment of respiration rapidly produces serious biochemical changes, in-cluding hypoxia (decreased oxygen concentration available to tissues),acidosis (increased acidity of blood reflected by low pH), and hypercarbia(excess levels of carbon dioxide in the blood).

These biochemical changes cause abnormal changes in pulmonary cir-culation. Arterioles constrict, resulting in vascular resistance and dimin-ished pulmonary blood flow to the organs and the lungs, and a largeright-to-left shunt through the ductus arteriosus. The foramen ovale re-opens as right atrial pressure exceeds left atrial pressure, and blood flowsfrom right to left. (See Chapter 26 for a review of normal newborn car-diopulmonary adaptation. ∞)

However, the most serious biochemical abnormality caused by hypoxia isa change from aerobic to anaerobic metabolism. This change results in thebuildup of lactate and development of metabolic acidosis. Simultaneous respi-ratory acidosis may also occur due to a rapid increase in carbon dioxide (PCO2)during asphyxia. In response to hypoxia and anaerobic metabolism, glycogenstores are mobilized to provide a continuous glucose source for the brain, andthe amounts of free fatty acids (FFAs) and glycerol in the blood increase.

The newborn has several protective mechanisms against hypoxic insults.These include a relatively immature brain and a resting metabolic rate lowerthan that of adults, an ability to mobilize substances within the body for anaer-obic metabolism and to use energy more efficiently, and an intact circulatorysystem able to redistribute lactate and hydrogen ions in tissues still being per-fused. Unfortunately, the body’s stores of glycogen may be used up rapidly dur-ing an asphyxial attack. Severe, prolonged hypoxia overcomes the body’sprotective mechanisms, resulting in brain damage or death of the newborn.

The newborn suffering apnea requires immediate resuscitative efforts.The need for resuscitation can be anticipated if specific risk factors are presentduring the pregnancy or labor and birth.

RISK FACTORS PREDISPOSING TO ASPHYXIAThe need for resuscitation may be anticipated if the mother demonstratesthe antepartal and intrapartum risk factors described in Table 10–1 inChapter 10 and Table 18–1 in Chapter 18. ∞ Neonatal risk factors for re-suscitation are as follows (Thureen, Deacon, Hernandez et al., 2005):

■ Nonreassuring fetal heart rate pattern

■ Difficult birth

■ Fetal scalp/capillary blood sample-acidosis

Cold stress, 831

Erythroblastosis fetalis, 836

Hemolytic disease of the newborn, 838

Hydrops fetalis, 836

Hyperbilirubinemia, 835

Hypoglycemia, 832

Jaundice, 835

Kernicterus, 835

Meconium aspiration syndrome(MAS), 829

Phototherapy, 837

Physiologic anemia, 844

Polycythemia, 845

Respiratory distress syndrome (RDS),819

Sepsis neonatorum, 846

KEY TERMS

814

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The Newborn at Risk: Birth-Related Stressors 815

■ Apneic episode unresponsive to tactile stimulation

■ Inadequate ventilation

■ Male infant

■ Prematurity

■ Small for gestational age

■ Multiple births

■ Structural lung abnormality (congenital diaphragmatichernia, lung hypoplasia)

■ Congenital heart disease

■ Sepsis with cardiovascular collapse

Risk factors are not always apparent prenatally. Particular at-tention must be paid to all at-risk pregnancies during the in-trapartal period. Certain aspects of labor and birth challengethe oxygen supply to the fetus, and often the at-risk fetus hasless tolerance for the stress of labor and birth.

CLINICAL THERAPYThe initial goal of medical management is to identify the fe-tus at risk for asphyxia, so that resuscitative efforts can beginat birth. Fetal biophysical assessment (see Chapter 16 ∞),combined with monitoring of fetal pH, fetal heart rates, andfetal oximetry if available, may help identify the presence ofnonreassuring fetal status. If nonreassuring fetal status ispresent, appropriate measures can be taken to deliver the fe-tus immediately, before major damage occurs, and to treatthe asphyxiated newborn.

The fetal biophysical profile enhances the ability topredict an abnormal perinatal outcome. In addition to thefetal biophysical profile, fetal scalp blood sampling may in-dicate asphyxic insult and the degree of fetal acidosis, whenconsidered in relation to the stage of labor, uterine con-tractions, and the presence of nonreassuring fetal heart rate(FHR) patterns. The stress of labor causes an intermittentdecrease in exchange of gases in the placental intervillousspace, which causes the fall in pH and fetal acidosis. Theacidosis is primarily metabolic.

During labor a fetal pH of 7.25 or higher is considerednormal (nonacidemia). A pH value of 7.2 or less is con-sidered an ominous sign of intrauterine asphyxia (aci-demia). However, low fetal pH without associated hypoxiacan be caused by maternal acidosis secondary to prolongedlabor, dehydration, and maternal lactate production.

Assessment of the newborn’s need for resuscitation be-gins at the time of birth. The nurse should note the time ofthe first gasp, first cry, and onset of sustained respirationsin order of occurrence. The Apgar score (see informationin Chapter 19 ∞) may be helpful in determining theseverity of the neonatal depression and may be predictiveof neonatal survival (de Ungria & Steinhorn, 2003; Fa-naroff, Martin, & Rodriguez, 2004).

The treatment of fetal or newborn asphyxia is resusci-tation. The goals of resuscitation are to provide an adequateairway with expansion of the lungs, to decrease the PCO2 andincrease the PO2, to support adequate cardiac output, and tominimize oxygen consumption by reducing heat loss.

RESUSCITATION MANAGEMENTInitial resuscitative management of the newborn is ex-tremely important. Suctioning is always performed beforeresuscitation so that mucus, blood, or meconium is not as-pirated into the lungs. Caregivers should keep the infant ina head-down position before the first gasp to avoid aspira-tion of the oropharyngeal secretions and must suction theoropharynx and nasopharynx immediately. Clearing thenasal and oral passages of obstructive fluid establishes apatent airway.

Breathing is established with the simplest form of re-suscitative measures initially, with progression to morecomplicated methods as required. For example:

1. Simple stimulation is provided by rubbing thenewborn’s back.

2. If respirations have not been initiated or areinadequate (gasping or occasional respirations), thelungs must be inflated with positive pressure. Themask is positioned securely on the face (over noseand mouth, avoiding the eyes), with the infant’s headin a “sniffing” or neutral position (Figure 31–1 ).

Demonstration of resuscitation of an infant with bag and mask. Note thatthe mask covers the nose and mouth, and the head is in a neutral posi-tion. The resuscitating bag is placed to the side of the baby so that chestmovement can be seen.

FIGURE 31–1

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816 CHAPTER 31

Hyperextension of the infant’s neck obstructs thetrachea and must be avoided. An airtight connection ismade between the baby’s face and the mask (thusallowing the bag to inflate). The lungs are inflatedrhythmically by squeezing the bag. Oxygen can bedelivered at 100% with an anesthesia bag withmanometer or modified self-inflating bag and adequateliter flow of at least 5 L/min. The self-inflating (Ambuor Hope) bag delivers only 40% oxygen unless it hasbeen adapted with an attached oxygen reservoir(American Academy of Pediatrics [AAP] Committeeon Fetus and Newborn & American College ofObstetricians and Gynecologists [ACOG] Committeeon Obstetrics, 2002). It may not be possible to maintainadequate inspiratory pressure with Ambu or Hopebags. In a crisis situation, it is crucial that 100% oxygenbe delivered with adequate pressure.

3. The rise and fall of the chest are observed for properventilation. Air entry and heart rate are checked byauscultation. Manual resuscitation is coordinated withany voluntary efforts. The rate of ventilation should bebetween 40 and 60 breaths per minute. Pressure shouldbe adequate to move the chest wall. The pressure gauge(manometer) must be in place to avoid overdistentionof the newborn’s lungs and other problems such aspneumothorax or abdominal distention. In newbornswith normal lungs, 15 to 25 cm H2O may be adequate.If the newborn has lung disease, 20 to 40 cm H2O maybe necessary. If the newborn has not taken a firstbreath after birth, pressures of > 30 cm H2O may betransiently required to expand collapsed alveoli. Ifventilation is adequate, the chest moves with eachinspiration, bilateral breath sounds are audible, and thelips and mucous membranes become pink. Distentionof the stomach is controlled by inserting a nasogastrictube for decompression.

4. Endotracheal intubation may be needed. However,most newborns, except for very-low-birth-weight(VLBW) infants (< 1500 g), can be resuscitated by bagand mask ventilation. With preterm newborns, positiveend expiratory pressure (PEEP) is required to helpprevent alveolar collapse. If the baby is intubated andthe color and heart rate fail to respond to ventilatoryefforts, poor or improper placement of an endotrachealtube may be the cause. If the baby is intubated properly,pneumothorax, diaphragmatic hernia, or hypoplasticlungs (Potter’s association) may exist.

Once breathing is established, the heart rate should in-crease to over 100 beats per minute. If the heart rate is ab-sent or if it remains less than 60 beats per minute after 30seconds of adequate assisted ventilation with 100% oxy-gen, external cardiac massage (chest compression) is be-

gun. Chest compressions are started immediately if there isno detectable heartbeat. The procedure for performingchest compressions is as follows:

1. The infant is positioned on a firm surface.

2. The resuscitator stands at the foot of the infant andplaces both thumbs over the lower third of thesternum (just below an imaginary line drawnbetween the nipples), with the fingers wrappedaround and supporting the back (Figure 31–2A ).

External cardiac massage. The lower third of the sternum is compressedwith two fingertips or thumbs at a rate of 90 compressions per minute.A, The thumb method uses the fingers to support the infant’s back anduses both thumbs to compress the sternum. B, The two-fingers methoduses the tips of two fingers of one hand to compress the sternum and theother hand or a firm surface to support the infant’s back.

FIGURE 31–2

A

B

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Alternatively, the resuscitator may use two fingersinstead of thumbs (Figure 31–2B). The two-thumbmethod is preferred because it may provide bettercoronary perfusion pressure; however, it makes accessto the umbilical cord for medication administrationmore difficult (de Ungria & Steinhorn, 2003).

3. The sternum is depressed to sufficient depth togenerate a palpable pulse or approximately one thirdof the anterior-posterior depth of the chest at a rate of90 compressions per minute (AAP & ACOG, 2002).Use a 3:1 ratio of heartbeat to assisted ventilation.

Drugs needed in the treatment of shock, cardiac arrest,and narcosis should be available in the birthing area. Oxy-gen is the drug most often used because of its effectivenessin ventilation.

After 30 seconds of ventilation and cardiac compres-sion, the newborn’s cardiopulmonary status is reassessedby palpating the umbilical cord for a pulse. If the newbornhas not responded with spontaneous respirations and aheart rate above 60 beats per minute, resuscitative med-ications are necessary (AAP & ACOG, 2002). The mostaccessible route for administering medications is the um-bilical vein. If bradycardia is present, epinephrine (0.1 to

0.3 mL/kg of a 1:10,000 solution or 0.01 to 0.03 mg/kg) isgiven through the umbilical vein catheter or the peripheralintravenous (IV) setup. When epinephrine is administeredby endotracheal tube, the IV dose of epinephrine shouldbe diluted with 1 mL of normal saline (Glomella, 2004).Sodium bicarbonate is rarely given in the birthing roomand only to correct metabolic acidosis after effective ven-tilation is established. Dextrose is given to prevent pro-gression of hypoglycemia. A 10% dextrose in water IVsolution is usually sufficient to prevent or treat hypo-glycemia in the birthing area. Naloxone hydrochloride(0.1 mg/kg), a narcotic antagonist, is used to reverse nar-cotic depression. See “Drug Guide: Naloxone Hydrochlo-ride (Narcan).”

If shock develops (low blood pressure or poor periph-eral perfusion), the baby may be given a volume expandersuch as normal saline, or lactated Ringer’s solution in adose of 10 mL/kg given over 5 to 10 minutes. Whole blood(O negative crossmatched against the mother), fresh frozenplasma, and packed red blood cells can also be used for vol-ume expansion and treatment of shock. In some instancesof prolonged resuscitation associated with shock and poorresponse to resuscitation, dopamine (5 mg/kg/min) may benecessary.

NALOXONE HYDROCHLORIDE (NARCAN)

DRUG GUIDE

Neonatal ContraindicationsNaloxone should not be administered to infants of narcotic-addictedmothers because it may precipitate acute withdrawal syndrome (in-creased heart rate and blood pressure, vomiting, tremors).

Respiratory depression may result from nonmorphine drugs,such as sedatives, hypnotics, anesthetics, or other nonnarcotic CNSdepressants.

Neonatal Side EffectsExcessive doses may result in irritability, increased crying, and possi-ble prolongation of partial thromboplastin time (PTT).Tachycardia may occur.

Nursing Considerations■ Monitor respirations closely—rate and depth for improved

respiratory effort.■ Assess for return of respiratory depression when naloxone

effects wear off and effects of longer acting narcotics reappear.■ Have resuscitative equipment, O2, and ventilatory equipment

available.■ Monitor bleeding studies.■ Note that naloxone is incompatible with alkaline solutions such

as sodium bicarbonate.■ Store at room temperature and protect from light.■ Compatible with heparin.

Overview of Neonatal ActionNaloxone hydrochloride (Narcan) is used to reverse respiratory de-pression due to acute narcotic toxicity. It displaces morphinelikedrugs from receptor sites on the neurons; therefore, the narcotics canno longer exert their depressive effects. Naloxone reverses narcotic-induced respiratory depression, analgesia, sedation, hypotension,and pupillary constriction.

Route, Dosage, FrequencyIntravenous dose is 0.1 mg/kg (0.25 mL/kg of 0.4 mg/mL prepa-ration 0.1 mL/kg of 1 mg/mL) concentration at birth, including pre-mature infants. This drug is usually given through endotracheal tube(ET) or IV, although naloxone can be given intramuscularly (IM) ifadequate perfusion exists. For IV push, infuse over at least 1minute; for ET administration, dilute in 1 to 2 millimeters of (NS)normal saline.

Reversal of drug depression occurs within 1 to 2 minutes af-ter IV administration and within 15 minutes of IM administration.The duration of action is variable (minutes to hours) and dependson the amount of the drug present and the rate of excretion. Dosemay be repeated in 3 to 5 minutes. If there is no improvement af-ter two or three doses, discontinue naloxone administration. If ini-tial reversal occurs, repeat dose as needed (Young & Mangum,2005).

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818 CHAPTER 31

NURSING MANAGEMENT

NURSING ASSESSMENT AND DIAGNOSISCommunication between the obstetric office or clinic andthe birthing area helps the birthing area nurse identify new-borns who may need resuscitation. When the woman ar-rives in the birthing area, have the antepartal record ready.Note any contributory perinatal history factors and assesspresent fetal status. As labor progresses, continue ongoingmonitoring of fetal heartbeat and its response to contrac-tions, assist with fetal scalp blood sampling, and observe forthe presence of meconium in the amniotic fluid to assessfor fetal asphyxia.Alert the resuscitation team and the prac-titioner responsible for the newborn’s care of any potentialhigh-risk laboring women.

Nursing diagnoses that may apply to the newborn withasphyxia and the newborn’s parents include the following:

■ Ineffective Breathing Pattern related to lack ofspontaneous respirations at birth secondary to inutero asphyxia

■ Decreased Cardiac Output related to impairedoxygenation

■ Ineffective Family Coping: Compromised related tobaby’s lack of spontaneous respirations at birth andfear of losing their newborn

PLANNING AND IMPLEMENTATION

Hospital-Based Nursing CareIn the high-risk nursery, resuscitation may be needed atany time. Check and maintain equipment to ensure its re-liability at all times. Inspect all equipment—bag and mask,oxygen and flow meter, laryngoscope, and suction ma-chine—for damaged or nonfunctioning parts before abirth or when setting up an admission bed. Sterilize resus-citative equipment in the birthing room after each use. Asystematic check of the emergency cart and equipment is aroutine responsibility of each shift. It is a good idea to beprepared by assembling equipment for pH and blood gasdetermination.

During resuscitation it is essential to keep the newbornwarm. Dry the newborn quickly with warmed towels orblankets to prevent evaporative heat loss, remove the wetblankets, and place him or her under the radiant warmer.This device provides an overhead radiant heat source (athermostatic mechanism taped to the infant’s abdomentriggers the radiant warmer to turn on or off to maintainconsistent temperature). Set the servocontrol at 36.5˚C(97.7˚F). Cover the newborn’s head with a hat as the head isa major source of heat loss (de Ungria & Steinhorn, 2003).An open bed is necessary for easy access to the newborn.

Training and knowledge about resuscitation are vital topersonnel in the birth setting for both normal and at-riskbirths. Since resuscitation must be a two-person effort forhigh-risk newborns, call for additional support as needed.One member must have the skill to perform airway man-agement and ventilation. Record resuscitative efforts onthe newborn’s chart so that all members of the healthcareteam have access to the information.

Parent TeachingThe new CPR guidelines favor family members being pre-sent during resuscitation in the birthing room and in theneonatal intensive care unit (NICU), but the procedure isparticularly distressing for parents. Advise parents that asupport person will be available for them if resuscitation isnecessary. As soon as the infant’s condition has stabilized,a member of the interdisciplinary team needs to discussthe newborn’s condition with the parents. The parents mayhave many fears about the reasons for resuscitation and thecondition of their baby after resuscitation.

EVALUATIONExpected outcomes of nursing care include the following:

■ The newborn requiring resuscitation is promptlyidentified, and intervention is started early.

■ The newborn’s metabolic and physiologic processes arestabilized, and recovery is proceeding withoutcomplications.

■ The parents can verbalize the reason for resuscitationand what was done to resuscitate their newborn.

■ The parents can verbalize their fears about theresuscitation process and potential implications fortheir baby’s future.

CARE OF THE NEWBORN WITHRESPIRATORY DISTRESSRespiratory distress is an inappropriate respiratory adapta-tion to extrauterine life. It is one of the most severe condi-tions that may affect the newborn. The nurse caring for ababy with respiratory distress needs to understand the nor-mal pulmonary and circulatory physiology (see “Respira-tory Adaptation” in Chapter 26 ∞), the pathophysiologyof the disease process, clinical manifestations, and support-ive and corrective therapies. Only with this knowledge canthe nurse make appropriate observations about responsesto therapy and development of complications. Unlike theverbalizing adult client, the newborn communicates needsonly by behavior or physiologic parameters that must beinterpreted by the NICU nurse. The neonatal nurse inter-

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You can help parents understand their baby’s respiratory distress byhaving them think of the air sacs (alveoli) of the lungs as tiny balloonsfilled with water and no air. When the tiny balloon (alveolus) is emp-tied (as in expiration), water droplets can remain inside the balloon.The sides of the balloon stick together, increasing the surface tension,making the next inspiration breath very difficult.

RESPIRATORY DISTRESS

TEACHING HIGHLIGHTS

prets this behavior as clues about the baby’s condition. Inthis section, we discuss respiratory distress syndrome, tran-sient tachypnea of the newborn, and meconium aspirationsyndrome.

RESPIRATORY DISTRESS SYNDROMERespiratory distress syndrome (RDS), also called hyalinemembrane disease (HMD), is the result of a primary absence,deficiency, or alteration in the production of pulmonarysurfactant. It is a complex disease that affects approximately20,000 to 30,000 infants a year in the United States, most ofwhom are preterm infants. RDS is a complication in about1% of pregnancies. The syndrome occurs more frequentlyin premature Causasian infants than in infants of Africandescent and almost twice as often in males as in females.

Not all the factors precipitating the pathologic changesof RDS have been determined, but two main factors asso-ciated with its development include:

1. Prematurity. All preterm newborns—whether AGA,SGA, or LGA—and especially infants of diabeticmothers are at risk for RDS. The incidence of RDSincreases with the degree of prematurity, and mostdeaths occur in newborns weighing less than 1500 g.The maternal and fetal factors resulting in pretermlabor and birth, complications of pregnancy, cesareanbirth (and its indications), and familial tendency areall associated with RDS.

2. Surfactant deficiency disease. Normal pulmonaryadaptation requires adequate surfactant, a lipoproteinthat coats the inner surfaces of the alveoli. Surfactantprovides alveolar stability by decreasing the alveoli’ssurface tension and tendency to collapse. Surfactant isproduced by type II alveolar cells starting at about 24weeks’ gestation. In the normal or mature newbornlung, it is continuously synthesized, oxidized duringbreathing, and replenished. Adequate surfactant levelslead to better lung compliance and permit breathingwith less work. RDS is due to alterations in surfactantquantity, composition, function, or production.

Development of RDS indicates a failure to synthesizesurfactant, which is required to maintain alveolar stability(see “Factors Opposing the First Breath” in Chapter 26 ∞).On expiration this instability increases atelectasis (lung col-lapse), which causes hypoxia and acidosis because of the lackof gas exchange. These conditions further inhibit surfactantproduction and cause pulmonary vasoconstriction. The re-sulting lung instability causes the biochemical problems ofhypoxemia (decreased Po2), hypercarbia (increased Pco2),and acidemia (decreased pH), which further increases pul-monary vasoconstriction and hypoperfusion. The cycle ofevents of RDS leading to eventual respiratory failure is dia-grammed in “Pathophysiology Illustrated: Respiratory Dis-tress Syndrome (RDS).”

Because of these pathophysiologic conditions, thenewborn must expend increasing amounts of energy to re-open the collapsed alveoli with every breath, so that eachbreath becomes as difficult as the first. The progressive ex-piratory atelectasis upsets the physiologic homeostasis ofthe pulmonary and cardiovascular systems and preventsadequate gas exchange. Breathing becomes progressivelyharder as lung compliance decreases, which makes it moredifficult for the newborn to inflate the lungs and breathe.

