Prelim – NCM109MCP (Pedia) PDF

NCM109MCP NOTE: Prematurity usually encounters problems Pediatrics with the Respiratory System. Care of Mother and Child...

NCM109MCP NOTE: Prematurity usually encounters problems Pediatrics with the Respiratory System. Care of Mother and Child - If a baby is premature, (born before 37 (at Risk or with Problems) weeks of pregnancy), they may NOT have made enough surfactant yet. Prepared by: - When there is not enough surfactant, the tiny alveoli collapse with each breath. Elmelyn Grace E. Basa - As the alveoli collapse, damaged cells Bachelor of Science in Nursing collect in the airways—they further affect breathing. 2nd Year (Second Semester) INTERVENTION: PRELIM Delay delivery Administer tocolytic. Prematurity ✓ Epinephrine Postmaturity ✓ Magnesium Sulfate Sepsis - Effects within 48 hours. Large for Gestational Age - For uterine relaxation. Small for Gestational Age Administer glucocorticoids. Hyperbilirubinemia - Given to the mother. Respiratory Distress Syndrome (RDS) - Produces surfactant. Meconium Aspiration Syndrome (MAS) - For lung maturity of the baby. Betamethasone – speeds up lung PREMATURITY maturity. I. Subcategories of Preterm Birth: II. Etiology < 37 weeks = Late Preterm < 34 weeks = Moderate Preterm There is an unknown cause of premature < 32 weeks = Very Premature labor and delivery. < 28 weeks = Extremely Premature Proceeded by premature rupture of membrane. 38 weeks = Full Term Infant ✓ 40 weeks (in some sources) Preterm may be: ✓ 38–42 weeks (in some sources) a. Elective - Conditions such as multiple gestation with Premature baby has NO surfactant. complications. - Pre-eclampsia - Placenta Previa/Placenta Accreta What is Surfactant? - Premature ROM Surfactant - Possible CS delivery - It reduces surface tension in alveoli. - It is good for breathing outside the b. Spontaneous womb. - May have/not an obvious immediate trigger. - It is mixture of proteins. - Example: Infection, Placental Abruption - It is developed within 25–34 weeks of gestation. III. Risk Factors a. Past Obstetric History - Prior to premature births - Prior to multiple pregnancies 1  - Prior to multiple therapeutic NOTE abortions/spontaneous miscarriages - Ideally, an infant should weigh between 2.5kg–3.5kg. b. Current Pregnancy – Related Factors - In-vitro fertilization - No prenatal care - Underdeveloped reflexes – happens - Poor nutrition during gestation involuntarily in response to stimulation. - Maternal age Moro Reflex = 37th week - Untreated infections Palmar Reflex = 32nd week - Cervical insufficiency Tonic Neck Reflex = 35th week c. Socioeconomic Factors Infant reflexes can occur in adults who have - Low socioeconomic factors Brain Damage or Stroke. - Mothers with less formal education Strength of a reflex is an important sign of - Unwed mother nervous system development and function. - Cigarette smoking V. Potential Complications NOTE: Because of immaturity, preterm infants are High Risk Mothers: prone to several specific conditions. - Above 35 years old - Below 16 years old Anemia of Prematurity Lying-In is for normal cases only, not for - It means that a baby born early high-risk patients. (prematurely) does NOT have enough Red Cases of breech presentation are Blood Cells (RBC). referred to the hospitals (cesarian operation). Acute Bilirubin Encephalopathy - It is an acute illness caused by severe hyperbilirubinemia. Ballard Scoring - To know the age of gestation Persistent Patent Ductus Arteriosus - To mother who have irregular menstruation - It is a persistent opening between two - Done within 12-24 hours. major blood vessels leading from the heart. ✓ 28 weeks – sole not visible (the more the crease, the mature the baby). Perventricular Hemorrhage - It is a common intracranial lesion in IV. Signs and Symptoms premature infant. - It is characterized as bleeding into the Thin, pink, and veins are visible. ventricular system due to the rupture of Lesser