Nursing Care of the Newborn with a Respiratory Disorder – Flashcards
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What Happens in the Neonate's Respiratory System?
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-Amniotic fluid is drained from the lungs -Lung fluid crosses the alveolar membrane into the capillaries -Surfactant lowers surface tension in the alveolus
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Physical Assessment
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-Count respirations with a stethoscope for 60 seconds -*Normal respiratory rate ranges from 30-60 breaths/minute* -Assess respiratory effort and quality of breath sounds -Respiratory rate should be determined first, before the neonate becomes active or agitated
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Physical Assessment
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-Count respirations with a stethoscope for 60 seconds -Assess respiratory effort -Assess quality of breath sounds
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High Risk Neonate Conditions
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-*Respiratory Distress Syndrome (RDS)* -*Transient Tachypnea of the Neonate (TTN)* -*Meconium Aspirate Syndrome (MAS)* -Persistent Pulmonary Hypertension of the Newborn (PPHN) -Apnea of Infancy (IOA) -Chronic Lung Disease (CLD) -Congenital Diaphragmatic Hernia
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Respiratory Distress Syndrome (RDS) (*surfactant*)
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-Is a disease related to immaturity of lung tissue -A complex disorder *manifested by signs of respiratory distress* -Self limiting disease with resp. symptoms abating after *72 hrs*, coincides w/ production of surfactant (Prenatal diagnosis-remember L/S ratio?)
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What do you administer for RDS?
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Betamethesone to increase production of fetal lung surfactant
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Risk factors for RDS
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Prematurity (*most likely the cause of RDS*) Maternal diabetes Stress during delivery
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Pathophysiology of RDS
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-*Lack of surfactant in lungs* -Surfactant decrease surface tension to allow the alveloli to remain open when air is exhaled -*Leads to atelectasis as well as labored breathing, respiratory acidosis, and hypoxemia*
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Pathophysiology of RDS
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-Blood flow to lungs decreases -Alveoli become necrotic -Capillaries are damaged -The lungs become noncompliant or "stiff"
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What does surfactant do?
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helps decrease surface tension in the alveoli allowing gas exchange & keeps the lungs open.
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What does a reticulogranular appearance in the lungs show?
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Is a diffused haziness or ground glass showing on a chest x-ray that represents micro-atelectasis
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Clinical Manifestations of RDS
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Tachypnea Dyspnea Pronounced intercostal or sub-sternal retractions Fine inspiratory crackles Audible expiratory grunt Flaring of the external nares Cyanosis or pallor
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Central cyanosis in r/t RDS
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is a major concern
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Steps for Treating RDS
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-*Administer surfactant (betamethasone) as ordered* -Institute thermoregulation -*Prevent hypotension* -*Prevent hypovolemia* -Correct respiratory acidosis with ventilatory support -Correct metabolic acidosis by administering sodium bicarbonate
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How would you correct respiratory acidosis caused from RDS?
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administer ventilatory support (ET tube) (can put surfactant through ET tube)
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How would you correct metabolic acidosis caused from RDS?
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administer sodium bicarbonate
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Pharmacology for RDS
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*Surfactant: used as an adjunct to O2 and ventilation therapy.* More info: Hockenberry, page 268
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What is missing from the lungs of infants whom are born before 34 weeks?
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Surfactant (they are given *exogenous surfactant* as 1 or more doses via an ET tube)
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Nursing Interventions for RDS
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-Continuous monitoring and close observation -Obtain necessary specimens for lab -*Continuously monitor pulse oximetry* -Suction as indicated, *not endotracheal suctioning* (see nursing alert, pg. 271, Hockenberry) -Maintain thermoregulation -Provide parenteral nutrition *avoid oral feedings* -Cluster nurse activities -Educate parents and provide emotional support -Silverman-Anderson Index
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Why can't you perform ET tube suctioning?
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Because it can cause: -bronchospasm -bradycardia (via vagal nerve stim) -hypoxia -increased ICP (predisposed to intraventricular hemorrhage)
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What can improper auctioning technique cause?
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Infection Airway damage Pneumothorax
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Prevention of RDS
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Most successful approach is to prevent pre term labor/delivery
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Methods for assessing fetal lung maturity
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Amniocentesis (Allows reasonable prediction of Surfactant production)
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What is the most essential nursing function r/t RDS?