The physiologic alterations of RDS produce the fol-lowing complications:

1. Hypoxia. As a result of hypoxia, pulmonary bloodvessels constrict and their resistance increases, whichreduces pulmonary blood flow. The increase inpulmonary blood vessel resistance may cause a returnto fetal circulation as the ductus opens and bloodflow is shunted around the lungs. This shuntingincreases the hypoxia and further decreasespulmonary perfusion. Hypoxia also causesimpairment or absence of metabolic response to cold;reversion to anaerobic metabolism, resulting inlactate accumulation (acidosis); and impaired cardiacoutput, which decreases perfusion to vital organs.

2. Respiratory acidosis. Persistently rising Pco2 anddecreases in pH are poor prognostic signs ofpulmonary function and adequacy because increasedPco2 and decreased pH are results of alveolarhypoventilation.

3. Metabolic acidosis. Because the cells lack oxygen, thenewborn begins an anaerobic pathway ofmetabolism, with an increase in lactate levels and aresulting base deficit (loss of bicarbonate). As thelactate levels increase, the pH decreases in an attemptto maintain acid-balance homeostasis.

The classic radiologic picture of RDS is diffuse bilateralreticulogranular density, with portions of the air-filledtracheobronchial tree (air bronchogram) outlined by the

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820 CHAPTER 31

Surfactant

Lung compliance

Atelectasis

Acidosis

Work of breathing

Pulmonary artery pressure

CO2

Ventilation

RespiratoryMetabolicAnaerobic metabolism

Pulmonary and peripheral vasoconstriction

Po2

R L Shunting Pulmonary blood flow

Surfactant

Poor peripheral perfusion

Arterial blood pressure

B

A

Respiratory Distress Syndrome (RDS)Respiratory Distress Syndrome (RDS)

A, Cycle of events of RDS leading to eventual respiratory failure.Used with permission from Gluck, L., & Kulovich, M. V. (1973). Fetal lungdevelopment. Pediatric Clinics of North America, 20, 375. Modified.B, RDS chest x-ray. Chest radiograph of respiratory distress syndromecharacterized by a reticulogranular pattern with areas of microatelectasis ofuniform opacity and air bronchograms.Courtesy of Carol Harrigan, RNC, MSN, NNP

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opaque (“white-out”) lungs and widespread atelectasis(Thureen et al., 2005). See “Pathophysiology Illustrated.”The progression of x-ray findings parallels the pattern ofresolution, which usually occurs in 7 to 10 days, and thetime of surfactant reappearance, unless surfactant re-placement therapy and mechanical ventilation have beenused (Blackburn, 2003). Echocardiography is a valuabletool in diagnosing vascular shunts that move blood ei-ther away from or toward the lungs.

CLINICAL THERAPYAntenatally, respiratory distress due to preterm labor istreated with therapies to enhance fetal lung development(see “Care of the Woman at Risk Due to Preterm Labor” inChapter 15 ∞). The goals of postnatal therapy are tomaintain adequate oxygenation and ventilation, correctacid-base imbalance, and provide the supportive care re-quired to maintain homeostasis.

Surfactant replacement therapy decreases the severityof RDS in low-birth-weight newborns. Surfactant replace-ment therapy is delivered through an endotracheal tubeand may be given in either the birthing room or the nurs-ery, as indicated by the severity of RDS. Repeat doses are of-ten required. The most frequently reported response totreatment is rapidly improved oxygenation and decreasedneed for ventilatory support.

Supportive medical management consists of ventila-tion therapy, transcutaneous oxygen and carbon dioxide

monitoring, blood gas monitoring, correction of acid-baseimbalance, environmental temperature regulation, ade-quate nutrition, and protection from infection. Ventilationtherapy is directed toward preventing hypoventilation andhypoxia. Mild cases of RDS may require only increased hu-midified oxygen concentrations. Moderately afflicted in-fants may need continuous positive airway pressure(CPAP). Babies with severe RDS require mechanical venti-latory assistance from a respirator (Figure 31–3 ).

One-day-old, 29 weeks’ gestational age, 1450-g baby on respirator and inisolette.Courtesy of Carol Harrigan, RNC, MSN, NNP.

FIGURE 31–3

CONTINUOUS POSITIVE AIRWAY PRESSURE FOR RESPIRATORY DISTRESS SYNDROME

Clinical QuestionCan continuous positive airway pressure (CPAP) reduce the use of inter-mittent positive pressure ventilation (IPPV) in preterm infants, without anincrease in adverse effects?

EvidenceThe standard treatment for many newborns with RDS is intermittent pos-itive pressure ventilation. IPPV has been demonstrated effective, but it isinvasive and may result in airway and lung injury. In order to determineif CPAP was a viable alternative for spontaneously breathing infants withRDS, four neonatal specialists conducted a systematic review for theCochrane Library. CPAP by mask, nasal prong, nasopharyngeal tube, orendotracheal tube was included. In these trials, CPAP was associatedwith benefits in terms of reduced respiratory failure and mortality. Thestudies had varying levels of pressure and delivery mode, so no finalconclusions can be drawn about optimal administration methods. Ba-bies on CPAP were reported to have a high rate of pneumothorax.

ImplicationsCPAP can be effective in reducing respiratory failure in spontaneouslybreathing preterm infants. It is less invasive, results in fewer complica-

tions, and costs less than IPPV. The infants in these trials tended to havea greater birth weight, but very small preterm infants may still requireIPPV, even if spontaneously breathing. You can assure parents that CPAPis an effective treatment for RDS in preterm infants who are breathingspontaneously, particularly if they are of greater birth weight. It is a lessinvasive procedure resulting in fewer injuries, and it is as effective asIPPV when used correctly and judiciously. More research is needed toidentify specific characteristics of those preterm infants who can safelyforgo IPPV for CPAP.

Critical ThinkingWhat assessments will you plan for the preterm infant on CPAP to helpyou identify early signs of pneumothorax?

ReferenceHo, J. J., Subramaniam, P., Henderon-Smart, D. J., & Davis, P. G. (2003). Continuous

distending pressure for respiratory distress syndrome in preterm infants (CochraneReview). In: The Cochrane Library, Issue 4. Chichester, UK: John Wiley & Sons.

EVIDENCE-BASED NURSING

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822 CHAPTER 31

Clinical Picture Significance

Skin ColorPallor or mottling

Cyanosis (bluish tint)

Jaundice (yellow discoloration of skin and mucous membranesdue to presence of unconjugated [indirect] bilirubin)

Edema (presents as slick, shiny skin)

TABLE 31–1 Clinical Assessments Associated with Respiratory Distress

These represent poor peripheral circulation due to systemic hypotension andvasoconstriction and pooling of independent areas (usually in conjunction withsevere hypoxia).Depending on hemoglobin concentration, peripheral circulation, intensity andquality of viewing light, and acuity of observer’s color vision, this is frankly visiblein advanced hypoxia. Central cyanosis is most easily detected by examination ofmucous membranes and tongue.

Metabolic alterations (acidosis, hypercarbia, asphyxia) of respiratory distressmean the newborn is predisposed to having bilirubin dissociate from albumin-binding sites and be deposited in the skin and central nervous system.

This is characteristic of preterm infants because their total protein concentrationis low, with a decrease in colloidal osmotic pressure and transudation of fluid.Edema of hands and feet is frequently seen within first 24 hours and resolved byfifth day in infants with severe RDS.

High-frequency and extracorporeal membrane oxy-genation (ECMO), a form of heart-lung bypass, has beentried when conventional ventilator therapy has not beensuccessful. Both of these have specific protocols for eligi-bility for use and require specially trained nurses and res-piratory therapists. Nitric oxide inhalation therapy mayalso be a useful adjunctive therapy for infants with RDS(Glomella, 2004). In some institutions, morphine or fen-tanyl is used for its analgesic and sedative effects. Sedationmay be indicated for infants who have air leak respiratoryproblems. Use of pancuronium (Pavulon) for muscle re-laxation in infants with RDS is controversial.

NURSING MANAGEMENT

NURSING ASSESSMENT AND DIAGNOSISLook for characteristics of RDS such as increasing cyanosis,tachypnea (> 60 respirations/min), grunting respirations,nasal flaring, significant retractions, and apnea. Table 31–1reviews clinical findings associated with respiratory distressin general. The Silverman-Andersen index (Figure 31–4 )may be helpful in evaluating the signs of respiratory distressin the birthing area.

Nursing diagnoses that may apply to the newborn withRDS include the following:

■ Risk for Ineffective Breathing Pattern related toimmature lung development

■ Ineffective Thermoregulation related to increasedrespiratory effort

■ Altered Nutrition: Less than Body Requirements relatedto increased metabolic needs in the infant

■ Risk for Fluid Volume Deficit related to increasedinsensible water losses


Hospital-Based Nursing CareBased on clinical parameters, the neonatal nurse imple-ments therapeutic approaches to maintain physiologichomeostasis and provides supportive care to the newbornwith RDS. (See “Nursing Care Plan: The Newborn withRespiratory Distress Syndrome.”)

Nursing interventions and criteria for institutingmechanical ventilation depend on institutional proto-col. Methods of oxygen monitoring and nursing inter-ventions are included in Table 31–2. The nursing care ofinfants on ventilators or with umbilical artery cathetersis not discussed here. These infants have severe respira-tory distress and are cared for in NICUs by nurses withadvanced knowledge and training. Ventilatory assis-tance with high-frequency ventilators has shown posi-tive results.

The parents of a baby with respiratory distress willneed a very supportive environment.


■ The newborn at risk of RDS is promptly identified andearly intervention is initiated.

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Respiratory SystemTachypnea (normal respiratory rate 30–60/minute, elevatedrespiratory rate 60�/minute)

Apnea (episode of nonbreathing for more than 20 seconds;periodic breathing, a common “normal” occurrence in preterminfants, is defined as apnea of 5–10 seconds alternating with10–15 seconds of ventilation)

Chest

Labored respirations (Silverman-Andersen index in Figure 31–4indicates severity of retractions, grunting, and nasal flaring,which are signs of labored respirations)

Retractions (inward pulling of soft parts of the chest cage—suprasternal, substernal, intercostal, subcostal—at inspiration)

Flaring nares (inspiratory dilation of nostrils)

Expiratory grunt (Valsalva maneuver in which the infantexhales against a closed glottis, thus producing an audiblemoan)

Rhythmic body movement with labored respirations (chintug, head bobbing, retractions of anal area)

Auscultation of chest reveals decreased air exchange, withharsh breath sounds or fine inspiratory rales; rhonchi may bepresent

Cardiovascular SystemContinuous systolic murmur may be audible

Heart rate usually within normal limits (fixed heart rate mayoccur with a rate of 110–120/minute)

Point of maximal impulse usually located at fourth to fifthintercostal space, left sternal border

Hypothermia

Muscle ToneFlaccid, hypotonic, unresponsive to stimuli

Hypertonia and/or seizure activity

TABLE 31–1 Clinical Assessments Associated with Respiratory Distress—continued

Increased respiratory rate is the most frequent and easily detectable sign ofrespiratory distress after birth. This compensatory mechanism attempts toincrease respiratory dead space to maintain alveolar ventilation and gasexchange in the face of an increase in mechanical resistance. As adecompensatory mechanism, it increases workload and energy output byincreasing respiratory rate, which causes increased metabolic demand foroxygen and thus increases alveolar ventilation on an already overstressedsystem. Shallow, rapid respirations increase dead space ventilation, thusdecreasing alveolar ventilation.

This poor prognostic sign indicates cardiorespiratory disease, CNS disease,metabolic alterations, intracranial hemorrhage, sepsis, or immaturity. Physiologicalterations include decreased oxygen saturation, respiratory acidosis, andbradycardia.

Inspection of the thoracic cage includes shape, size, and symmetry ofmovement. Respiratory movements should be symmetric and diaphragmatic;asymmetry reflects pathology (pneumothorax, diaphragmatic hernia). Increasedanteroposterior diameter indicates air trapping (meconium aspirationsyndrome).

Indicates marked increase in the work of breathing.

These reflect the significant increase in negative intrathoracic pressurenecessary to inflate stiff, noncompliant lungs. Infants try to increase lungcompliance by using accessory muscles. Lung expansion markedly decreases.Seesaw respirations are seen when the chest flattens with inspiration and theabdomen bulges. Retractions increase the work of breathing and oxygen need sothat assisted ventilation may be necessary due to exhaustion.

This compensatory mechanism attempts to lessen the resistance of the narrownasal passage.

This increases transpulmonary pressure, which decreases or preventsatelectasis, thus improving oxygenation and alveolar ventilation. Intubationshould not be tried unless the infant’s condition is rapidly deteriorating, becauseit prevents this maneuver and allows the alveoli to collapse.

This is a result of using abdominal and other respiratory accessory musclesduring prolonged forced respirations.

Decrease in breath sounds and distant quality may indicate interstitial orintrapleural air or fluid.

Patent ductus arteriosus is common with hypoxia, pulmonary vasoconstriction,right-to-left shunting, and congestive heart failure.

A fixed heart rate indicates a decrease in vagal control.

Displacement may reflect dextrocardia, pneumothorax, or diaphragmatic hernia.

This is inadequate functioning of metabolic processes that require oxygen toproduce necessary body heat.

These may indicate deterioration in the newborn’s condition and possible CNSdamage due to hypoxia, acidemia, or hemorrhage.

Clinical Picture Significance

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824 CHAPTER 31

■ The newborn is free of respiratory distress andmetabolic alterations.

■ The parents verbalize their concerns about their baby’shealth problem and survival and understand therationale behind the management of their newborn.

TRANSIENT TACHYPNEA OF THE NEWBORNSome AGA preterm and near-term infants may developprogressive respiratory distress that can resemble classicRDS. They may have had intrauterine or intrapartal as-phyxia due to maternal oversedation, maternal bleeding,prolapsed cord, breech birth, or maternal diabetes. Thenewborn then fails to clear the airway of lung fluid, mucus,and other debris or has an excess of fluid in the lungs dueto aspiration of amniotic or tracheal fluid. Transienttachypnea occurs in 11 per 1000 live births. It is also moreprevalent in cesarean birth newborns who have not hadthe thoracic squeeze that occurs during vaginal birth andremoves some of the lung fluid (Glomella, 2004).

Usually the newborn experiences little or no difficultyat the onset of breathing. However, shortly after birth, expi-ratory grunting, flaring of the nares, and mild cyanosis maybe noted in the newborn breathing room air. Tachypnea isusually present by 6 hours of age, with respiratory rates ashigh as 100 to 140 breaths per minute. Mild respiratory andmetabolic acidosis may be present at 2 to 6 hours.

Clinical TherapyInitial x-ray findings may be identical to those showingRDS within the first 3 hours. However, radiographs of in-fants with transient tachypnea usually reveal a generalizedoverexpansion of the lungs (hyperaeration of alveoli),which is identified principally by flattened contours of thediaphragm. Dense streaks (increased vascularity) radiatefrom the hilar region and represent engorgement of thelymphatic vessels, which clear alveolar fluid when airbreathing begins. Within 48–72 hours the chest x-ray ex-amination is normal (Glomella, 2004).

Upper chest

Grade 0

Grade 1

Grade 2

Synchronized

Lag on inspiration

See-saw

Lower chest

No retractions

Just visible

Marked

Xiphoid retractions

None

Just visible

Marked

Nares dilation

None

Minimal

Marked

Expiratory grunt

None

Stethoscope only

Naked ear

Evaluation of respiratory status using the Silverman-Andersen index. The baby’s respiratory status is assessed. A grade of 0, 1, or 2 is determined foreach area, and a total score is charted in the baby’s record or on a copy of this tool and placed in the chart.Used with permission from Ross Laboratories, Nursing Aid No. 2. Columbus, OH; Silverman, W. A., & Andersen, D. H. (1956). Pediatrics, 17, 1–10. Copyright 1956, American Academy of Pediatrics.

FIGURE 31–4

NURSING PRACTICE

In babies with RDS who are on ventilators, increased urination (deter-mined by weighing diapers) may be an early clue that the baby’s con-dition is improving. As fluid moves out of the lungs and into thebloodstream, alveoli open and kidney perfusion increases, whichresults in increased voiding. At this point, monitor chest expansionclosely. If chest expansion is increasing, ventilator settings may haveto be decreased. Too high a ventilator setting may “blow the lung,”resulting in pneumothorax.

Ambient oxygen concentrations of 30% to 50%, usu-ally under an oxygen hood, may be required to correct

(continues on page 826)

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Type Function and Rationale Nursing Interventions

Pulse Oximetry—SPO2

Estimates beat-to-beat arterialoxygen saturation.

Microprocessor measures saturationby the absorption of red and infraredlight as it passes through tissue.

Changes in absorption related toblood pulsation through vesseldetermine saturation and pulse rate.

Transcutaneous Oxygen Monitor—TcPO2

Measures oxygen diffusion across the skin.

Clark electrode is heated to 43°C(preterm) or 44°C (term) to warmthe skin beneath the electrode andpromote diffusion of oxygen acrossthe skin surface. PO2 is measuredwhen oxygen diffuses across thecapillary membrane, skin, andelectrode membrane (Askin & Diehl-Jones, 2004).

TABLE 31–2 Oxygen Monitors

Understand and use oxyhemoglobin dissociationcurve.

Monitor trends over time and correlate with arterialblood gases.

Check disposable sensor at least q8h.

Use disposable cuffs (reusable cuffs allow too muchambient light to enter, and readings may beinaccurate).

Use TcPO2 to monitor trends of oxygenation withroutine nursing care procedures.

Clean electrode surface to remove electrolytedeposits; change solution and membrane once aweek.

Allow machine to stabilize before drawing arterialgases; note reading when gases are drawn and usevalues to correlate.

Ensure airtight seal between skin surface andelectrode; place electrodes on clean, dry skin onupper chest, abdomen, or inner aspect of thigh;avoid bony prominences.

Change skin site and recalibrate at least every 4 hours; inspect skin for burns; if burns occur, uselowest temperature setting and change position ofelectrode more frequently.

Adhesive disks may be cut to a smaller size, or skinprep may be used under the adhesive circle only;allow membrane to touch skin surface at center.

Calibration is automatic.

Less dependent on perfusion than TcPO2 andTcPCO2; however, functions poorly if peripheralperfusion is decreased due to low cardiacoutput.

Much more rapid response time than TcPO2—offers real-time readings.

Can be located on extremity, digit, or palm ofhand, leaving chest free; not affected by skincharacteristics.

Requires understanding of oxyhemoglobindissociation curve.

Pulse oximeter reading of 87% to 95% reflectsclinically safe range of saturation.

Extreme sensitivity to movement; decreases ifaverage of 7th or 14th beat is selected ratherthan beat to beat.

Poor correlation with extreme hyperoxia.

When transcutaneous monitors are properlycalibrated and electrodes are appropriatelypositioned, they provide reliable, continuous,noninvasive measurements of PO2, PCO2, andoxygen saturation.

Readings vary when skin perfusion isdecreased.

Reliable as trend monitor.

Frequent calibration necessary to overcomemechanical drift.

Following membrane change, machine must“warm up” 1 hour prior to initial calibration;otherwise, after turning it on, it must equilibratefor 30 minutes prior to calibration.

When placed on infant, values will be low untilskin is heated; approximately 15 minutesrequired to stabilize.

Second-degree burns are rare but possible ifelectrodes remain in place too long.

Decreased correlations noted with older infants(related to skin thickness), with infants with lowcardiac output (decreased skin perfusion), andwith hyperoxic infants.

The adhesive that attaches the electrode mayabrade the fragile skin of the preterm infant.

May be used for both preductal and postductalmonitoring of oxygenation for observations ofshunting.

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826 CHAPTER 31

NURSING CARE PLAN

THE NEWBORN WITH RESPIRATORY DISTRESS SYNDROME

Intervention Rationale Expected Outcome

1. Nursing Diagnosis: Risk for Ineffective Breathing Pattern related to immature lung development

■ Review maternal birth records notingmedications given to mother prior to birthand the infant’s condition at birth such asApgar scores and resuscitative measures.

■ Initiate cardiac and respiratory monitoringand calibrate these monitors every8 hours.

■ Monitor infant’s respiratory rate andrhythm, pulse, blood pressure, andactivity.

■ Assess skin color; note signs of cyanosis,duskiness, and pallor.

■ Clear infant’s airway by suctioning prnwith bulb syringe.

■ Administer warmed, humidified oxygen byoxygen hood and monitor the oxygenconcentrations every 30 minutes.

■ Do not allow oxyhood to touch infant’sface; maintain a stable oxygenconcentration by increasing anddecreasing oxygen by 5%–10%increments.

Collaborative: Obtain arterial blood gases(ABGs) per physician orders.1. Maintain constant O2 concentration for

15–30 minutes before sample isobtained.

2. Avoid stimulating infant 15 minutes priorto obtaining sample.

3. Avoid suctioning infant prior to obtainingsample.

4. Obtain sample in heparinized tuberculinsyringe and maintain the temperature ofthe sample.

5. Assess the patency of the IV line toprevent clot formation, then replace bloodused to clear line.

6. Flush line with 2 mL heparinized solutionbefore restarting flow of IV fluids.

7. Monitor transcutaneous pulse oximetercontinuously or hourly and record. Rotatesensor site every 3–4 hours.

■ Assess infant’s need for mechanicalventilation: apnea present, hypoxia (PaO2< 50 mm Hg), hypercapnia (PaCO2 > 60mm Hg), respiratory acidosis (pH < 7.2).

■ Administer mechanical ventilation perhospital protocol.

■ Several drugs suppress respiratoryfunction in the newborn.

■ Close monitoring detects periodic apneicspells and allows for medical interventionif necessary.

■ Increases in respiratory rate and pulse,alteration in rhythm, and blood pressuremay indicate respiratory distress.

■ Any changes in the normal skin color mayindicate a physiologic change occurring.

■ Opens airway by clearing mucus andallows maximum respiratory effort.

■ Prevents mucosal dryness and maintainsan even level of oxygen administration.

■ Allowing oxyhood to touch infant’s facemay cause apnea by stimulating thefacial nerve.

■ Obtaining arterial blood gases is essentialin managing an infant receiving oxygen.Suctioning may cause a discrepancy inABG readings and should be avoided.

