NURSING CARE FOR A FAMILY 5.

Establishment of waste elimination

WITH A HIGH-RISK NEWBORN 6. Prevention of infection

7. Establishment of an infant–parent relationship

Assessment
8. Developmental care, or care that balances
 All infants need to be assessed at birth for
physiologic needs and stimulation for best
obvious congenital anomalies and gestational
development
age.

Nursing Diagnosis

 Ineffective airway clearance related to

presence of mucus or amniotic fluid in airway
 Ineffective cardiovascular tissue perfusion
related to breathing difficulty
 Risk for deficient fluid volume related to
insensible water loss
 Ineffective thermoregulation related to
newborn status and stress from birth weight
Initiating and Maintaining Respirations
variation
 Risk for imbalanced nutrition, less than body  Most deaths occurring during the first 48 hours

requirements related to lack of energy for after birth result from the newborn’s inability to

sucking establish or maintain adequate respirations.

 Risk for infection related to lowered immune  If respiratory activity does not begin
response in newborn immediately, respiratory acidosis will increase.

Outcome Evaluation

 Infant maintains a patent airway.

 Infant tolerates all procedures without
accompanying apnea.

NEWBORN PRIORITIES IN THE FIRST

DAYS OF LIFE

All newborns have eight priority needs in the first

few days of life:

1. Initiation and maintenance of respirations

Resuscitation
2. Establishment of extrauterine circulation
 If breathing is ineffective, circulatory shunts,
3. Control of body temperature
particularly the ductus arteriosus, can fail to
4. Intake of adequate nourishment
close.
 left-side heart pressure is stronger than right-  An infant who still makes no effort at
side pressure spontaneous respirations requires immediate
 blood circulates through a patent ductus laryngoscopy to open the airway.
arteriosus left to right or from the aorta to the  Laryngoscopes - Size 0 or 1 is used with
pulmonary artery, creating ineffective pump newborns.
action in the heart  Infants under 1000 g need a 2.5-mm
 Struggling to breathe and circulate blood, an endotracheal tube;
infant uses available serum glucose quickly and  those over 3000 g need a 4.0mm tube.
may become hypoglycemic.  Primary Apnea - In the first few seconds of life,
 Resuscitation follows an organized process: a newborn this severely depressed may take
1. establish and maintain an airway, several weak gasps of air and then almost
2. expand the lungs, and immediately stop breathing.
3. initiate and maintain effective ventilation.  Secondary Apnea - After 1 or 2 minutes of
apnea, an infant again tries to initiate
Airway
respirations with a few strong gasps.
 bulb syringe suction - removes mucus and o However, a newborn cannot maintain this
prevents aspiration of any mucus and amniotic effort longer than 4 or 5 minutes.
fluid present in the mouth or nose; all that is o After this, the respiratory effort will
necessary to help establish a clear airway FOR become weaker again and the heart rate
A WELL TERM NB will fall further until the newborn stops the
 If a newborn does not draw in a first breath gasping effort altogether.
spontaneously
Lung Expansion
 suction the infant’s mouth and nose with a
bulb syringe again and  The sound of the baby crying is proof that lung

 rub the back to see if skin stimulation initiates expansion is good.

respirations.  An infant cannot sustain effective respirations

 Be certain an infant is dry : If a newborn has may need oxygen by bag and mask to aid lung

to attempt to raise body temperature because expansion.

of chilling, this will increase the need for  The pressure needed to open lung alveoli for

oxygen, which the baby cannot supply the first time is approximately 40 cm H2O.

because breathing has not yet been initiated. After that, pressures of 15 to 20 cm H2O are

 If a newborn’s amniotic fluid was meconium generally adequate to continue inflating alveoli.

stained:
Drug Therapy
 do not stimulate an infant to breathe by
rubbing the back or administering air or  If RespiDep is caused by narcotic during labor -

oxygen under pressure as doing so could push narcotic antagonist such as naloxone (Narcan)

meconium down into an infant’s airway injected into an umbilical vessel or

intramuscularly into a thigh will relieve the
depression.
 The dose of naloxone is determined by
institutional policy but is usually 0.01 to 0.1
mg/kg

Ventilation Maintenance

 If Respiratory rate is increased, undress the

baby’s chest and look for retractions.
 NB with increased RR should be placed under an
infant warmer and have the weight of clothing
removed from the chest.

