1
Q
Normal findings head to toe assessment
A
- uncovering infant
- observe positioning
- looking at symmetry of movement
- skin for bruising, abrasion, rashes, birthmarks
- skin colour: pallor, cyanosis
- skin: clear? tissue turgor satisfactory?
- baby feel warm?
- stethoscope (warm it first): auscultate chest and abdomen –> for heart and bowel sounds
- while baby is calm & quiet: listen for respirations and quality of sounds on each side of chest (upper and lower lung field)
- RR: 30-60 breaths per minute
- Heart rate for full minute (100-160bpm) for any irregularities
- murmur may be normal
- bowel sounds in all 4 quadrants
- abdomen: soft? round?
HEAD - look at the side and size of head
- look for caput succedaneum (slight swelling on presenting part and cross suture line): pitting indentation (edema): resolve spontaneously 3-4days
- look for cephalohematoma: blood collected between skull bone and periosteum (swelling dont cross suture line): increases in the first 3-4days and resolve 2-3weeks
- assess anterior fontanelle and posterior fontanelle: feel for fullness or bulge
- fontanelle: soft? flat? sutures approximated?
- feel over suture bones (may still be overlapped)
- check ear for normal shape and position (any asymmetry?)
- check eyes (in align with pinna ears)
- note rotation of neck as you turn infants head
- neck: masses? crepitus?
FACE - look for symmetry of eyes, eyelid edema resolve 2-3days,
- assess lips, nail beds, earlobes for cyanosis
- observe nose for nasal flaring
- check palate and note the sucking reflex, can tongue extend itself beyond the lower lip or is there tongue tied?
- displaying rooting relfex: stroking baby cheek and to see if he turns in that same direction of the stroking
CHEST - note work of breathing,
- note retraction: subcostal, intercostal or substernal
- check to see if chest and abdomen are symmetrical
- check capillary refill by pressing on sternum and toes,
- look at umbilicus
- if cord clamp on: 3 vessel cord (2 arteries, 1 vein) –> keep this area clean and dry
Open diaper: - move down to check femoral pulses (in line with the nipples): hold your two fingers down in that area and feel for the pulses
- once you feel the femoral pulse, go feel for the brachial pulse: to assess if they are even
GENITAL and ANUS - stooling? voiding?
- may appear swollen (normal): resolve 2-3 days
- for female: inspect urethra, vagina, and anus: note patency of vaginal opening
- for male: note size and location of urethra: hypospadias (under side) or epispadius (on top of penis)
- DO NOT retract the foreskin
- palpate testes to make sure they have descended
- turn baby over to check anus patency
- may have mongolian spots (buttock or on back): benign + flat + congenital birth mark with wavy borders + irregular shape –> resolve by puberty
- while baby is prone check spine
SPINE - looking for curvature of spine and its intactness. look at the bottom of spine for sacral dimple
- return infant to its back
HANDS - how many fingers
- open each hand and look for palmar creases (2 creases on each hand)
LEG - are they equal in length
- rotate at the joints easily?
- observe foot position
- assess toes for colour and capillary refill
TEMP - check temperature auxillary 36.5-37.2: hold arm across chest with probe under armpit
WEIGHT - weight loss? gain?
DRESS the baby again - all infant are at risk for temperature instability
2
Q
Whats included in the clinical decision-making process?
A
- knowing the self
- knowing the profession
- knowing the case
- knowing the person
- knowing the patient
- thinking
- cues, judgement, decision-making, and evaluation
3
Q
What is the difference of basic assessment and in-depth assessment?
A
- Basic assessment is aimed at gathering basic data from all systems.
- In-depth assessment is aimed at gathering more than basic data
- Some infants will require only basic assessments. If they remain vulnerable, but do not become ill, they may never require more than a basic assessment.
- Infants who do become ill will likely require both a basic assessment and a more in-depth assessment.
4
Q
What can be gathered from “hands off” assessment of infant?
A
- Tone and colour are readily apparent.
- Work of breathing, chest movement, and respiratory rate can be determined.
- Movements, position, sleep–wake state, and responsiveness can be observed.
- The abdomen may be visible, depending on the infant’s position.
- IV sites may also be visible.
- Monitors reveal HR, RR, and O2 saturation
5
Q
When is hands on and hands off assessment done?
A
- Hands-off assessment is done continuously.
- Hands-on assessment is done routinely with handling and otherwise only when needed.
- Unless an infant must be disturbed for another reason, they should be assessed in a hands-off manner: colour, sleep/wake state, RR, work of breathing, tone
- Hands-on assessment should be done with other handling unless there are abnormal findings in the hands-off assessment that warrant handling: head to toe assessment
6
Q
What is systematic inquiry?