■ Mechanical ventilation improvesoxygenation and ventilation, resulting inrise in PaO2 and decrease in PaCO2.

■ CPAP or PEEP can be administered bynasal prongs or by nasopharyngeal ororal intubation.

■ The infant will maintain an effectivebreathing pattern as evidenced by:respirations are 30–60 breaths/min,arterial blood gases are within a normalrange, infant is free of signs of retractionsor nasal flaring, and blood pH is7.35–7.45.

NIC Intervention:

Respiratory monitoring: Collection andanalysis of patient data to ensure airwaypatency and adequate gas exchange

NOC Outcome:

Respiratory status: Ventilation: Movementof air in and out of the lungs

Goal: The infant will maintain an effective breathing pattern.

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NURSING CARE PLAN—continued



2. Nursing Diagnosis: Ineffective Thermoregulation related to increased respiratory effort

■ Review maternal prenatal andintrapartum records. Note anymedications mother received duringthese times.

■ Assess infant’s temperature frequently.

■ Observe for signs of increased oxygenconsumption and metabolic acidosis.

■ Warm all inspired gases and recordtemperature of delivered gases.

■ Use radiant warmers or isolettes withservocontrols, incubators, and open cribswith appropriate clothing.

■ Note signs and symptoms of respiratorydistress, including tachypnea, apnea,cyanosis, acrocyanosis, bradycardia,lethargy, weak cry, and hypotonia.

■ Medications such as Demerol andmagnesium sulfate used by the motherduring the prenatal or intrapartumperiods significantly interfere with theinfant’s ability to retain heat.

■ Hypothermia leads to pulmonaryvasoconstriction because of the increasein oxygen consumption.

■ Cold stress leads to increased oxygenneeds; thereby, brown fat is used tomaintain body temperature.

■ Hypoxia and acidosis further depressessurfactant production.

■ Maintains neutral thermal environment.

■ These signs can predispose the infant tometabolic acidosis.

■ The infant will not exhibit signs andsymptoms of hypothermia as evidencedby temperature maintenance of97.7–99.1°F and no signs andsymptoms of respiratory distress.

■ Cold air/oxygen blown in face of newbornis stimulus for consumption of oxygenand glucose and increased metabolicrate.

NIC Intervention:

Temperature regulation: Attaining ormaintaining body temperature within anormal range

NOC Outcome:

Thermoregulation: Newborn: Balanceamong heat production, heat gain, and heatloss during the neonatal period

Goal: The infant will exhibit no signs of hypothermia.

3. Nursing Diagnosis: Altered Nutrition: Less than Body Requirements related to increased metabolic needs in the infant

NIC Intervention:

Newborn monitoring: Measurement andinterpretation of physiologic status of thenewborn the first 24 hours

■ Assess suck, swallow, gag, and coughreflexes.

■ Assess respiratory status of infant. Ifproblems are noted, notify physician.

■ Monitor IV rates per infusion pump(starting at 60 mL/kg/day) or as orderedby physician.

■ Record hourly intake and output (I&O)and daily weights.

■ Provide total parenteral nutrition (TPN)when indicated.

■ Prevents feeding problems and assists indetermining the best method of feedingfor infant.

■ In the presence of respiratory distress,avoid oral fluids and initiate parenteralnutrition per physician’s orders.

■ Allows for close monitoring of fluid intake.

■ IV fluids are administered to replacesensible and insensible water loss, aswell as evaporative water loss secondaryto infant respiratory distress. MonitoringI&O will prevent circulatory systemoverload that can lead to pulmonaryedema and cardiac problems.

■ TPN is used as nutritional alternative ifbowel sounds are not present and/orinfant remains in acute distress.

NOC Outcome:

Nutritional status: Food and fluid intake:Amount of food and fluid taken into the bodyover a 24–hour period

■ The infant will maintain steady weightgain as evidenced by < 2%/day weightloss, tolerates oral feedings, and urineoutput is 1–3 mL/kg/hour.

Goal: Infant will gain weight in a normal curve.

(continued)

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828 CHAPTER 31




4. Nursing Diagnosis: Risk for Fluid Volume Deficit related to increased insensible water losses

NIC Intervention:

Fluid monitoring: Collection and analysis ofpatient data to regulate fluid balance

NOC Outcome:

Fluid balance: Balance of water in theintracellular and extracellular compartmentsof the body

Goal: The infant will not exhibit signs of dehydration and will display appropriate weight gain.

■ Observe for weight fluctuations byobtaining daily weights.

■ Document cumulative balances of intake(IV fluid administration and feedings) andoutput (urine collection bags, weighing orcounting diapers) hourly.

■ Obtain urinalysis, monitor closely specificgravity and nitrites.

■ Monitor vital signs, including bloodpressure, pulse, temperature, and meanarterial pressure (MAP).

■ Assess client for signs of dehydration(i.e., poor skin turgor, pale mucousmembranes, and sunken anteriorfontanelle).

■ Assess IV site for signs of infection(erythema and edema) and infiltration.

Collaborative: Obtain labs for Hct, serumcalcium, serum magnesium, serumpotassium, blood urea nitrogen (BUN),creatinine, and uric acid levels.■ Administer fluids, blood products, and

electrolytes as ordered by physician.

■ Fluctuations in weight may indicate waterimbalance or inadequate caloric intake.

■ Balanced fluid intake and output suggesthomeostasis.

■ Specific gravity > 1.013 and nitritespresent in the urine are indicative of notenough fluid intake.

■ A MAP of less than 20 mm Hg mayindicate hypotension.

■ Detecting signs and symptoms ofdehydration early in the infant isimportant because early intervention isvital to prevent further damage.

■ If signs and symptoms of infection arenoted, intervention is necessary and IVsite should be changed.

■ Determines necessity for TPNadministration.

■ Replaces low nutrient stores and treatsanemia if present.

■ The infant will be free of signs andsymptoms of dehydration as evidencedby intake equaling output, urine specificgravity in normal range, and a weight gainof at least 20–30 grams/day.

■ Advance, based on tolerance, fromintravenous to gastrointestinal (GI)feedings. Gavage or nipple-feedings areused, and IV is used as supplement(discontinued when oral intake issufficient).

■ Provide adequate caloric intake: consideramount of intake, type of formula, routeof administration, and need forsupplementation of intake by otherroutes.

■ Assess infusion site for signs andsymptoms of infection, includingerythema, edema, and drainage with afoul odor.

■ If IV is discontinued before oral intake isestablished, baby will not receiveadequate calories.

■ Formula or breast milk stimulate GIhormones necessary for a functionalabsorptive GI tract.

■ Avoid complications associated withnutrition by IV route only.

■ Calories are essential to preventcatabolism of body proteins, andmetabolic acidosis due to starvation orinadequate caloric intake.

■ Appropriate intervention can be initiatedwhen signs and symptoms of infectionare detected early. Treatment may avoidinfection and sepsis in the infant.

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the hypoxemia (Figure 31–5 ). Fluid and electrolyterequirements should be met with IV fluids during theacute phase of the disease. Oral feedings are contraindi-cated because of rapid respiratory rates. The infantshould be improving by 8 to 24 hours. The clinicalcourse of transient tachypnea lasts approximately 72hours (Glomella, 2004).

When hypoxemia is severe and tachypnea continues,persistent pulmonary hypertension must be considered andtreatment measures initiated. If pneumonia is suspectedinitially, antibiotics may be administered prophylactically.

Nursing ManagementFor nursing actions, see “Nursing Care Plan: The Newbornwith Respiratory Distress Syndrome.”

CARE OF THE NEWBORN WITH MECONIUMASPIRATION SYNDROMEBecause the body’s response to asphyxia is increased peri-stalsis (movement) within the bowels and relaxation of theanal sphincter, the presence of meconium in the amnioticfluid indicates that the fetus may be suffering asphyxia.However, if the fetus is in a breech position, the presence ofmeconium in the amniotic fluid does not necessarily indi-cate asphyxia.

Approximately 13% of live-born infants are bornthrough meconium-stained amniotic fluid (MSAF). Of thenewborns born through MSAF, an average of 5% developmeconium aspiration syndrome (MAS) (Gelfand, Fanaroff,& Walsh, 2004). This fluid may be aspirated into the tra-cheobronchial tree in utero or during the first few breathstaken by the newborn. This syndrome primarily affectsterm, SGA, and postterm newborns and those who haveexperienced a long labor.

Meconium in the lungs produces a ball-valve action (airis allowed in but not exhaled), so that alveoli overdistendand rupture, resulting in pulmonary air leaks such as pneu-momediastinum or pneumothorax. The meconium alsotriggers a chemical pneumonitis in the lung, causing oxygenand carbon dioxide to be trapped there and the lungs to hy-perinflate. Secondary bacterial pneumonia can occur.

CLINICAL MANIFESTATIONS OF MASClinical manifestations of MAS include (1) fetal hypoxia inutero a few days or a few minutes before birth, indicated bya sudden increase in fetal activity followed by diminishedactivity, slowing of FHR or weak and irregular heartbeat,loss of beat-to-beat variability, and meconium staining ofamniotic fluid; and (2) signs of distress at birth, such as pal-lor, cyanosis, apnea, slow heartbeat, and low Apgar scores(below 6) at 1 and 5 minutes. Newborns with intrauterineasphyxia, meconium-stained newborns, or newborns thathave aspirated meconium are depressed at birth and requireresuscitation to establish adequate respiratory effort.

After the initial resuscitation, the severity of clinicalsymptoms depends on the extent of aspiration. Many in-fants need mechanical ventilation at birth because of im-mediate signs of distress (generalized cyanosis, tachypnea,and severe retractions). An overdistended, barrel-shapedchest with increased anteroposterior diameter is common.Auscultation reveals diminished air movement, withprominent rales and rhonchi. Abdominal palpation mayreveal a displaced liver caused by diaphragmatic depressionresulting from the overexpansion of the lungs. The skin,nails, and umbilical cord usually have yellowish staining.

The chest x-ray film reveals nonuniform, coarse,patchy densities and hyperinflation (9 to 11 rib expansion)

THINKING CRITICALLY

TRANSIENT TACHYPNEA OF THE NEWBORNYou are caring for baby girl Linn, who is a 39-week, AGA female bornby repeat cesarean birth to a 34-year-old G3, now P3, mother. BabyLinn’s Apgar scores were 7 and 9 at 1 and 5 minutes. At 2 hours ofage, an elevated respiratory rate of 100 to 120 and mild cyanosiswere noted. She is now receiving 30% oxygen and has a respiratoryrate of 70 to 80. The baby’s clinical course, chest x-ray examination,and lab work are all consistent with transient tachypnea of the new-born. Her mother calls you to ask about her baby. She tells you thather last child was born at 30 weeks’ gestation, has respiratory dis-tress syndrome requiring ventilator support, and was hospitalized for6 weeks. She asks you, “Is this the same respiratory distress?” Whatwill you tell her?

Premature infant under an oxygen hood. Infant is nested and has a non-nutritive sucking pacifier.Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.

FIGURE 31–5

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830 CHAPTER 31

(Glomella, 2004). Evidence of pulmonary air leak is fre-quently present. Extreme hypoxia is also caused by the car-diopulmonary shunting and resultant failure to oxygenateand can lead to persistent pulmonary hypertension of thenewborn (PPHN).

CLINICAL THERAPYThe maternity and pediatric teams must work together toprevent MAS. The most effective form of preventive man-agement is as follows:

1. After the head is born and while the shoulders andchest are still in the birth canal, the baby’soropharynx and then nasopharynx are suctioned bythe birth attendant with the use of a bulb syringe orDeLee attached to wall suction. (This is also donewith a cesarean birth.) To decrease the possibility ofHIV transmission, low-pressure wall suction is used.

2. If the infant is vigorous even if there is thick or thinmeconium in the amniotic fluid, no subsequentspecial resuscitation is indicated (de Ungria &Steinhorn, 2003).

3. If the infant has absent or depressed respirations, heartrate less than 100 beats per minute, or poor muscle tone,direct tracheal suctioning by specially trained personnelsuch as a neonatal nurse practitioner, an experiencedNICU nurse trained in those skills, a respiratorytherapist, or a nurse anesthetist is recommended. Theglottis is visualized with a laryngoscope and the tracheasuctioned (Gelfand et al., 2004).

If the newborn’s head is not adequately suctioned at thetime the head is born but the shoulder and chest are still inthe vagina, respiratory or resuscitative efforts will pushmeconium into the airway and into the lungs. Stimulationof the newborn should be avoided to minimize respiratorymovements. Further resuscitative efforts are undertaken asindicated, following the same principles of clinical therapyused for asphyxia (discussed earlier in this chapter). Resus-citated newborns should be transferred immediately to theNICU for closer observation. An umbilical arterial line maybe used for direct monitoring of arterial blood pressures;blood sampling for pH and blood gases; and infusion of in-travenous fluids, blood, or medications.

Treatment usually involves delivering high levels of oxy-gen and high-pressure ventilation.Ventilation with low PEEPis preferred to avoid pulmonary air leaks such as pneumo-thorax. Unfortunately, high pressures may be needed to causesufficient expiratory expansion of obstructed airways or tostabilize airways weakened by inflammation so that the mostdistal atelectatic alveoli are ventilated.

Surfactant replacement therapy is most effective whenused prophylactically. It improves oxygenation and de-

creases the incidence of air leaks. Systemic blood pressureand pulmonary blood flow must be maintained.Dopamine or dobutamine, volume expanders, or both maybe used to maintain systemic blood pressure.

Newborns over 2 kg (7 lb) with respiratory failure whoare not responding to conventional ventilator therapy mayneed treatment with high-frequency ventilation and/or ni-tric oxide therapy or ECMO (Zukowsky, 2004). ECMOtreatment has proved successful for newborns with meco-nium aspiration, pneumonia, and PPHN who are not re-sponding to traditional treatments.

Treatment includes chest physiotherapy (chest percus-sion, vibration, and drainage) to remove debris. Fre-quently, prophylactic intravenous antibiotics are given.Bicarbonate (to correct metabolic acidosis) may be neces-sary for several days for severely ill newborns. Mortality interm or postterm infants is very high, because the cycle ofhypoxemia and acidemia is difficult to break.

NURSING MANAGEMENT

NURSING ASSESSMENT AND DIAGNOSISDuring the intrapartum period, observe for signs of fetal hy-poxia and meconium staining of amniotic fluid. At birth as-sess the newborn for signs of distress. Carefully observe forcomplications such as pulmonary air leaks; anoxic cerebral in-jury manifested by convulsions; myocardial injury evidencedby congestive heart failure or cardiomegaly; disseminated in-travascular coagulation (DIC) resulting from hypoxic hepaticdamage that depresses liver-dependent clotting factors; anoxicrenal damage demonstrated by hematuria, oliguria, or anuria;fluid overload; sepsis secondary to bacterial pneumonia; andany signs of intestinal necrosis from ischemia, including gas-trointestinal obstruction or hemorrhage.

Nursing diagnoses that may apply to the newborn withMAS and the infant’s parents include the following:

■ Impaired Gas Exchange related to aspiration ofmeconium and amniotic fluid during birth

■ Altered Nutrition: Less than Body Requirements relatedto respiratory distress and increased energyrequirements

■ Ineffective Family Coping: Compromised related to life-threatening illness in term newborn


Hospital-Based Nursing CareInitial interventions are aimed at preventing aspiration byhelping remove the meconium from the infant’s orophar-ynx and nasopharynx before the first extrauterine breath.When significant aspiration occurs, the primary goals of

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therapy are to maintain appropriate gas exchange and min-imize complications. Nursing interventions after resuscita-tion should include maintaining adequate oxygenation andventilation, regulating temperature, performing glucosetesting by glucometer at 2 hours of age to check for hypo-glycemia, observing intravenous fluids administration, cal-culating necessary fluids (which may be restricted in thefirst 48 to 72 hours due to cerebral edema), providingcaloric requirements, and monitoring intravenous antibi-otic therapy.


■ The newborn at risk of MAS is promptly identified,and early intervention is initiated.

■ The newborn is free of respiratory distress andmetabolic alterations.

■ The parents verbalize their concerns about their baby’shealth problem and survival and understand therationale behind the management of their newborn.

CARE OF THE NEWBORN WITH COLD STRESSCold stress is excessive heat loss that requires a newborn touse compensatory mechanisms (such as increased respira-tions and nonshivering thermogenesis) to maintain corebody temperature. Newborns experience heat loss that re-sults in cold stress through the mechanisms of evaporation,convection, conduction, and radiation. (See “Heat Loss” inChapter 26 for types of thermoregulation. ∞)

Heat loss at birth that leads to cold stress can play a sig-nificant role in the severity of RDS and the ultimate outcomefor the infant. Both preterm and SGA newborns are at risk forcold stress because they have decreased adipose tissue, brownfat stores, and glycogen available for metabolism.As discussedin Chapter 26, the newborn infant’s major source of heat pro-duction in nonshivering thermogenesis (NST) is brown fatmetabolism. ∞ The infant’s ability to respond to cold stressby NST is impaired in the presence of several conditions:

■ Hypoxemia (PO2 less than 50 torr)

■ Intracranial hemorrhage or any CNS abnormality

■ Hypoglycemia (blood glucose level < 40 mg/dL)

When these conditions occur, the infant’s temperatureshould be monitored closely and the neutral thermal envi-ronment conscientiously maintained. The nurse must rec-ognize these conditions and treat them as soon as possible.The metabolic consequences of cold stress can be devastat-ing and potentially fatal to an infant. Oxygen requirementsrise, glucose use increases, acids are released into the blood-stream, and surfactant production decreases. The effectsare graphically depicted in Figure 31–6 .

NURSING MANAGEMENTThe amount of heat an infant loses depends largely on theactions of the nurse or caregiver. For example, followingthe transfer of a NICU newborn from one bed to another,a transient, although not significant, decrease in tempera-ture for up to 1 hour may be noted. Prevention of heat lossis especially critical in the VLBW infant. Placing the VLBW

Cold stress

Decreased surfactant production

Decreased oxygenation

Atelectasis

Increased anaerobic metabolism

Increased nonesterified fatty acids

Hyperbilirubinemia

Increased metabolic rate

Increased O2 consumption

Increased utilization of glucose

Hypoglycemia

Release of norepinephrine (to stimulate brown fat metabolism)

Pulmonary vasoconstriction

Decreased blood flow through the lungs

Hypoxemia

Acidemia

Cold stress chain of events. The hypothermic, or cold-stressed, newborn attempts to compensate by conserving heat and increasing heat production.These physiologic compensatory mechanisms initiate a series of metabolic events that result in hypoxemia and altered surfactant production, metabolicacidosis, hypoglycemia, and hyperbilirubinemia.

FIGURE 31–6

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832 CHAPTER 31

newborn in a polyethylene wrapping immediately follow-ing birth can decrease the postnatal fall in temperature thatnormally occurs. Both convective and evaporative heat losscan be reduced (Blackburn, 2003).

Observe the baby for signs of cold stress, including in-creased movement and respirations, decreased skin tempera-ture and peripheral perfusion,development of hypoglycemia,and possibly development of metabolic acidosis.

Vasoconstriction is the initial response to cold stress.Because it initially decreases skin temperature, monitorand assess skin temperature instead of rectal temperature.A decrease in rectal temperature means that the core tem-perature of the infant has decreased and the infant haslong-standing cold stress. By monitoring skin temperature,possible decrease will become apparent before the infant’score temperature is affected.

If skin temperature decreases, determine whether hy-poglycemia is present. Hypoglycemia is a result of themetabolic effects of cold stress and is suggested by glu-cometer values below 45 mg/dL, tremors, irritability orlethargy, apnea, or seizure activity.

If the baby becomes hypothermic, initiate the follow-ing care plan (Blackburn, 2003):

■ Keep the ambient air temperature 1˚C to 1.5˚C higherthan the infant’s temperature.

■ Warm the newborn slowly because rapid temperatureelevation may cause hypotension and apnea.

■ Increase the air temperature in hourly increments of1˚C until the infant’s temperature is stable.

■ Monitor skin temperature every 15 to 30 minutes todetermine if the newborn’s temperature is increasing.

■ Remove plastic wrap, caps, and heat shields whilerewarming the infant so that cool air is not trappedalong with the warm air.

■ Warm intravenous fluids prior to infusion.

■ Block heat loss by evaporation, radiation, convection,and conduction and maintain the newborn in a neutralthermal environment.

Assess for anaerobic metabolism and treat the resultingmetabolic acidosis. Burning brown fat increases oxygenconsumption, lactic acid levels, and metabolic acidosis.Hypoglycemia may be reversed by adequate glucose intake,as described in the following section.

CARE OF THE NEWBORN WITH HYPOGLYCEMIAA widely used cutoff point or threshold for intervention innewborn hypoglycemia is a plasma glucose concentrationat or below 40 mg/dL (Armentrout, 2004). Plasma glucose

values less than 20 to 25 mg/dL should be treated with par-enteral glucose, regardless of the age or gestation. Hypoglyce-mia is the most common metabolic disorder in IDMs, SGAinfants, and preterm AGA infants. The pathophysiology ofhypoglycemia differs for each classification.

AGA preterm infants have not been in utero longenough to store glycogen and fat. As a result they have de-creased ability to carry out gluconeogenesis. This situationis further aggravated by the tissues’ increased use of glucose(especially in the brain and heart) during stress and illness(chilling, asphyxia, sepsis, RDS).

Infants of White’s classes A–C or type 1 diabetic moth-ers have increased stores of glycogen and fat (see “CommonComplication of the IDM” in Chapter 30 ∞) and highercirculating insulin and insulin responsiveness levels thanother newborns. Because the high in utero glucose loadsstop at birth, the newborn experiences rapid, profound hy-poglycemia (Armentrout, 2004).