Establishing Extrauterine Circulation

 Closed-Chest Massage - Perform If an infant has

no audible heartbeat, or if the cardiac rate is
below 80 beats per minute
 Depress the sternum approximately one third of
its depth (1 or 2 cm) at a rate of 100 times per
minute.
 Lung ventilation at a rate of 30 times per
minute.
 If not effective - 0.1 to 0.3 mL/kg epinephrine
(1:10,000) may be sprayed into the endotracheal
tube to stimulate cardiac function.

Maintaining Fluid and Electrolyte

Balance

 Hypoglycemia - may result from the effort the

newborn expended to begin breathing.
 Dehydration- may result from increased
insensible water loss from rapid respirations.
 Hypoglycemia are treated initially with 10%
dextrose in water to restore their blood glucose
level. LR and D5W
 Fluids are monitored carefully - a high fluid
intake can lead to patent ductus arteriosus or
heart failure.
 An output less than 2 mL/kg/hr or a specific  maintain an infant’s axillary temperature at
gravity greater than 1.015 to 1.020 suggests 97.8° F (36.5° C).
inadequate fluid intake.
 If an infant has hypotension without
hypovolemia, a vasopressor such as dopamine Radiant Heat Sources
may be given to increase blood pressure and  open beds that have an overhead radiant heat
improve cell perfusion. source.
 Hypovolemia:  Abdominal skin temperature, when measured
o tachypnea this way, should be 95.9° to 97.7° F (35.5° to
o pallor 36.5° C). If an infant’s temperature falls below
o tachycardia this level, an alarm will sound.
o decreased arterial blood pressure
 tape the probe or disk onto the infant’s
o decreased central venous pressure
abdomen between the umbilicus and the
 Normal saline or Ringer’s lactate may be xiphoid process.
administered to increase blood volume.
 DO NOT TAPE IT UNDER AN INFANT – IT WILL

Regulating Temperature CAUSE FALSE HIGH READING

 Also DO NOT PLACE IT OVER THE LIVER,
 neither too hot nor too cold because increased metabolism may lead to
 If the environment is too hot, they must falsely high readings.
decrease metabolism to cool their body.  A plastic bridge or shield placed over the child
 If it is too cold, they must increase metabolism will better preserve heat by reducing
to warm body cells convection and radiation losses; plastic wrap
o The increased metabolism required calls placed over an infant will produce this same
for increased oxygen; without this effect.
oxygen available, body cells become
Incubators
hypoxic.
 To save oxygen for essential body functions,  Use of an additional acrylic shield inside the
vasoconstriction of blood vessels occurs. incubator helps prevent radiation and
 In short, because of becoming chilled, heart convection heat loss when portholes are opened
action, breathing, and electrolytic balance are for care.
all affected.
Skin-to-Skin Care
 To prevent a newborn from becoming chilled:
o after birth, wipe an infant dry,  kangaroo care
o cover the head with a cap, and  Undress the infant except for a diaper and
o place the baby immediately under a perhaps a cap.
prewarmed radiant warmer or in a  Assist the parent to sit comfortably in a chair
warmed incubator and hold the infant snugly against his or her
o Skin-skin contact chest, skin to skin. Place a blanket over the
infant for added warmth.
Establishing Adequate Nutritional  Common viruses that affect infants in utero
are cytomegalovirus and toxoplasmosis
Intake
virus.
Infants who experienced severe asphyxia at birth  Early-onset sepsis is most commonly caused
usually receive intravenous fluids so they do not by group B streptococcus, E. coli, Kelbsiella,
become exhausted from sucking or until and Listeria monocytogenes.
NECROTIZING ENTEROCOLITIS (NEC) has been ruled
Establishing Parent–Infant Bonding
out, result from the temporary reduction in oxygen
to the bowel.  parents of a high-risk newborn are kept
informed of what is happening during
 Preterm infants should be breastfed if possible
resuscitation at birth.
because of the immune protection this offers.
 They should be able to visit the special
 If breastfeeding is not possible because the
nursing unit to which the child is admitted as
infant is too immature to suck effectively, a
often as they choose, and, after washing and
mother can manually express breast milk.
gowning, hold and touch their child.
 Her expressed breast milk can be used in the
 If an infant dies despite newborn
infant’s gavage feeding.
resuscitation attempts, parents need to see
 BREASTMILK should be stored in nonshiny
the infant without being covered by a
plastic bags or bottles to avoid the infant being
myriad of equipment.
exposed to polycarbonate.
o reassure themselves their newborn was
 If Gavage fed, need ORAL STIMULATION –
a perfect baby in every other way except
PACIFIER.
lung function or whatever was the
 Except those too immature to have a sucking
infant’s fatal disorder.
reflex and infants who must not swallow air,
such as those with a tracheoesophageal fistula Anticipating Developmental Needs
Establishing Waste Elimination Follow-up of High-Risk Infants at Home