A
- correct diagnosis requires systemic inquiry aimed at compiling a complete picture of sources of vulnerability, risk factors, and clusters of signs.
- This enables you to create a list of more likely problems and eliminate less likely diagnoses.
- from a list of more likely problems, you can continue to systematically inquire, look for pieces of information that were previously missing, ask specific questions, and hone in until you have identified one or two most likely explanations for an infant’s illness.
7
Q
What is an important factor to consider when determining infants vulnerability?
A
- their gestational age
- premature infant: particularly vulnerable because their organ systems are not only immature, but so much so that extrauterine life poses a severe threat to the functioning of those systems
- late premature infant: are challenging to care for because we aren’t always sure about the likelihood that a particular problem will occur.
8
Q
What can be used to determine gestational age (3)?
A
- date of the mother’s last menstrual period,
- ultrasound measurements, and
- fundal height
9
Q
What is vernix? lanugo?
A
Vernix caseosa:
- is a white, creamy, naturally occurring biofilm covering the skin of the fetus during the last trimester of pregnancy.
- Vernix coating on the neonatal skin protects the newborn skin
Lanugo:
- Lanugo is fine, soft, unpigmented hair that is often present in fetuses, newborns,
10
Q
Does the uncertainty about how a late-preterm infant can be expected to do increase the infant’s vulnerability?
A
- particularly when an infant’s actual gestational age is not accurately estimated and the infant is younger than the staff think he or she is.
- These kinds of inaccuracies can prevent borderline premature infants from receiving the monitoring and care appropriate for their degree of vulnerability
11
Q
What are 3 signs of infant developing respiratory distress?
A
- tachypnea (ex. RR 68)
- hypothermia (ex. 36.2)
- feeding difficulties
12
Q
What are some problems late pre term infants at risk for in every system (1)?
A
- respiratory: RDS, transient tachypnea of the newborn (TTN)
- cardiovascular: patent ductus arteriosus (PDA)
- neurological: intraventricular hemorrhage (IVH)
- gastrointestinal: NEC, feeding difficulties
- genitourinary: fluid and electrolyte imblanace
- metabolic: hypothermia, hyperbilirubinemia
- immune: sepsis
13
Q
What is P from PWSOAC framework?
A
Pink: Establish and maintain respirations
- initial breaths are swallow and irregular
- normal RR is 30-60
- infant are nasal breathers
- RR and WOB should be monitored
- skin to skin contact be maintained
14
Q
What is W in PWOSAC framework?
A
Warm: regulate temperature
- Thermoregulation: the balance between heat loss and heat production
- Thermogenesis: primarily from brown fat
- Newborns have a large surface area -to-body weight ratio.
- Changes in environmental temperature will affect the infant.
- Temperature needs to be monitored.
- Skin-to-skin contact should be maintained.
15
Q
What are the 4 ways heat loss happens in infants? What are the preventions for each one?
A
Evaporation:
- Loss of heat through conversion of a liquid to a vapour as water evaporates from the infant’s body—about 20%:
- Dry the NB immediately after birth to prevent heat loss (32 weeks and under—do not dry, immediately place in a polyethylene plastic bag).
Conduction:
- Transfer of body heat to a cooler solid object in contact with the body —about 5%
- Do not place NB on cold surfaces such as the weighing scale.
Convection:
- Flow of heat from body surface to cooler surroundings—about 40%
- Wrap the NB immediately with a blanket and promote flexion to minimize body surface exposed to cool air.
Radiation:
- Transfer of body heat to a cooler solid object not in contact with the body—about 40%
- Wrap the NB immediately with a blanket and promote flexion.
16
Q
What is S in PWSOAC framework?
A
Sweet: Maintain blood sugar
-Provide early access to breast, bottle, NG/OG feeds, or intravenous therapy for nutrition.
- Monitor blood sugar levels.
- Monitor intake.
- Maintain skin-to-skin contact.
17
Q
What is O in PWSOAC framework (3)?
A
Organized: Maintain an optimum state
- An organized infant is one that is free of stress; this allows for optimal growth as stress increases calorie consumption.
- Pace handling of the infant.
- Limit invasive procedures if possible; if not, provide supportive care.
- Bundle care to allow for long periods of uninterrupted sleep.
- Limit noise to protect sleep.
- Provide non-pharmacologic and pharmacologic pain management as appropriate.
- Maintain skin-to-skin contact.
18
Q
What is A in PWSOAC framework?
A
Attached: Promote attachment with family
- Facilitate care by parents.
- Provide family-centred care.
- Encourage and support breastfeeding.
- Maintain skin-to-skin contact.
