nursing management of low birth weight babies

low birth weight babies , LBW BABIES

1. Assessment and management of high risk newborn

2. Admission of neonates in the neonatal intensive care units protocols

3. NICU : stands for Neonatal Intensive Care Unit. NICU is highly specialized area in the hospital where critically ill or sick Newborn/Neonatal cared to reduce mortality and morbidity. INTRODUCTION

4. Neonatal care is defined as the management of complex life threatening diseases provision of intensive monitoring & initiation of life sustaining therapies in and organized manner to critically ill child in care unit. DEFINITION

5. LEVELS OF CARE T hese are the main levels of neonatal care:

6. To improve the condition of critically ill Neonate keeping in mind the survival of Neonate so as to reduce the mortality and morbidity rate. To maintain the functioning of pulmonary, cardiovascular, Renal, gastrointestinal and nervous system. AIMS/GOALS OF NICU

7. To Provide continuing service and training to medicine and nursing personnel in the care of Newborn. To monitor Vital Signs. To measure the oxygen concentration of the blood by oxygen analyzer. To administer the precise amount of fluids and minutes concentration of drugs through I.V infusion pump. CONT.

8. Low birth weight baby ( 2000gm) Large babies (more than or equal to 4kg) Birth Asphyxia Meconium Aspiration Syndrome Sever Jaundice Infant of diabetic mother CRITERIA FOR ADMISSION IN NICU

9. Neonatal sepsis/meningitis Neonatal convulsions/seizures Severe congenital malformation/ Cyanotic congenital heart disease Oxygen therapy/ perinatal nutrition Cardiovascular Monitoring Exchange blood transfusion Mother of ‘Hepatitis B Carrier’ Injured Neonate etc . CONT.

10. Warm incubator ( 36°C) Adequate light supply Resuscitation and Treatment trolley stocked History , diet , treatment, problem list/sheet and flow chart. Oxygen air and suction apparatus Oxygen air tubing or flow meter Vital sign monitoring apparatus Specific equipment as indicated by diagnosis . Preparation of NICU

11. Data should be collected within 24hours(if possible much sooner) History and examination Maternal history Paternal history Obstetrical history Labour Delivery Apgar score Vital Signs ADMISSION PROCEDURE

12. On admission Notify the doctor and nurse in-charge . Check infant identification Label. Quickly examine/observe the infant head to toe for obvious abnormalities condition . Resuscitate infant as necessary and maintain warmth. CONT.

13. Anthropometric examination Transfer to normal environment as soon as possible. Commonest observations: Temperature Heart rate Respiration Color Apgar score Reflexes.

14. Record keeping Birth History (Done in labour room) Ward History Contains Patient Registration Sheet Apgar score and examination sheet Feed chart and progress chart Treatment chart Growth chart

15. NURSING MANAGEMENT OF LOW BIRTH WEIGHT(LBW)

16. Babies with a birth weight of less than 2500 g, irrespective of the period of their gestation are classified as low birth weight babies . DEFINITION

17. Very low-birth- Weight infant :an infant whose birth weight is less than 1500g. Extremely low birth weight infant: An infant whose birth-weight is less than1000g. CONT.

18. According to birth weight and gestational age LBW Preterm SGA(small for gestational age)

19. Preterm: the growth potential is normal and is appropriate for the gestational period. SGA Constitutionally IUGR by small pathological process CONT.

20. OPTIMAL MANAGEMENT AT BIRTH Attended by a senior pediatrician. Air passage cleared of mucus. Delayed clamping of cord helps in improving iron store but lead to hypervolemia and hyperbilirubinemia . So clamp the cord quickly. Promptly dry, keep effectively covered and warm Vitamin K 0.5mg IM CARE OF PRETERM  BABIES

21. Vital signs monitoring Activity and behavior Color: pink, pale grey, blue, yellow. Tissue perfusion: pink color, capillary refill over upper chest <2sec, warm and pink extremities, normal BP, urine output >1.5 ml/kg/ hr , absence of metabolic acidosis, lack of disparity between PaO2 and SPO2. MONITORING

22. Monitor ABG and electrolyte Tolerance of feeds: vomiting, gastric residuals and abdominal girth. Look for development of apnic attack, sepsis Weight gain. CONT.

23. Create soft comfortable nestled and cushioned bed . Avoid excessive light, sound, rough handling and painful procedures. Use effective sedation and analgesia for procedures. Provide warmth and ensure asepsis. Prevent evaporative skin losses by effectively covering the baby, application of oil or liquid paraffin. PROVIDE IN UTERUS MILIEU

24. Provide effective and safe oxygenation. Provide parenteral nutrition partially and give trophic feeds ( minimal volumes of milk feeds (10–15 mL/kg/day) with EBM. Provide tactile and kinesthetic stimulation- skin to skin contact, interaction, music caressing and cuddling. CONT.