 Carefully document any voidings that occur  Thorough education and referral to a home
during resuscitation. This is proof that care agency may be necessary to help
hypotension is improving and the kidneys are parents continue with the level of care that
being perfused. is required when their infant is discharged
 Immature infants also may pass stool later than home.
the term infant because meconium has not yet  “car seat challenge” - all preterm infants be
reached the end of the intestine at birth. assessed for cardiorespiratory stability in
their car seat prior to discharge
Preventing Infection
High-Risk Infants and Child Abuse
 Stresses the immature immune system
 If infection causes chilling, can lead to  Preterm children are at high risk for abuse
increased oxygen demands
 THE NEWBORN AT RISK BECAUSE OF  INTRAUTERINE INFECTION such as rubella
ALTERED GESTATIONAL AGE OR BIRTH or toxoplasmosis or has a chromosomal

WEIGHT abnormality.

Birth weight is normally plotted on a growth Assessment

chart such as the Colorado (Lubchenco)
 A sonogram can then demonstrate the
Intrauterine Growth Chart
decreased size.
 TERM - Infants born after the beginning of  A biophysical profile including a nonstress test,
week 38 and before week 42 of pregnancy placental grading, amniotic fluid amount, and
 PRETERM - less than the full 37th week of ultrasound examination can provide additional
pregnancy information on placental function.
 POSTTERM, DYSMATURE, OR POSTMATURE
Appearance
- after the onset of week 43 of pregnancy
 overall wasted appearance
 APPROPRIATE FOR GESTATIONAL AGE
 small liver, which can cause difficulty regulating
(AGA) - Infants who fall between the 10th
glucose, protein, and bilirubin levels after birth.
and 90th percentiles of weight for their age
 poor skin turgor
regardless of gestational age
 large head because the rest of the body is so
 SMALL FOR GESTATIONAL AGE (SGA) - fall
small
below the 10th percentile
 LARGE FOR GESTATIONAL AGE (LGA) - Laboratory Findings
above the 90th percentile
 high hematocrit level
 LBW – below 2,500 g
 polycythemia - increase in red blood cells occurs
 VLBW - 1000 to 1500 g
because anoxia during intrauterine life
 EXTREMELY VERY-LOW-BIRTH-WEIGHT
stimulates the development of red blood cells.
INFANTS (EVLB) - 500 to 1000 g
- increased blood viscosity

The Small-for-Gestational-Age Infant  polycythemia is extreme, vessels may actually

become blocked and thrombus formation can
 they have experienced intrauterine growth
result
restriction (IUGR)
 hypoglycemia - decreased blood glucose, or a

Etiology level below 45 mg/dL

 MOST COMMON CAUSE of IUGR is a The Large-for-Gestational-Age Infant

placental anomaly:
-Macrosomia
o the placenta did not obtain sufficient
nutrients from the uterine arteries Etiology
o it was inefficient at transporting
 Infants who are LGA have been subjected to an
nutrients to the fetus
overproduction of growth hormone in utero.
 lack of adequate nutrition
 infants of women with diabetes mellitus
 Pregnant adolescents
 women who are obese  Delivering even though it was just Braxton-Hicks
 Extreme macrosomia occurs in fetuses of  On gross inspection, a preterm infant appears
diabetic women whose symptoms are poorly small and underdeveloped
controlled, because these fetuses are exposed
to high glucose levels.
 Multiparous women are also prone to have
large babies because with each succeeding
pregnancy, babies tend to grow larger.
 Beckwith syndrome (a rare condition
characterized by overgrowth), and congenital
anomalies such as omphalocele.