19
Q
What is C in PWSOAC framework?
A
Clean: Protect from infection
-Ensure hand-washing.
- Follow aseptic procedures.
- Ensure aseptic IV and central line insertion and management.
- Bathe as per hospital protocol.
- Change IV solutions/tubing as per hospital protocol.
- Provide mouth care/OIT with breast milk/colostrum.
- Feed with mother’s own/donor breast milk.
- Monitor for signs and symptoms of infection (temperature, CBC, CRP, blood culture, LP, IV site monitoring, perfusion, colour, VS, WOB).
- Clean and change isolette/cot as per hospital protocol.
- Change linen as per hospital protocol.
- Maintain skin-to-skin contact.
20
Q
What makes late pre-term infants experience mild degree RDS?
A
directly related to their prematurity:
- lower levels of surfactant,
- fewer alveoli,
- fewer capillaries,
- weak respiratory muscles, and a
- compliant rib cage.
21
Q
What is transient tachypnea of the newborn (TTN) or wet lung?
A
- respiratory disorder (temporary difficulty with breathing)
- caused by a delay in the clearing of fluid from the lungs after birth
22
Q
What is the difference between RDS and TTN?
A
RDS is a problem of immature lungs:
- few alveoli,
- few capillaries,
- soft rib cage,
- weak muscles,
- lack of surfactant
RDS typically affects preterm infants, and the lower the gestational age, the more likely RDS is to develop.
TTN is a problem of inadequate clearage of lung fluid immediately after birth.
- TTN typically affects infants born by C-section
- those born without labour.
**RDS is restrictive, TTN is obstructive.
23
Q
Which infant are most at risk for pneumonia? why?
A
Preterm infants are most at risk because:
- their immune systems are immature.
- have less IgG (passed transplacentally in the last trimester),
- likely to be intubated and experience other invasive procedures.
Other infants at risk are those born to mothers who:
- are Group B streptococcus positive,
- have a UTI,
- have fever, or
- have prolonged rupture of membranes.
Any infant who is ill and/or is in the NICU is at increased risk.
- Handling by multiple caregivers and invasive procedures threaten to introduce microorganisms.
- Colonization can quickly become infection and, just as quickly, sepsis.
- Term newborns are less at risk as their immune systems are somewhat more developed, but are still immature.
**Until age 3, children’s immune systems are growing and developing.
24
Q
What can be done to keep infant pink (3)?
A
- monitor with pulse oximetry
- keep oxygen saturations 90% or greater
- position prone with head of bed slightly elevated (only when monitored)
- maintain temperature
- minimize handling
- prevent pneumonia with clean and aseptic techniques
- provide comfort and other developmentally supportive measures
- facilitate skin-to-skin care with parents
25
What are some reasons as to why oxygenation could be supported by positioning infant prone with head of his bed slightly elevated (2)?
- the infants feel safe, contained, and comfortable (leading to better sleep and decreased oxygen consumption),
- the position allows for increased perfusion to the dorsal lung fields,
- decreasing ventilation/perfusion mismatching,
- improved lung expansion
26
What are the benefits of good positioning for infant (3)?
- promotes improved rest
- supports optimal growth
- helps normalize neurobehavioural organization
- increase sense of security and support through containment
- decrease stress
- makes infant calmer
- helps gain weight
- support self-regulation behaviours
27
What are the Phillips positioning tool include (6)?
- Snuggle up: help provide proper positioning and physiological stability
- bendy bumper: promote containment and flexion, provide a reflex stimulus
- Frederick t frog: mimics comforting hands to support around head and neck. weighted support
- Prone plus: provides ventral support, help support NB to facilitate natural rounding of the shoulders, hand to mouth coordination
- Gel-E donuts: assist in alleviating pressure (head molding)
- Squishon 2 & 3: support NB head and body, help relieve pressure caused by prolonged immobility
28
What sleeping positions can Philips positioning tool for infants?
- supine
- side lying
- prone
29
What is the infant normal temperature? hypothermia?
- normal: 36.5- 37.5
- cold stress or mild hypothermia: 36.0 - 36.4
- moderate hypothermia: 32.0 - 35.9
- severe hypothermia: <32.0
30
What is non-shivering thermogenesis?
- the main mechanism of heat production in neonates (use of brown fat)
- process in which newborns produce heat by increasing their metabolic rate.
- This type of heat production has a large caloric demand
31
What are 2 consequences of cold stress?
- increased metabolic rate: decreased surfactant production + hypoxemia, increase consumption of glucose, failure to gain weight
- metabolism of brown fat: metabolic acidosis
32
What happens when the metabolic rate increased due to cold stress (3)?
