the premature infant: nursing assessment and management, 2 nd edition

© 2006, March of Dimes

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

Lyn E. Vargo, PhD, NNP, RNC

Carol Wiltgen Trotter, PhD, NNP, RNC

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


9.4

11.9 12.310.8

10.1

7.6

0

4

8

12

1981 1991 2001 2003 2007 2010

Preterm Births United States

Percent

Healthy People Objective

March of Dimes Objective

27 percent increase from 1981 to 2001


• Requires many physiologic changes for the infant

• Nurses need to understand general principles of delivery-room management, resuscitation and thermoregulation for premature infants.

Transition to Extrauterine Life


Delivery-Room Management

Certification by the Neonatal Resuscitation Program (NRP) of the American Heart Association (AHA) and the American Academy of Pediatrics (AAP) is essential for all nurses who work with premature infants.


• Tendency to have difficulty with transition

• Vulnerable to cold stress • More lung immaturity and RDS• More intracranial hemorrhage• More hypoglycemia• Potential for oxygen-related injuries• High risk of developing NEC

Delivery-Room Management Risks


• Follow resuscitation from NRP guidelines.• Avoid rough handling during

resuscitation.• Reduce heat loss even if resuscitation is

not required.• Preterm infants may require endotracheal

intubation and surfactant administration soon after birth.

Delivery-Room Management Precautions


Delivery-Room Management Precautions, Continued

• Administer medication slowly as recommended by NRP guidelines.

• Follow glucose levels carefully. Glycogen stores may be decreased. Infant may experience hypoglycemia secondary to perinatal compromise.

• Maintain normal oxygen range after resuscitation.


Major Physiologic Problems of the Premature Infant

• RDS, BPD, apnea of prematurity and chronic lung disease

• PDA and hypotension• ROP• Immune-system immaturity that

increases the risk of infection• P-IVH


Additional Physiologic Problems of the Premature Infant

• Skin immaturity and fragility• Thermoregulation • GI issues • Fluid and electrolyte imbalances related to

immature renal function• Acid-base disorders• Pain management• Developmental issues related to the CNS• Impact of the NICU environment


RDS

• Incidence 10% for all premature infants• Incidence 50% for 26 week to 28 weeks• Risk factors:

– Low gestational age– Male– Born to diabetic mothers– Born after an asphyxial insult before birth– Born after maternal-fetal hemorrhage– Multiple gestation


RDS, Continued

Complex respiratory disease characterized by diffuse alveolar atelectasis of the lungs, primarily caused by a deficiency of surfactant. This leads to higher surface tension at the surface of alveoli, which interferes with normal exchange of oxygen and carbon dioxide.


NIH Recommendations for Use of Antenatal Steroids

• Give to all pregnant women 24 to 34 weeks gestation who are at risk for preterm delivery within 7 days: – 2 doses of 12 mg of betamethasone IM 24 hours

apart OR

– 4 doses of 6 mg of dexamethasone IM 12 hours apart

• Repeat courses of corticosteroids should not be given routinely in pregnant women.


Chain of Events with Surfactant Delivery


Signs and Symptoms of RDS

• Difficulty in establishing normal respiration, especially if infant has risk factors for RDS

• Expiratory grunting while the infant is not crying

• Intercostal and sternal retractions due to increased rib cage compliance and decreased lung compliance


• Nasal flaring• Cyanosis• Tachypnea

Signs and Symptoms of RDS, Continued


• Thermoregulation• Fluid balance and nutrition• Skin care• Pain assessment• Developmental care• Family care

RDS Treatment


RDS Treatment, Continued

• Focus is to prevent and minimize atelectasis.

• Minimize untoward effects of oxygen and barotrauma or volutrauma.

• Treat underlying cardiovascular infectious and other physiologic problems.

• Maintain a balanced physiologic environment.


Surfactant Therapy

• Surfactant coats the inside of the alveoli. It prevents collapse (atelectasis) and keeps alveoli open at the end of expiration.

• It is given via endotracheal tube.

• Prophylactic therapy appears more beneficial than rescue therapy.


• Criteria for identifying at-risk infants who would benefit from prophylactic treatment are unclear.

• Multiple doses lead to improved clinical outcomes.

