Preterm Neonate

details of preterm neonate

1. CHARACTERISTICS OF PRETERM NEONATE

2. DEFINITION Preterm baby are those who are born fewer than 37 weeks of gestation irrespective of birth weight. Preterm baby refers to the birth of a baby before the developing organs are mature enough to suffice normal postnatal survival.

3. CAUSES OF PRETERM BIRTH SPONTANEOUS APH, Cervical Incompetence, Bicornuate uterus. Chronic & systemic maternal diseases or infection Threatened abortion, acute emotional stress, trauma Low maternal weight gain, malnutrition, poor socio-economic condition. Multiple pregnancy, congenital malformations. History of previous preterm delivery. INDUCED Maternal Diabetes, severe heart disease. Placental dysfunction. Pre- eclampsia, Eclampsia, hypertension. APH Severe Rh isoimmunization. Iatrogenic

4. PHYSICAL CHARACTERISTICS OF PRETERM INFANT

5. PRETERM NEONATE

6. MEASUREMENTS A PRETERM BABY IS SMALL IN SIZE WITH LARGE HEAD. CROWN-HEEL LENGTH IS LESS THAN 47CM. HEAD CIRCUMFERENCE IS LESS THAN 33 CM BUT IT EXCEEDS THE CHEST CIRCUMFERENCE BY MORE THAN 3 CM.

7. POSTURE TERM NEONATE PRETERM NEONATE

8. GENERAL ACTIVITY Poor with sluggish or incomplete neonatal reflexes such as Moro, sucking and swallowing reflex. Limbs are extended due to hypotonia with poor recoil of flexed forearm when it is extended.

9. HEAD & FACE Head is larger than body. Skull bones are soft, sutures are widely separated and fontanelles are large. Face is small with small chin and scanty buccal fat. Hairs are scanty, wooly and fuzzy.

10. EYES Eyes remain closed. Eyes are protruding due to shallow orbits. Visualization difficult.

11. EARS Ears are soft, flat and cartilage is not fully developed. Pinna does not recoil when pressed against skull.

12. SKIN It is shiny, thin, delicate and pink with little vernix caseosa and ample lanugo. Subcutaneous fat is scanty and edema may be present.

13. BREAST NODULES These are absent or less than 5mm. Nipples and areola are flat.

14. ABDOMEN Abdomen is full, soft and round with prominent veins.

15. EXTREMITIES Nails are short & not grown till the tip. Deep creases over soles and palms are absent or less.

16. GENITALIA Male: Testes are undescended, scrotum poorly pigmented with few rugae.

17. GENITALIA Female: Labia minora does not cover labia minora, clitoris is hypertrophied & prominent.

18. PHYSIOLOGICAL HANDICAPS

19. RESPIRATORY FUNCTIONS Respiration is rapid, shallow, irregular with periods of apnea and cyanosis. Breathing is diaphragmatic with intercostal recessions due to soft ribs. Cough & gag reflex are weak or absent. Common complication are Pulmonary aspiration, atelectasis, hyaline Membrane disease, Broncho-pulmonary dysplasia. Resuscitation is challenging due to weak respiratory muscle, poor expansion of lungs, inefficient respiratory center & deficient surfactant

20. IMMATURE CNS They are inactive & lethargic. Difficulty in feeding due to in coordinated sucking & swallowing reflex. Babies are prone to Kernicterus, Brain damage, Retrolental Fibroplasia, intraventricular or periventricular hemorrhage.

21. CIRCULATORY DISTURBANCES May have delayed closure of Ductus Arteriosus. Peripheral circulation is inadequate. Complications like Thromboembolism, Intracranial Hemorrhage, Hemorrhagic problems due to hypofunctional Bone Marrow may occur.

22. IMPAIRED THERMOREGULATION Prone to develop Hypothermia due to under-developed heat regulation center, poor insulating fats, poor food intake, poor muscular activity, less oxygen consumption. Environmental factors add to the heat loss of the baby.

23. INSUFFICIENT GASTRO-INTESTINAL & HEPATIC FUNCTIONS Poor intake of food is due to poor sucking & swallowing reflex. Regurgitation & aspiration occurs due to less stomach capacity & incompetent cardiac sphincter. Carbohydrate & protein is digested well but not fats. Hypotonia leads to abdominal distension & functional intestinal obstruction. Complications like Necrotizing enterocolitis, Hyperbilirubinemia, Hypoglycemia, Malnutrition, Anemia, Vitamin deficiencies, Hemorrhagic diseases may occur.