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-Observe & assess the infant's response to therapy -Continuous monitoring & close observation *O2 ventilation & saturation parameters are based on ABG & pulse ox*
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What does the Silverman-Anderson Index assess?
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-Upper chest -Lower chest -Xiphoid retractions -Nares dilation -Expiratory grunt
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Transient Tachypnea of the Neonate (TTN) (*fluid*)
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It's a mild to moderate problem that lasts about 3 days It results from *delayed absorption of fetal lung fluid after birth* (*increased RR that comes & goes*)
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Risk for TTN
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-Neonates born by c-section -Multiple gestation (twins for more) -Neonates of diabetic or asthma mothers -Macrosomia (large for gestational age babies) -Excessive maternal sedation -Prolonged or precipitous labor
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Pathophysiology of TTN
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-Before birth, the fetal lungs are filled with fluid -TTN spontaneously fades as lung fluid is absorbed, usually by *72 hrs of life, as respiratory activity becomes effective*
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What does TTN result from?
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TTN results from aspiration of amniotic or tracheal fluid compounded either by delayed clearing of the airway or by excess fluid entering the lungs (*before birth*)
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Assessment findings for TTN
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-Respiratory rate >60 breaths/minute -Expiratory grunting -Nasal flaring -Slight cyanosis -Retractions -Tachypnea
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What tests tell you
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-Pulse ox is used to monitor O2 requirement -CBC to evaluate for infection -*Chest X-ray-Diagnostic STANDARD*
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ABG levels r/t TTN
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-*hypoxemia* and decreased CO2 levels -Increased CO2 levels may be a sign of fatigue & impending resp. failure
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What does a chest x-ray reveal in r/t TTN?
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Will reveal streaking which correlates with lymphatic engorgement of retained fetal lung fluid
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Steps for Treating TTN
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-Administer oxygen -Maintain acid-base balance -Institute thermoregulation -Provide adequate nutrition *via gavage feedings or IV fluids* -Institute oxygen monitoring
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Nursing interventions for TTN
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-Closely monitor the neonate's vital signs -Provide respiratory support -Maintain thermal environment -Antibiotic therapy *until sepsis is ruled out* -Provide nutritional support -Educate the parents and provide emotional support
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Chest percussion r/t TTN
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Is a nursing intervention where a nurse percusses the baby's chest. Done especially in c/s babies & precipitous labor babies.
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Meconium Aspiration Syndrome (MAS) (*meconium*)
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-*Involves aspiration of meconium into the lungs* -The neonate inhales the meconium mixed with amniotic fluid.
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When does inhalation of meconium occur?
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Typically with in the first breath or can also happen when the neonate is in-utero.
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What results from MAS?
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Lack of O2 which can lead to brain damage.
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Risk Factors for MAS
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-Maternal diabetes or hypertension -Difficulty delivery -Fetal distress -Intrauterine hypoxia -Advanced gestational age -Poor intrauterine growth
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Intrauterine hypoxia r/t MAS
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Can occur because of shoulder dystocia OR if the infant holds its breath for an extended amount of time during a contraction (*late decelerations*)
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Pathophysiology of MAS
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*Asphyxia in utero leads to increased fetal peristalsis, relaxation of the anal syincter, passage of meconium into the amniotic fluid and reflex gasping of amniotic fluid into the lungs*
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What does MAS create?
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Ball-valve effect Chemical pneumonitis
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Assessment Findings for MAS
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-Fetal hypoxia (*decrease FHR during labor/delivery*) -Dark greenish staining or streaking of the amniotic fluid -Observe vocal cords for mec staining -Meconium in the amniotic fluid -Greenish staining of neonate's skin -Signs of distress at delivery-*lump appearance* -Coarse crackles -Low Apgar score -Rapid breathing (tachypnea) -Low heart rate before birth -*Hypothermia, hypoglycemia and hypocalcemia* -Signs of post-maturity -*Chest radiograph* show patches or streaks of mec in the lungs and reveal if air is trapped -*Cyanosis*
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Dx test for MAS?
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Chest Radiograph -shows patches or streaks of meconium in the lungs & reveals if air is trapped.