Surfactant Therapy, Continued


Adjunct Treatments for RDS

• CPAP– A method of assisting lung expansion with

continuous distending pressure

– A valuable adjunct when spontaneous breathing is adequate and pulmonary disease is not excessive

– Increases transpulmonary pressure; improves oxygenation and ventilation

– Reduces tachypnea and grunting


• HFV– Allows the use of small tidal volumes

(smaller than anatomic dead space) and high frequencies.

– Rates of 150 to 3,000 breaths per minute can be used depending on the type of HFV.

– HFV limits large tidal volumes and wide ventilator pressure swings associated with volutrauma/ barotrauma caused by traditional mechanical ventilation.

• Oscillation

Adjunct Treatments for RDS, Continued


RDS Nursing Care

Any nurse caring for an infant with RDS must:• Be familiar with RDS pathophysiology• Recognize symptoms of RDS • Initiate interventions as indicated


RDS Nursing Care, Continued

• Maintain paO2 and oxygen saturation levels.

• Recognize importance of weaning oxygen and other ventilator parameters.

• Recognize complications arising from RDS, intubation and mechanical ventilation.

• Utilize proper endotracheal suctioning techniques.


• Provide mouth and skin care.• Maintain proper positioning.• Provide adequate fluid and electrolyte

balance.• Monitor blood glucose levels.• Reduce environmental stressors.• Provide parental support.

RDS Nursing Care, Continued


BPD

• A significant problem for premature infants

• Uncommon after 32 weeks gestation

• A secondary disease that develops in neonates treated with positive pressure ventilation and oxygen for primary lung problems such as RDS

• 7,500 new cases every year in the United States

• 10% die by 1 year of age


Signs and Symptoms of BPD

• Hypoxemia with prolonged oxygen requirement

• Hypercapnia, tachypnea with increased work of breathing

• Episodic bronchospasm with wheezing• In severe cases, CHF with cor

pulmonale• Abnormal postures of neck and upper

trunk


Cascade of Events Occurring in BPD


BPD Treatment

• Therapy is preventive and supportive.• Preventive measures begin prenatally

with preventing prematurity and using a single course of antenatal steroids.

• Includes early, careful management of RDS, use of low ventilator pressures, and careful use of oxygen and exogenous surfactant treatment.


AAP/CPS Summary/Recommendations on Postnatal Steroids

• Systemic administration of dexamethasone to mechanically ventilated premature infants decreases incidence of chronic lung disease and extubation failure. Does not decrease overall mortality.

• Dexamethasone treatment for VLBW infants is associated with complications (impaired growth and neurodevelopmental delay).


• Use of inhaled corticosteroids to prevent CLD has not shown benefits.

• Routine use of dexamethasone for the prevention of BPD in VLBW infants is not recommended.

• Postnatal use of systemic dexamethasone for the prevention of BPD should be limited to carefully designed randomized double-masked controlled trials.

AAP/CPS Summary/Recommendations on Postnatal Steroids, Continued


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

AAP/CPS Summary/Recommendations on Postnatal Steroids, Continued


BPD Nursing Care

• Prevent further lung damage. • Wean ventilator and oxygen support

slowly.• Recognize that stressful situations can

minimize hypoxemia-inducing events.• Use sucrose with nonnutritive sucking

before painful procedures to decrease pain.


BPD Nursing Care, Continued

• Preoxygenation (increasing FiO2 just before suctioning) may help prevent hypoxemia with suctioning.

• A consistent caregiver is helpful to parents.• Use fortified breastmilk or premature

specialty formula for a consistent weight gain of 10 g to 30 g per day.

• Kangaroo care promotes bonding.