(1) Decreased surfactant production and hypoxemia leading to respiratory distress:
- When the metabolic rate of a neonate is increased, the need for oxygen also increases.
- As cold stress progresses, surfactant production also diminishes, thereby impeding lung expansion.
- As a result, hypoxemia will be noted and mild respiratory distress can become severe hypoxia if oxygen must be used for heat production
(2) Increased consumption of glucose, resulting in hypoglycemia:
- When the metabolic rate rises for the body to produce heat, the glucose requirement also increases.
- As the demand of glucose surges, the body compensates for this need by converting glycogen stores to glucose.
- When glycogen stores are converted to glucose, they may be quickly used up, resulting in hypoglycemia.
(3) Failure to gain weight:
- Infants who must use glucose for temperature regulation and maintenance have a smaller available supply for growth and development.
33
What happens when brown fat is metabolized in presence of low O2 supply due to cold stress?
- When brown fats are metabolized in the presence of insufficient oxygen supply, increased acid production will result.
- Rising amount of acids causes metabolic acidosis, which can be a life-threatening condition.
- Aside from that, elevated fatty acids in the blood can interfere with the transport of bilirubin to the liver for conjugation, thus increasing the risk of jaundice in a newborn.
34
What are some factors contributing to a preterm infant temperature being below normal (3)?
- small size,
- decreased fat stores/brown fat,
- large body-surface-to-weight ratio,
- poor feeding/lack of intake resulting in decreased ability to generate heat
- immature CNS response,
- lack of ability to regulate temperature
- radiant and convective heat loss due to cool ambient temperature
- evaporative heat loss from respiratory distress/dry environment/uncovered while feeding/visiting
35
How often would nurse check infants temperature if its below normal? for how long?
- Q1H until stable and normal,
- then Q3–4H with handling
36
What are some ways to increase infants temperature (3)?
- such as skin-to-skin cuddling,
- incubator,
- radiant overhead warmer, and
- use of a blanket and hat,
- plastic bag/wrap,
- skin protectors,
- humidity, and
- warming pads
37
Why is humidity important factor in thermoregulation?
- Very preterm infants require the addition of humidity to their isolette in order to prevent heat loss and reduced trans-epidermal water loss.
- more premature the infant is, the higher percentage of humidity they require. For example, an infant less that 28 weeks will require 85% humidity initially,
- while an infant born greater than 32 weeks will not require any additional humidity at all
**Infants are generally slowly weaned off humidity to support the maturation of the epidermis and stratum corneum (the outermost layer of the skin).
38
What are some nursing care aimed at minimizing hypothermia (3)?
- monitoring temperature Q1H until stable, then Q3–4H with handling
- maintaining neutral thermal temperature
- preventing heat loss by evaporation, radiation, convection, and conduction
- using skin-to-skin contact to provide thermoregulation
- using isolette to provide heat
- weaning to a cot with clothes, blankets, and a hat when stable
39
What are some feeding difficulty a late preterm infant have (3)?
- be sleepy and require waking for feeding
- need assistance to latch effectively and stimulation throughout the feed in order to take in sufficient calories for growth
- tire easily
- have immature suck/swallow reflexes; this results in an inability to feed without assistance and gavage feeds may be necessary
- have increased risk for jaundice and may therefore be drowsy
40
What should be closely monitored to ensure infant getting required amount of nutrition to promote growth and development (3)?
- feeding patterns
- time
- weight
41
What is premature infant at risk for due to decreased glycogen stores?
- hypoglycemia
42
A mother mentions about bottle feeding while breastfeeding, how would a nurse counsel the family about breastfeeding?
- clarify any misconceptions
- we have a lot of strategies to deal with breastfeeding problems;
- that low milk supply is usually easily remedied with attention to simple measures such as position and latch
- discuss supply and demand principle of breastfeeding and how bottles can interfere with this
- ensure family are well informed regarding benefits of breastfeeding
- ensure that mom is well informed regarding potential hazards of introducing bottles before breastfeeding is well established and
- that bottling once per day may decrease duration of breastfeeding and milk supply
- teach and support pumping to establish milk supply
- discuss the role that fathers can play in care other than feeding: diapering, bathing, settling babe to sleep, playing, quiet time
** support their choice once you know they have made a well-informed choice and clarify any concern parents may have
43
What is gavage fed?
- A way of giving medicines and liquids, including liquid foods, through a small tube placed through the nose or mouth into the stomach or small intestine.
- she will have to feed “measured” amounts, either via N/G tube.
44
What are some assessment and monitoring guidelines for late preterm infants after birth (3)?
