Respiratory Distress

Syndrome
Altered oxygenation and
impaired gas exchange
 RDS
An inappropriate respiratory adaptation
to extrauterine life
 referred to Hyaline membrane Disease
(HMD).
 The result of a primary absence,
deficiency, or alteration in the
production of pulmonary surfactant
 Occurs more frequently in infant 30
weeks gestation or less.
 Occurs almost twice as often in males
than in females © 2006,
March of
Dimes
Risk factors:
 Low gestational age
 Born to diabetic mothers
 Born after an asphyxial insult
before birth
 Born after maternal-fetal
hemorrhage
 Multiple gestation
Contributing factors:
 Prematurity
 Surfactant deficiency disease
Signs and Symptoms of
RDS
 Difficulty in establishing normal respiration,
 Expiratory grunting while the infant is not crying
 Intercostal and sternal retractions due to
increased rib cage compliance and decreased
lung compliance
 Nasal flaring
 Cyanosis
 Tachypnea

© 2006,
March of
Dimes
Treatment
 Thermoregulation
 Fluid balance and nutrition
 Skin care
 Pain assessment
 Developmental care
 Family care
© 2006,
March of
Dimes
VAPOTHERM
Cont. Treatment
prevent and minimize atelectasis.
Minimize untoward effects of oxygen
cardiovascular infectious and other
physiologic problems.
Maintain a balanced physiologic
environment.

© 2006,
March of
Dimes
 Surfactant Therapy
Surfactant coats the inside of the alveoli
1. It prevents collapse (atelectasis)
2. keeps alveoli open at the end of
expiration
 given via endotracheal tube.
Prophylactic therapy(Criteria for
identifying at-risk infants who would
benefit from prophylactic treatment are
unclear
© 2006,
March of
Dimes
Complications:
 Hypoxia
 Respiratory acidosis
 Metabolic acidosis
Nursing Care
nurse caring for an infant with RDS
must:
 Be familiar with RDS
pathophysiology
 Recognize symptoms of RDS
 Initiate interventions as indicated
 Maintain paO2 and oxygen
saturation levels.
© 2006,
March of
Dimes
Nursing Care, Cont.
Recognize importance of weaning
oxygen and other ventilator
parameters.
Recognize complications arising from
RDS, intubation and mechanical
ventilation.
Utilize proper endotracheal suctioning
techniques.
© 2006,
March of
Dimes
Nursing Care, Cont.
Provide mouth and skin care.
Maintain proper positioning.
Provide adequate fluid and
electrolyte balance.
Monitor blood glucose levels.
Reduce environmental stressors.
Provide parental support.

© 2006,
March of
Dimes
Intrauterine Growth Restriction

 Incidence reported as high as 20 %

 Contributing factors:
Maternal vascular disease
Hypertension
Intrauterine infection
Chromosomal abnormalities
Intrauterine Growth Restriction

 Oligohydramnios
 Hypoxia
 Fetaldistress
 Asphyxia
 Intrauterine and neonatal death
 Birth Asphyxia
 Primary Risk factors:
Prematurity
Fetal growth disorders
Maternal vascular disease
Peripartum maternal hyperglycemia
Drives catabolism of the oversupply of
nutrients
depletes fetal O2 stores  episodic
fetal hypoxia
 Other names for birth asphyxia include perinatal
asphyxia and neonatal asphyxia. Birth asphyxia occurs
when an infant does not receive enough oxygen when
born, potentially leading to difficulty breathing. It can
happen just before, during, or after birth

 Symptoms of birth asphyxia may not be obvious, but the

most common symptoms include:
 Before birth, abnormal fetal heart rate and low pH
levels, indicating too much acid.
 At birth, poor skin color, low heart rate, weak muscle
tone, gasping or weak breathing and meconium stained
amniotic fluid.
Hypoglycemia
 RiskFactors
Prematurity
Birth asphyxia
Cesarean section
Disorders of fetal growth
 Neonatal hypoglycemia, defined as a plasma glucose
level of less than 30 mg/dL (1.65 mmol/L) in the first 24
hours of life and less than 45 mg/dL (2.5 mmol/L)
thereafter, is the most common metabolic problem in
newborns