Assessment

 may have extensive bruising or

 a birth injury such as a broken clavicle or
Erb-Duchenne Paralysis
 caput succedaneum, cephalhematoma, or
 The head is disproportionately large (3 cm
molding.
greater than chest size).
Cardiovascular Dysfunction
 Scant Lanugo
 signs of hyperbilirubinemia - which may result  Skin is Ruddy
from absorption of blood from bruising and  Eyes appear small, pinna falls forward (no
polycythemia cartilage)

Hypoglycemia

 Rebound Hypoglycemia - increased insulin levels

in the uterus

A Preterm Infant

 Late Preterm – 34-37 weeks

 Early Preterm – 24-34 weeks
 Lung Surfactant forms 34th week- makes them
susceptible to RDS

Etiology

Assessment

 A good answer to her direct inquiries about

causes is, “No one really knows what causes
prematurity.” To prevent guilt of the mother.
Potential Complications  Adminster IV Cautiously - to avoid
increasing blood pressure and further
Anemia of Prematurity compounding this problem

 normochromic, normocytic anemia (normal  Indomethacin or ibuprofen may be used

cells, just few in number)  A side effect of indomethacin is oliguria, so

 infant will appear pale and may be lethargic urine output needs to be monitored closely

and anorectic. if this is used, decreased platelet count,

 immaturity of the hematopoietic system + gastric irritation.

destruction of red blood cells because of low Periventricular/Intraventricular

levels of vitamin E
Hemorrhage
 Excessive blood drawing for electrolyte or
blood gas analysis  periventricular hemorrhage -bleeding into
the tissue surrounding the ventricles)
Kernicterus
 intraventricular hemorrhage -bleeding into
 destruction of brain cells by invasion of the ventricles
indirect bilirubin  Cause: Fragile capillaries and immature
 results from the high concentrations of vascular development
indirect bilirubin in the blood from excessive  Grade 1 – Bleeding in the periventricular
breakdown of red blood cells. germinal matrix, occurring in one ventricle
 Preterm infants are more prone because  Grade 2 – bleeding within the lateral
with the acidosis that occurs from poor ventricle without dilation of the ventricle
respiratory exchange, brain cells are more  Grade 3 – bleeding causing enlargement of
susceptible to the effect of indirect bilirubin the ventricles
than usually.  Grade 4 – bleeding in the ventricles and
 Preterm infants also have less serum intraparenchymal hemorrhage
albumin available to bind indirect bilirubin  Hydrocephalus may occur from bleeding
and inactivate its effect. into the aqueduct of Sylvius
 12 mg per 100 mL of indirect bilirubin
Other Potential Complications
Persistent Patent Ductus Arteriosus
 respiratory distress syndrome
Pathophysiology  apnea,