24. METABOLIC DISTURBANCES Poor metabolic activities may lead to hypoglycemia, hypocalcemia, hypoxia, acidosis and hypoproteinemia.

25. INCREASED SUSCEPTIBILITY TO INFECTIONS They are 3 to 10 times more vulnerable to infections than normal neonates due to inefficient cellular immunity & low IgG level. Excessive handling, humid environment, resuscitation, invasive procedures are responsible for infections

26. IMPAIRED RENAL FUNCTIONS They are prone to acidosis due to low GFR. May be dehydrated due to inability to conserve water. Urination is delayed. Complications like edema due to solute retention, renal failure may occur.

27. DRUG TOXICITY If precautions during drug administration is not taken, then toxicity may develop due to poor hepatic detoxification. Oxygen toxicity may cause retinopathy of prematurity due to anoxic damage and retinal detachment.

28. POTENTIAL NURSING DIAGNOSIS

29. Ineffective airway clearance related to inadequate surfactant levels, immaturity of CNS and neuromuscular system. Review information related to the infant’s condition like APGAR Score, type of delivery, duration, maternal medication, gestational age and weight. Assess respiratory status, note signs of distress. Apply transcutaneous o2 monitor, record levels hourly. Suction oropharynx and nose in attempt to clear secretions. Provide bag ventilation followed by suctioning. Promote rest, minimize stimulation and energy expenditure. Check ABG values & chest X ray.

30. Ineffective thermoregulation, less than 36.5°C related to immature CNS development, decreased subcutaneous fat and brown fat, limited glycogen stores. Frequent monitoring of temperature. Infant to be placed in open bed with radiant warmer with appropriate clothing, reduce exposure to drafts. Change wet clothing or linen immediately when wet. Development of tachycardia, flushed colour, lethargy, apnea, seizure, etc. Monitor ABGs, serum glucose, electrolyte and bilirubin levels. Provide supplemental oxygen as needed. Administer medications as indicated.

31. Risk for deficient fluid volume related to excessive fluid loss due to thin skin, lack of insulating fat, inability of kidneys to concentrate urine. Neonate’s weight is measured daily, with same scale on same time of the day. Fluid balance to be calculated in each shift. Specific gravity of urine to be measured. Insensible fluid loss through clothing, radiant warmer or oxygenation to be minimized. Monitor BP, Pulse, MAP. Parenteral infusion can be administered, 180 ml/kg/day.

32. Risk for imbalanced nutritional status less than body requirements related to immaturity of enzymatic production, lax cardiac sphincter, small stomach capacity, minimal stored nutrients. Assessment of reflexes associated with feeding such as sucking, swallowing, gagging, etc. Auscultate for the presence of bowel sounds, respiratory status, etc. Initiate intermittent or tube feeding if indicated. In case of EBM or formula, Slow instillation at rate of 1ml/min to be given. Assessment of presence of diarrhea, vomiting, excessive gastric residual. Monitoring for local or systemic reactions to parenteral feeding like increased temperature, dyspnea, cyanosis, vomiting, etc. Administer supplemental vitamins, minerals, iron, etc.

33. Risk for infection related to immature immune response, invasive procedures, traumatized tissue, fragile skin. Reviewing of record of delivery, resuscitative measures, length of rupture of membrane, gestational age at birth. Performance of meticulous hand-washing . Assess signs of infection, hypo or hyperthermia, lethargy, respiratory distress, jaundice, discharge from eyes, umbilicus, petechiae, etc. Sites of invasive procedures to be done with 70% alcohol and betadine. Sites of infusion and invasive monitoring lines to be checked for signs of infection. Use of aseptic techniques for suctioning, routine cleaning and replacement of respiratory equipment. Observation for signs of shock like bradycardia, decreasing BP, temperature instability, edema, etc.

34. POSSIBLE COMPLICATIONS 1) Anemia 2) Bronchopulmonary dysplasia (BPD) 3) Mental or Physical disability 4) Neonatal sepsis 5) Retinopathy of prematurity 6) Risk of disabilities 7) Hypoglycemia 8) Neonatal respiratory distress syndrome 9) Pulmonary hemorrhage 10) Kernicterus 11) Patent Ductus Arteriosus 12) Necrotizing Enterocolitis.

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