25. Most love to lie in a prone position, cry less and feels more comfortable Relieves abdominal discomfort by passage of flatus and reduce risk of aspiration. POSITION THE BABY

26. Increase ventilation, and increase dynamic lung compliance and enhances arterial oxygenation. Unsupervised prone positioning beyond neonatal period recognized as a risk factor for SIDS( Sudden Infant Death Syndrome). CONT.

27. Pre-warmed open care system or incubator should be available. Care in a thermo neutral environment with a servo sensor geared to maintain skin temperature of mid epigastria region at 36.5  c Application of oil or liquid paraffin reduce convective heat loss and evaporative water loss. THERMAL COMFORT

28. Extremely low babies covered with a cellophane or thin transparent plastic sheet to prevent convective and evaporative losses from skin. As soon as condition stabilizes effectively clothe the baby. Partial kangaroo care to prevent hypothermia. CONT.

29. Oxygen should be administered with a head box when saturation is less than 85% and withdrawn gradually when > 90% OXYGEN THERAPY

30. Jaundice is common due to immaturity, hypoxia, hypoglycemia, infections and hypothermia. Due to immaturity of blood brain barrier, hypoproteinemia and perinatal distress factors bilirubin brain damage may occur at relatively lower level. Initiate phototherapy early. PHOTOTHERAPY

31. Handling should be reduced to minimum. Vigilance maintained on all procedures PREVENTION OF NOSOCOMIAL INFECTION

32. Babies  with weight <1200gm or gestational age <30 weeks and sick baby should be started on IV dextrose solution Wt.>1000gm:- 10% dextrose Wt <1000gm :- 5% dextrose. Trophic feeds with EBM (1-2 ml 4 times a day) through Ng tube can be started in all babies irrespective of birth weight FEEDING AND NUTRITION

33. When stabilized enteral feeds are begun with EBM starting with a volume of 30 ml/kg/day on day1. Depending on tolerance feeds increased by 10-20 ml/kg/day every day and IVF are reduced FEEDING AND NUTRITION

34. When baby is stable, EBM can be fortified with human milk fortifier(HMF) for additional calories and protein. Multivitamin drops containing folic acid started at 2 weeks of age. Iron supplements after 2-3 weeks. Vitamin E which prevents powerful antioxidant and prevent hemolytic anemia and edema. NUTRITIONAL SUPPLEMENTS

35. Gentle touch, massage, cuddling, stroking and flexing by the nurse or preferably by mother. Soothing auditory stimuli can be given to preterm baby in the form of family voices or music. Visual input provided with the help of coloured objects, diffuse light and eye to eye contact. GENTLE RHYTHMIC STIMULATION

36. Antenatal administration of Betamethasone or dexamethasone if labor starts before 34 weeks. In infants who did not receive antenatal steroids a single dose of dexamethasone 0.2 mg/kg iv at 4 hrs of age is recommended in very LBW babies. UTILITY OF CORTICOSTEROIDS

37. Accurate weighing is a sensitive index of well being. Most LBW babies loss weight during 1st 3 to 4 days of life up to 10 to 15% of birth weight. The weight remains stationary for next 4 to 5 days then starts to gain at a rate of 1.0 to 1.5 % of body weight per day and regain birth weight by the end of 2nd week . WEIGHT RECORD

38. The dose is not reduced in preterm babies. Administer 0 day vaccines on the day of discharge IMMUNIZATION

39. Family should be constantly informed and involved in care of baby Mother should be encouraged to touch and talk with her baby and provide routine care under guidance of nurses. Assist to provide kangaroo care. FAMILY SUPPORT

40. Baby who is feeding well, reasonably active with a stable body temperature irrespective of weight qualifies for transfer to open cot. The baby should be observed for another 12 hours after putting incubator off. TRANSFER FROM TO COT

41. Infant  is small Skin is thin , blood vessels can be easily seen beneath the epidermis. Skin wrinkled and red with an excess of lanugo and little or no vernix . No subcutaneous fat deposits. Head is large in proportion to the body. Eyes prominent but closed. Ears are soft and chin recedes. Thorax is less firm . NURSING ASSESSMENT

42. Abdomen   protruded Genitalia Male: few scrotal rugae , testes are not descended Female: labia and clitoris are prominent. Extremities: thin, muscle are small. Nail : soft and short Palms and sole: minimal creases and appear smooth Generally lies inactive with arms and legs extended Reflex activity not fully developed. NURSING ASSESSMENT

43. Risk for impaired parenting related to inadequate bonding secondary to parent child separation. Participate in frank discussion with parents about infant’s condition. A llow parents to express fear, guilt, anxiety- assist parent with bonding by role modeling and staying. Demonstrate how to provide basic care: holding , diapering, turning. NURSING DIAGNOSIS

44. Imbalanced nutrition less than body requirement related to diminished sucking Feed prescribed amount of breast milk by NG/PO M onitor blood glucose level Weigh baby daily Maintain I/O chart P lace child in semi sitting position for feeds P osition post feeds on right side or prone position. NURSING DIAGNOSIS