Kangaroo Care

• Improvement in gas exchange and temperature in premature infants

• No adverse affect on physiologic stability

• Improvement in lactation outcomes in mothers wishing to breastfeed premature infants

• Positive impact on the parenting process


Apnea of Prematurity

• 50% of NICU infants • Periods of cessation of respiration for

longer than 10 seconds to 15 seconds• Apneic episodes frequently

accompanied by cyanosis, bradycardia, pallor or hypotonia

• Exact cause unknown but thought to be due to immature CNS


Types of Apnea in Premature Infants

• Central: Absent breathing movements/ effort

• Obstructive: Breathing movements but no air flow

• Mixed: Mixture of obstructive and central apnea


Apnea Treatment

• Cardiac and respiratory monitoring until no apnea episodes for 5 to 7 days

• Neutral thermal environment• Careful positioning; avoid flexion and

hyperextension of the neck


• Attention to gastric tube placement and infusion rate during tube feeding

• Nasal CPAP • Methyxanthines (oral to intravenous

aminophylline, theophylline and caffeine)

Apnea Treatment, Continued


Apnea Nursing Care

• Assess infant’s color, perfusion, respiratory rate, heart rate, position and oxygen saturation.

• Document frequency and severity of episodes and type and amount of stimulation required to interrupt the event.

• Ensure bag and mask set-ups with oxygen available at infant bedside.


PDA

• The most common cardiac complication in premature infants

• Incidence inversely related to gestational age

• Occurs in 45% of infants with a birthweight <1,750 g

• Occurs in 80% of infants with a birthweight <1,200 g


Signs and Symptoms of PDA

• Signs and symptoms of congestive heart failure, increased need for oxygen and inability to wean from ventilator

• Widened pulse pressure, an active precordium, bounding peripheral pulses and tachycardia with or without a gallop

• Echocardiogram most useful to evaluate PDA


Left-to-Right Shunt Through PDA


PDA Treatment

• Treatment is controversial.• Medical management with fluid

restriction and diuretics may be the initial approach.

• Indomethacin has been effective in closing PDAs (dosage depends on weight, gestation and renal function).


PDA Nursing Care

• Continually assess high-risk infants for pulse, heart rate, pulse pressure, perfusion, and auscultation for the presence of a murmur.

• Know dosage and contraindications for indomethacin.

• Assess infant after indomethacin for ductal closure, decreased urine output and thrombocytopenia.

• Teach and reassure parents.


ROP

• A significant cause of blindness in children initiated by delay in retinal vascular growth

• The more premature the infant, the more likely the infant is to have ROP.

• 82% of infants weighing <1,000 g at birth develop ROP.


• 47% of infants weighing 1,000 g to 1,500 g at birth develop ROP.

• Other risk factors: prolonged mechanical ventilation and oxygen administration, hyperoxia, hypoxia, sepsis, acidosis, shock

ROP, Continued


Long-Term Consequences of ROP

• Myopia (nearsightedness)• Strabismus (crossed eye)• Amblyopia (lazy eye)• Astigmatism• Glaucoma• Late retinal detachment• Blindness


AAP: Screening Premature Infants for ROP

• First exam occurs 4 to 6 weeks after birth or 31 to 33 weeks postconceptional age.

• Two exams after pupillary dilation using indirect ophthalmoscopy if:– Weight at birth <1,500 g or gestational age

<28 weeks– High-risk event and weight at birth 1,501 g

to 2000 g or gestational age 29 to 36 weeks


ROP Treatment

• ROP progresses at different rates in different infants.

• The goal of treatment for ROP is prevention of blindness.

• Surgical therapies—Laser photocoagulation and cryotherapy


Characteristics of Neonatal SepsisEarly Onset

<7 daysLate Onset

7 days to 3 months

Late, Late Onset>3 months

Intrapartum complications

Often present Usually absent Varies

Transmission Vertical; organisms often acquired from mother’s genital tract

Vertical or via postnatal environment

Usually postnatal environment

Clinical manifestations

Fulminant course, multisystem involvement, pneumonia

Insidious, focal infection, meningitis common

Insidious

Case-fatality rate

5 percent to 20 percent

5 percent Low

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


Deficiencies in Neonatal Host Defenses that Predispose to Infection

• Anatomic barriers—Injuries during delivery (skin abrasions)

• Invasive procedures in the nursery (umbilical artery catheters, endotracheal tubes)