subcutaneous fat microvessels within the germinal matrix Weigh 42 weeks = Post Term Pregnancy Asphyxia 40 weeks = Placental Aging - Body is deprived of oxygen. I. Pathophysiology Meconium Aspiration Syndrome - Occurs when a newborn breathes a mixture - May have continued fetal growth. of meconium and amniotic fluid into the - Sometimes placenta involutes with multiple lungs around the time of delivery. imparts, villous degeneration. Hypoglycemia 40 weeks (Placenta Duration) - Decrease of glycogen stores → then it will involute ↓ Hypothermia Placental Insufficiency Syndrome - Low body temperature - Happens after 40 weeks. - Doesn’t have enough subcutaneous fats. - Insufficient nutrients and O2 from the mother ↓ V. Treatment Fetus receives inadequate nutrients and O2 from the mother. Treatment of complications ↓ Prognosis and treatment depend on Decrease O2 leads to hypoxia. complications. ↓ Surfactant replacement therapy is Stimulates vagus reflex. frequently helpful. 4  SEPSIS Lumbar Puncture Blood Cultures Highest rates occur in: Low Birth Weight (LBW) Infants Infants with depressed function NOTE: Infants with maternal perinatal risk Procalcitonin is being investigated as an factors acute-phase reactant marker for neonatal sepsis. Minorities Males V. Treatment I. Etiology Antibiotic Therapy Early Onset = Early 90th percentile for gestational age. III. Signs and Symptoms Macrosomia Diminished spontaneous activity. - Infant that with an excessive birth weight. Less vigorous sucking - Is birth weight >4000 g in term infant Anorexia I. Etiology Apnea Bradycardia Genetics Temperature instability (hypothermia or Maternal Diabetes Mellitus hyperthermia) ✓ Beta Cells produces insulin (it keeps blood glucose from dropping too low) IV. Diagnosis ✓ Alpha Cells produces glucagon (it keeps blood glucose from rising too High index of suspicion high) Blood, CSF, and sometimesurine culture II. Assessment NOTE: Early diagnosis of neonatal sepsis is A woman’s uterus appears to be unusually important and requires awareness of risk large for the date of the pregnancy. factors and high index of suspicion A sonogram can confirm suspicion. when any neonate deviates from the A non-stress test to assess the placenta’s norm in the first few weeks of life. ability to sustain large fetus during labor may be prescribed. 5  Cesarean Birth may be necessary because of shoulder dystocia. 2. Assymetric Growth Restrictions - Results from placental or maternal III. Signs and Symptoms problems that typically manifest in the 2nd or 3rd trimester. Large Obese Common causes include: Plethoric (reddish color) a. Maternal Disease 5 minite AS may be low. b. Multiple Gestation Listless, limp, and feed poorly c. Placental Involution d. Pulmonary or Cardiac Disease IV. Delivery Complications e. Maternal Malnutrition f. Assisted Reproductive Difficult Vaginal Delivery/Birth Injury = g. Opoids, cocaine, alcohol and or tabacco shoulder dystocia, fracture of the clavicle, or during pregnancy limbs. Perinatal Asphyxia – the failure to establish II. Signs and Symptoms breathing at birth. True Cephalic Disproportion (Operative Physical characteristics and behavior Delivey) similar with normal size infant Thin V. Other Complications Sunken facial feature Thin and small umbilical cord Respiratory Distress - Elevated insulin levels decrease surfactant III. Complications production. Meconium Aspiration Perinatal Asphyxia Hypoglycemia - It is defined as the failure to establish - Because of the state of hyperinsulinism and breathing at birth. the sudden termination of maternal glucose Meconium Aspiration when the umbilical cord is cut Hypoglycemia Polycythemia Polycythemia - Elevated inuslin levels increase fetal Hypothermia metabolism and thus oxygen consumption. IV. Treatment Hyperbilirubinemia - Decreased tolerance for oral Supportive Care feedings/polycythemia is present, the bilirubin load increase. HYPERBILIRUBINEMIA Hemolytic Disease of the