The SGA infant has used up glycogen and fat stores be-cause of intrauterine malnutrition and has a blunted hepaticenzymatic response with which to produce and use glucose.Any newborn stressed at birth (from asphyxia or hypother-mia) also quickly uses up available glucose stores and becomeshypoglycemic. Epidural anesthesia may alter maternal-fetalglucose homeostasis, resulting in hypoglycemia.

CLINICAL THERAPYThe goal of management includes early identification ofhypoglycemia through observation and screening of new-borns at risk (Sperling & Menon, 2004). The newborn maybe asymptomatic, or any of the following may occur:

■ Lethargy, jitteriness

■ Poor feeding

■ Vomiting

■ Pallor

■ Apnea, irregular respirations, respiratory distress, cyanosis

■ Hypotonia, possible loss of swallowing reflex

■ Tremors, jerkiness, seizure activity

■ High-pitched cry

■ Exaggerated Moro reflex

Aggressive treatment is recommended after a single lowblood glucose value if the infant shows any of these symp-toms. In at-risk infants, routine screening should be donefrequently during the first 4 hours of life and then when-ever any of the noted clinical manifestations appear or at4-hour intervals until the risk period has passed.

Differential diagnosis of a newborn with nonspecifichypoglycemic symptoms includes determining if the new-born has any of the following:

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NURSING PRACTICE

Wrapping the foot in a warm washcloth or disposable diaper is a sim-ple way to create adequate vasodilation for taking a blood specimen.

■ CNS disease

■ Sepsis

■ Metabolic aberrations

■ Polycythemia

■ Congenital heart disease

■ Drug withdrawal

■ Temperature instability

■ Hypocalcemia

Hypoglycemia may also be defined as a glucose oxidasereagent strip below 45 mg/dL, but only when corrobo-rated with laboratory plasma glucose testing (see Skill10–1 ). Common bedside methods use whole blood,an enzymatic reagent strip, and a reflectance meter or colorchart. Bedside glucose oxidase strip tests can screen for hy-poglycemia, but laboratory determinations must confirmthe results before a diagnosis of hypoglycemia can bemade. Glucose reagent strips should not be used by them-selves to screen for and diagnose hypoglycemia, becausetheir results depend on the baby’s hematocrit and there isa wide variance (5 to 15 mg/dL) between their results andlaboratory plasma determinations.

SKILLS

Adequate caloric intake is important. Early formula-feeding or breastfeeding is a major preventive approach. Ifearly feeding meets the infant’s fluid and caloric needs, theblood glucose concentration is likely to remain above thehypoglycemic level. During the first hours after birth,asymptomatic newborns may also be given oral glucose.Another plasma glucose measurement is then obtained 30to 60 minutes after feeding.

Intravenous infusions of a dextrose solution (5% to10%) begun immediately after birth also should preventhypoglycemia. Plasma glucose levels are obtained when theparenteral infusion is started. However, in the very smallAGA infant, infusions of 10% dextrose solution may causehyperglycemia to develop, requiring an alteration in theglucose concentration. Infants require 6 to 8 mg/kg/min ofglucose to maintain normal glucose concentrations. There-fore, an intravenous glucose solution should be calculatedbased on the infant’s body weight, with blood glucose teststo determine adequacy of the infusion treatment.

A rapid infusion of 25% to 50% dextrose is con-traindicated because it may lead to profound rebound hy-poglycemia following an initial brief increase. In moresevere hypoglycemic periods, corticosteroids may be ad-ministered. It is thought that steroids enhance gluconeoge-nesis from noncarbohydrate protein sources (Armentrout,2004). The untreated hypoglycemia may result in perma-nent, untreatable CNS damage or death.

NURSING MANAGEMENT

NURSING ASSESSMENT AND DIAGNOSISThe objectives of nursing assessment are to identify new-borns at risk and to screen symptomatic infants. For

NURSING PRACTICE

Blood samples for the laboratory should be placed on ice and ana-lyzed within 30 minutes of drawing to prevent the red blood cells fromcontinuing to metabolize glucose and giving a falsely low reading.

Blood glucose sampling techniques can significantlyaffect the accuracy of the blood glucose value. Whole bloodglucose concentrations are 10% to 15% lower than plasmaglucose concentrations—the higher the hematocrit, thegreater the difference between whole blood and plasmavalues. Also, venous blood glucose concentrations are ap-proximately 15% to 19% lower than arterial blood glucoseconcentrations because the tissues extract some glucosebefore the blood enters the venous system (“Neonatal Hy-poglycemia,” 2000). Newer techniques, such as using a glu-cose oxidase analyzer or an optical bedside glucoseanalyzer, are more reliable for bedside screening but mustalso be validated with laboratory chemical analysis.

PAIN RELIEF IN THE NICUOral administration of sucrose for pain management from proceduralpain (heel sticks, venipuncture, IM injections, oral suctioning, etc.)has been introduced in the NICU. The sweetness of the sucrose, a di-saccharide, elevates the infant’s pain threshold through endogenousopioid release in the central nervous system.A range of 0.05 to 2 mLof 24% sucrose is administered on the anterior part of the baby’stongue via a syringe or nipple approximately 2 minutes prior to theprocedure (Walden & Jorgensen, 2004). But it is important to becareful because with repeated doses of sucrose, hyperglycemia mayarise in the infant.Also, repeated use of sucrose analgesia in preterminfants may impact their neurologic development and behavioral out-comes. Until further research is done, repeated doses of sucrose arenot recommended (Mitchell & Waltman, 2003).

COMPLEMENTARY CARE

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newborns diagnosed with hypoglycemia, assessment isongoing and includes careful monitoring of glucose val-ues. In addition, urine dipstick and urine volume tests(monitor only if above 1 to 3 mL/kg/hr) may be evalu-ated frequently for osmotic diuresis and glycosuria.

Nursing diagnoses that may apply to the newborn withhypoglycemia include the following:

■ Altered Nutrition: Less than Body Requirements relatedto increased glucose use secondary to physiologic stress

■ Ineffective Breathing Pattern related to tachypnea andapnea

■ Acute Pain related to frequent heel sticks secondary toglucose monitoring

PLANNING AND IMPLEMENTATIONMonitor infants in at-risk groups no later than 2 hours afterbirth and before feedings or whenever there are abnormalsigns (Armentrout, 2004). Monitor the IDM within 30 min-utes of birth. Once an at-risk infant’s blood sugar level is sta-ble, glucose testing every 2 to 4 hours (or per agencyprotocol), or prior to feedings, adequately monitors glucoselevels. The infant’s lateral heel is the preferred site for the glu-cose sample, so that the posterior tibial nerve and artery andthe important longitudinally oriented fat pad of the heel willnot be damaged (Figures 31–7 and 31–8 ).

Calculate glucose requirements and maintain intra-venous glucose levels for any symptomatic infant with lowserum glucose levels. The method of feeding greatly influ-ences glucose and energy requirements; thus, pay carefulattention to glucose monitoring during the transition

from intravenous to oral feedings. Titration of intravenousglucose may be required until the infant can take adequateamounts of formula or breast milk to maintain a normalblood sugar level. Titrate by decreasing the concentrationof parenteral glucose gradually to 5%, then reducing therate of infusion to 6 mg/kg/min, then to 4 mg/kg/min, andslowly discontinuing it over 4 to 6 hours. Enteral feedingsare increased to maintain an adequate glucose and caloricintake.

Identify any discrepancies between the baby’s caloricrequirements and received calories. Weigh the newborndaily at consistent times, preferably before feeding. Onlythen can findings of unusual losses or gains, as well as thepattern of weight gain, be considered reliable.

The therapeutic nursing measure of nonnutritivesucking during gavage feedings has been reported to in-crease the baby’s daily weight gain and lead to earlierbottle-feeding or breastfeeding and discharge. Nonnutri-tive sucking may also lower activity levels, which allowsnewborns to conserve their energy stores. Activity can in-crease energy requirements; crying alone can double thebaby’s metabolic rate.

Establishing and maintaining a neutral thermal envi-ronment has a potent influence on the newborn’s metabo-lism. Pay careful attention to environmental conditions,physical activity, and organization of care, and integratethese factors into nursing care.

Heel stick. With a quick, piercing motion, puncture the lateral heel with amicrolance. Be careful not to puncture too deeply.

FIGURE 31–7

Puncture sites

Potential sites for heel sticks. Avoid shaded areas to prevent injury to ar-teries and nerves in the foot and the important longitudinally oriented fatpad of the heel, which in later years could impede walking.

FIGURE 31–8

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■ The newborn at risk for hypoglycemia is promptlyidentified, and intervention is started early.

■ The newborn’s glucose level is stabilized, and recoveryis proceeding without sequelae.

CARE OF THE NEWBORN WITH JAUNDICEThe most common abnormal physical finding in new-borns is jaundice. Jaundice is a yellowish coloration of theskin and sclera of the eyes that develops from deposits ofthe yellow pigment bilirubin in lipid tissues. Normally theplacenta clears fetal unconjugated (indirect) bilirubin inutero, so total bilirubin at birth is usually less than 3mg/dL unless an abnormal hemolytic process has beenpresent. Postnatally the infant must conjugate bilirubin(convert a lipid-soluble pigment into a water-soluble pig-ment) in the liver.

The rate and amount of conjugation of bilirubin de-pend on the rate of hemolysis, the bilirubin load, the ma-turity of the liver, and the presence of albumin-bindingsites. (See Chapter 26 for discussion of conjugation ofbilirubin. ∞) The liver of a normal, healthy term infantis usually mature enough and producing enough glu-curonyl transferase that the total serum bilirubin does notreach a pathologic level.

PHYSIOLOGIC JAUNDICEPhysiologic or neonatal jaundice is a normal processthat occurs during transition from intrauterine to ex-trauterine life and appears after 24 hours of life. Somedegree of jaundice occurs in about half of all healthyterm newborns and in 80% of preterm newborns(Madan, MacMahon, & Stevenson, 2005). It is due to thenewborn’s shortened cell life span, slower uptake by theliver, lack of intestinal bacteria, and poorly establishedhydration.

Lab tests reveal a predominance of unconjugated biliru-bin. The average level of unconjugated bilirubin in cordblood is approximately 2 mg/dL at birth. This level rises toan average of 5 to 6 mg/dL between the third and fifth daysof life. The jaundice is usually not visible after 10 days. Thepattern of physiologic jaundice differs between breastfedand formula-fed newborns (for further discussion of physi-ologic jaundice, see “Physiologic Jaundice” in Chapter 26

∞). Physiologic jaundice remains a common problem forthe term newborn and may require treatment with pho-totherapy.

PATHOPHYSIOLOGY OF HYPERBILIRUBINEMIASerum albumin-binding sites are usually able to conju-gate enough bilirubin to meet the demands of the normalnewborn. However, certain conditions tend to decreasethe number of sites available. Fetal or neonatal asphyxiaand neonatal drugs such as indomethacin decrease thebinding affinity of bilirubin to albumin, because acidosisimpairs albumin’s capacity to hold bilirubin. Hypother-mia and hypoglycemia release free fatty acids that dislo-cate bilirubin from albumin. Maternal use of sulfa drugsor salicylates interferes with conjugation or with serumalbumin-binding sites by competing with bilirubin forthese sites. Finally, premature infants have less albuminavailable for binding with bilirubin. Neurotoxicity is pos-sible because unconjugated bilirubin has a high affinityfor extravascular tissue, such as fatty tissue (subcuta-neous tissue) and cerebral tissue.

Bilirubin not bound to albumin can cross the blood-brain barrier, damage cells of the CNS, and produce ker-nicterus or bilirubin encephalopathy (Watson, 2004).Kernicterus (meaning “yellow nucleus”) refers to depositsof indirect or unconjugated bilirubin in the basal gangliaof the brain and to the permanent neurologic sequelae ofuntreated hyperbilirubinemia (elevation of bilirubinlevel).

The classic bilirubin encephalopathy of kernicterusmost commonly found with Rh and ABO blood group in-compatibility is less common today due to aggressive treat-ment with phototherapy and exchange transfusions. Butcases of kernicterus are reappearing as a result of early dis-charge and the increased incidence of dehydration (as a re-sult of discharge before the mother’s milk is established).Current therapy can reduce the incidence of kernicterusencephalopathy but cannot distinguish all infants who areat risk.

CAUSES OF HYPERBILIRUBINEMIAA primary cause of pathologic hyperbilirubinemia is he-molytic disease of the newborn secondary to Rh incom-patibility. All pregnant women who are Rh negative orwho have blood type O (possible ABO blood incompati-bility) should be asked about outcomes of any previouspregnancies and history of blood transfusion. Prenatalamniocentesis with spectrophotographic examinationmay be indicated. Cord blood from newborns is evalu-ated for bilirubin level, which should not exceed 5mg/dL. Newborns of Rh-negative and O blood typemothers are carefully assessed for jaundice and levels ofserum bilirubin.

Alloimmune hemolytic disease, also known aserythroblastosis fetalis, occurs when an Rh-negative

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mother is pregnant with an Rh-positive fetus and maternalantibodies cross the placenta. Maternal antibodies enter thefetal circulation, then attach to and destroy the fetal redblood cells (RBCs). The fetal system responds by increasingRBC production. Jaundice, anemia, and compensatory ery-thropoiesis result. A marked increase in immature RBCs(erythroblasts) also occurs, hence the designation ery-throblastosis fetalis. Because of the use of Rh immune glob-ulin (RhoGAM), the incidence of erythroblastosis fetalishas dropped dramatically.

Hydrops fetalis, the most severe form of erythroblas-tosis fetalis, occurs when maternal antibodies attach to theRh site on the fetal RBCs, making them susceptible to de-struction; severe anemia and multiorgan system failure re-sult. Cardiomegaly with severe cardiac decompensationand hepatosplenomegaly occurs. Severe generalized mas-sive edema (anasarca) and generalized fluid effusion intothe pleural cavity (hydrothorax), pericardial sac, and peri-toneal cavity (ascites) develop. Jaundice is not present ini-tially because the bilirubin pigments are excreted throughthe placenta into the maternal circulation. The hydropichemolytic disease process is also characterized by hyper-plasia of the pancreatic islets, which predisposes the infantto neonatal hypoglycemia similar to that of IDMs. In addi-tion the associated thrombocytopenia and hypoxic damageto the capillaries means these infants have increased bleed-ing tendencies. Hydrops is a frequent cause of intrauterinedeath among infants with Rh disease.

ABO incompatibility (the mother is blood type O andthe baby is blood type A or B) may result in jaundice, al-though it rarely results in hemolytic disease severe enoughto be clinically diagnosed and treated. Hepatosplenomegalymay be found occasionally in newborns with ABO incom-patibility, but hydrops fetalis and stillbirth are rare.

Other prenatal and perinatal factors predispose thenewborn to hyperbilirubinemia. During pregnancy, pre-disposing maternal conditions include hereditary sphe-rocytosis, diabetes, intrauterine infections, and gram-negative bacilli infections that stimulate production ofmaternal alloimmune antibodies, drug ingestion (such assulfas, salicylates, novobiocin, diazepam), and oxytocinadministration.

In addition to Rh or ABO incompatibility, other con-ditions predispose the newborn to hyperbilirubinemia:polycythemia (central hematocrit 65% or more), pyloricstenosis, obstruction or atresia of the biliary duct or of thelower bowel, low-grade urinary tract infection, sepsis, hy-pothyroidism, enclosed hemorrhage (cephalhematoma,large bruises), asphyxia neonatorum, hypothermia,acidemia, and hypoglycemia. Neonatal hepatitis, atresia ofthe bile ducts, and gastrointestinal atresia all can alterbilirubin metabolism and excretion.

The prognosis for a newborn with hyperbilirubinemiadepends on the extent of the hemolytic process and the un-derlying cause. Severe hemolytic disease results in fetal andearly neonatal death from the effects of severe anemia—cardiac decompensation, edema, ascites, and hydrothorax.Hyperbilirubinemia may lead to kernicterus if not aggres-sively treated. The resulting neurologic damage may causedeath, cerebral palsy, possible mental retardation, or hearingloss or, to a lesser degree, perceptual impairment, delayedspeech development, hyperactivity, muscle incoordination,or learning difficulties.

DEVELOPING CULTURALCOMPETENCE

ETHNIC VARIATIONS AND JAUNDICEEast Asian infants (Japanese, Chinese, and Filipino ethnic groups)have a higher occurrence of hyperbilirubinemia than Caucasian in-fants. Infants with Asian fathers and Caucasian mothers have a higherincidence of jaundice than if both parents are Caucasian. Other eth-nic groups at risk for increased bilirubinemia are Navajo, Eskimo, andSioux Native American newborns; Greek newborns; Sephardic-Jewish(oriental ancestry) newborns; and some Hispanic newborns.

CLINICAL THERAPYNeonatal hyperbilirubinemia can be considered pathologicand requires further investigation if any of the followingcriteria are met (American Academy of Pediatrics Subcom-mittee on Hyperbilirubinemia, 2004; Madan et al., 2005):

1. Clinically evident jaundice before first 24 hours of life

2. Serum bilirubin concentration rising more than 0.2mg/dL/hour or 5 mg/dL/per day

3. Total serum bilirubin (TSB) exceeding the 95thpercentile on the nomogram

4. Signs of underlying illness in any infant (vomiting,lethargy, poor feeding, excessive weight loss, apnea,tachypnea, or temperature instability)

5. Clinical jaundice persisting for more than two weeksin a term newborn

6. Conjugated bilirubin concentrations greater than 2mg/dL or more than 20% of the total serum bilirubinconcentration

Initial diagnostic procedures are aimed at differentiatingjaundice resulting from increased bilirubin production, im-paired conjugation or excretion, or a combination of thesefactors. When one or more predisposing factors for jaundiceare present, the maternal and neonatal blood types should betested in the laboratory for Rh or ABO incompatibility. Earlyprenatal identification of the fetus at risk for Rh or ABO in-

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compatibility allows prompt treatment. (See Chapter 15 fordiscussion of in utero management of this condition.∞)

Because of the shorter life span of red blood cells in thenewborn, a significant bilirubin load is produced. Whenbilirubin breaks down, carbon monoxide (CO) is released.This production of carbon monoxide is being investigated asa marker in the study of bilirubin production. Measuringend-tidal CO (ETCO) has been shown to provide results sim-ilar to laboratory measures of bilirubin (Madan et al., 2005).

Other needed laboratory evaluations are Coombs’ test,serum bilirubin levels (direct and total), hemoglobin, retic-ulocyte percentage, white cell count, and positive smear forcellular morphology.

The Coombs’ test determines whether jaundice is dueto Rh or ABO incompatibility. The indirect Coombs’ testmeasures the amount of Rh-positive antibodies in themother’s blood. Rh-positive RBCs are added to the mater-nal blood sample. If the mother’s serum contains antibod-ies, the Rh-positive RBCs agglutinate (clump) when rabbitimmune antiglobulin is added, which is a positive test result.

The direct Coombs’ test reveals antibody-coated (sen-sitized) Rh-positive RBCs in the newborn. Rabbit immuneantiglobulin is added to the specimen of neonatal bloodcells. If the neonatal RBCs agglutinate, they have beencoated with maternal antibodies, a positive result.

If the hemolytic process is due to Rh sensitization, labo-ratory findings will reveal the following: (1) an Rh-positivenewborn with a positive Coombs’ test; (2) increased ery-thropoiesis with many immature circulating red blood cells(nucleated blastocysts); (3) anemia, in most cases; (4) ele-vated levels of bilirubin in cord blood (5 mg/dL or more);and (5) a reduction in albumin-binding capacity. Maternaldata may include an elevated anti-Rh titer and spectropho-tometric evidence of a fetal hemolytic process.

Laboratory findings reveal an increase in immatureblood cells (reticulocytes) when the hemolytic process isdue to ABO incompatibility. The resulting anemia is usu-ally not significant during the newborn period and is rarelater on. The direct Coombs’ test may be negative or mildlypositive, whereas the indirect Coombs’ test may be stronglypositive. Infants with a positive direct Coombs’ test haveincreased incidence of jaundice, with bilirubin levelsabove 10 mg/dL. Increased numbers of spherocytes(spherical, plump, mature erythrocytes) are seen on a pe-ripheral blood smear. Increased numbers of spherocytesare not seen on blood smears from infants with Rh disease.

THERAPEUTIC MANAGEMENTWhatever the cause of hyperbilirubinemia, management ofthese infants is directed toward alleviating anemia, remov-ing maternal antibodies and sensitized erythrocytes, in-

creasing serum albumin levels, reducing serum bilirubinlevels, and minimizing the consequences of hyperbiliru-binemia. Early discharge of newborns from birthing centershas significantly affected the diagnosis and management ofneonatal jaundice in that setting and increased the empha-sis on outpatient and home care management.

Hemolytic disease may be treated with phototherapy,exchange transfusion, and drug therapy. When determin-ing the appropriate management of hyperbilirubinemiadue to hemolytic disease, the three relevant variables arethe newborn’s (1) serum bilirubin level, (2) birth weight,and (3) age in hours. If a newborn has hemolysis with anunconjugated bilirubin level of 14 mg/dL, weighs less than2500 g (birth weight), and is 24 hours old or less, an ex-change transfusion may be the best management. However,if that same newborn is over 24 hours of age, which is pastthe time when an increase in bilirubin would be due topathologic causes, phototherapy may be the treatment ofchoice to prevent the possible complication of kernicterus.

Phototherapy is the exposure of the newborn to high-intensity light. It may be used alone or in conjunction withexchange transfusion to reduce serum bilirubin levels. Ex-posure of the newborn to high-intensity light (fluorescentlight bulbs or bulbs in the blue-light spectrum) decreasesserum bilirubin levels in the skin by facilitating biliary ex-cretion of unconjugated bilirubin. Phototherapy decreasesserum bilirubin levels by changing bilirubin from the non-water soluble (lipophilic) form to water-soluble by-prod-ucts that can then be excreted. When bilirubin absorbslight, three forms of photochemical reaction occur: photo-oxidation, photoisomerization, and structural isomeriza-tion. Photo-oxidation is a minor contributor to bilirubinelimination. Structural isomerization is the most impor-tant pathway for decreasing serum bilirubin levels. Biliru-bin is converted to lumirubin which is bound to albuminand transported to the liver. It is a stable water-soluble mol-ecule so it is excreted into the urine and bile for excretion.Photoisomerization occurs when the natural form ofbilirubin is exposed to light at a certain wavelength and thebilirubin is converted to a less toxic form. The new isomer,photobilirubin, is created rapidly, but is quite unstable.Photobilirubin is bound to albumin, transported to theliver, and is incorporated into bile. If it is not quickly elim-inated from the bowel it can convert back to its originalform and return to the bloodstream.