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Treating MAS
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-Provide endotracheal suctioning at delivery *after* assessment of the baby's condition at birth -Offer respiratory assistance by chest physiotherapy or via mechanical ventilation -Maintain a neutral thermal environment -*Administer surfactant and an antibiotic if ordered (prevents sepsis)* -pre-delivery amniofusion & post-delivery suction (?)
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Nursing Interventions for MAS
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-During labor, continuously monitor s/s of fetal distress -Immediately inspect fluid with ROM -Assist with suctioning, deep or endotracheal at delivery -Monitor lung status closely -Frequently assess vital signs -Admin treatment such as O2 & respiratory support -Monitor feeding -Teach parents and provide emotional support
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Persistent Pulmonary Hypertension of the Newborn (PPHN)
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-Combined findings of *pulmonary hypertension, right to left shunting & structurally normal heart* -Also called persistent fetal circulation (PFC) because the syndrome includes *reversion to fetal pathways for blood flow*
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PPHN r/t MAS, congenital diaphragmatic hernia, & RDS
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PPHN can be either a single entity (cause) OR the main component of MAS, congenital diaphragmatic hernia, & RDS
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What can precipitate PPHN?
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Any process that interferes with the transition from fetal circulation to neonatal circulation.
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What can happen with PPHN?
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-Characteristically proceeds into a downward spiral of *exacerbating hypoxia & pulmonary vasoconstriction*. -Prompt recognition & aggressive intervention are required to reverse this process
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What does PPHN start with?
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Presents with tachycardia and cyanosis and within minutes or hours progresses to severe respiratory compromise
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What does PPHN management depend on?
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Management depends on the underlying etiology
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What is used to help increase the chance of survival with PPHN?
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Use of Inhaled Nitric Oxide (INO) and extracorporeal membrane oxygenation (ECMO) has improved the chances of survival of these infants
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Inhaled Nitric Oxide (INO) indications
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-*Used in term & near term infants with conditions such as PPHN, MAS, congenital diaphragmatic hernia* -May be used in conjunction with surfactant replacement therapy
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What is INO?
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Is a colorless, highly diffusible gas that can be administered through the ventilator circuit blended with oxygen
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Extracorporeal Membrane Oxygenation (ECMO)
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*Used in management of term infants with acute severe respiratory failure for the same conditions as INO*
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What is ECMO?
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Is a modified heart/lung machine that doesn't stop the heart & the blood does not entirely bypass the lungs
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What does ECMO do?
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Provides oxygen to the circulation allowing the lungs to rest and *decrease pulmonary hypertension and hypoxemia*
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Apnea of Prematurity
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*Refers to the cessation of breathing for more than 20 seconds*
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Where is apnea of prematurity seen most in?
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In preterm neonates & neonates with secondary stress
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Pathophysiology of apnea of prematurity
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-The respiratory control centers located in the brain are immature -*Additionally, the amount of surfactant may be insufficient*
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Assessment Findings for apnea of prematurity
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-Breathing stops for more than 20 seconds -Bradycardia -Early cyanosis
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Where would you place apnea monitor leads on the baby?
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-Place the lead on the mid-axilary line, 2 inches BELOW the nipple on BOTH right & left sides of the baby -*first, wipe the vernix discharge from the area of the skin where the lead will be placed*
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Vernix is found in?
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Premature infants
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Treating Apnea
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-Provide respiratory support -Tactile stimulation -Evaluate ABG levels -Provide suctioning -Administer caffeine as prescribed -Administer nasal continuous positive airway pressure (CPAP)
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Pharmacology for Apnea of Prematurity
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Caffeine citrate: (See Gahart for more information)
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Mechanism of Action for Caffeine Citrate
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Is a CNS and cardiac stimulant
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Indications for Caffeine Citrate
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Short term treatment of prematurity in infants more than 28 but less than 33 weeks.