 The normal range of blood glucose is around 1.5–6

mmol/l in the first days of life, depending on the age of
the baby, type of feed, assay method used, and possibly
the mode of delivery. Up to 14% of healthy term babies
may have blood glucose less than 2.6 mmol/l in the first
three days of life.
Signs of Hypoglycemia
 Tremors
 Jitteriness
 Irritability
 Lethargy
 Apnea
 Cyanosis
 Hypothermia
 Weak or high pitched cry
 Poor feeding
 Seizures
 Early breastfeeding or formula feeding is a major
preventative approach.
 Intravenous therapy with 10% dextrose may be indicated
with rate based on weight.
 Oral glucose may be used.
 Repeat blood sugar in 30 minutes.
 Use heelstick method to obtain blood sugar values.
 Use left lateral heel site to avoid damage to the
newborn’s heel (pg. 885- 886
Maternal Diabetes

Harmful effects on the fetus

recognized over 100 years ago
GDM----3 to 10 %
IDDM --0.1 to 0.3 %
Gestational diabetes (GDM) in the mother
increases

1. The risk of a high birth weight baby

(LGA)

2. The risk of GDM in subsequent

pregnancies
Infant of a Diabetic Mother
(pg.813-814)

 Excessive fetal growth is caused by:

1) exposure to high levels of
maternal glucose, 2) fetal response of
increased insulin production, and 3)
insulin has a “growth hormone effect”
that results in greater linear growth.
 Complications include: hypoglycemia,
hypocalcemia, hyperbilirubinemia,
birth trauma, polycythemia,
respiratory distress syndrome, and
congenital anomalies.
Newborn exposed to HIV/AIDS (pg. 840)

 Transmission during the perinatal and newborn periods

can occur across the placenta or through breast milk or
contaminated blood.
 The majority of infants born to infected mothers
ultimately remain uninfected (Vertical transmission
decreased by AZT during gestation).
 May show signs and symptoms within days of birth
(enlarged spleen and liver, swollen glands, recurrent
respiratory infection, weight loss, urinary tract infections
and candidiasis infection.
 Routine newborn care, standard precautions.
 Hand washing is crucial.
 All infants born to HIV positive mothers require regular
clinical, immunologic, and virologic monitoring.
 Routine immunizations except for the live polio vaccine.
Newborn with Congenital
Anomalies (pg.841)
 Congenital hydrocephalus
 Anencephaly
 Choanal atresia
 Cleft lip
 Cleft palate
 Tracheoesophageal fistula
 Diaphragmatic hernia
 Myelomeningocele
 Omphalocele
 Gastroschisis
Newborn with Congenital Heart Defect
(pg. 844)

 Classified as acyanotic (without cyanosis) or

cyanotic (with cyanosis).
 The common cardiac defects seen in the first 6
days of life are left ventricular outflow
obstructions (mitral stenosis, aortic stenosis, or
atresia), hypoplastic left heart, coarctation of the
aorta, patent ductus arteriosis, transposition of
the great vessels, tetrology of Fallot, and large
ventricular septal defect or atrial septal defects.
 Many cardiac defects will not clearly manifest
themselves until after discharge from the birthing
unit.
 Three most common manifestations are: cyanosis,
detectable heart murmur, and signs of congestive
heart failure (tachycardia, tachypnea,
diaphoresis).
Newborn with Inborn Errors of
Metabolism
 Inborn errors of metabolism are a group of hereditary
disorders that are transmitted by mutant genes:
Phenylketonuria (PKU), Maple syrup urine disease
(MSUD), Homocystinuria, Galactosemia, and congenital
hypothyroidism.
 PKU is the most common.
 Phenylalanine is the essential amino acid used by the
body for growth and excess is converted to Tyrosine.
 The newborn with PKU lacks the ability to convert
resulting in high levels of phenylalanine which results in
a progressive mental retardation.
 PKU is required by law in most states. The PKU must
be drawn 24 to 72 hours after initiation of breast
milk or formula feeding.
Birth Related Stressors (pg 863-902)

 Newborn at risk due to asphyxia

 Newborn with respiratory distress/Transient Tachypnea
 Newborn with meconium aspiration syndrome
 Newborn with persistent pulmonary hypertension
 Newborn with complications due to respiratory therapy
 Newborn with cold stress
 Newborn with hypoglycemia
 Newborn with jaundice
 Newborn with polycythemia
 Newborn with infection
Nursing Assessment and Diagnosis
(pg. 866)

 Observe for the infant at risk.