- newborn assessments and weight daily
- vital signs hourly x 3 hours; then Q4H x 24 hours
- blood glucose at 2 hours of age; notify physician if result less than 2.6 mmol/L
- support breastfeeding with minimum Q2 to Q3H (minimum 8 feeds/24hours) and continuous skin-to-skin contact with mother (or other family member)
- refer to lactation consultant
- bilirubin monitoring
45
What kind of nursing assessment/monitoring should be done for unstable premature infant?
- temperature q 1 hour until stable
- thorough hands-on assessment when awake or when disturbed for feeds: head-to-toe assessment
- hands-off assessment about q 2 hours until stable: colour, sleep/wake state, RR, work of breathing, tone
46
What are the assessment when monitoring infants fluid balance (3)?
- weight
- urine output
- serum sodium
- tissue turgor
- fontanelles
- mucous membranes
- vital signs
**recommended guideline provided in your text of 80 mL/kg/day
47
How do we calculate how much infant needs to eat/ have IV fluids on hourly basis?
The equation is:
- Step 1: Convert infant’s weight from grams to kilograms (1,000 gm = 1 kg): physician’s orders are generally in kilograms.
- Step 2: Multiply the physician’s order (or the guideline being used) by the infant’s weight.
- Step 3: Divide by 24 hours in order to get an hourly intake.
Example:
80 mL/kg/day × 2.25 kg = 180 mL/day
180 ÷ 24 = 7.5 mL/hr
7.5 × 2 = 15 mL Q2H
7.5 × 3= 22.5 mL Q3H
48
What weight is used to calculate fluids? birth weight or daily weight?
- Birth weight: use for the first few days as the infant will lose weight
- Daily weight: use once the infant’s weight surpasses the birth weight
49
What is the relationship of "vaginal squeeze" and lung clearance in infant?
- the “vaginal squeeze” that occurs during vaginal delivery is what starts lung fluid clearance
- without that squeeze, fluid was retained
50
What is the relationship of C-section and TTN?
- rate of TTN increases as more C-sections are performed
- Infants born by C-section appear to be less able to clear lung fluid and often take several days to complete the process.
- During this time, the excess fluid interferes with alveolar expansion and tidal volume diminishes.
- In order to compensate for the lowered tidal volume and still maintain minute ventilation, the rate of breathing increases, leading to the tachypnea typically seen in these infant
51
What is the relationship of gut microbiome and vaginal birth vs caesarean birth?
- gut microbiome is thought to be responsible for many different health factors, including gut and immune system development.
- When infants are born vaginally, their guts becomes colonized with the beneficial bacteria in the birth canal;
- when they are born via C-section, this microbiota is altered.
52
What are some factors c-section birth interfere with (3)?
- increase risk of TTN
- infant less able to clear lung fluid
- gut microbiome is altered
- separated from mother for a period of time:
- delay of skin to skin: negatively affect attachment and breastfeeding.
53
What is late preterm?
- 34.0 to 36.6 weeks
- may be in NICU or postpartum
- care is like term babies
54
What is LBW? VLBW? ELBW?
- low birth weight <2500g
- very low birth weight <1500g
- extremely low birth weight <1000g
55
What is the difference gestation age (GA)? day of life (DOL)? postmenstrual age (PMA)?
- gestational age: estimated time since conception/born at this many weeks
- day of life (DOL): days since birth
- postmenstrual age (PMA): corrected gestational age
GA: 32+1 weeks
DOL: 2
PMA: 32+3 weeks
56
What is thermoregulation?
-the ability to keep body temperature within certain boundaries even when the surrounding temperature is very different
57
What does thermoregulation depends on (3)?
- integrity of CNS
- adequacy of brown fat
- availability of O2 and glucose
58
What reasons that premature infants are at risk for temperature instability (3)?
- Large skin surface area for the weight of infant
- Decrease in subcutaneous fat and thus less insulation
- Less brown fat
- Inability to acquire enough calories to provide nutrients for thermogenesis
- 02 consumption is limited in some babies because of pulmonary problems
59
How can babies warm themselves?
babies cant shiver so babies uses non-shivering thermogenesis:
- burn brown fat
- convert glycogen to glucose
- initially blood sugar goes up and then will go down depleting any stores the baby may have
- become active/irritable depends on age and weight of baby
60
What is neutral thermal environment (NTE)? How can nurses help to minimize infant baby O2 consumption (3)?
- when the baby is able to use the least amount of energy, oxygen, and calories to maintain normal temperature
Nurses help:
- overhead warmer
- cot
- incubator
- skin to skin
- hat on head
61
What is cold stress? what can it lead to (2)?