Phototherapy is an intervention that is used more forthe prevention of hyperbilirubinemia in order to haltbilirubin levels from climbing dangerously high. The deci-sion to start phototherapy is based on 2 factors: gestationalage and age in hours. Phototherapy is the most effective inthe first 24 to 48 hours of usage; frequently the light can bediscontinued during or immediately after this time frame.

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Phototherapy plays an important role in preventing arise in bilirubin levels but does not alter the underlyingcause of jaundice, and hemolysis may continue to pro-duce anemia. Many authors have recommended initiat-ing phototherapy “prophylactically” in the first 24 hoursof life in high-risk, very-low-birth-weight or severelybruised infants.

Phototherapy can be provided through halogen spot-lights, (although this is less often used due to the risk ofthermal burns), conventional banks of phototherapylights or by a fiberoptic blanket attached to a halogenlight source around the trunk of the newborn or a com-bination of both delivery methods. The banks of bilirubinlights utilize light in the blue spectrum. This is the mosteffective source available, but can mask cyanosis, andcauses dizziness and nausea in the staff. With the fiberop-tic blanket, the light stays on at all times, and the newbornis accessible for care, feeding, and diaper changes; greatersurface area is exposed and there are no thermoregulationissues. The eyes are not covered. Fluid and weight loss arenot complications of this system. Furthermore, it makesthe infant accessible to the parents and is less alarming toparents than standard phototherapy. A combination of afiberoptic light source in the mattress under the baby anda standard light source above may also be used. This istermed intensive phototherapy. Intensive phototherapyshould reduce the TSB by 1–2 mg/dL within 4–6 hoursand should continue to decline. If this goal is not reachedthen an exchange transfusion should be considered.Many institutions and pediatricians use fiberoptic blan-kets for home care (see Figure 31–9 ).

Exchange TransfusionExchange transfusion is the withdrawal and replacement ofthe newborn’s blood with donor blood. It is used to treatanemia with RBCs that are susceptible to maternal anti-bodies, remove sensitized RBCs that would be lysed soon,remove serum bilirubin, and provide bilirubin-free albu-min to increase the binding sites for bilirubin. Concernsabout exchange transfusion are related to the use of bloodproducts, which include the potential for HIV infectionand hepatitis.

If the TSB is at or approaching the exchange level, sendblood for immediate type and crossmatch. Blood for ex-change transfusion is modified whole blood (red cells andplasma) crossmatched against the mother and compatiblewith the infant.

NURSING MANAGEMENT

NURSING ASSESSMENT AND DIAGNOSISAssessment is aimed at identifying prenatal and perinatalfactors that predispose the newborn to the development ofjaundice and at recognizing the jaundice as soon as it is ap-parent. (See“Nursing Care Plan: The Newborn with Hyper-bilirubinemia.”) Clinically,ABO incompatibility presents asjaundice and occasionally as hepatosplenomegaly. Fetal hy-drops or erythroblastosis is rare. Suspect hemolytic diseaseof the newborn if the placenta is enlarged, if the newborn isedematous with pleural and pericardial effusion plus as-cites, if pallor or jaundice is noted during the first 24 to 36hours, if hemolytic anemia is diagnosed, or if the spleen and

• Use total bilirubin. Do not subtract direct reacting or conjugated bilirubin.

• Risk factors = isoimmune hemolytic disease, G6PD deficiency, asphyxia, significant lethargy, temperature instability, sepsis, acidosis, or albumin < 3.0g/dL (if measured)

• For well infants 35-37 6/7 wk can adjust TSB levels for intervention around the medium risk line. It is an option to intervene at lower TSB levels for infants closer to 35 wks and at higher TSB levels for those closer to 37 6/7 wk.

• It is an option to provide conventional phototherapy in hospital or at home at TSB levels 2-3 mg/dL (35-50mmol/L) below those shown but home phototherapy should not be used in any infant with risk factors.

FIGURE 31–9

Guidelines for phototherapy in hospitalized infants of 35 or more weeks’ gestation.American Academy of Pediatrics Subcommittee on Hyperbilirubinemia (2004). Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 114(1), 297–316.Used with permission.

(continues on page 842)

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NURSING CARE PLAN

THE NEWBORN WITH HYPERBILIRUBINEMIA


1. Nursing Diagnosis: Impaired Tissue Integrity related to predisposing factors associated with hyperbilirubinemia

■ Evaluate baby’s history for predisposingfactors for hyperbilirubinemia.

■ Observe color of amniotic fluid at time ofrupture of membranes.

■ Assess baby for developing jaundice indaylight if possible.

1. Observe sclera.

2. Observe skin color and assess byblanching.

3. Check oral mucosa, posterior portionof hard palate, and conjunctival sacsfor yellow pigmentation in dark-skinned newborns.

Report jaundice occurring within 24 hours ofbirth.

Early identification of risk factors enables thenurse to monitor babies for early signs ofhyperbilirubinemia. Acidosis, hypoxia, andhypothermia increase the risk ofhyperbilirubinemia at lower bilirubin levels.■ Amber-colored amniotic fluid indicates

hyperbilirubinemia.■ Early detection is affected by nursery

environment. Artificial lights (with pinktint) may mask beginning of jaundice.

1. Most visible sign of hyperbilirubinemia isjaundice noted in skin, sclera, or oralmucosa. Onset is first seen on face andthen progresses down trunk.

2. Blanching the skin leaves a yellow colorto the skin immediately after pressure isreleased.

3. Underlying pigment of dark-skinnedpeople may normally appear yellow.

■ Baby’s jaundice is identified early.

NIC Intervention:

High–risk newborn care: Identification andmanagement of a high-risk newborn topromote healthy outcomes for baby

NOC Outcome:

Risk control: Actions to eliminate or reduceactual, personal, and modifiable healththreats

Goal: Babies at risk for jaundice and early signs of jaundice will be identified.

2. Nursing Diagnosis: Risk for Fluid Volume Deficit related to phototherapy

NIC Intervention:

Fluid monitoring: Collection and analysis ofpatient data to regulate fluid balance

■ Offer feedings every 2 to 3 hr. Breastfeedon demand with no supplementationunless excessive weight loss or increasingTSB with adequate feeding.

■ Provide 25% extra fluid intake.

■ Assess for dehydration:1. Poor skin turgor2. Depressed fontanelles3. Sunken eyes4. Decreased urine output5. Weight loss6. Changes in electrolytes

■ Adequate hydration increases peristalsisand excretion of bilirubin.

■ Replace fluid losses due to watery stools,if under phototherapy.

■ Phototherapy treatment may cause liquidstools and increased insensible waterloss, which increases risk of dehydration.

NOC Outcome:

Fluid balance: Balance of water in theintracellular and extracellular compartmentsof the body

■ Baby will have good skin turgor, clearamber urine output of 1-3 mL/kg/hr, sixto eight wet diapers/day, and willmaintain weight.

Goal: The infant will not exhibit signs of dehydration and will display appropriate weight gain.

(continued)

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3. Nursing Diagnosis: Potential for Injury related to use of phototherapy lights

NIC Intervention:

Newborn monitoring: Measurement andinterpretation of physiologic status of thenewborn the first 24 hr after birth

NOC Outcome:

Risk Control: Actions to eliminate or reduceactual, personal, and modifiable healththreats

Goal: Baby will not have any corneal irritation or drainage, skin breakdown, or major fluctuations in temperature.

■ Cover baby’s eyes with eye patches whileunder phototherapy lights. Covertestes/penis in male infants.

■ Make certain that eyelids are closed priorto applying eye patches.

■ Remove baby from under phototherapyand remove eye patches during feedings.

■ Inspect eyes each shift for conjunctivitis,drainage, and corneal abrasions due toirritation from eye patches.

■ Administer thorough perianal cleansingwith each stool or change of perianalprotective covering.

■ Provide minimal coverage—only of diaperarea.

■ Avoid the use of oily applications on theskin.

■ Reposition baby q 2 hours.

■ Observe for bronzing of skin.

■ Place Plexiglas shield between baby andlight.Monitor baby’s skin and core temperaturefrequently until temperature is stable.

■ Check axillary temperature with readingson servo-controlled unit on incubator.Regulate incubator temperature asneeded.

■ Protects retina from damage due to high-intensity light and testes from damagefrom heat.

■ Prevents corneal abrasions.

■ Provides visual stimulation and facilitatesattachment behaviors.

■ Prevents or facilitates prompt treatmentof purulent conjunctivitis.

■ Frequent stooling increases risk of skinbreakdown. Prevents infection.

■ Provides maximal exposure. Shieldedareas become more jaundiced, somaximum exposure is essential.

■ Prevents superficial burns to skin.

■ Provides equal exposure of all skin areasand prevents pressure areas.

■ Bronzing is related to use of phototherapywith increased direct bilirubin levels orliver damage; may last for 2 to 4 months.

■ Hypothermia and hyperthermia arecommon complications of phototherapy.Hypothermia results from exposure tolights, subsequent radiation, andconvection losses.

■ Hyperthermia may result from theincreased environmental heat. Additionalheat from phototherapy lights frequentlycauses a rise in the baby’s andincubator’s temperatures. Fluctuations intemperature may occur in response toradiation and convection.

■ Baby’s eyes are protected, skin is intact,and baby maintains a stabletemperature.

Monitor intake and output (I & O).Weigh daily.Report signs of dehydration.■ Administer IV fluids:

1. Monitor flow rates.2. Assess insertion sites for signs of

infection.

■ Prevents fluid overload. IV fluids may beused if baby is dehydrated or in presenceof other complications. IV may be startedif exchange transfusion is to be done.

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4. Nursing Diagnosis: Risk for Impaired Parenting related to deficient knowledge of infant care and prolonged separation of infant andparents secondary to illness

■ Encourage parents to provide tactilestimulation during feeding and diaperchanges.

■ Encourage cuddling and eye contactduring feedings.

■ Offer suggestions to comfort restlessinfant:1. Nesting when beneath bili lights2. Talking softly and singing quietly to

infant3. Taped music or tape recording of

evening activities from home4. Rhythmic patting of buttocks5. Firm, nonstroking touch, assisting with

control of extremities6. Pacifier for nonnutritive sucking

■ Encourage family/friend support ofmother/parents (i.e., meals, rest, childcare for siblings, allow expressions ofconcerns/feelings).

■ Evaluate additional psychosocial needs.

■ Discuss rationale for treatment andpossible side effects of phototherapy withfamily (stool changes, increased fluidloss, possible temp instability, slightlethargy, rash, altered sleep-wakepatterns).Instruct family on infant’s care whileundergoing phototherapy:1. Safety precautions—bili mask,

incubator door closed and latched,covering genitalia per policy.

2. Skin care, cord care, circumcision careas appropriate.

3. Lab draws, rationale for intake andoutput.

■ Encourage parent/significantother/sibling involvement in infant careas possible.

■ Evaluate family’s understanding ofinformation.

■ Give explanation of equipment beingused and changes in bilirubin levels.Allow parents an opportunity to askquestions; reinforce or clarify informationas needed.

■ Newborn has normal needs for tactilestimulation.

■ Provides opportunity for parents to bondwith their newborn.

■ Provides comfort and decreases sensorydeprivation. Presence of equipment maydiscourage parents from interacting withnewborn.

■ Decreases strain on mother/parents byassisting with other responsibilities andallows for additional time with newbornfor bonding, care, etc.

■ Parents may not understand what ishappening or why.

■ Physician preference of treatmentmodalities may vary. Parents may notunderstand why their newborn is notreceiving a treatment that another withthe same condition is receiving.

■ The parent will demonstrate ability toperform basic infant care tasks asevidenced by exhibiting appropriateattachment behaviors (i.e., talking to andholding infant), feeding infant, and caringfor infant under home bili therapy.

■ Parents verbalize understanding ofrationale and possible side effects fromphototherapy; parents/familydemonstrate safety precautions whencaring for infant; parents getting mealsand rest; parents verbalize support given.

NIC Intervention:

Teaching: Infant care: Instruction onnurturing and physical care needed duringthe first year of life

NOC Outcome:

Parenting: Provision of an environment thatpromotes optimum growth and developmentof dependent children

Goal: Parents will bond with infant and have realistic expectations about their infant. Parents are comfortable taking their infant home. They are ableto demonstrate normal infant care and assessments of possible complications, and they know when to return for follow-up.

(continued)

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■ As necessary, review role of pumpingbreasts and offering formula for limitedtime.

■ Assist mother to pump her breasts tomaintain milk supply.

■ The etiology of breast milk jaundiceremains uncertain. The serum bilirubinlevels begin to fall within 48 hr afterdiscontinuation of breastfeeding. Opinionof physicians varies regarding the needfor discontinuing breastfeeding.

■ If breastfeeding is temporarilydiscontinued, assess mother’s knowledgeof pumping her breasts and provideinformation and support as needed.

liver are enlarged. Carefully note changes in behavior andobserve for evidence of bleeding. If laboratory tests indicateelevated bilirubin levels, check the newborn for jaundiceabout every 2 hours and record observations.

To check for jaundice in lighter-skinned babies, blanchthe skin over a bony prominence (forehead, nose, ster-num) by pressing firmly with the thumb. After pressure isreleased, if jaundice is present, the area appears yellow be-fore normal color returns. In darker-skinned babies, checkoral mucosa and the posterior portion of the hard palateand conjunctival sacs for yellow pigmentation. Becausebirthing units are often decorated with pink walls and sur-roundings, which may mask yellowish tints, and becauseyellow light makes differentiation of jaundice difficult,perform the assessment in daylight for the best results.

In addition to visually inspecting the newborn, use re-flectance photometers that measure transcutaneous biliru-bin (TcB) to screen and monitor neonatal jaundice. Analysisfor end-tidal carbon monoxide is another portable screeningtool. This analysis allows quick identification of those new-borns with significant hemolytic disease who may be at riskfor further complications of unconjugated hyperbilirubine-mia (American Academy of Pediatrics Subcommittee onHyperbilirubinemia, 2004).

If jaundice appears, record and report the time of on-set and carefully observe for any increase in depth of coloror changes in the newborn’s behavior. Assess the newborn’sbehavior for neurologic signs associated with hyperbiliru-binemia, which are rare but may include hypotonia, di-minished reflexes, lethargy, or seizures.

Some hospitals have developed a mandatory screeningpolicy of all newborns prior to discharge utilizing the TcBmonitor. If the level comes back as high as earlier levels thena follow-up TSB will be performed.

Nursing diagnoses that may apply to care of a newbornwith jaundice include the following:

■ Risk for Fluid Volume Deficit related to phototherapy,increased insensible water loss, and frequent loose stools

■ Potential for Injury related to use of phototherapy

■ Sensory-Perceptual Alterations related to neurologicdamage secondary to kernicterus

■ Risk for Altered Parenting related to deficientknowledge of infant care and prolonged separation ofinfant and parents secondary to illness


Hospital-Based Nursing CareHospital-based care is described in “Nursing Care Plan:The Newborn with Hyperbilirubinemia.” If phototherapylights are used, expose the newborn’s entire skin surface tothe light. Minimal covering may be applied over the geni-tals and buttocks to expose maximum skin surface whilestill protecting the bedding from soiling. Measure pho-totherapy success every 12 hours or with daily serumbilirubin levels (more frequently if there is hemolysis or ahigher level prior to initiation of phototherapy). Turnlights off while blood is drawn to ensure accurate serumbilirubin levels. Because it is not known if phototherapyinjures the delicate eye structures, particularly the retina,apply eye patches over the newborn’s closed eyes during ex-posure to banks of phototherapy lights (Figure 31–10 ).Stop phototherapy and remove the eye patches at least onceper shift to assess the eyes for conjunctivitis. Also removepatches to allow eye contact during feeding (social stimu-lation) or when parents are visiting (to promote parentalattachment).

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can be replaced before its effectiveness is lost. Be carefulabout using ointment under bilirubin lights because thiscombination may cause burns.

To parents, the terms jaundice, hyperbilirubinemia, ex-change transfusion, and phototherapy may sound frighten-ing and threatening. Some parents may feel guilty abouttheir baby’s condition and think they have caused the prob-lem. Under stress, parents may not be able to understandthe physician’s first explanations.Anticipate that the parentswill need explanations repeated and clarified and that theymay need help voicing their questions and fears. Coach par-ents when they visit with the baby and encourage eye andtactile contact with the newborn. After the mother’s dis-charge, keep parents informed of their infant’s conditionand encourage them to return to the hospital or call at anytime so that they can be fully involved in the care of their in-fant. Advise parents that they can expect a rebound of 1 to2 mg/dL after discontinuation of phototherapy and that afollow-up bilirubin test may be done (Watson, 2004).

While the mother is still hospitalized, phototherapycan also be carried out in the parents’ room if the onlyproblem is hyperbilirubinemia. The parents must be will-ing to keep the baby in the room for 24 hours a day, be ableto take emergency action (e.g., for choking) if necessary,and complete instruction checklists. Some institutions re-quire that parents sign a consent form. Instruct the parentsbut also continue to monitor the infant’s temperature, ac-tivity, intake and output, and positioning of eye patches (ifconventional light banks are used) at regular intervals(Table 31–3).

Nursing Care in the CommunitySome studies have shown that with early discharge of new-borns and their mothers comes an increase in hospitalreadmission and elevated risk of pathologic hyperbiliru-binemia. Home phototherapy use is only recommended if

NURSING PRACTICE

If the area of jaundice around the eyes begins to disappear, then the eye patches are allowing light to enter and better eye protectionis needed.

Infant receiving phototherapy via overhead bilirubin lights. The photother-apy light is positioned over the isolette. Bilateral eye patches are alwaysused to protect the baby’s eyes during phototherapy.Courtesy of Lisa Smith-Pederson, RNC, MSN, NNP.

FIGURE 31–10

Most phototherapy units provide the desired level of ir-radiance when the infant is 45 to 50 cm below the lamps.Use a photometer to measure and maintain desired irradi-ance levels. Disadvantages of lights are that they create adifficult work environment and can distort an infant’scolor. A harmless, temporary bronze discoloration of theskin may occur with phototherapy when the infant has ele-vated direct serum bilirubin levels or liver disease. As a sideeffect of phototherapy, some newborns develop a macu-lopapular rash.

Monitor the newborn’s temperature to prevent hyper-thermia and hypothermia. The newborn needs additionalfluids to compensate for the increased loss of waterthrough the skin and loose stools. Loose stools and in-creased urine output result from increased bilirubin excre-tion. Observe the infant for signs of dehydration andperianal excoriation (see Skill 5–7 ).

When assessing the newborn’s skin color for jaundiceand bronzing, also examine the skin for developing pres-sure areas. Reposition the newborn at least every 2 hours topermit the light to reach all skin surfaces, to prevent pres-sure areas, and to vary the stimulation to the infant. Keeptrack of the number of hours each lamp is used so that it

SKILLS

Explain and demonstrate the placement of eye patches and explainthat they must be in place when the infant is under the lights.

Explain the clothing to be worn (diaper under lights, dress and wrap when away from the lights).

Explain the importance of taking the infant’s temperature regularly.Explain the importance of adequate fluid intake.Explain the charting flow sheet (intake, output, eyes covered).Explain how to position the lights at a proper distance.Explain the need to keep the infant under phototherapy except during

feeding and diaper changes.

TABLE 31–3 Instructional Checklist forIn-Room Phototherapy

MED

IALIN

KNursing in Action: Infant Receiving Phototherapy

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Newborn on fiberoptic “bili” mattress and under phototherapy lights. Acombination of fiberoptic light source and standard phototherapy lightsource above baby may also be used.

FIGURE 31–11the bilirubin level is plotted on the nomogram and foundto be in the “optional phototherapy” range. Any neonatewith a level in the higher range should be hospitalized forcontinual phototherapy and serum bilirubin levels closelymonitored on a regular schedule (American Academy ofPediatrics Subcommittee on Hyperbilirubinemia, 2004).

Jaundice and its treatment can be very disturbing toparents and may generate feelings of guilt and fear. Reas-surance and support are vital especially for the breastfeed-ing mother, who may question her ability to adequatelynourish her newborn. The parents’ perception of and/ormisconceptions about jaundice can affect parent-infantinteractions. The nurse should explain the causes of jaun-dice and emphasize that is is usually a transient problemand one to which all infants must adapt after birth. It is es-sential that the impact of cultural beliefs be considered.Some Latina women believe that showing strong maternalemotions during pregnancy and during breastfeeding canbe detrimental. “Bilis” associated with anger may beblamed by some Latina women for jaundice. Cultural be-liefs lead mothers to interpret illness within their culturalframework, especially when left without clear and under-stood explanations. Maternal reactions can be lessened bycareful explanations to the mothers about the diagnosis,prognosis, duration, management options for jaundice,and possibility of recurrence.

If the baby is to receive phototherapy at home, teachthe parents to record the infant’s temperature, weight, fluidintake and output, stools, and feedings and to use the pho-totherapy equipment. If phototherapy lights are beingused, parents must agree that the baby will be exposed tothe lights for long periods of time; that they will hold thebaby for only short periods for feeding, comforting, anddiaper changing; and that the room temperature will beregulated to minimize heat loss. A combination of pho-totherapy lights and fiberoptic mattress may be used(Figure 31–11 ). Fiberoptic phototherapy blankets elim-inate the need for eye patches, decrease heat loss becausethe baby is covered, and provide more chances for baby-parent interaction. The best method of home photother-apy depends on the cause of the hyperbilirubinemia andthe rate of progression of the jaundice. Ongoing monitor-ing of bilirubin levels is essential with home phototherapyand can be carried out in the home, in the follow-up clinic,or in the clinician’s office.