 Ineffective Breathing Pattern related
to lack of spontaneous respirations at
birth secondary to intrauterine
asphyxia.
 Decreased Cardiac Output related to
impaired oxygenation.
 Ineffective Family Coping:
Compromised related to baby’s lack
of spontaneous respirations at birth
and fear pf losing their newborn.
Nursing Plan and Implementation
(pg. 866)

 Assemble the necessary equipment and insure proper

functioning (LDR, DR, OR, Nursery, NICU).
 Restock immediately after use.
 Call for additional support- resuscitation is at least a
two person effort.
 Document, document, document.
 Parent teaching: keep parents informed.
Evaluation (pg. 867)

 The risk of asphyxia is promptly

identified and intervention is started.
 The newborn’s metabolic and
physiological processes are stabilized
and recovery proceeds without
complications.
 The parents can describe the reason
for resuscitation and what was done to
resuscitate their newborn.
 Parents can verbalize their fears about
the resuscitation process and potential
implications for their infant’s future.
Transient Tachypnea of the
Newborn (pg. 870)
 Occurs more frequently in AGA and near term
infants.
 Incident during the birth process which
results in failure to clear the airway of lung
fluid and or mucous.
 An excess of fluid in the lungs due to
aspiration of amniotic fluid.
 Occurs more frequently in c-section newborns
 Onset occurs shortly after birth with signs of:
expiratory grunting, nasal flaring, and mild
cyanosis.
 Respiratory rates may be as high as 100 to 140
breaths per minute.
Transient Tachypnea of the
Newborn (pg. 870)
Clinical Therapy:
 Initial x-ray resembles RDS with minor differences.
 Chest x-ray is clear in 48 to 72 hours
 O2 at 30% to 50% usually under oxyhood correct
hypoxemia.
 IVF’s for fluid and electrolyte imbalances
 Oral feedings are contraindicated due to high
respiratory rate.
 Infant usually begins to improve by 8 to 24 hours.
 Duration of clinical course is 72 hours.
 R/O pneumonia and persistent pulmonary
hypertension.
Persistent Pulmonary Hypertension
(pg. 878)

 Respiratory disease resulting from right to left

shunting of blood away from the lungs and
through the ductus arteriosis and patent
foramen ovale.
 May also be called persistent fetal circulation
because the syndrome includes a return to
fetal circulation.
 Typically born at term or postterm and
presents with tachycardia and cyanosis.
 ECMO has improved chance of survival in these
infants.
 High frequency ventilation is another mode of
treatment.
Complications Due to
Respiratory Therapy (pg. 880)
 Pulmonary Interstitial Emphysema: the
accumulation of air in the lung tissues.
Overdistention and rupture of the alveoli
occur related to high ventilator pressures.
 Pneumothorax: the accumulation of air into
the thoracic cavity between the parietal and
visceral pleura when alveoli are
overdistended, rupture and air leaks into the
thoracic cavity (pg.881)
 Bronchiopulmonary Dysplasia (BPD): most
commonly occurs in very compromised low-
birth-weight infants who require oxygen
therapy and assisted mechanical ventilation
for treatment of RDS.
Cold Stress (pg. 882)

Pathophysiology:
 Excessive heat loss resulting in the use of
compensatory mechanisms (increased respirations
and non-shivering thermogenesis) to maintain core
body temperature.
 Occurs thought the mechanisms of evaporation,
convection, conduction and radiation.
 Metabolic consequences of cold stress can be
devastating and potentially fatal to the infant.
Care management:
 Warm newborn slowly
 Monitor skin temp
 Initiate efforts to maintain neutral thermal
environment
Jaundice (pg. 887)

 The most common abnormal finding in the newborn is

jaundice.
 Physiologic jaundice is due to the newborn’s shorter red
cell life span, slower uptake by the liver, lack of
intestinal bacteria, and poorly established hydration.
 Hypothermia, hypoglycemia, asphyxia and some neonatal
medications increase the chances of a newborn becoming
jaundiced.
 Hyperbilirubinemia: Excessive amount of bilirubin in the
blood; indicative of hemolytic processes due to blood
incompatibility, intrauterine infection, septicemia,
neonatal renal infection, and other disorders.
 Jaundice (pg. 887)