1. Lack of lung Surfactant  retinopathy of prematurity

2. Difficulty in movement of blood into the  necrotizing enterocolitis

pulmonary artery
3. Pulmonary Hypertension
4. Interferes with the closure of Ductus
Arteriosus
Impaired gas exchange related to  A preterm newborn experiences a high
insensible water loss because of a large body
immature pulmonary functioning
surface relative to total body weight.
 Immature pulmonary capillaries  also cannot concentrate urine well because of
 Lung surfactant does not form in adequate immature kidney function.
amounts until about the 34th to 35th week of  Intravenous fluid administration typically begins
pregnancy. Inadequate lung surfactant leads to within hours after birth to fulfill this fluid
alveolar collapse with each expiration. requirement and provide glucose to prevent
 Forces the infant to use maximum strength to hypoglycemia.
inflate lung alveoli each time.  Intravenous fluid should be given via a
 a preterm infant may still be in a breech position continuous infusion pump to ensure a constant
at birth. Breech-born infants are apt to expel infusion rate and prevent accidental overload.
meconium into the amniotic fluid.  Always assess iv site - because if infiltration
 If the fetus aspirates either vaginal secretions or should occur, the lack of subcutaneous tissue
meconium, the respiratory problem can be places a preterm newborn at risk for damaged
aggravated by inflammation or pneumonia. tissue.
 Cesarean birth may lead to additional  Specially designed 27-gauge needles are
respiratory complications because of retained available for use on small veins.
lung fluid.  If lack adequately sized peripheral veins for even
 Give mother O2 by mask to to help infant have this small a needle - need to receive intravenous
adequate O2 sat, minimize analgesia fluid by an umbilical venous catheter.
 Susceptible to Reversible Acidosis – prepare  Monitor the baby’s weight, urine output and
medications, keep them warm, carry out specific gravity, and serum electrolytes to
procedures gently because bruising can cause ensure adequate fluid intake.
hyperbilirubinemia  Too little fluid and calories can lead to
 Manifests Periodic Respirations (quick dehydration and starvation, acidosis, and
successive breaths then cessation for 5-10 weight loss
seconds)  Overhydration may lead to nonnutritional
 Be alarmed for true apnea (cessation for >20 weight gain, pulmonary edema, and heart
seconds) failure
 Soft ribs causes lung collapse during respirations  Measure urine output by weighing diapers
and no back up muscles to be used when rather than using urine collection bags, as
fatigued disposable collection bags can lead to skin
 Increased O2 causes: Pulmonary Edema and irritation
ROP  40 to 100 mL per kg per 24 hours, compared
with the normal 10 to 20 mL per kg per 24 hours.
Risk for deficient fluid volume related
The specific gravity is low, rarely more than
to insensible water loss at birth and 1.012 (normal 1.030).Because they cannot

small stomach capacity concentrate urine.

 test urine for glucose and ketones.  A preterm infant needs 115 to 140 calories per
 Hyperglycemia caused by the glucose infusion kilogram of body weight per day, compared with
may lead to glucose spillage into the urine and 100 to 110 needed by a term infant.
an accompanying diuresis, and fluid loss.  Protein requirements are 3 to 3.5 g per kilogram
 If too little glucose is being supplied and body of body weight, compared with 2.0 to 2.5 for a
cells are using protein for metabolism, ketone term newborn.
bodies will appear in urine.  Feedings may be as small as 1 or 2 mL every 2 to
 Blood glucose should range between 40 and 60 3 hours.
mg/dL
Gavage Feeding
 Check for blood in stools to evaluate possible
 Gag reflex - occurs at 32 weeks
bleeding from the intestinal tract. This is helpful
 Sucking and swallowing – occurs at 34 weeks
in determining the possible cause of
hypovolemia  Offer pacifier to strengthen sucking reflex during
gavage feeding
Risk for imbalanced nutrition, less  Inability to digest this way is also a sign that
than body requirements, related to necrotizing enterocolitis, a destructive intestinal
disorder
additional nutrients needed for
Breastmilk
maintenance of rapid growth, possible
 Immunologic properties of breast milk play a
sucking difficulty, and small stomach
role in preventing necrotizing enterocolitis
 a preterm newborn requires a larger amount of  Breast milk from mother high sodium content
nutrients than the mature infant.  The mother who wants to breastfeed can
 hypocalcemia (decreased serum calcium) or manually express breast milk for her infant’s
 azotemia (low protein level in blood). gavage feedings.
 Delayed feeding and a resultant decrease in  expressed breast milk can be frozen for safe
intestinal motility may also add to transport and storage.
hyperbilirubinemia
Formula
 Immature Stomach and intestine – Milk
Digestion Problems
 Needs to supplement with iron, calcium and
 Immature Reflexes – ineffective sucking and
phosphorus and electrolytes such as sodium,
swallowing
potassium and chloride.
 Immature Cardiac Sphincter – allows more
 Vit A- for improve healing and reduce lung
incedents of cardiac regurgitation
disease
Feeding Schedule  Vit E- prevents haemolytic anemia
 The caloric concentration of formulas used for
 Delayed if with TPN or IVF
preterm infants is usually 24 cal/oz, compared
 Feeding is begun as soon as an infant is able to
with 20 cal/oz for a term baby.
tolerate them to prevent deterioration of the
intestinal villi.
 As with a term neonate, vitamin K should be  Handle and stoke the infant in the incubator, let
administered at birth. However, the amount the mother hold the baby before and after
administered is more often 0.5 mL instead of 1 gavage feeding.
mL because of the infant’s small size.  Primary nursing or case management with one
nurse helps reduce the number of people who
Ineffective thermoregulation r/t contact the parents

immaturity  Try to welcome siblings to build family unity.