■ The newborn at risk for development ofhyperbilirubinemia is identified, and care is providedto minimize the potential impact ofhyperbilirubinemia.

■ The baby does not have any corneal irritation ordrainage, skin breakdown, or major fluctuations intemperature.

■ Parents understand the rationale for, goal of, andexpected outcome of therapy.

■ Parents verbalize their concerns about their baby’scondition and identify how they can facilitate theirbaby’s improvement.

CARE OF THE NEWBORN WITH ANEMIANeonatal anemia is often difficult to recognize by clinicalevaluation alone. The hemoglobin concentration in a termnewborn is 15 to 20 g/dL, slightly higher than that in pre-mature newborns, in whom the mean hemoglobin is 14to 18 g/dL. Infants with hemoglobin values of less than14 g/dL (term) and 13 g/dL (preterm) are usually con-sidered anemic. The most common causes of neonatal ane-mia are blood loss,hemolysis, and impaired RBC production.

Blood loss (hypovolemia) occurs in utero from placen-tal bleeding (placenta previa or abruptio placentae). Intra-partal blood loss may be fetomaternal, fetofetal, or theresult of umbilical cord bleeding. Birth trauma to abdom-inal organs or the cranium may produce significant bloodloss, and cerebral bleeding may occur because of hypoxia.

Excessive hemolysis of RBCs is usually a result of bloodgroup incompatibilities but may be caused by infection.The most common cause of impaired RBC production is agenetically transmitted deficiency in glucose-6-phosphatedehydrogenase (G6PD) deficiency. Anemia and jaundiceare the presenting signs.

A condition known as physiologic anemia results fromthe normal gradual drop in hemoglobin for the first 6 to 12

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weeks of life or corresponds with the decline in fetal he-moglobin. Theoretically the bone marrow stops produc-tion of RBCs in response to higher oxygen levels that resultfrom breathing changes after birth. When the amount ofhemoglobin decreases to levels of 10 to 11 g/dL at about 6to 12 weeks of age in term newborns, the bone marrow be-gins production of RBCs again, and the anemia disappears.

Anemia in preterm newborns is seen earlier than interm newborns, and increased production of RBCs doesnot start until hemoglobin is 7 to 9 g/dL. The pretermbaby’s hemoglobin reaches a low sooner (by 4 to 8 weeksafter birth) than does a term newborn’s (6 to 12 weeks) be-cause a preterm infant’s RBC survival time is shorter thanthat of a term newborn (Diehl-Jones & Askin, 2004). Thisdifference is due to several factors: the preterm infant’srapid growth rate, decreased iron stores, and an inadequateproduction of erythropoietin (EPO).

CLINICAL THERAPYHematologic problems can be anticipated based on thepregnancy history and clinical manifestations. The age atwhich anemia is first noted is also of diagnostic value. Clin-ically, light-skinned anemic infants are very pale when theydo not have other symptoms of shock and usually have ab-normally low RBC counts. In acute blood loss, symptomsof shock (such as pallor, low arterial blood pressure, and adecreasing hematocrit value) may be present.

The initial laboratory workup should include hemo-globin and hematocrit measurements, reticulocyte count,ferritin concentrations, examination of peripheral bloodsmear, bilirubin determinations, direct Coombs’ test of in-fant’s blood, and examination of maternal blood smear forfetal erythrocytes (Kleihauer-Betke test). Clinical manage-ment depends on the severity of the anemia and whetherblood loss is acute or chronic. The baby should be placedon constant cardiac and respiratory monitoring. Mild orslow chronic anemia may be treated adequately with ironsupplements alone or with iron-fortified formulas. Fre-quent determinations of hemoglobin, hematocrit, andbilirubin levels (in hemolytic disease) are essential. In se-vere cases of anemia, transfusions are the treatment ofchoice. Management of anemia due to prematurity in-cludes recombinant human erythropoietin (rEPO) andsupplemental iron. Blood transfusions (dedicated units ofblood) are kept to a minimum.

NURSING MANAGEMENTAssess the newborn for symptoms of anemia (pallor). If theblood loss is acute, the baby may show signs of shock (a cap-illary filling time greater than 3 seconds, decreased pulses,tachycardia, and low blood pressure). Continued observa-tion identifies physiologic anemia as the preterm newborn

grows. Signs of compromise include poor weight gain,tachycardia, tachypnea, and apneic episodes. Promptly re-port any symptoms indicating anemia or shock. Record theamount of blood drawn for all laboratory tests so that totalblood removed can be assessed and replaced by transfusionwhen necessary. For long-term management, see “Normo-cytic Anemia” in Chapter 49. ∞CARE OF THE NEWBORN WITH POLYCYTHEMIAPolycythemia, a condition in which blood volume andhematocrit values are increased, is more common in SGAand full-term infants with delayed cord clamping,maternal-fetal and twin-to-twin transfusions, or chronic intrauterinehypoxia than in other newborns (Diehl-Jones & Askin,2004). An infant is considered polycythemic when the cen-tral venous hematocrit value is greater than 65% to 70% orthe venous hemoglobin level is greater than 22 g/dL duringthe first week of life. Other conditions that present withpolycythemia are chromosomal anomalies such as trisomy21, 18, and 13; endocrine disorders such as hypoglycemiaand hypocalcemia; and births at altitudes over 5000 feet.

CLINICAL THERAPYThe goal of therapy is to reduce the central venous hemat-ocrit value to a range of 55% to 60% in symptomatic in-fants. To decrease the RBC mass, the symptomatic infantreceives a partial exchange transfusion in which blood is re-moved from the infant and replaced milliliter for milliliterwith fresh frozen plasma or 5% albumin. The infant needssupportive treatment of presenting symptoms until thecondition is resolved; this usually happens spontaneouslyafter the partial exchange transfusion.

NURSING MANAGEMENTAssess for, record, and report symptoms of polycythemia.Also do an initial screening of the newborn’s hematocritvalue on admission to the nursery. If a capillary hematocritis done, warming the heel prior to obtaining the blood helpsto decrease falsely high values. Peripheral venous hematocritsamples are usually obtained from the antecubital fossa.

Many infants are asymptomatic, but as symptoms de-velop, they are related to the increased blood volume, hy-perviscosity (thickness) of the blood, and decreaseddeformability of RBCs, all of which result in poor perfusionof tissues. The infants have a characteristic plethoric(ruddy) appearance. The most common symptoms include:

■ Tachycardia and congestive heart failure due to theincreased blood volume.

■ Respiratory distress with grunting, tachypnea, andcyanosis; increased oxygen need; or respiratory

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hemorrhage due to pulmonary venous congestion,edema, and hypoxemia.

■ Hyperbilirubinemia due to increased numbers of RBCsbreaking down.

■ Decrease in peripheral pulses, discoloration ofextremities, alteration in activity or neurologicdepression, renal vein thrombosis with decreased urineoutput, hematuria, or proteinuria due tothromboembolism.

■ Jitteriness, decreased activity and tone, and seizuresdue to decreased perfusion of the brain andincreased vascular resistance secondary to sluggishblood flow, which can result in neurologic ordevelopmental problems.

Observe closely for the signs of distress or change in vitalsigns during the partial exchange. Assess carefully for par-tial exchange transfusion complications such as transfu-sion overload (which may result in congestive heartfailure), irregular cardiac rhythm, bacterial infection, hy-povolemia, and anemia. Reunite the newborn with the par-ents as soon as the baby’s status permits.

CARE OF THE NEWBORN WITH INFECTIONNewborns up to 1 month of age are particularly susceptibleto an infection, referred to as sepsis neonatorum, caused byorganisms that do not cause significant disease in older chil-dren. Once any infection occurs in the newborn, it can spreadrapidly through the bloodstream, regardless of its primarysite. The incidence of primary neonatal sepsis is 0.1 to 0.8 per1000 live births (1% to 8%) (Glomella, 2004). The frequencyof nosocomial infection is less in normal newborn infantsand increases for infants in the NICU.

Prematurity and low birth weight are associated withnosocomial infection rates up to 15 times higher than av-erage. The general debilitation and underlying illnesses of-ten associated with prematurity necessitate invasiveprocedures such as umbilical catheterization, intubation,resuscitation, ventilator support, monitoring, parenteralalimentation (especially lipid emulsions), and prior broad-spectrum antibiotic therapy.

However, even full-term infants are susceptible, be-cause their immunologic systems are immature. Theylack the complex factors involved in effective phagocyto-sis and the ability to localize infection or to respond witha well-defined, recognizable inflammatory response. Inaddition, newborns lack the IgM immunoglobulin neces-sary to protect against bacteria, because it does not crossthe placenta (refer to “Immunologic Adaptations” inChapter 26 for immunologic adaptations in the newbornperiod ∞).

Most nosocomial infections in the NICU present as bac-teremia or sepsis, urinary tract infections, meningitis, orpneumonia. Maternal antepartal infections such as rubella,toxoplasmosis, cytomegalic inclusion disease, and herpesmay cause congenital infections and resulting disorders inthe newborn. Intrapartum maternal infections, such as am-nionitis and those resulting from premature rupture ofmembranes (PROM) and precipitous birth, are sources ofneonatal infection (see “Care of the Woman with a PerinatalInfection”in Chapter 15 for more detailed information ∞).Passage through the birth canal and contact with the vaginalflora (�-hemolytic streptococci, herpes, Listeria, gonococci)expose the infant to infection (Table 31–4). When the fetusor newborn has an infection anywhere, the adjacent tissuesor organs are easily penetrated.The blood-brain barrier is in-effective.Septicemia is more common in males,except for in-fections caused by group B �-hemolytic streptococcus.

Gram-negative organisms (especially Escherichia coli,Enterobacter, Proteus, and Klebsiella) and the gram-positiveorganism �-hemolytic streptococcus are the most commoncausative agents. Pseudomonas is a common fomite contam-inant of ventilator support and oxygen therapy equipment.Gram-positive bacteria, especially coagulase-negativestaphylococci, are common pathogens in nosocomial bac-teremias, pneumonias, and urinary tract infections. Othergram-positive bacteria that commonly cause infection areenterococci and Staphylococcus aureus (Glomella, 2004).

Protection of the newborn from infections starts pre-natally and continues throughout pregnancy and birth.Prenatal prevention should include maternal screening forsexually transmitted infections and monitoring of rubellatiters in women who test negative. Intrapartum steriletechnique is essential. Smears from genital lesions aretaken, and placental and amniotic fluid cultures are ob-tained if amnionitis is suspected. If genital herpes is presenttoward term, cesarean birth may be indicated. All new-borns’ eyes should be treated with an antibiotic ophthalmicointment to prevent damage from gonococcal infection.Prophylactic antibiotic therapy for asymptomatic womenwho test positive for group B streptococcus (GBS) duringthe intrapartum period helps prevent early-onset sepsis.

CLINICAL THERAPYCultures should be taken as soon after birth as possible forinfants with a history of possible exposure to infection inutero (e.g., PROM more than 24 hours before birth orquestionable maternal history of infection). They shouldbe obtained before antibiotic therapy is begun.

1. One blood culture is obtained from differentperipheral sites. They are taken from a peripheralrather than an umbilical vessel, because catheters may

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Infection Nursing Assessment Nursing Plan and Implementation

Group B Streptococcus1%–2% colonized, with 1 in 10 developing diseaseEarly onset—usually within hours of birth or within first weekLate onset—1 week to 3 months

SyphilisSpirochetes cross placenta after 16th–18th week of gestation

GonorrheaApproximately 30%–35% of newborns born vaginally to infected mothers acquire the infection

Herpes Type 21 in 7500 birthsUsually transmitted during vaginal birth; a few cases of in utero transmission have been reported

Oral Candidal Infection (Thrush)Acquired during passage through birth canal

Chlamydia TrachomatisAcquired during passage through birth canal

TABLE 31–4 Maternally Transmitted Newborn Infections

Early assessment of clinical signs necessary.Assist with x-ray examination—shows aspiration pneumonia or hyaline membrane disease.Immediately obtain blood, gastric aspirate, external ear canal, and nasopharynx cultures.Administer antibiotics, usually aqueous penicillin or ampicillincombined with gentamicin, as soon as cultures are obtained.Early assessment and intervention are essential to survival.

Refer to evaluate for blindness, deafness, learning or behavioralproblems.Use isolation techniques until infants have been on antibiotics for48 hours.Administer penicillin.Provide emotional support for parents because of their feelings about mode of transmission and potential long-termsequelae.

Administer 1% silver nitrate solution or ophthalmic antibioticointment (see “Drug Guide: Erythromycin [llotycin] OphthalmicOintment” in Chapter 28 ∞) or penicillin.Make a follow-up referral to evaluate any loss of vision.

Carry out careful handwashing and gown and glove isolation withlinen precautions.Administer intravenous vidarabine (Vira A) or acyclovir (Zovirax).Make a follow-up referral to evaluate potential sequelae ofmicrocephaly, spasticity, seizures, deafness, or blindness.Encourage parental rooming-in and touching of their newborn.Show parents appropriate handwashing procedures andprecautions to be used at home if mother’s lesions are active.Obtain throat, conjunctiva, cerebral spinal fluid (CSF), blood, urine,and lesion cultures to identify herpesvirus type 2 antibiotics inserum IgM fraction. Cultures positive in 24–48 hours.

Differentiate white plaque areas from milk curds by using cotton tipapplicator (if it is thrush, removal of white areas causes raw,bleeding areas).Maintain cleanliness of hands, linen, clothing, diapers, and feedingapparatus.Instruct breastfeeding mothers on treating their nipples withnystatin.Administer gentian violet (1%–2%) swabbed on oral lesions 1 hour after feeding or nystatin instilled in baby’s oral cavity and onmucosa.Swab skin lesions with topical nystatin.Discuss with parents that gentian violet stains mouth and clothing.Avoid placing gentian violet on normal mucosa; it causes irritation.

Instill ophthalmic erythromycin (see “Drug Guide: Erythromycin[Ilotycin] Ophthalmic Ointment” in Chapter 28 ∞).Make a follow-up referral for eye complications and latedevelopment of pneumonia at 4–11 weeks postnatally.

Severe respiratory distress (grunting and cyanosis)May become apneic or demonstrate symptoms ofshockMeconium-stained amniotic fluid seen at birth

Check perinatal history for positive maternal serologyAssess infant for

Elevated cord serum IgM and FTA-ABS IgMRhinitis (snuffles)Fissures on mouth corners and excoriated upperlipRed rash around mouth and anusCopper-colored rash over face, palms, and solesIrritabilityGeneralized edema, particularly over joints; bonelesions; painful extremitiesHepatosplenomegaly, jaundiceCongenital cataractsSGA and failure to thrive

Assess forOphthalmia neonatorum (conjunctivitis)Purulent discharge and corneal ulcerationsNeonatal sepsis with temperature instability, poorfeeding response, and/or hypotonia, jaundice

Small cluster vesicular skin lesions over all the bodyCheck perinatal history for active herpes genitallesionsDisseminated form—DIC, pneumonia, hepatitis withjaundice, hepatosplenomegaly, and neurologicabnormalities. Without skin lesions, assess for feveror subnormal temperature, respiratory congestion,tachypnea, and tachycardia

Assess newborn’s buccal mucosa, tongue, gums, andinside the cheeks for white plaques (seen 5 to 7days of age)Check diaper area for bright-red, well-demarcatederuptionsAssess for thrush periodically when newborn is onlong-term antibiotic therapy

Assess for perinatal history of preterm birthSymptomatic newborns present with pneumonia—conjunctivitis after 3–4 daysChronic follicular conjunctivitis (cornealneovascularization and conjunctival scarring)

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848 CHAPTER 31

yield false-positive results due to contamination. Theskin is prepared by cleaning with an unit-specificantiseptic solution and allowed to dry; the specimenis obtained with a sterile needle and syringe.

2. Spinal fluid culture is done following a spinaltap/lumbar puncture if there is concern of CNSsymptoms/pathology.

3. The specimen for urine culture is best obtained bysterile catheterization or suprapubic bladder aspiration.

4. Skin cultures are taken of any lesions or drainagefrom lesions or reddened areas.

5. Nasopharyngeal, rectal, ear canal, conjunctival, andgastric aspirate cultures may be obtained.

Other laboratory investigations include a complete bloodcount, C-reactive protein (CRP), chest x-ray examination,serology, and Gram stains of cerebrospinal fluid, urine, skinexudate, and umbilicus. White blood cell (WBC) countwith differential may indicate the presence or absence ofsepsis. A level of 30,000–40,000 mm3 WBCs may be normalin the first 24 hours of life, and a low WBC count (<5000–7500/mm3) may indicate sepsis. A low neutrophilcount and a high band (immature WBCs) count indicate aninfection. Stomach aspirate should be sent for culture andsmear if a gonococcal infection or amnionitis is suspected.The C-reactive protein level may or may not be elevated.Serum IgM levels are elevated (normal level less than 20mg/dL) in response to transplacental infections. If avail-able, counterimmunoelectrophoresis tests for specific bac-terial antigens are performed.

Evidence of congenital infections may be seen onskull x-ray films (cerebral calcifications such as in cy-tomegalovirus or toxoplasmosis), on bone x-ray films(syphilis or cytomegalovirus), and in serum-specific IgMlevels (rubella). Cytomegalovirus infection is best diag-nosed by urine culture.

Because neonatal infection causes high mortality, ther-apy begins before results of the septic workup are obtained.A combination of two broad-spectrum antibiotics, such asampicillin and gentamicin, is given in large doses until aculture with sensitivities is obtained.

After the pathogen and its sensitivities are determined,appropriate specific antibiotic therapy is begun. Combina-tions of penicillin and gentamicin are increasingly beingused because of kanamycin-resistant enterobacteria andpenicillin-resistant staphylococcus. Rotating aminoglyco-sides has been suggested to prevent development of resis-tance. Use of cephalosporins and, in particular, cefotaximehas emerged as an alternative to aminoglycoside therapy inthe treatment of neonatal infections. Duration of therapyvaries from 7 to 14 days (Table 31–5). If cultures are nega-

tive and symptoms subside, antibiotics may be discontin-ued after 3 days. Supportive physiologic care may be re-quired to maintain respiratory, hemodynamic, nutritional,and metabolic homeostasis.

NURSING MANAGEMENT

NURSING ASSESSMENT AND DIAGNOSISThe nurse most often notices symptoms of infection dur-ing daily care of the newborn (Short, 2004). The infantmay deteriorate rapidly in the first 12 to 24 hours afterbirth if �-hemolytic streptococcal infection is present, withsigns and symptoms mimicking RDS. In other cases the on-set of sepsis may be gradual, with more subtle signs andsymptoms. The most common signs include the following:

1. Subtle behavioral changes; the infant “is not doingwell” and is often lethargic or irritable (especiallyafter the first 24 hours) and hypotonic; color changesmay include pallor, duskiness, cyanosis, or a “shocky”appearance; skin is cool and clammy

2. Temperature instability, manifested by eitherhypothermia (recognized by a decrease in skintemperature) or, rarely in newborns, hyperthermia(elevation of skin temperature) necessitating acorresponding increase or decrease in isolettetemperature to maintain a neutral thermalenvironment

3. Feeding intolerance, as evidenced by a decrease intotal intake, abdominal distention, vomiting, poorsucking, lack of interest in feeding, and diarrhea

4. Hyperbilirubinemia

5. Tachycardia initially, followed by spells of apnea orbradycardia

Signs and symptoms may suggest CNS disease (jitteriness,tremors, seizure activity), respiratory system disease(tachypnea, labored respirations, apnea, cyanosis), hema-tologic disease (jaundice, petechial hemorrhages, he-patosplenomegaly), or gastrointestinal disease (diarrhea,vomiting, bile-stained aspirate, hepatomegaly). A differen-tial diagnosis is necessary because symptoms are similar tothose of other more specific conditions.

Nursing diagnoses that may apply to the infant withsepsis neonatorum and the family include the following:■ Risk for Infection related to newborn’s immature

immunologic system■ Fluid Volume Deficit related to feeding intolerance

■ Ineffective Family Coping related to present illnessresulting in prolonged hospital stay for the newborn

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Dose (mg/kg)Total Daily Schedule for

Drug Dose Divided Doses Route Comments

Ampicillin

Cefotaxime

Gentamicin

Methicillin

Nafcillin

Penicillin G (aqueous crystalline)

Vancomycin

TABLE 31–5 Neonatal Sepsis Antibiotic Therapy

Effective against gram-positive microorganisms,Haemophilus influenzae, and most Escherichia colistrains. Higher doses indicated for meningitis. Used withaminoglycoside for synergy.

Active against most major pathogens in infants; effectiveagainst aminoglycoside-resistant organisms; achievesCSF bactericidal activity; lack of ototoxicity andnephrotoxicity; wide therapeutic index (levels notrequired); resistant organisms can develop rapidly ifused extensively; ineffective against Pseudomonas,Listeria.

Effective against gram-negative rods and staphylococci;may be used instead of kanamycin against penicillin-resistant staphylococci and E. coli strains andPseudomonas aeruginosa. May cause ototoxicity and nephrotoxicity. Need to follow serum levels. Mustnever be given as IV push. Must be given over at least30–60 minutes. In presence of oliguria or anuria, dosemust be decreased or discontinued. In infants less than1000 g or 29 weeks, lower dosage 2.5–3 mg/kg/day.Monitor serum levels before administration of seconddose.Peak 5–10 mcg/mLTrough 1–2 mcg/mL

Effective against penicillinase-resistant staphylococci.Monitor CBC and UA.Slow IV push.

Effective against penicillinase-resistant staphylococci.Caution in presence of jaundice.

Initial sepsis therapy effective against most gram-positivemicroorganisms except resistant staphylococci; cancause heart block in infants.