• Phagocytic cells– Small PMN leukocyte storage pool– Decreased PMN leukocyte adherence– Decreased PMN leukocyte and monocyte

chemotaxis– Decreased phagocytosis in stressed

neonates– Decreased PMN leukocyte intracellular

killing in stressed neonates

Deficiencies in Neonatal Host Defenses that Predispose to Infection, Continued



• Complement– Decreased levels of complement– Decreased expression of complement

receptors

• Cellular immunity– Possible defects in T-cell

immunoregulation


• Humoral immunity– Decreased IgA, IgM– Decreased IgG in premature neonates– Impaired antibody function– Decreased levels of fibronectin– Decreased levels of cytokine (interferon,

tumor necrosis factor)



• Severely debilitating illness in VLBW infants• Caused by the same pathogens that cause

sepsis • Incidence of culture-proven meningitis: 1.8% • Occurs in neonates with lower mean birth-

weights and gestational ages• Residual major neurologic abnormalities and

subnormal scores on MDI on the Bayley Scales of Infant Development

Meningitis


Meningitis, Continued

• Most common etiology is hematogenous spread from the bloodstream to the meninges.

• Can be early- or late-onset• Mortality is usually higher with early

onset disease.


• Lethargy• Hypotonia• Temperature instability• Increased oxygen requirements• Apnea• Bradycardia• Feeding intolerance• Seizures

Signs and Symptoms of Meningitis


Pneumatocele


Pneumonia in a Premature Infant


• Developed:– In utero through transplacental transfer of

organisms and aspiration of pathogens from amniotic fluid of mothers with chorioamnionitis

–During/After delivery through aspiration of infected materials

–Postdelivery through inhalation of particles from individuals or equipment; through contaminated endotracheal tubes; through hematogenous spread from pathogens in the bloodstream

• Most common cause is GBS.

Pneumonia


Signs and Symptoms of Pneumonia

Early signs are the same as for sepsis:• Lethargy or irritability• Poor feeding• Temperature instability • Poor color• Respiratory signs--tachypnea, apnea,

cyanosis, retractions, grunting, nasal flaring and retractions


Treatment of Sepsis, Meningitis and Pneumonia

• Early identification of neonate at risk is essential for prevention of morbidity and mortality.

• Develop a culture of prevention of infection in NICU.

• Eradicate the pathogen with medications.

• Minimize sequelae.


Nursing Care of Sepsis, Meningitis and Pneumonia

• Monitor respiratory status, oxygen support, mechanical ventilation.

• Watch for worsening apnea/bradycardia.

• Suctioning PRN• Volume replacements PRN with

isotonic solutions


• Blood products PRN• Minimal handling to avoid extra stress• Watch for seizures.

Nursing Care of Sepsis, Meningitis and Pneumonia, Continued


NEC

• The most common neonatal intestinal emergency

• Characterized by intestinal ischemia, most often involving the terminal ileum

• Pathogenesis is uncertain.• Three major factors: bowel wall

ischemia; bacterial invasion of the bowel wall; enteral feedings


Pathogenesis of NEC


Three Stages of NEC

1. Generalized symptoms of early sepsis, including temperature instability, lethargy, apnea and bradycardia, feeding intolerance, abdominal distention, and stools that test positive for occult blood

2. Severe abdominal distention and tenderness, visible bowel loops, grossly bloody stools, metabolic acidosis, poor perfusion and a mottled skin color

3. Fulminant signs of SIRS, including shock, mixed acidosis, DIC and neutropenia


NEC Treatment

• Goals:– Stabilize the neonate.– Treat the infection.– Rest the intestinal tract.

• Discontinue feedings.• Initiate IV access for fluids and

antibiotics.• NG tube to decompress GI tract


NEC Nursing Care

• Monitor vital signs.• Monitor blood gases and pH.• Examine for abdominal distention,

tenderness, emesis, bloody stools, temperature instability, metabolic acidosis, apnea, bradycardia.

• Support parents.• Encourage mother to pump breasts and

freeze breastmilk.