 They have large surface area per kilogram of Deficient diversional activity (lack
body weight and they don’t flex thus increasing stimulation) r/t preterm infant rest
the rapid cooling from evaporation
needs
 Limited amount of brown fat, cannot shiver and
cannot sweat.
 They need to conserve energy for growth and
 Keep them radiant warmer , incubators or do
respiratory function – organize procedure to
skin to skin contact
maximize the amount of rest available to the
infant.
Risk for infection related to immature
 Be sensitive to move objects and noise away
defences in the preterm infant from the infant to avoid overstimulation
 Look directly into the infant in the
 Skin is easily traumatized plus have difficulty
straightforward position as much as possible to
producing phagocytes as well as deficiency in
provide stimulation of a human face
IgM –
 Provide a talk time – words spoken softly but
 do not share linens with other infants ,
clearly into their ears
 staff members should be free of infection ,
 Provide human contact – stroke their back and
 wear gowns and do hand washing .
their head.

Risk for impaired parenting r/t

Risk for disorganized infant behaviour
interference with patient – infant
r/t prematurity and environmental
attachment resulting from
overstimulation
hospitalization of infant at birth.
 Developmental care( care designed to meet the
 They need as much attention as a term newborn specific needs of each infant)can lead to
- rock , sing and talk to them to develop a sense increased weight gain and decrease crying and
of trust apnea spells in preterm infants
 Parents need to come to terms with their  Dim the lights , cover an incubator, turning to
feelings of disappointment or guilt . sides and contain the body using rolled towels
(nesting)
Parental health – seeking behaviour The Postterm Infant
r/t infants needs for health  Postterm infant is one born after the 42nd week

maintenance. of a pregnancy.
 Most nurse-midwives and obstetricians
 Before NICU discharge, parents needs to learn recommend inducing labor at 2 weeks postterm
and practice special methods of care basic to avoid postmature births
immunization , plotting of child's weight and  They are at risk because the Placenta only
height according to the baby’s adjusted age, functions for 40 weeks.
evaluate growth and development milestones.  it seems to lose its ability to carry nutrients
effectively to the fetus.
 A fetus who remains in utero with a failing
placenta may die or develop postterm
syndrome:
o dry, cracked, almost leather-like skin
from lack of fluid, and absence of vernix.
 The amount of amniotic fluid may be less at birth
than normal, and it may be meconium stained.
 a sonogram is usually obtained to measure the
biparietal diameter of the fetus. A nonstress test
or complete biophysical profile may be done to
establish whether the placenta is still
functioning adequately.
 Cesarean birth may be indicated if a nonstress
test reveals that compromised placental
functioning may occur during labor.
 hypoglycemia may develop because the fetus
had to use stores of glycogen for nourishment
in the last weeks of intrauterine life.
 Subcutaneous fat levels may also be low, having
been used in utero. This can make temperature
regulation difficult, making it important to
prevent a postterm infant from becoming chilled
at birth
 Polycythemia may have developed from
decreased oxygenation in the final weeks. The
hematocrit may be elevated.
 ILLNESS IN THE NEWBORN Therapeutic management

Respiratory Distress Syndrome (RDS)  RDS can be largely prevented by the

administration of surfactant at birth into an
 Formerly hyaline membrane disease, is most ET tube by a syringe or catheter (lung
often seen in newborns born prematurely. lavage)

 Other causes: meconium aspiration syndrome,  It is important an infant’s airway not be

sepsis, a newborn who is slow to transition to suctioned for as long a period as possible
extrauterine life and pneumonia after administration of surfactant to avoid
suctioning the drug away.
Assessment
 Oxygen administration
 Difficulty initiating respiratory at birth
 Subtle signs of RDS (symptom free) o Can be administered via simple cannula
mask, continuous positive airway
o Low body temp pressure (CPAP) or assisted ventilation
o Nasal flaring with positive end expiratory pressure
o Sternal and subcostal retractions (PEEP)
o Tachypnea
o Cyanotic mucous membranes  Ventilation