- a body temp of ≤ 36.4°C as mild hypothermia
Leads to:
- Metabolic acidosis
- Hypo or hyperglycemia
- Apneas, tachypnea, bradycardia, tachycardia
- Hypoxia and shock
- Irritability, lethargy
- Pale, mottled
62
What makes newborn at risk for hypothermia? What makes premature infants at increased risk for hypothermia?
newborns:
- Limited CNS control over temperature
- Limited ability to shiver or vasoconstrict
- Larger surface-area-to-body-mass ratio
premature:
- less white and brown fat
- less ability to flex
- higher insensible water loss
63
How does infant body respond to hypothermia?
- Initially the infant will respond with peripheral vasoconstriction leading to anaerobic metabolism and metabolic acidosis
- This may cause pulmonary vasoconstriction leading to enhanced hypoxia in an already hypoxic body
64
During hypothermia, what does increasing metabolic rate causes (3)?
- Decreased surfactant production
- Increased oxygen consumption
- Increased glucose consumption
↑ metabolic rate → ↑ glucose requirement → hypoglycemia
- Poor weight gain
- Metabolism of brown fat (except preterms)
65
Does infants shiver to keep warm?
- no
- to thermoregulate when they are cold: they use non-shivering thermogenesis (heat produced by increasing metabolic rate)
66
What are things that can be done to keep baby warm (4)?
- warm delivery room
- immediate drying
- skin to skin
- breastfeeding
- bathing and weighing postponed
- appropriate clothing and bedding
- mother and baby together
- warm transportation
- warm resuscitation
- staff and family member education
67
What are 4 ways heat can be loss? 3 nursing care for each way?
- radiation: occur when heat is loss to cooler object surrounding infant although there is no skin to skin contact (Cold wall, window). nursing care: hat, bundled, flexed nested position, double wall incubator
- convection: the loss of heat from infant to cold air. nursing care: nurse baby in incubator, ambient temp ~25, avoid air draft
- evaporation: when wet surface are exposed to air. nursing care: dry baby, use medium to high humidity in incubator, place infant <32 week in plastic bag
- conduction: when skin come in direct contact with cooler surface. nursing care: pre-warming bedding, cover scale with towel, ensure dry bedding
68
What is hyperthermia? What are the causes? What is the nursing care?
- axillary temp >37.5
causes:
- latogenic,
- infections
- CNS disorders
- maternal hyperthermia,
- certain medication: prostaglandin
Nursing care:
- need to figure the cause and treat it
- infection? antibiotics
- environment too hot? wearing too many layers?
69
What is glucose?
- Glucose is the main source of energy for brain cells
- Metabolized in the body to produce energy to fuel essential body functions
- Regulated by insulin and glucagon
- At birth, the principal source of blood glucose must shift from the placenta to the baby’s own energy stores (endogenous) within minutes
70
How does glucose and insulin work?
Glucose is used by all tissues of the body:
- serves as the chief source of energy in the body
- the body makes glucose from proteins, fats and, in largest part carbohydrates
- glucose is carried to each cell through the bloodstream
- Cells cannot use glucose without the help of insulin
- A preterm infant’s brain accounts for the most use of glucose
- glucose is the mail and insulin is the mail carrier
71
What is a normal blood sugar level?
- normal range 2.6 to 10 mmol/L
- <2.6 is critical low
- >10 is critical high
***infant with glucose less than 2.6 in first 72 hours is hypoglycemia
72
Why might hypoglycaemia occur for all infants after birth?
- Glucose production & intake cannot meet the rate of glucose utilization
Ex. Infants born to diabetic mothers
Placenta delivering glucose to fetus → ↑ glucose crossing placenta → fetus’ pancreas secretes ↑ insulin → BIRTH → ↑ glucose crossing placenta come to abrupt stop → ↑ insulin continues → Hypoglycemia
73
What is transitional vs persistent hypoglycaemia? Risk factors?
transitional:
- blood sugar <2.6mmol/L in the first 2-72hours
risk factors:
-Prematurity including late preterm
- SGA/IUGR
- Stressed and asphyxiated
- Cold stress
- Sepsis
- Congenital heart disease
- LGA > 4.5 Kg
- Infants of diabetic mothers (well managed)
persistent:
- blood sugar <3.3 mmol/L beyond 72 hours
risk factors:
- Infants of diabetic mothers (unstable glucose mgmt)
- Hyperinsulinemia
- Metabolic & endocrine disorders: Beckwith-Wiedemann syndrome
74
What are signs and symptoms of hypoglycaemia(4)?
- poor feeding
- vomiting
- apnea
- ABDs
- hypothermia
- jitteriness, grunting, irritability
- lethargy
- tremor and seizure
- hypotonic
- diaphoresis
75
When should nurse check for hypogylcemia?