Effective for methicillin-resistant strains (Staphylococcusepidermidis); must be administered by slow intravenousinfusion to avoid prolonged cutaneous eruption. Forsmaller infants, < 1200 g, < 29 weeks, smaller dosagesand longer intervals between doses. Nephrotoxic,especially in combination with aminoglycosides.Slow IV infusion over at least 60 minutes.Peak 25–40 mcg/mLTrough 5–10 mcg/mL

50–100 mg/kg

50 mg/kg100–150 mg/kg/day

2.5–3 mg/kg5–7.5 mg/kg/day

4–5 mg/kg/dose (first week of life)

25–50 mg/dose50–100 mg/kg/day

25–50 mg/kg50–100 mg/kg/day

25,000–50,000 units/kg50,000–125,000 units/kg/day

10–20 mg/kg30 mg/kg/day

Every 12 hours*

Every 8 hours†

Every 12 hours*

Every 8 hours

Every 12–24 hours*‡

Every 8–24 hours†

Every 24–48 hours

Every 12 hours*


Every 8–12 hours*


Every 12 hours*

Every 8 hours†

Every 12–24 hours*‡

Every 8 hours†

IM or IV

IM or IV

IM or IV

IM or IV

IM or IV

IM or IV

IV

*Up to 7 days of age.†Greater than 7 days of age.‡Dependent on gestational age.

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850 CHAPTER 31

PLANNING AND IMPLEMENTATIONIn the nursery, environmental control and prevention of ac-quired infection are the responsibilities of the neonatalnurse. An infected newborn can be effectively isolated in anisolette and receive close observation. Promote strict hand-washing technique for all who enter the nursery, includingnursing colleagues; physicians; laboratory,x-ray,and respira-tory therapists; and parents. Discourage visits to the nurseryarea by unnecessary personnel. Be prepared to assist in theaseptic collection of specimens for laboratory investiga-tions. Scrupulous equipment care (per agency protocol)—changing and cleaning of isolettes, removing and sterilizingwet equipment, preventing cross use of linen and equipment,cleaning sink-side equipment such as soap containers period-ically, and taking special care with the open radiant warmers(access without prior handwashing is much more likely thanwith the closed isolette)—prevents contamination.

Provision of Antibiotic TherapyAdminister antibiotics as ordered by the nurse practitioneror physician. In addition to the five rights of drug admin-istration, be knowledgeable about the following:

■ The proper dose to be administered, based on the weightof the newborn and desired peak and trough levels

■ The appropriate route of administration, because someantibiotics cannot be given intravenously

■ Admixture incompatibilities, because someantibiotics are precipitated by intravenous solutionsor by other antibiotics

■ Side effects and toxicity

In term infants being treated for infections, neonatal homeinfusion of antibiotics should be considered as a viable alter-native to continued hospitalization. The infusion of antibi-otics at home by skilled RNs facilitates parent-infant bondingwhile meeting the infant’s ongoing healthcare needs.

Provision of Supportive CareIn addition to antibiotic therapy, physiologic supportivecare is essential in caring for a septic infant. Responsibili-ties of the nurse include the following:

■ Observe for resolution of symptoms or development ofother symptoms of sepsis.

■ Maintain neutral thermal environment with accurateregulation of humidity and oxygen administration.

■ Provide respiratory support: administer oxygen andobserve and monitor respiratory effort.

■ Provide cardiovascular support: observe and monitorpulse and blood pressure; observe for hyperbilirubinemia,anemia, and hemorrhagic symptoms.

■ Provide adequate calories; oral feedings may bediscontinued due to increased mucus, abdominaldistention, vomiting, and aspiration.

■ Provide fluids and electrolytes to maintainhomeostasis; monitor weight changes, urine output,and urine specific gravity.

■ Observe for the development of hypoglycemia,hyperglycemia, acidosis, hyponatremia, andhypocalcemia.

Restricting parents’ visits to the nursery has not beenshown to have any effect on the rate of infection and maybe harmful for the newborn’s psychologic development.With instruction and guidance, both parents should be al-lowed to handle the baby and participate in daily care. Sup-port of the parents is crucial. They need to be informed ofthe newborn’s prognosis as treatment continues and to beinvolved in care as much as possible. They also need to un-derstand how infection is transmitted.


■ The risks for development of sepsis are identified early,and immediate action is taken to minimize thedevelopment of the illness.

■ Appropriate use of aseptic technique protects thenewborn from further exposure to illness.

■ The baby’s symptoms are relieved, and the infection istreated.

■ The parents verbalize their concerns about their baby’sillness and understand the rationale behind themanagement of their newborn.

CARE OF THE FAMILY OF AN AT-RISK NEWBORNThe birth of a preterm or ill infant or an infant with a con-genital anomaly is a serious crisis for a family. Throughoutthe pregnancy, the parents have felt excitement, experi-enced thoughts of acceptance, and pictured what theirbaby would look like. Both parents have wished for a per-fect baby and feared an unhealthy one. Each parent andfamily member must accept and adjust when the fantasizedfears become reality.

PARENTAL RESPONSESFamily members have acute grief reactions to the loss of theidealized baby they have envisioned. In a preterm birth, themother is denied the last few weeks of pregnancy that seemto prepare her psychologically for the stress of birth and the

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attachment process. Attachment at this time is fragile, andinterruption of the process by separation can affect the fu-ture mother-child relationship. Parents express grief asshock and disbelief, denial of reality, anger toward self andothers, guilt, blame, and concern for the future. Self-esteemand feelings of self-worth are jeopardized.

Feelings of guilt and failure often plague mothers ofpreterm newborns. They may question themselves: “Whydid labor start?” or “What did I do [or not do]?” A womanmay have guilt fantasies and wonder: “Was it because I hadsex with my husband [a week, 3 days, a day] ago?” “Was itbecause I carried three loads of wash up from the base-ment?” or “Am I being punished for something done in thepast—even in childhood?”

The period of waiting between suspicion and confir-mation of abnormality or dysfunction is a very anxiousone for parents because it is difficult, if not impossible, tobegin attachment to the infant if the newborn’s future isquestionable. During the waiting period, parents needsupport and acknowledgment that this is an anxious time.They must be kept informed about tests and efforts togather additional data, as well as efforts to improve theirbaby’s outcome. It is helpful to tell both parents about theproblem at the same time, with the baby present. An hon-est discussion of the problem and anticipatory manage-ment at the earliest possible time by health professionalshelp the parents (1) maintain trust in the physician andnurse, (2) appreciate the reality of the situation by dis-pelling fantasy and misconception, (3) begin the grievingprocess, and (4) mobilize internal and external support.

Although reactions and steps of attachment are alteredby the birth of these infants, a healthy parent-child relation-ship can occur. Kaplan and Mason (1974) identified four psy-chologic tasks as essential for coping with the stress of anat-risk newborn and for providing a basis for the maternal-infant relationship:

1. Anticipatory grief as a psychologic preparation forpossible loss of the child while still hoping for hisor her survival

2. Acknowledgment of maternal failure to produce aterm or perfect newborn expressed as anticipatorygrief and depression and lasting until the chances ofsurvival seem secure

3. Resumption of the process of relating to the infant,which was interrupted by the threat of nonsurvival;continuous threat of death or abnormality mayimpair this task, and the mother may be slow in herresponse of hope for the infant’s survival

4. Understanding of the special needs and growthpatterns of the at-risk newborn, which are temporaryand yield to normal patterns

Solnit and Stark (1961) postulated that grief andmourning over the loss of the loved object—the idealizedchild—mark parental reactions to a child with abnormali-ties. Grief work, the emotional reaction to a significant loss,must occur before adequate attachment to the actual childis possible. Parental detachment precedes parental attach-ment. The parents must first grieve the loss of the wished-for perfect child and then must adopt the imperfect childas the new love object.

Parental responses to a child with health problems maybe viewed as a five-stage process (Klaus & Kennell, 1982):

1. Shock is felt at the reality of the birth of this child. Thisstage may be characterized by forgetfulness, amnesiaabout the situation, and a feeling of desperation.

2. There is disbelief (denial) of the reality of thesituation, characterized by a refusal to believe thechild has a problem. This stage is exemplified byassertions that “It didn’t really happen!” or “There hasbeen a mistake; it’s someone else’s baby.”

3. Depression over the reality of the situation and acorresponding grief reaction follows acceptance ofthe situation. This stage is characterized by muchcrying and sadness. Anger may also emerge at thisstage. A projection of blame on others or on self andfeelings of “not me” are characteristic of this stage.

4. Equilibrium and acceptance are characteristic of adecrease in the emotional reactions of the parents.This stage is variable and may be prolonged by acontinuing threat to the infant’s survival. Someparents feel chronic sorrow in relation to their child.

5. Reorganization of the family is necessary to dealwith the child’s problems. Mutual support of theparents facilitates this process, but the crisis of thesituation may precipitate alienation between themother and father.

DEVELOPMENTAL CONSEQUENCESThe baby who is born prematurely, is ill, or has a malfor-mation or disorder is at risk for emotional, intellectual, andcognitive developmental delays. The risk is directly pro-portional to the seriousness of the problem and the lengthof treatment. The necessary physical separation of familyand infant and the tremendous emotional and financialburdens may adversely affect the parent-child relationship.The recent trend to involve the parents with their newbornearly, repeatedly, and over protracted periods of time hasdone much to facilitate positive parent-child relationships.

Parents must have a clear picture of the reality of the dis-ability and the types of developmental hurdles ahead. Unex-pected behaviors and responses from the baby due to his orher problem or disorder can be upsetting and frightening.

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852 CHAPTER 31

The demands of care for the child and disputes regardingmanagement or behavior stress family relationships. Theentire multidisciplinary team may need to pool their re-sources and expertise to help parents of children born withproblems or disorders so that both parents and childrencan thrive.

NURSING MANAGEMENT

NURSING ASSESSMENT AND DIAGNOSISA positive nurse-family relationship helps informationgathering in areas of concern. A concurrent illness of themother or other family members or other concurrent stress(lack of hospitalization insurance, loss of job, age of par-ents) may change the family response to the baby. Feelingsof apprehension, guilt, failure, and grief expressed verballyor nonverbally are important aspects of the nursing history.These observations enable all professionals to be aware ofthe parental state, coping behaviors, and readiness for at-tachment, bonding, and caretaking. Appropriate nursingassessments during interviewing and relating to the familyinclude the following:

1. Level of understanding: observations concerning theability to assimilate the information given and to askappropriate questions; the need for constantrepetition of information

2. Behavioral responses: appropriateness of behavior inrelation to information given; lack of response; flataffect

3. Difficulties with communication: deafness (readslips only); blindness; dysphagia; understanding onlyof foreign language

4. Paternal and maternal education level: parentsunable to read or write; parents with eighth-grade-level education; parents with a graduate-level degreeor healthcare background

Documenting such information, gathered through con-tinuing contact and development of a therapeutic rela-tionship with the family, lets all professionals understandand use the nursing history to provide continuous indi-vidual care.

Visiting and caregiving patterns indicate the level or lackof parental attachment. A record of visits, caretaking proce-dures, affect (in relating to the newborn), and telephone callsis essential. It is important to note serial observations ratherthan just isolated observations that cause concern. Grant(1978) developed a conceptual framework depicting adap-tive and maladaptive responses to parenting an infant withan actual or potential problem (Figure 31–12 ).

If a pattern of distancing behaviors evolves, interveneappropriately. Follow-up studies have found that a statisti-cally significant number of preterm, sick, and congenitallydefective infants suffer from failure to thrive, battering, orother parenting disorders. Early detection and interventionprevents these aberrations in parenting behaviors fromleading to irreparable damage or death.

Nursing diagnoses that may apply to the family of anewborn at risk include the following:

■ Dysfunctional Grieving related to loss of idealizednewborn

■ Fear related to emotional involvement with an at-risknewborn

■ Altered Parenting related to impaired bondingsecondary to feelings of inadequacy about caretakingactivities


Hospital-Based Nursing CareIn their sensitive and vulnerable state, parents are acutelyperceptive of others’ responses and reactions (particularlynonverbal) to the child. Parents can be expected to identifywith the responses of others. Therefore, it is imperativethat medical and nursing staff be fully aware of and cometo terms with their own feelings so they are comfortableand at ease with the baby and grieving family.

Nurses may feel uncomfortable, may not know what tosay to parents, or may fear confronting their own feelings aswell as those of the parents. Each nurse must work out per-sonal reactions with instructors, peers, clergy, parents, or sig-nificant others. It is helpful to have a stockpile of therapeuticquestions and statements to initiate meaningful dialoguewith parents. Opening statements might include the follow-ing: “You must be wondering what could have caused this,”“Are you thinking that you (or someone else) may have donesomething?”“How can I help?”and“Are you wondering howyou are going to manage?”Avoid statements such as“It couldhave been worse,”“It’s God’s will,”“You have other children,”“You are still young and can have more,” and “I understandhow you feel.” This child is important now.Support of Parents for Initial Visit to the Newborn. Before parentssee their child, prepare them for the visit. Maintain a posi-tive, realistic attitude about the infant. An overly negative,fatalistic attitude further alienates the parents from theirinfant and retards attachment behaviors. Instead of begin-ning to bond with their child, the parents will anticipatetheir loss and begin the process of grieving. Once started,the grieving process is difficult to reverse.

Before preparing parents for the first view of their in-fant, observe the baby. All infants exhibit strengths as well

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Parental Tasks

Realistically perceive infant’s medical condition and needs

Adapt to infant’s hospital environment

Assume primary caretaking role

Assume total responsibility for infant upon discharge

Cope with death of infant

Maladaptive Responses

Failure to visit infant or call

Emotional withdrawal from infant

Difficulty interacting comfortably with infant during hospitalization

Resistance to providing minimal caretaking during hospitalization

Failure to achieve sense of parental competence

Failure to achieve sense of attachment to infant

Distortion of medical information received

Debilitating preoccupation with infant’s condition

Ascribing blame for infant’s condition

Fear of taking infant home

Distorted view of infant and potential needs at time of discharge

Failure to verbalize needs and concerns to staff and family

Hostility toward and distrust of staff

Adaptive Responses

Frequent visits and calls

Emotional involvement with infant

Development of comfortable interaction with infant during hospitalization

Interest in assuming maximum amount of caretaking during hospitalization

Growing sense of parental competence

Growing sense of attachment to infant

Objective interpretation of medical information received

Acceptance of and constructive adaptation to infant’s condition

Objective understanding of the causes of infant’s condition

Confidence in assuming total responsibility for infant

Realistic view of infant and potential needs at time of discharge

Free verbalization of needs and concerns to staff and family

Realistic view of expectations of staffUnhealthy Outcome

Disturbed parent-child relationship

Failure to thrive

Vulnerable child syndrome

Deterioration of marital and family equilibrium

Healthy Outcome

Positive parent-child relationship

Maintenance of marital and family equilibrium

Maladaptive and adaptive parental responses during crisis period, showing unhealthy and healthy outcomes.Used with permission from Grant, P. (1978). Psychological needs of families of high-risk infants. Family and Community Health, 11(3), 93; with permission of Aspen Publishers, Inc., © 1978. 11, 93,Fig. 1, Philadelphia: Lippincott Williams & Wilkins.

FIGURE 31–12

as deficiencies; prepare the parents to see both the devia-tions and the normal aspects of their infant. The nurse maysay, “Your baby is small, about the length of my two hands.She weighs 2 lb, 3 oz, but is very active and cries when wedisturb her. She is having some difficulty breathing but isbreathing without assistance and in only 35% oxygen.”

Describe the equipment being used for the at-risknewborn and its purpose before the parents enter the in-tensive care unit. Many NICUs have booklets for parents toread before entering the units. Explanations and picturesmake the parents better prepared to deal with the feelingsthey may experience when they see their infant for the firsttime (Figure 31–13 ).

Upon entering the unit, parents may be overwhelmed bythe sounds of monitors, alarms, and respirators, as well as bythe unfamiliar language and“foreign”atmosphere. Preparingthe parents by having the same healthcare professionals ac-company them to the unit can be reassuring. The primarynurse and physician caring for the newborn need to be withthe parents when they first visit their baby. Parental reactionsvary, but initially there is usually an element of shock. Helpthem by providing chairs and time to regain composure.Slow, complete, and simple explanations—first about the in-fant and then about the equipment—allay fear and anxiety.

As parents attempt to deal with the initial stages ofshock and grief, they may fail to grasp new information.

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854 CHAPTER 31

This 25 weeks’ gestational age infant with respiratory distress syndromemay be frightening for her parents to see for the first time due to the tech-nology that is attached to her.Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.

FIGURE 31–13

They may need repeated explanations to accept the realityof the situation, procedures, equipment, and the infant’scondition on subsequent visits.

Concern about the infant’s physical appearance is com-mon yet may remain unvoiced. Parents may express suchconcerns as, “He looks so small and red—like a drownedrat,”“Why do her genitals look so abnormal?”and“Will thatawful-looking mouth [cleft lip and palate] ever be normal?”Anticipate and address such questions. Use of pictures, suchas of an infant after cleft lip repair, may be reassuring todoubting parents. Knowledge of the development of a“nor-mal” preterm infant allows the nurse to make reassuringstatements such as, “The baby’s skin may look very red andtransparent with lots of visible veins, but it is normal for hermaturity. As she grows, subcutaneous fat will be laid down,and these superficial veins will begin to disappear.”

The nursing staff set the tone of the NICU. Nurses fos-ter the development of a safe, trusting environment byviewing the parents as essential caregivers, not as visitors ornuisances in the unit. Providing privacy when needed andoffering easy access to staff and facilities are important indeveloping an open, comfortable environment. An un-crowded and welcoming atmosphere lets parents knowthey are welcome there. However, even in crowded physicalsurroundings, the nurses can convey an attitude of open-ness and trust.

A trusting relationship is essential for collaborative ef-forts in caring for the infant. Therapeutically use personal

responses to relate to the parents on a one-to-one basis.Each person has different needs, different ways of adaptingto crisis, and different means of support. Use techniquesthat feel real and spontaneous, and avoid words or actionsthat feel foreign. Gauge interventions so that they matchthe parents’ pace and needs.Facilitation of Attachment if Neonatal Transport Occurs. Transportto a regional referral center that may be some distance fromthe parents’ community may be necessary. It is essential thatthe mother see and touch her infant before the infant istransported. Bring the mother to the nursery or take the in-fant in a warmed transport isolette to the mother’s bedsideto let her see the infant before transportation to the center.When the infant reaches the referral center, a staff membershould call the parents with information about the infant’scondition during transport, safe arrival at the center, andpresent condition.

Support of parents with explanations from the profes-sional staff is crucial. Occasionally the mother may be un-able to see the infant before transport (e.g., if she is stillunder general anesthesia or experiencing complicationssuch as shock, hemorrhage, or seizures). In these cases, takea photograph of the infant to give to the mother, and pro-vide an explanation of the infant’s condition and problemsand a detailed description of the infant’s characteristics. Anadditional photograph is also helpful for the father to sharewith siblings or extended family. With the increased atten-tion on improved fetal outcome, prenatal maternal trans-ports, rather than neonatal transports, are occurring morefrequently. This practice gives the mother of an at-risk in-fant the opportunity to visit and care for her infant duringthe early postpartal period.Promotion of Touching and Parental Caretaking. Parents visitinga small or sick infant may need several visits to becomecomfortable and confident in their ability to touch the in-fant without injuring him or her. Barriers such as isolettes,incisions, monitor electrodes, and tubes may delay themother’s development of comfort in touching the new-born. Knowledge of this normal delay in touching behav-ior will help the nurse understand parental behavior.

Klaus and Kennell (1982) demonstrated a significantdifference in the amount of eye contact and touching be-haviors of mothers of normal newborns and mothers ofpreterm infants. Whereas mothers of normal newbornsprogress within minutes to palm contact of the infant’strunk, mothers of preterm infants are slower to progressfrom fingertip to palm contact and from the extremities tothe trunk. The progression to palm contact with the in-fant’s trunk may take several visits to the nursery.

Use support, reassurance, and encouragement to helpthe mother develop positive feelings about her parentingabilities and her importance to her infant. Touching facili-tates familiarity with the infant and thus establishes a bond

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Mother of this 26 weeks’ gestational age, 600-g baby begins attachmentthrough fingertip touch.Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.

FIGURE 31–14

This mother of a 35 weeks’ gestational age infant with respiratory distresssyndrome is spending time with her newborn and meeting the baby’s needfor cuddling.Courtesy of Carol Harrigan, RNC, MSN, NNP.

FIGURE 31–15

caretaking also increases their self-esteem, which may havebeen damaged by feelings of guilt and failure. Never give theparents a task that they might not be able to accomplish. Cuesthat the parents are ready to become involved with thechild’s care include their reference to the baby by name andtheir questioning as to amount of feeding taken, sleepingpatterns, appearance today, and the like (Loo, Espinosa,Tyler et al., 2003).

Often parents of high-risk infants have ambivalentfeelings toward the nurse. As they watch the nurse compe-tently perform caretaking tasks, they may feel both grate-ful for the nurse’s abilities and expertise and jealous of thenurse’s ability to care for their infant (Bruns & McCollum,2002). These feelings may take the form of criticism of thecare of the infant, manipulation of staff, or personal guilt.Instead of fostering (by silence) these inferiority feelings ofparents, recognize that such feelings are needed to inter-vene appropriately to enhance parent-infant attachment.For example, avoid making unfavorable comparisons be-tween the baby’s responses to parental and nursing care-taking. During a quiet time it may help to encourage theparents to talk about their hopes and fears and to facilitatetheir involvement in parent groups. Parents are also oftenanxious when their baby is transferred from the NICU tothe “regular nursery.” They may feel that their infant is notbeing cared for as proficiently because the nurses are not atthe infant’s bedside as often as they were in the NICU.