Intrapartum prophylaxis not indicated• Previous pregnancy with positive GBS

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

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

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

Intrapartum Antibiotic Prophylaxis to Prevent Perinatal GBS

Intrapartum prophylaxis indicated• Previous infant with invasive GBS disease• GBS bacteriuria during current pregnancy• Positive GBS screening culture during

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

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

– Delivery at <37 weeks gestation– Amniotic membrane rupture ≥18 hours– Intrapartum temperature ≥100.4°F

(≥38.0°C)†

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


GBS Prophylaxis for Women with Threatened Preterm Delivery


Prevention of Early-Onset GBS Disease in the Newborn


PBPs for Prevention of Nosocomial Infections in NICUs

• Increased compliance with hand-hygiene standards

• Improved accuracy of the diagnosis of bacteremia

• Reduced line and line connection (hub) bacterial contamination


• Maximal barrier precautions for central line placement

• Decreased – Number of skin punctures– Duration of IV lipid infusion– Duration of central venous line use

PBPs for Prevention of Nosocomial Infections in NICUs, Continued


IVH/PVH

• 50% will die.• Occurs in 25% to 30% of all VLBW

infants discharged from Level III NICUs • Associated primarily with prematurity• Infants <28 weeks gestation are at

greatest risk.


IVH/PVH, Continued

• Small (Grades I and II)– Grade I hemorrhage is an isolated

germinal matrix hemorrhage.– Grade Il is an IVH with normal ventricular

size.

• Moderate (Grade III) is an IVH with acute ventricular dilation.

• Severe (Grade IV) is an IVH with parenchymal hemorrhage.


Venous Drainage of Cerebral White Matter


Signs and Symptoms of IVH/PVH

• Can be subtle; sometimes only decreased hematocrit or hemoglobin levels

• May evolve over several hours and include decreased activity, hypotonia, altered consciousness, respiratory disturbances

• Can develop rapidly, with seizures, decerebrate posturing, fixed pupils


IVH/PVH Treatment and Nursing Care

• Optimal treatment is prevention.• Minimize brain tissue destruction.• Minimize pain and stress.• Minimize crying, suctioning, rapid

bolus infusions.


• Maintain neutral thermal environment.• Elevate head 30º.• Use sucrose pacifiers, topical

anesthetics for procedures.• Provide parental support.

IVH/PVH Treatment and Nursing Care, Continued


PBPs for Prevention of IVH and PVL

• Administer antenatal steroids.• Optimize peripartum management. • Administer antenatal antibiotics for

preterm rupture of the membranes. • Delivery-room resuscitation by

neonatologists and an experienced team


• Maintain the baby’s temperature >36° centigrade.

• Maintain cardiorespiratory stability while administering surfactant.

• Optimize direct clinical management by neonatologists.

• Implement measures to minimize pain and stress responses.

PBPs for Prevention of IVH and PVL, Continued



• Use developmental care.• Judiciously use narcotic sedation (low

dose, continuous).• Avoid early lumbar puncture (72

hours old).• Use optimal positioning.


• In terms of fluid volume treatment of hypotension, there is no evidence demonstrating benefit of using MAP 30 rather than MAP > estimated gestational age weeks.

• Use postnatal indomethacin judiciously.• Optimize respiratory management. • Use postnatal dexamethasone judiciously.



Goals of Nursing Care to Promote Parental Attachment

• Opening the intensive care nursery to parents

• Transporting the mother to be near her infant

• Maternal day care for premature infants• Rooming in for parents• Individualized nursing care plans• Early discharge


• Listening to parents during the infant’s hospitalization and after discharge

• Parent support groups• Programmed contact and reciprocal

interaction• Transporting the healthy premature

infant to the mother

Goals of Nursing Care to Promote Parental Attachment, Continued


• Home-based interventions for young parents

• Discussion with parents after discharge• Kangaroo care• Nurse home visitation

Goals of Nursing Care to Promote Parental Attachment, Continued


March of Dimes Prematurity Campaign

Multi-year, multimillion-dollar campaign to help families have healthier babies by:• Funding research to find causes of

premature birth• Educating women about risk reduction• Providing support to families


• Expanding access to health care coverage for prenatal care

• Helping providers learn ways to help reduce risk of early delivery

• Advocating for access to insurance to improve maternity care and infant health outcomes

March of Dimes Prematurity Campaign, Continued


March of Dimes NICU Family Supportsm

• Provides emotional and informational resources to families with a newborn in the NICU

• In more than 50 NICUs in the United States by 2007

• marchofdimes.com/prematurity/nicu


• Online community for families with a child in the NICU

• Users share NICU experiences, participate in online discussions and meet other NICU families.

• More than 10,000 registered members• marchofdimes.com/share

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