- 2 hours of age for at risk newborns (such as late-preterm)
- If symptomatic
Nursing care:
- Preform point of care test
- Refer to CPS/ACORN Hypoglycemia protocol
- May need to increase feeding amount and frequency
- May need to start PIV & give a dextrose bolus
- Change fluids to higher dextrose concentration
76
What is hyperglycemia? What causes it? treatment?
- blood glucose >10mmol/L
- Prematurity
- IUGR
- Stress
- Sepsis
- Asphyxiated infants
- Infants on TPN (incorrect infusion)
- Medications – (phenytoin, steroids)
- Surgery
treatment:
- lower blood sugar by treating the cause
- changing the fluid
- starting antibiotics if septic
- starting infusion of insulin (acute care)
- repeat blood sugar to assess effectiveness of change
77
What are the nutrition goals for infants?
- Achieve postnatal growth rates approximating to intrauterine growth
- Prevent nutritional deficiency such as anaemia of prematurity
- Optimize long term neurodevelopmental outcome
- Prevent feeding related morbidities such as NEC
**Premature infants have greater nutrition needs due to their faster growth and increased metabolic rate
78
What are 3 factors that affect nutritional needs in infants?
- gestational age
- environmental stress
- health status
- baby fever? baby ill?
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What are some nutritional route?
total parental nutrition
- IV: UVC, PICC, PIV
enteral nutrition
- NG, OG tube feeding
- bottle feeding by mouth PO feeds
- breastfeeding PO feeds
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How are preterm infant <32 weeks fed?
- All neonates born <32 weeks will start on TPN in conjunct with enteral feeds
- Enteral feeds start within 24 – 72 hours: Enteral feeds initially started by NG/OG
Why NG/OG and not by mouth?
- Unable to coordinate suck-swallow breathe until approx. 33 weeks (32-34 weeks)
- Any GA on respiratory support
81
What are some NG vs OG considerations?
Ng:
- Baby can breast/bottle feed with NG
- Baby can have NG feed when intubated
OG:
- Use OG when infant is on non-invasive respiratory support
* Nare partially occluded ↑ work of breathing → secretions around NG
82
How does check NG/OG placement?
- measured from nare to earlobe to middle of xiphoid process and umbilicus
- Auscultation not reliable
- Ph testing
- check marking and measurement
- check tapes are secure
- check X-ray
83
What are some nursing care for NG/OG?
- changed: q30days
- open or closed barrel: if on CPAP then open barrel to allow air/gas to escape
- size of tube: 5Fr for NG and 6.5Fr for OG
- bolus: is by gravity
- pump: if infant is spitting up then on pump for 1 hr
- continuous: for infant <1000g
84
Whats oral immune therapy (OIT)?
- Given when infant cannot feed by mouth
- OIT is used with fresh colostrum/EBM
- Colostrum contains many beneficial immune, bioactive & trophic substances
- Colostrum interacts with lymphoid tissue in the oropharynx and gut
- 0.1mL buccal q2-4hrs
- Administer using Q-tip or soother buccally
- NPO is not a contraindication
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What is a standardized feeding plans?
- Preterm neonates start on feeds (such as standardized feeding plans) within 24-72 hours after
birth
- Must be on intravenous fluids (ie.TPN) in order to use feeding plans
- Birthweight of <1000g – start with trophic feeds
- Trophic feeds are not included in the total fluid intake (TFI)
- Stimulates GI hormones, motility, & maturation
86
How is increasing feeds and weaning IV done?
- When feeds are started and tolerated, or increased, you need to reduce intravenous fluids to maintain ordered TFI
- First: Decrease dextrose (if dextrose running)
- Then: Decrease TPN (rate can change)
- Lipid rate must be lower or equal to TPN rate
- D/C lipids if unachievable (lipids will never run lower than your primene)
- TPN is last to stop when full oral feeds reached
**feeds and lipids dont get changed
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How is oral feeding readiness assessed (3)?
- co-ordination of suck-swallow-breathing
- minimal ABDs
- quiet alert behavioural state
- focused and attentive
- oral aversion: unpleasantness in mouth
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What are 4 benefits of expressed breast milk?
- nutritional advantage
- immunological protection
- reduced incidence of infections
- improve feeding tolerance
- enhanced maternal self esteem
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Whats one way to ensure good lactation? How often to express milk?
- start expressing ASAP after birth
- encourage all mothers to hand express/pump
- small amounts can be used for OIT
- Establishing supply: 7-8 times per day (including night)
- Maintaining supply: 5-6 hours per day
90
What is expressed milk/mature milk?