Newborn SMALL FOR GESTATIONAL AGE It is a condition in which there is too much Infants whose weight is less than the 10 th bilirubin in the baby’s blood. percentile on an intrauterine growth curve for gestational age. When Red Blood Cells (RBC) break down, a substance called Bilirubin is formed. I. Etiology Babies are NOT easily able to rid of it, and it 1. Symetric Growth Restrictions can build up in the blood and other tissues - A fetal pattern problem that begins early in and fluids in the infant’s body. gestation, often the 1st trimester. I. Mechanism of Hyperbilirubinemia Common cause: - Many genetic disorder Increased production - First trimester congenital disorder Decreased hepatic uptake. 6  Decreased conjugation - It is the rapid rise in a baby’s bilirubin level. Impaired excretion - It should raise concern. Impaired bile flow - It always requires investigation. Increased enterohepatic circulation. NOTE: II. Classification Jaundice is considered pathologic if it is present within the first 24 hours after Physiologic birth. - Occurs in almost neonates. - Due to shorter neonatal RBC life span - Deficient conjugation III. RH Incopatibility - Low bacterial levels in the intestines Active exchange of fetal-maternal blood as - Physiological jaundice is normal. placenta villi loosens and delivered. - It is noticeable when the baby is 2 to 4 days ↓ old. Mother blood Rh (D) negative and Fetal blood - Most of the time, it does NOT cause Rh positive (contains D antigen) problems and goes away within 2 weeks. ↓ Sensitization (72H after birth) Women begun to NOTE: form antibodies against D antigen. The best treatment for physiologic (Few antibodies form this way during pregnancy) jaundice is frequent and effective ↓ breastfeeding. 2nd pregnancy high level of antibody D circulating in the woman’s bloodstream. (Because of surge in antibody formation of Pathologic pregnancy) - Jaundice appears in the first 24 hours, after ↓ first week of life or lasts >2 weeks. If new fetus us Rh (+), antibody will act to - Total serum bilirubin rises by >5 mg/dL/day destroy the fetal RBC in early pregnancy. (>86mcmol/L/day) ↓ - Total serum bilirubin is >18 mg/dL (>308 Fetus is severely compromised by the end of mcmol/L/day). 2nd pregnancy. - Infant shows symptoms or signs of a serious illness. Rho immune globulin (RhIG or RhoGAM) — (passive Rh antibody) Common Pathologic causes are: - Within 72 hours after birth of an Rh (+) child ✓ Immune or nonimmune hemolytic - Abrupt stop in process and sensitization of anemia antibody formation. ✓ G6PD deficiency IV. ABO Incompatibility How does G6PD cause anemia? A Glucose-6-phosphate Maternal blood type O and fetal blood type is A dehydrogenase (G6PD) deficient state ↓ may accentuate (heighten) the decrease Hemolysis (1st pregnancy) lifespan of the RBC. ↓ Together, these result in increased Naturally occuring antibodies to A and B cell bilirubin load in the blood circulation type (fetus) and in liver cells of an infant. ↓ Moreover, the infant’s liver is relatively Antibodies are of large (immune globulin [lg]M functionally immature, resulting in class and so do NOT cross the placenta decreased uptake of bilirubin in the ↓ blood. An infant of an ABO incompatibility NOT born anemic ↓ - It is the most serious type of jaundice. 7  Hemolysis begins with birth when blood and NOTE: antibodies are exchanged during mixing of - If jaundice in NOT properly handled, it maternal blood and fetal blood. can lead to Kernicterus— a dangerous and permanent form of brain damage. Destructions continue as long as 2 weeks. V. Management RESPIRATORY DISTRESS SYNDROME Acute Conditions of Neonate Phototherapy - It is a treatment with special type of light Pulmonary Surfactant Deficiency (not sunlight). - Due to lack of surfactant - It is used to treat newborn jaundice by Fetal lung immaturity < less than 37 weeks making it easier for the baby’s liver to of gestation breakdown and remove the