o Normal ventilation inspiration shorter

 Expiratory grunting caused by closed glottis—
than expiration
an attempt to increase pressure in alveoli
o RDS infant reversed I/E ratio 2:1 to
 Fine rales and diminished breath sounds—poor
deliver to a stiff, non-complaint lung
air entry
o Complications: pneumothorax and
 Increased distress
impaired cardiac output—decreased
o Seesaw respiration - on inspiration, the blood flow though the pulmonary artery
anterior chest wall retracts and the from increased lung pressure
abdomen protrudes; on expiration, the
 another method of increasing pulmonary blood
sternum rises
flow is by using muscle relaxants. Pancuronium
o Heart failure
(Pavulon) can be administered intravenously
o Pale, gray skin
 its effect can be interrupted by the
o Periods of apnea
administration of atropine
o Bradycardia
o Pneumothorax  Nitric oxide

o A potent vasodilator but does not cause

 Diagnosis of RDS: grunting, central cyanosis in
decrease in vascular tone
room air, tachypnea, nasal flaring and
retractions, chest radiograph reveal haziness in
the lungs, respiratory acidosis
 Extracorporeal Membrane Oxygenation or mature surfactant but is a direct result of
(ECMO) retained lung fluid.
 Transient tachypnea occurs more often in
o first developed as a means of oxygenating
infants who are born by cesarean birth, in
blood during cardiac surgery.
infants whose mothers received extensive fluid
o blood is removed from the baby by gravity
administration during labor, and in preterm
using a venous catheter advanced into the
infants.
right atrium of the heart. The blood
 Infants born by cesarean birth are probably
circulates from the catheter to the ECMO
more prone to develop this form of respiratory
machine, where it is oxygenated and
distress because the thoracic cavity is not
rewarmed.
compressed as it is in vaginal birth, so less lung
fluid is expelled than normally.
 Liquid Ventilation
 Watch for beginning signs of a more serious
o Liquid ventilation involves the use of disorder, because a rapid respiratory rate is
perfluorocarbons often the first sign of respiratory obstruction.
o As the liquid moves into a lung, oxygen  Oxygen administration may be necessary.
is carried along with it; as the liquid  Transient tachypnea of the newborn peaks in
spreads over all lung surfaces, an intensity at approximately 36 hours of life and
exchange of oxygen occurs then begins to fade. Typically, by 72 hours of
life, it spontaneously fades as the lung fluid is
 Supportive care
absorbed and respiratory activity becomes

o Keep warm, provide hydration and nutrition effective.

with IV fluids and glucose or gavage feedings

Meconium Aspiration Syndrome
Transient Tachypnea of the Newborn  Meconium is present in the fetal bowel as early

(TTN) as 10 weeks’ gestation.