- Mature milk is produced from approximately ten days after delivery up until the termination of the breastfeeding
Mature milk contains:
- Energy
- Lipids- fat
- Casein - protein
- Whey - protein
- Non-protein Nitrogen - amino acids
- Lactose - carbohydrate
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What are some factors for expressing breast milk correctly?
- Good hand washing
- Right labeling
- Correct use of equipment
- Best storage
- Double checking/scanning
- Careful handling
Storage:
- room temp: 6 hr
- refrigerator: 72hrs
- freezer in fridge: 1 month
- freezer with separate fridge door: 6 months
- deep freezer: 6-12months
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What happens if error occurs with EBM?
- Like blood and medications, EBM is double checked by two nurses to prevent the small chance of transmission occurring
- If an error occurs, then parents will need to be informed
- Blood tests/ serology will be required from donor mother and recipient baby
93
What is pasteurized donor milk (PDHM)?
- The purpose of PDHM is to provide breastmilk rather than formula until mother’s own milk comes in
- Milk is screened and pasteurized some protection is lost
- Strict criteria to donate milk: smoker cant donate
- Can be used in LDR and NICU
- Criteria constantly changing
- Refer to PSBC for current criteria
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Whats formula?
- Manufactured under sterile conditions,
- commercial formulas attempt to duplicate mother's milk using a complex combination of proteins, sugars, fats, and vitamins
95
What are the different type formulas?
- term: enfamil
- preterm: enfamil premature
- Neocate or Nutramigen AA: Short bowel syndrome – free of amino acids
- Pregestimil A+: MCT oil, Hypoallergenic term formula
- Nutramigen A+: No MCT oil, Hypoallergenic term formula
- Alimentum: Hypoallergenic term forumla
- Lipidstart: Chylothorax infants – high MCH oil decreases flow of fat to allow healing
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Whats EBM fortifiers?
Human Milk Fortifier (HMF) to provide preterm infants with additional supplements to enhance their growth
- additional protein
- vitamins
- calcium
- phosphorous
- plus calories
- Along with the protective and nutritional benefits of mother’s own milk
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What are some blood work monitoring done for enteral nutrition
- Weekly; every other week
- Iron status
- Electrolyte status
- Bone status (Cai, PO4, ALK Phos)
- Protein status (BUN, ALB, Prealbumin)
- Urine Na (GI babies)
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Whats NON NUTRITIVE SUCKING (NNS)?
- Refers to sucking without liquid
- Can be done at the breast or with a pacifier
- Encouraged for infants who cannot feed by mouth (premature, acutely ill)
Increases periods of:
- Alert/wakefulness
- Self soothing behavior
- Less crying
- Heartrate stability
99
What are pros and cons of bottle feeding (3)?
LIMITATIONS:
* Decrease interest in breast
* Reduces motivation to continue breastfeeding
* Expense if formula used
* Bottle preference
ADVANATAGE:
* Intake amount known
* Other caregivers can help
* Can individualize flow
100
What should be consider when choosing formula milks?
- infants gestation
- intrauterine growth
- weight
- bottle: PDHM, EMB, formula
- HMF can not be added to a bottle of formula when feeding infant
**When intermediate formulas are not used the infant should receive iron and vitamin supplements (vitamin D, trivasol)
101
What are some benefits of skin to skin for infants? for parents?
infants:
- Infants thermo-regulate
- Has more deep sleep and quiet alertness
- Fewer episodes of periodic breathing
- Less apnea and bradycardia
- Greater weight gain
- Decrease pain response to painful stimuli
- Less crying
- No increase in infections
parents:
- Increase and lasting lactation
- Easier transition to breastfeeding
- Builds parental confidence
- Parents recognize & respond to their infant's behavioral cues
- Decrease in Maternal stress
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What should be considered for skin to skin?
- Allow a minimum of 30 minutes as many infants fall into a deep sleep during cuddling
- Signs of unrest during cuddling, in spite of consoling interventions, indicates the need for the infant to be returned to bed
- Discuss observations with parents and provide reassurance to support the parent's confidence
- Plan the next cuddling occasion with parents
- No age restriction
- Stable respiratory support not requiring arterial lines
- Securely taped ETT
Infant has shown ability to:
- recover from baseline vital signs after procedures temperature stability.
- minimal bradycardia and/or desaturations with handling
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If an infant who is at risk for hypoglycemia has glucose of 2.3, it would be appropriate to feed ad lib and recheck prior to next feed.
false
104
An undressed infant placed directly on a weighing scale will lose heat by?
- conduction
105
If an infant who is at risk for hypoglycemia has glucose ≥2.6 mmol/L, it would be appropriate to feed ad lib and recheck prior to next feed.
true