Verbalizations that improve parental self-esteem are es-sential and easily shared. For example, point out that, in ad-dition to physiologic use, breast milk is important because ofthe emotional investment of the mother. Pumping, storing,

between mother and infant. Touching and seeing the infanthelp the mother realize the “normal” aspects and potentialof her baby (Figure 31–14 ).

Encourage parents to meet their newborn’s need forstimulation. Stroking, rocking, cuddling, singing, andtalking should be an integral part of the parents’ caretak-ing responsibilities. Promote bonding by encouraging par-ents to visit and become involved in their baby’s care(Figure 31–15 ). When visiting is impossible, the parentsshould feel free to phone whenever they wish to receive in-formation about their baby. A warm, receptive attitudeprovides support. Facilitate parenting by personalizing ababy to the parents, by referring to the infant by name, orby relating personal behavioral characteristics. Remarkssuch as “Jenny loves her pacifier” help make the infantseem individual and unique.

The variety of equipment needed for life support ishardly conducive to anxiety-free caretaking by the parents.However, parents may care for even the sickest infant, ifonly in a small way. Promote the parents’ success by facili-tating parental caretaking. Demonstration and explana-tion, followed by support of the parents in initial caretakingbehaviors, positively reinforce this behavior. Changingtheir infant’s diaper, providing skin or oral care, or helpingturn the infant may at first provoke anxiety, but the parentswill become more comfortable and confident in caretakingand feel satisfied by the baby’s reactions and their ability“todo something.”Complimenting the parents’ competence in

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labeling, and delivering quantities of breast milk is a time-consuming labor of love for mothers. Positive remarks aboutbreast milk reinforce the maternal behavior of caretaking andproviding for her infant: “Breast milk is something that onlyyou can give your baby,”“You really have brought a lot of milktoday,” “Look how rich this breast milk is,” or “Even smallamounts of milk are important, and look how rich it is.”

If the infant begins to gain weight while being fedbreast milk, it is important to point this correlation out tothe mother. Advise the parents that initial weight loss withbeginning nipple-feedings is common because of the in-creased energy expended when the infant begins activerather than passive nutritional intake.

Encourage parents to provide care for their infant evenif the baby is very sick and likely to die. Detachment is eas-ier after attachment, because the parents are comforted bythe knowledge that they did all they could for their childwhile he or she was alive.Facilitation of Family Adjustment. During crisis it is difficultto maintain interpersonal relationships. Yet in a newbornintensive care area, the parents are expected to relate tomany different care providers. It is important that parentshave as few professionals as possible relaying informationto them. A primary nurse should coordinate care and pro-vide continuity for parents. Care providers are individualsand thus will use different terms, inflections, and atti-tudes. These subtle differences are monumental to parentsand may confuse, confound, and produce anxiety. Thetransfer of the baby from NICU to a step-down unit ortransport back to the home hospital provokes parentalanxiety because they must now deal with new healthcareprofessionals. The nurse not only functions as a liaison be-tween the parents and the various professionals interact-ing with the infant and parents but also offersclarification, explanation, interpretation of information,and support to the parents.

Encourage parents to deal with the crisis with helpfrom their support system. The support system attempts tomeet the emotional needs and to provide support for thefamily members in crisis and stress situations. Biologic kin-ship is not the only valid criterion for a support system; anemotional kinship is the most important factor. In our mo-bile society of isolated nuclear families, the support systemmay be a next-door neighbor, a best friend, or perhaps aschoolmate. Search out the significant others in the lives ofthe parents and help them understand the problems so thatthey can support the parents.

The impact of the crisis on the family is individual andvaried. Interact with the family to find out about the fam-ily’s ability to adapt to the situation. To begin appropriateinterventions, view the birth of the infant (normal new-born, preterm infant, or infant with congenital anomaly) asit is defined by the family.

It is important to encourage open communicationwithin the family. Discourage family members from keepingsecrets from one another,especially between spouses,becausesecrets undermine the trust of relationships. Well-meaningrationales such as“I want to protect her,”“I don’t want him toworry about it,” and so on can be destructive to open com-munication and to the basic element of a relationship—trust.

Open communication is especially important whenthe mother is hospitalized apart from the infant. The firstperson to visit the infant relays information regarding theinfant’s care and condition to the mother and family. Inthis situation the mother has had minimal contact, if any,with her infant. Because of her anxiety and isolation, shemay mistrust all those who provide information (the fa-ther, nurse, physician, or extended family) until she sees theinfant for herself. This can put tremendous stress on the re-lationship between spouses. The parents (and family)should be given information together. This practice helpsovercome misunderstandings and misinterpretations andpromotes cooperative “working through” of problems.

Encourage the entire family—siblings as well as otherrelatives—to visit and obtain information about the baby.Interventions that help the family cope with the situationinclude providing support, confronting the crisis, and un-derstanding the reality. Support, explanations, and thehelping role must include the extended family, as well asthe nuclear family, to aid the extended family in communi-cation and to support ties with the nuclear family.

Do not overlook the needs of siblings. Siblings have beenlooking forward to the new baby, and they too suffer a degreeof loss.Young children may react with hostility and older oneswith shame at the birth of an infant with an anomaly.Both re-actions may make them feel guilty. Parents, who may be pre-occupied with working through their own feelings, oftencannot give the other children the attention and support theyneed. Sometimes another child becomes the focus of familytension.Anxiety can take the form of finding fault or of over-concern. This is a form of denial; the parents cannot face thereal worry—the infant at risk. After assessing the situation,the observant nurse can ensure that another family memberor friend steps in to support the siblings of the affected baby.

Respect and seek to meet the desires and needs of thepeople involved and understand that differences can existside by side. It is often possible to elicit the parents’ feelingsabout the experience by asking “How are you doing?” Theemphasis is on the word you, and the interest must be sincere.

Parents from minority cultures must deal with lan-guage barriers and cultural differences that can make feel-ings of isolation and uncertainty more acute (Shah &Campbell, 2004). Feelings of isolation and uncertainty in-fluence not only the parents’ emotional responses to the illnewborn, but also their ability to access and use services aswell as their interaction with health professionals. Hospital

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Cobedding of twins facilitates delivery of care and parent interaction withhealthcare members.Courtesy of Carol Harrigan, RNC, MSN, NNP.

FIGURE 31–16

cultural interpreter programs can assist families with inter-actions with staff, and provide translation during familymeetings and multidisciplinary family conferences.

Families with children in the NICU may becomefriends and support one another. To encourage the devel-opment of these friendships and to provide support, manyunits have established parent groups. The core of thegroups consists of parents whose infants were once in theintensive care unit. Most groups make contact with fami-lies within a day or two of the infant’s admission to theunit, through either phone calls or visits to the hospital.Early one-on-one parent contacts are more effective thandiscussion groups in helping families work through theirfeelings. This personalized method gives the grieving par-ents a chance to express personal feelings about the preg-nancy, labor, and birth and their different-than-expectedinfant with others who have experienced the same feelingsand with whom they can identify.

Nursing Care in the CommunityPredischarge planning begins once the infant’s conditionbecomes stable and it seems likely the newborn will survive(AAP & ACOG, 2002). Discharge preparation and careconferences should involve a multidisciplinary team ap-proach. NICU nursing staff is the fulcrum for aiding in thetransition of high-risk infants from the intensive care unitto the home. Effective open communication with familiesduring the entire discharge-planning phase of care em-powers them to assume the role of primary caregiver fortheir children (Allen, Donohue, & Porter, 2002).

Adequate predischarge teaching helps parents trans-form any feelings of inadequacy they may have into feel-ings of self-assurance and attachment. From thebeginning, teach the parents about their infant’s special

needs and growth patterns. This teaching and involvementare best facilitated by a nurse who is familiar with the in-fant and his or her family and who has developed a com-fortable and supportive relationship with them. Whentwins are being discharged, inform parents that cobeddingof twins allows for clustering of care and facilitates the par-ents’ ability to spend time with both of their children(Figure 31–16 ).

Provide home care instructions in an optimal environ-ment for parental learning. Learning should take place overtime, to avoid bombarding the parents with instructions inthe day or hour before discharge. Parents often enjoy per-forming minimal caretaking tasks, with gradual expansionof their role.

Many NICUs provide facilities for parents to room-inwith their infants for a few days before discharge. This

COBEDDING OF TWINSAs NICUs have become more and more “developmentally” friendly,complementary and alternative therapies have become an adjunct tothat nurturing environment.

Cobedding of stable twins and higher order multiples replicatesthe closeness of the in utero environment whereby the siblings areplaced together in the same incubator or crib to maintain physicalcontact. Clustering of care provided by the bedside nurse is a trueadvantage to cobedding. This in turn proves beneficial to the parentsbecause they have interactions with fewer nurses and other mem-bers of the healthcare team. In addition the parents can care forand visit with all the infants at one time (Lutes & Altimier, 2001).Discharge teaching, therefore, is easily facilitated. Cobedding isalso a strategy to maximize the synchronization of sleep-wake cy-cles (Hayward, 2003; Lutes & Altimier, 2001).

COMPLEMENTARY CARE

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practice allows parents a degree of independence in thecare of their infant with the security of nursing helpnearby. It is particularly helpful for anxious parents, par-ents who have not had the opportunity to spend extendedtime with their infant, or parents who will be giving com-plex physical care at home, such as tracheostomy care.

Transitional care centers (TCCs) also allow parents tomaster caring for the at-risk newborn prior to discharge.The TCCs shorten the length of hospitalization and de-crease readmission rates (Allen et al., 2002). Families areable to interact with the staff while gradually transitioning tothe role of sole caretakers of their medically complex, high-risk infant. When discharging a medically fragile infant tohome, schedule a predischarge home visit by a public healthnurse or home health agency. This predischarge visit evalu-ates the home for any possible issues that may complicate theparents’ ability to care for their at-risk infant, especially ifthere are multiple monitoring-equipment needs.

The basic elements of discharge and home care in-struction are as follows:

1. Teach the parents routine well-baby care, such asbathing, taking a temperature, preparing formula,and breastfeeding.

2. Help parents learn to do special procedures as neededby the newborn, such as gavage or gastrostomyfeedings, tracheostomy or enterostomy care,medication administration, cardiopulmonaryresuscitation (CPR), and operation of the apneamonitor. Before discharge, the parents should be ascomfortable as possible with these tasks and shoulddemonstrate independence. Written instructions areuseful for parents to refer to once they are home withthe infant, but they should not replace actualparticipation in the infant’s care.

3. Make sure that all applicable screening (metabolic,vision, hearing) tests, immunization, and respiratorysyncytial virus (RSV) prophylaxis are done prior todischarge and that all records are given to the primarycare provider and parents.

4. Refer parents to community health and supportorganizations. The Visiting Nurses’ Association,public health nurses, or social services can assist theparents in the stressful transition from hospital tohome by providing predischarge home visits and thenthe necessary home teaching and support. SomeNICUs have their own parent support groups to helpbridge the gap between hospital and home care.Parents can also find support from a variety ofcommunity organizations, such as mothers-of-twinsgroups, trisomy 13 clubs, the March of Dimes BirthDefects Foundation, handicapped children services,and teen mother and child programs. Each

community has numerous agencies capable ofassisting the family in adapting emotionally,physically, and financially to the chronically ill infant.Be familiar with community resources and help theparents identify which agencies may benefit them.

5. Help parents recognize the growth and developmentneeds of their infant. A development program begun inthe hospital can be continued at home, or refer parentsto an infant development program in the community.

6. Arrange medical follow-up care before discharge. Afamily pediatrician, a well-baby clinic, or a specialtyclinic may provide follow-up care for the infant. Thefirst appointment should be made before the infant isdischarged from the hospital.

7. Evaluate the need for special equipment for infantcare (such as a respirator, oxygen, apnea monitor) inthe home. Any equipment or supplies should be inthe home before the infant’s discharge.

8. Arrange for neonatal hospice for parents of themedically fragile infant as needed.

Further evaluation after the infant has gone home is usefulin determining whether the crisis has been resolved satisfac-torily. The parents are usually given the intensive care nurs-ery’s telephone number to call for support and advice. It is agood idea for staff to follow up with each family with visitsor telephone calls at intervals for several weeks to assess andevaluate the infant’s (and parents’) progress.


■ The parents are able to verbalize their feelings ofgrief and loss.

■ The parents verbalize their concerns about their baby’shealth problems, care needs, and potential outcome.

■ The parents participate in their infant’s care and showattachment behaviors.

CONSIDERATIONS FOR THE NURSE WHOWORKS WITH AT-RISK NEWBORNSThe birth of a baby with a problem is a traumatic event withthe potential for either disruption or growth of the involvedfamily. The staff NICU nurses may never see the long-termresults of the specialized, sensitive care they give to parentsand their newborns. Their only immediate evidence of ef-fective care may be the beginning of resolution of parentalgrief; discharge of a recovered, thriving infant to the care ofhappy parents; and the beginning of reintegration of fam-ily life.

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Nurses cannot provide support unless they them-selves are supported. Working in an emotional environ-ment of life-and-death situations takes its toll on staff.NICUs are among the most stressful areas in healthcarefor patients, families, and nurses. Nurses bear most of thestress and largely determine the atmosphere of theNICU. The nurse’s ability to cope with stress is the key tocreating an emotionally healthy environment and a pos-itive working atmosphere. The emotional needs and feel-

ings of the staff must be recognized and dealt with so thatstaff can support the parents. An environment of open-ness to feelings and support in dealing with their humanneeds and emotions is essential for personnel.

As caregivers, nurses may be unaware of their need togrieve for their own losses in the NICU. Nurses must also gothrough the grief work that parents experience. Techniquessuch as group meetings, individual support, and primarycare nursing may help maintain staff mental health.

Critical Concept ReviewLEARNING OBJECTIVES CONCEPTS

Discuss how to identify infants in need ofresuscitation and the appropriate methodof resuscitation based on the labor recordand observable physiologic indicators.

Based on clinical manifestations,differentiate between the various types ofrespiratory distress (respiratory distresssyndrome, transient tachypnea of thenewborn, and meconium aspirationsyndrome) in the newborn and their relatednursing care.

1. Infants at risk for resuscitation include:■ Nonreassuring fetal heart pattern, meconium-stained amniotic fluid and/or acidosis

detected by fetal scalp sample.■ Cardiac disease diagnosed prenatally.■ Other congenital abnormality diagnosed prenatally.■ Premature birth.■ Infant of multiple pregnancy.■ Prolonged or difficult delivery.

2. Infants needing resuscitation:■ Weak cry at birth.■ Poor respiratory effort at birth.■ Retractions at birth.

3. Resuscitation methods:■ Stimulation by rubbing the newborn’s back. (Done initially to all infants.)■ Use of positive pressure to inflate the lungs. (Used if respirations are inadequate or have

not been initiated.)■ Endotracheal intubation. (Used immediately for severely premature infants, infants with

known congenital anomalies, and infants who do not respond to stimulation or bag andmask.)

■ Medications: Naloxone (Narcan) may be used to reverse effects of narcotics given tomother prior to birth.

1. Respiratory distress syndrome:■ Lack of sufficient surfactant causes labored respirations and increased work at breathing.■ Seen most frequently in premature newborns.■ Nursing care involves administration of surfactant, close assessment, and supportive care if

mechanical ventilation is needed.2. Transient tachypnea of the newborn (TTNB):

■ Usually results from excess fluid in the lungs.■ Infant breathes normally at birth, but develops symptoms of respiratory distress by 4-6

hours of age.■ Nursing care involves initiating oxygen therapy and restricting oral feedings until respiratory

status improves.3. Meconium aspiration syndrome:

■ Signs and symptoms of respiratory distress beginning at birth.■ May depend upon the amount of meconium that is aspirated.■ Nursing care involves suctioning of oropharynx and nasopharynx prior to infant’s first

breath.■ After initial suctioning and resuscitation efforts, nursing care involves ongoing assessment

for signs and symptoms of respiratory distress and supportive care of the infant requiringmechanical ventilation or ECMO.

(continued)

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Discuss selected metabolic abnormalities(including cold stress and hypoglycemia),their effects on the newborn, and the nursingimplications.

Differentiate between physiologic andpathologic jaundice based on onset, cause,possible sequelae, and specificmanagement.

1. Cold stress sets up the chain of physiologic events of hypoglycemia, pulmonaryvasconstriction, hyperbilirubinemia, respiratory distress, and metabolic acidosis.

2. Nursing interventions include:■ Keep infant warmed during any transport.■ Observe for any signs of hypoglycemia.■ Have infant go to breast or feed early in neonatal period.■ Assess blood glucose frequently.

1. Physiologic jaundice:■ Occurs in 50% of all newborns.■ Appears after 24 hours of age.■ Not visible after 10 days of age.■ May require phototherapy.

2. Pathologic jaundice:■ Usually caused by ABO or Rh incompatibility.■ Jaundice may be present within 24 hours of birth.■ Treatment begins with phototherapy, but may progress to exchange transfusions.

3. Untreated hyperbilirubinemia (due to either type of jaundice) may result in neurotoxicity.

Explain how Rh incompatibility or ABOincompatibility can lead to the developmentof hyperbilirubinemia.

1. Rh incompatibility:■ Maternal antibodies enter the fetal circulation, then attach to and destroy fetal red blood cells.■ Fetal system produces more RBCs.■ Hyperbilirubinemia, anemia, and jaundice result.

2. ABO incompatibility:■ Mother is type O and infant is type A or B.■ Less severe than Rh incompatibility.

Identify nursing responsibilities in caring forthe newborn receiving phototherapy.

Nursing responsibilities for the newborn receiving phototherapy include:1. Expose maximum amount of skin surface for optimal therapeutic results.2. Apply eye patches while phototherapy is in progress.3. Assess eyes for signs/symptoms of conjunctivitis per agency protocol.4. Frequently monitor temperature.5. Offer infant water and formula frequently to assist in excretion of bilirubin.6. Keep parents informed of need for phototherapy and encourage parents to hold and care for

infant while undergoing phototherapy.

Discuss selected hematologic problems suchas anemia and polycythemia and the nursingimplications associated with each one.

Describe the nursing assessments that wouldlead the nurse to suspect newborn sepsis.

1. Anemia in newborns results from prenatal blood loss, birth trauma, infection, or blood groupincompatibility:■ Nursing assessments for signs and symptoms of anemia.■ Record all amounts of blood taken during laboratory testing.

2. Polycythemia may result from delayed cord clamping, twin-to-twin transfusion, or chronicintrauterine hypoxia:■ Nursing assessments for signs and symptoms of polycythemia.

The most common signs of newborn sepsis include:1. Lethargy or irritability.2. Pallor or duskiness.3. Hypothermia.4. Feeding intolerance.5. Hyperbilirubinemia.6. Tachycardia, bradycardia, or apneic spells.

Relate the consequences of selectedmaternally transmitted infections, such asmaternal syphilis, gonorrhea, herpesvirus,and chlamydia, to the care of the infant inthe neonatal period.

1. All infants receive eye prophylaxis with opthalmic antibiotic due to possibility of transmission ofgonorrhea or chlamydia during the birth process.

2. Maternal syphilis requires that the infant be isolated from other newborns and receiveantibiotics at birth.

3. Maternal herpes virus infection requires administration of IV antiviral medications in the immediatenewborn period as well as multiple cultures (skin, spinal fluid) for presence of herpesvirus.

LEARNING OBJECTIVES CONCEPTS

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CRITICAL THINKING IN ACTION

View the Critical Thinking in Action video in Chapter 31 of the CD-ROM. Then, answer the questions that follow.

Rebecca Prince, age 21, G2now P2, gives birth to a5 pound baby at 38 weeks’gestation by primary cesareanbirth for fetal distress. Theinfant’s Apgars are 7 and 9 at 1and 5 minutes. The infant issuctioned and given free flowoxygen at birth, then isadmitted to the newbornnursery for transitional care and

does well. You are the nurse caring for baby Prince at 36 hours old. Youreview the newborn’s record and note that the baby’s blood type is A�

and his mother is O�. Rebecca wants to breastfeed. You are performinga shift assessment on baby Prince when you observe the infant has a

unilateral cephalhematoma and is lethargic. You blanch the skin over thesternum and observe a yellow discoloration of the skin. Lab tests reveal aserum bilirubin level of 12 mg/dL, hematocrit 55%, a mildly positivedirect Coombs’ test, and a positive indirect Coombs’ test. Baby Prince isdiagnosed with hyperbilirubinemia secondary to ABO incompatibility andcephalhematoma. You provide phototherapy by fiberoptic blanket aroundthe trunk of the infant and take the baby to his mother’s room.

1. How would you explain the purpose of phototherapy with the mother?2. Describe the care the mother can give to the newborn.3. Discuss the advantage of the fiberoptic blanket phototherapy for the

newborn.4. Newborns up to 1 month of age are susceptible to organisms that

do not cause significant disease in older children. Explore thecircumstances that cause susceptibility to infection.

5. Describe how to distinguish between oral thrush and milk curds.

Describe the interventions to facilitateparental attachment with the at-risknewborn.

1. Assess the parent’s level of understanding of the infant’s problem.2. Prepare and facilitate the parents’ viewing of the infant.3. Promote touching and facilitate parental participation in care of the infant.4. Facilitate parental adjustment to the infant’s special needs.

Identify the special initial and long-termneeds of parents of at-risk infants.

1. Initially, the parents need to understand the infant’s problem, including expected treatments.2. Need to understand routine well-baby care.3. Need to understand how to perform any special procedures needed to care for the infant.4. Need referral for normal infant screening procedures.5. Need to understand normal growth and development of infants.6. Need to have medical follow-up arranged.7. Need referral for any special equipment required at home.

LEARNING OBJECTIVES CONCEPTS

MEDIALINK www.prenhall.com/london

■ NCLEX-RN® Review, case studies, and otherinteractive resources for this chapter can befound on the Companion Website athttp://www.prenhall.com/london. Click on“Chapter 31” to select the activities for thischapter.

■ For animations, more NCLEX-RN® Reviewquestions, and an audio glossary, access theaccompanying CD-ROM in this textbook.

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