bilirubin from Surfactant available at 37 weeks the baby’s blood. - Produce type 2 pneumocytes. - Prevents lungs to collapse. Nursing Considerations for Phototherapy - Reduce surface tension of the lungs. Undress the infant. Infant’s eyes must always be covered. I. Pathophysiology Why? - A possible complication of phototherapy Surfactant is retinal damage. Therefore, eye Type 2 pneumocytes protective measures are important for Surfactant helps alveoli function properly. prevention. Alveoli terminal ends of respiratory rate Surfactant Deficiency Exchange Transfusion (ET) ↓ - It is the removal of an infant’s blood with Hyperinflation begins to occur and pulmonary high bilirubin levels and/or antibody-coated resistance increases red blood cells (RBCs) and replacement ↓ with fresh donor blood. Shunting of foramen ovale and the ductus arteriosus KEY POINTS: ↓ Neonatal jaundice is caused by Lungs become poorly perfused. increased bilirubin production, Labored grunting respiration decreased bilirubin clearance, or - Sternal retractions, flaring of nasal alae. increased enterohepatic circulation. - Decreased breath sounds Some jaundice is normal in neonates. ↓ Risk varies with postnatal age, TSB Production of surfactant decreases even value, prematurity, and health of the further. neonate. ↓ Treatment depends on cause and Poor oxygen exchange— tissue hypoxia degree of bilirubin elevation, the more (increase RR) preterm the infant the lower the ↓ threshold (intensity) level for treatment. Infant becomes hypoxic - Cyanosis Definitive treatments include - Decreased PO2 & O2 Saturation Level phototherapy and exchange - Diminished Breath Sounds transfusion. - Fine Rales ↓ Release of Lactic Acid— increase CO2 Levels ↓ ↓ Pulmonary Further limits 8 Vasoconstriction surfactant Reduces the risk of RDS or decrease its production (total severity. lost) ↓ KEY POINTS: Alveolar Collapse RDS is caused by Pulmonary ↓ ↓ ↓ Surfactant Deficiency – alveoli Seesaw Shock CXR –Atelectasis close or fail to open, lungs diffusely respiration, heart atelectasis, triggering inflammation, failures, pale gray and pulmonary edema. skin, pneumothorax Occurs in neonate born at < 37 weeks AOG. II. Symptoms Worsen with increasing prematurity. Infant become hypoxemic (below normal level of oxygen in the blood) MECONIUM ASPIRATION SYNDROME - Increase RR, labored grunting respiration. Acute Conditions of Neonate - Sternal retractions - Flaring of Nasal Alae Meconium is being produced within the 13th - Decreased breath sounds week of gestation. Yellow (Meconium) III. Diagnosis White Clinical Evaluation I. Etiology ABG (Arterial Blood Gas) - Hypoxemic – decreased O2 Placental Insufficency - Hypercapnia – increased CO2 Pre-eclampsia CXR (Chest X-Ray) Maternal Infection/Chorioamninitis - Atelectasis – A complete or partial collapse Fetal Hypoxia of the entire lung or area (lobe) of the lung. II. Signs and Symptoms IV. Treatment Severe respiratory distress Surfactant Staining of the fingernails Supplemental O2 Green urine Intratracheal via Endotracheal Intubation III. Pathophysiology V. Prevention Meconium Aspiration When a fetus must be delivered between ↓ 24-34 weeks, giving the mother Mechanical Plugging (Obstruction) betamethasone, induces fetal surfactant Chemical Irritation (Release of Cytokines) production. Surfactant Inactivation Betamethasone 12 mg IM Q24H X 2 doses ↓ Dexamethasone 6 mg IV or IM Q12H or Small Airway Obstruction (Atelectasis) atleast 48H before delivery ↓ Overinflation/Airtrapping ↓ Barrel Shape Chest, Rales, Ronchi, Hypoxemia, Acidosis IV. Diagnosis Meconium passage Respiratory distress 9 V. Prognosis Generally good Varies with underlying physiologic stressors. Overall mortality is slightly increased. At risk with asthma at later life VI. Treatment Suctioning at birth before the first breath Endotracheal intubation as needed. Supplemental O2 IV Antibiotics/Prophylaxis (to prevent infection) ~ + End of Notes + ~ 10