45. Risk for ineffective breathing pattern related to effects of prematurity Monitor pulse and respiration Q 2 H Assess respiratory distress, cyanosis, grunting, nasal flaring. Provide rest period between nursing care M aintain oxygenation NURSING DIAGNOSIS

46. Infection Control in Neonatal Intensive Care Unit

47. Newborn babies who need intensive medical attention are often admitted into a special area of the hospital called the Neonatal Intensive Care Unit (NICU). Introduction

48. The NICU combines advanced technology and trained health care professionals to provide specialized care for the tiniest patients. NICUs may also have intermediate or continuing care areas for babies who are not as sick but do need specialized nursing care. Some newborn babies will require care in a NICU, and giving birth to a sick or premature baby can be quite unexpected for any

49. 4. Host risk factors for infection in newborns include Low birth weigh- Acuity of underlying illness- Immature immune system- Permeable skin- 5. Some studies have shown, type of infection in newborn 1- Bacterial infection **Gram positive infections Staphylococcus aureus - Strepto pyogenes - **Gram negative infections E.coli - Pseudomonas- Neisseria meningitides-

50. 6.  2-Viral infections - Hepatitis HIV- Herpes- 3-Fungal  infections: Candidiasis- 4-Parasitic infections -Toxoplasmosis 7.  According to provincial  infectious diseases advisory committee (PIDAC) The types of infection transmission are: 1-contact transmission *Direct contact: occurs through touching the patient ex, colonized or infected microorganism from staff. *Indirect contact: occurs when microorganism transferred from patient to patient via contaminated objects or the contaminated hands of health care provider.

51. 8.  2-Droplet transmission wborns known  or suspected of having an infection that can mitted by large respiratory droplets such as cough or sneez travels for up to two meters le of microorganisms transmitted by droplet transmission in atory tract viruses (e.g. Adenovirus, influenza and Para influ ses , rhinovirus, RSV), rubella, mumps and Bordetella pertu

52. 9.  3-Airborne transmission Airborne transmission  occurs when airborne particles remain suspended in the air, travel on air currents and are then inhaled by others who are nearby or who may be some distance away from newborns or if there have been insufficient air exchange. The only microorganisms transmitted by the airborne rout are Mycobacterium tuberculosis (TB), varicella virus (chickenpox virus) and measles virus.

53. 10.  Aims This paper is  aimed to: - Control and prevention nosocomial infection in neonatal intensive care unit (NICU). -Provide and identify hospital and health care facilities policy information.

54. 11.  infection control precaution *staff  precaution: 1-Hand hygiene: Removal of visible soil and microorganism. Five moments for hand hygiene: - before touching the patient. - before clean/aseptic procedure. - after body fluid exposure risk. - after touching the patient. - after touching the patient surroundings.

55. 12.  *Impediments to effective  hand hygiene: - Accessories - long nail - nail polish - artificial nail

56. 2- Personal protective  equipment "PPE" - gloves - gowns - facial protection - caps - boots Personal protective equipment (PPE) is worn to prevent transmission of microorganisms from patient to patient and from patient to staff or from staff to patient. To protect newborns health unit care staff should take necessary vaccinations that effect them (measles ,mumps ,rubella, pertussis ,varicella , hepatitis B and influenza vaccine).

57. Environmental precautions: Observe cleaning in unit care environment is important to newborns safety ,staff and visitors. Daily cleaning and disinfection the environment surface should be in frequent period.

58. Equipment precautions: The medical equipment should be clean and sterilized. The cleaning and disinfection of the equipment on consistent basis following with cleaning methods and instructions for equipment.

59. visitor precautions: For safe  visit to the newborns and spending time or checking on them should occur depending on some considerations: Limiting number of visitors. - visitors or family members should not visit if they have signs and symptoms of being ill or unwell, such as: •Fever •cough or influenza •runny nose •vomiting or diarrhea •rash •conjunctivitis. - hand hygiene before and after visiting. - the visitor should be wearing personal protective

60. Patient precautions: - neonatal skin care : Bathing - management of central venous catheters - management of peripheral arterial catheters - management of umbilical artery and vein catheters - prevention of ventilator associated pneumonia

61. To provide a clean and safe neonatal intensive care unit Along with hospital infection control policy reviewed for newborn babies this paper recommended that: for staff: Staff have infection illness should be excluded from work. Hand hygiene including : hand washing , hand rub. Personal protective equipment including : gloves, gowns, boots, caps,- masks. Recommendations

62. For Environment: - clean neonatal intensive care unit at least twice per day and additionally as required. - clean isolettes / warmers according to schedule and additionally as required. - terminally clean neonatal intensive care unit isolette / warmer and environment on discharge of the newborn. - terminally clean transport equipment after each newborn transport. Frequent audits of practice should be included as part of the

63. For equipment: Reusable medical equipment must be cleanable and be to able to be disinfected or sterilized. *for visitor: Family members and others should not visit if they are unwell.

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