 If hypoxia occurs, a vagal reflex is stimulated,
 At birth, a newborn may have a rapid rate of
resulting in relaxation of the rectal sphincter.
respirations, up to 80 breaths per minute when
 This releases meconium into the amniotic fluid.
crying, caused by retained lung fluid.
 Babies born breech may expel meconium into
 within 1 hour, however, this rapid rate slows to
the amniotic fluid from pressure on the
between 30 and 60 breaths per minute. In
buttocks.
 Mild retractions but not marked cyanosis
 Meconium can cause severe respiratory distress
 mild hypoxia
in three ways:
 hypercapnia may be present. o it causes inflammation of bronchioles
 Feeding is difficult because the child cannot suck because it is a foreign substance;
and breathe this rapidly at the same time. o it can block small bronchioles by
 Transient tachypnea may reflect a slight mechanical plugging; and
decrease in production of phosphatidyl glycerol
 o it can cause a decrease in surfactant  Surfactant may be administered to increase
production through lung trauma. lung compliance.
 secondary infection of injured tissue may lead to  pneumothorax or pneumomediastinum- caused
pneumonia. by noncompliant lung tissue causing high
 Hypoxemia, carbon dioxide retention may occur inspiratory pressure.
 Because of increased pulmonary resistance, the
Assessment
ductus arteriosus may remain open,
 difficulty establishing respirations at birth  causing blood to shunt from the pulmonary
 he Apgar score is apt to be low. Almost artery into the aorta, compromising cardiac
immediately, tachypnea, retractions, and efficiency and increasing hypoxia.
cyanosis occur.
Apnea
 an infant should be suctioned with a bulb
syringe or catheter while at the perineum,  Apnea is a pause in respirations longer than 20
before the birth of the shoulders, to avoid seconds with accompanying bradycardia.
meconium aspiration.  preterm infants have periods of apnea as a result
 Do not administer oxygen under pressure (bag of fatigue or the immaturity of their respiratory
and mask) until an infant has been intubated and mechanisms.
suctioned, so that the pressure of the oxygen  secondary stresses, such as infection,
does not drive small plugs of meconium farther hyperbilirubinemia, hypoglycemia, or
down into the lungs, worsening the irritation hypothermia, tend to have a high incidence of
and obstruction. apnea
 air trapping may also cause enlargement of the  Gently shaking an infant or flicking the sole of
anteroposterior diameter of the chest (barrel the foot often stimulates the baby to breathe
chest). again,
 A chest radiograph will show bilateral coarse  To help prevent episodes of apnea, maintain a
infiltrates in the lungs, with spaces of neutral thermal environment and use gentle
hyperaeration (a peculiar honeycomb effect). handling to avoid excessive fatigue.
 using indwelling nasogastric tubes rather than
Therapeutic Management
intermittent ones can also reduce the amount
 Amnioinfusion can be used to dilute the amount of vagal stimulation.
of meconium in amniotic fluid and reduce the  careful burping also helps to reduce this effect.
risk of aspiration. Used only in distress.  Theophylline or caffeine sodium benzoate may
 CS be administered to stimulate respirations.
 After birth and tracheal suction, infants may
need to be treated with oxygen administration
and assisted ventilation.
 Antibiotic therapy may be used to forestall the
development of pneumonia as a secondary
problem.
Sudden Infant Death Syndrome (SIDS)  They need this assurance if they are to plan for
other children.
 Sudden unexplained death in infancy.
o Infants of adolescent mothers, Apparent Life-Threatening Event
o infants of closely spaced pregnancies,
 An episode of infants discovered cyanotic and
o and underweight and preterm infants.
limp in their beds but have survived after mouth-
 Prone to SIDS are infants with
to-mouth resuscitation by parents.
bronchopulmonary dysplasia, twins, Native
 Apnea monitoring in place, an alarm sounds
American infants, Alaskan Native infants,
when the neonate experiences a period of
economically disadvantaged black infants
apnea of 20 seconds or longer or a decreased
 The peak age of incidence is 2 to 4 months of
heart rate below 80 beats per minute
age
 parents are going to use an apnea monitor at
 Contributing factors include:
home, make certain they will be able to hear it
o Viral respiratory or botulism infection
in all parts of the house or apartment.
o Pulmonary edema
 Having someone periodically review with them
o Brain stem abnormalities
what steps to take should the alarm sound
o Neurotransmitter deficiencies
(jiggle the baby, begin mouth-to-mouth
o Heart rate abnormalities
resuscitation, call the emergency response
o Distorted familial breathing patterns
personnel) can be very comforting.
 do not appear to make any sound as they die,
which indicates they die with laryngospasm. Periventricular Leukomalacia
 autopsy often reveals petechiae in the lungs
 abnormal formation of the white matter of the
and mild inflammation and congestion in the
brain
respiratory tract.
 caused by an ischemic episode that interferes
 American Academy of Pediatrics made its
with circulation to a portion of the brain.
recommendation to put newborns to sleep on
o Phagocytes and macrophages invade the
their back and with a pacifier, the incidence of
area to clear away necrotic tissue.
SIDS has declined
o What is left is an abnormality in the white
 Many parents experience a period of somatic
matter of the brain
symptoms that occur with acute grief, such as
 most frequently in preterm infants who
nausea, stomach pain, or vertigo.
experience cerebral ischemia.
 Parents should be counseled by a nurse or
 infants may die of the original insult; they may
someone else trained in counseling at the time
be left with long-term effects such as learning
of the infant’s death; it helps if they can talk to
disabilities.
this same person periodically for however long it

takes to resolve their grief.
 Reading that their child’s death was
unexplained can help to reassure parents the
death was not their fault.