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Nursing Interventions for Apnea of Prematurity
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-Assess respiratory status closely and frequently -*Use an apnea monitor* -If apnea noted, gently flick the neonate's sole -Anticipate the need for ventilatory support -Maintain thermal environment -Group nursing care -*Avoid measuring temperature rectal*
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Chronic Lung Disease
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Formerly called Bronchopulmonary Dysplasia (BPD) *Is a chronic obstructive pulmonary disease occurring in infants after prolonged oxygen therapy and mechanical ventilation*
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Chronic lung disease r/t RDS
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Premature infants with chronic lung disease have usually survived RDS *infants on long term O2 via ventilation will have their lungs permanently damaged*
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Pathophysiology of Chronic Lung Disease
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-High oxygen concentrations and mechanical ventilation damage -Lung immaturity is a major contributor and improved survival rates of premature infants have increased the incidence of BPD -There may be a genetic predisposition and males have increased morbidity
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Assessment for Chronic Lung Disease
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-Diagnosed with chest x-ray -Blood gases -Respiratory observation (tachypnea & barrel chest, Pallor, activity intolerance & poor feeding)
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What is Chronic Lung Disease diagnosed with?
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-Chest x-ray -ABG blood gases
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S/S of chronic lung disease
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-Tachypnea -Barrel-shaped chest -Pallor -Activity intolerance -Poor feeding -*Older kids: will have activity intolerance*
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Nursing Interventions for Chronic Lung Disease
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-Infants are cared for in intensive care unit *with ventilation* -Suctioning, turning and weighing -Monitor respiratory status continuously -Monitor fluid overload -Cluster care (parents & RN do care together) -Parental education and quiet stimulation and bonding to promote normal infant development
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Congenital Diaphragmatic Hernia results from?
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A defect in the formation of the diaphragm, allowing the abdominal organs to be displaced into the thoracic cavity
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What can congenital diaphragmatic hernia cause?
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Herniation of the abdominal viscera into the thoracic cavity may cause *severe respiratory distress and neonatal emergency*
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Congenital Diaphragmatic Hernia
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May be minimal and easily repaired or may be so extensive that normal development of pulmonary tissue is prevented
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Where is the congenital hernia usually found?
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Defect is usually on the left because that is the side of the diaphragm that fuses last
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When & how is a congenital hernia found?
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Usually discovered prenatally on ultrasound
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Congenital Diaphragmatic Hernia Assessment
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-Most affected infants have severe respiratory distress and worsening distress as the bowel fills with air -Breath sounds are diminished and bowel sounds heard in chest -Heart sounds heard on *right side of chest* -Physical examination reveals a flat abdomen. -Barrel-shaped chest & scaphoid (sunken) abdomen because intestines are in the chest & not the abdomen
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How can infant hernias be repaired?
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May be repaired by fetal surgery
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How is a congenital hernia diagnosed?
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Can be made on the basis of the *x-ray* finding of loops of intestine in the thoracic cavity and the *absence of intestine in the abdominal cavity*
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What is a congenital hernia prognosis based on?
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Depends on the degree of fetal pulmonary development
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Congenital Diaphragmatic Hernia Nursing Interventions
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-Participating in the stabilization of the infant's condition until surgical repair can be done. -Inhaled Nitric oxide (INO) has been used in many centers with moderate success *to treat the accompany persistent pulmonary hypertension*.
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Potential Nursing Diagnosis for newborns with a respiratory disorder
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-*Impaired gas exchange* (biggest dx r/t RDS) -Risk for infection -Risk for imbalanced nutrition -Risk for impaired parenting r/t separation & interruption of parent/infant attachment -Parental anxiety
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What causes lung immaturity?
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More cartilage in the chest collapsing inward in response to less compliant or "stiff" lung tissue.
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Alveoli in immature lungs lack a final?
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Folding of the Septa which occurs in the last trimester (Leads to uninflatable alveoli)
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Immature lungs cause an increase in?
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PVR b/c: -blood is shunted by ductus arteriosus & foramen ovale
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Deficient surfactant production causes?
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Unequal inflation of alveoli on inspiration & collapse on end expiration
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Increased exhaustion in RDS causes?
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Fewer & fewer openings of alveoli *causing wide spread atelectasis
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PVR in RDS
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Increases in normal lung expansion when normally, it decreases *causing hypoperfusion to the lung tissue & decreased pulmonary blood flow* *causes partial reversion of fetal circulation RT to LT shunt via ductus arteriosus & foramen ovale*
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Betamethosone is administered to?
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Maternal mother
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Exogenous Surfactant is administered to?
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Preterm neonates in 1 or more doses