Clinical Therapy:
 Phototherapy: the treatment of jaundice by
exposure to high intensity light.
 Exposure to high intensity light decreases serum
bilirubin levels in the skin by facilitating biliary
excretion of unconjugated bilirubin.
 Phototherapy does not alter the underlying cause
of the jaundice.
 Phototherapy can be provided through
conventional banks of phototherapy lights, by a
fiber optic blanket or a combination of both.
 Exchange transfusion is the withdrawal and
replacement of the newborn’s blood with donor
blood.
Jaundice (pg. 887)

Nursing Assessment and Nursing Plan and

Diagnosis Implementation
 Identify the newborn at  Monitor temperature for
risk: assess for jaundice. hyperthermia or
 Monitor bilirubin levels. hypothermia.
 Apply eye patches over
 Risk for Altered Parenting
newborns closed eyes.
related to parenting a
newborn with jaundice.  Turn off lights when
 Risk for Injury related to drawing blood for repeat
bilirubin.
use of phototherapy.
 Maintaining a neutral
 Fluid Volume Deficit
thermal environment.
related to increased
insensible water loss and  Observe for signs of
frequent loose stools. dehydration and perineal
excoriation.
 Weigh daily
Polycythemia (pg. 895)

 An abnormal increase in the number of total red

blood cells in the newborn’s circulation.
 Observed more commonly in SGA, full term
newborns with delayed cord clamping, maternal-
fetal and twin to twin transfusions, or chronic
intrauterine hypoxia.
 Hct levels of 65 to 70 are considered
polycythemic.
 Symptoms include: ruddy appearance,
tachycardia, congestive heart failure, grunting,
tachypnea, and cyanosis.
 Partial exchange transfusions may be indicated in
infants who are symptomatic but controversial in
newborns who are asymptomatic.
Infection (pg. 896)

 Most nosocomial infections in the NICU

present as bacteremia/sepsis, urinary
tract infections, meningitis, or
pneumonia.
 Maternal antepartal infections such as
rubella, toxoplasmosis, cytomegalic
inclusion disease, and herpes may cause
congenital infection.
 Prevention of infection is essential
prenatally and intrapartally, Erythromycin
ointment in the eyes post delivery for GC,
antibiotic therapy for asymptomatic
positive group B streptococcal infection
intrapartally.
Infection (pg. 896)
Clinical Therapy:
 Two blood cultures from two peripheral sites.
 Spinal fluid culture following spinal tap.
 Urine specimen for culture typically done by supra-pubic
bladder aspiration.
 Skin cultures are taken if there are any lesions or drainage
from lesions.
 Nasopharyngeal, rectal, ear canal, and gastric aspirate
cultures may be obtained.
 CBC, chest x-ray, serology (WBC 30,000 normal first 24 hours.)
 A low neutrophil count and high band (immature white cells)
count indicate an infection is present.
 Antibiotic therapy is initiated after cultures with Ampicillin
and Gentamicin.
 After cultures are evaluated, appropriate antibiotic therapy is
instituted. Therapy may continue for 7 to 14 days or may be
discontinued on the 3rd day.
 Infection (pg. 896)

Nursing Assessment and Diagnosis Nursing Plan and Implementation

 Identify the newborn at risk:  Monitor temperature for
assess for infection. hyperthermia or hypothermia.
 Assess for subtle behavioral  Promote strict hand washing
changes, lethargy or technique.
irritability, color changes  Scrupulous care of equipment
(pallor, duskiness,
cyanosis). (to include isolettes,
warmers, soap dispensers
 Assess for feeding stethoscopes).
intolerance, temperature  Maintaining a neutral thermal
instability (hypothermia),
and hyperbilirubinemia. environment.
 Observe for signs of
 Risk for Infection related to
immature immunologic dehydration.
system.  Provide respiratory support.
 Fluid Volume Deficit related  Provide adequate calories.
to feeding intolerance.  Weigh daily
TORCH (pg. 429)

 Tests for : toxoplasmosis, rubella, cytomegalovirus,

and herpes simplex virus.
 Cytomegalovirus may be acquired
transplacentally
 Diagnosis is CMV in the urine of the pregnant client.
 No treatment exist for the pregnant client or the
newborn.
 Infection in the fetus can result in extensive tissue
damage and after birth microcephaly, hydrocephaly,
cerebal palsy, and /or mental retardation.