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  1. GENERAL OVERVIEW—Successful newborn adaptation to the demands of independent extrauterine life may be complicated by environmental insults during the prenatal period or those arising in the period immediately surrounding birth. The nursing role focuses on minimizing the effect of present and emerging health problems and on facilitating and supporting a successful transition to extrauterine life.
  2. GENERAL ASPECTS—common neonatal risk factors:
    1. Gestational age profile (see Table 4-15. Assessment: Normal Newborn Reflexes and Table 4-16. Estimation of Gestational Age: Common Clinical Parameters ):
      1. Prematurity.
      2. Dysmaturity.
      3. Postmaturity.
    2. Congenital disorders.
    3. Birth trauma.
    4. Infections.
  3. DISORDERS AFFECTING PROTECTIVE FUNCTIONS: NEONATAL INFECTIONS
    1. Assess for intrauterine infections.
    2. Oral thrush (mycotic stomatitis).
      1. Pathophysiology—local inflammation of oral mucosa due to fungal infection.
      2. Etiology:
        1. Organism—Candida albicans.
        2. More common in newborn who is vulnerable (i.e., sick, debilitated; those receiving antibiotic therapy).
      3. Mode of transmission—direct contact with:
        1. Maternal birth canal, hands, and linens.
        2. Contaminated feeding equipment, staff 's hands.
      4. Assessment:
        1. White patches on oral mucosa, gums, and tongue that bleed when touched.
        2. Occasional difficulty swallowing.
      5. Analysis/nursing diagnosis:
        1. Pain related to irritation of oral mucous membrane secondary to oral moniliasis.
        2. Altered nutrition, less than body requirements related to irritability and poor feeding.
      6. Nursing care plan/implementation: Goal: prevent cross-contamination.
        1. Aseptic technique; good hand washing.
        2. pillImageGive medications as ordered:
          1. Aqueous gentian violet, 1% to 2%: apply to infected area with swab.
          2. Nystatin (Mycostatin)—instill into mouth with medicine dropper, or apply to lesions with swab, after feedings. Note: Before medicating, feed sterile water to rinse out milk.
      7. Evaluation/outcome criteria:
        1. Oral mucosa intact, lesions healed, no evidence of infection.
        2. Feeds well; maintains weight or regains weight lost, if any.
    3. Neonatal sepsis
      1. Pathophysiology—generalized infection; may overwhelm infant's immature immune system.
      2. Etiology:
        1. Prolonged rupture of membranes.
        2. Long, difficult labor.
        3. Resuscitation procedures.
        4. Maternal infection (e.g., β-hemolytic streptococcus vaginosis).
        5. Aspiration—amniotic fluid, formula, mucus.
        6. Iatrogenic (nosocomial)—caused by infected health personnel or equipment.
      3. Assessment:
        1. Respirations—irregular, periods of apnea.
        2. Irritability or lethargy.
      4. Analysis/nursing diagnosis:
        1. Fatigue related to increased oxygen needs.
        2. High risk for infection related to septic condition.
      5. Nursing care plan/implementation:
        1. Cultures (spinal, urine, blood).
        2. Check vitals.
        3. Monitor respirations.
        4. Give medications, as ordered.
      6. Evaluation/outcome criteria:
        1. Responds to medical/nursing regimen (all assessment findings within normal limits).
        2. Parent(s) verbalize understanding of diagnosis, treatment; demonstrate appropriate techniques in participating in care (as possible).
        3. Parent(s) demonstrate effective coping with situation; express satisfaction with care.
  4. DISORDERS AFFECTING NUTRITION: INFANT OF THE DIABETIC MOTHER (IDM)
    1. Pathophysiology—hyperplasia of pancreatic beta cells → increased insulin production → excessive deposition of glycogen in muscles, subcutaneous fat, and tissue growth. Results in fetal:
      1. Macrosomia—LGA infant.
      2. Enlarged internal organs—common.
        1. Cardiomegaly.
        2. Hepatomegaly.
        3. Splenomegaly.
      3. Neonatal—inadequate carbohydrate reserve to meet energy needs.
      4. Associated with increased incidence of:
        1. Congenital anomalies (five times average incidence with pregestational diabetes) includes cardiac, pelvic, and spinal anomalies.
        2. Preterm birth: respiratory distress syndrome (RDS); increased insulin needs prenatally lead to decreased surfactant production.
        3. Fetal dystocia—due to CPD.
        4. Neonatal metabolic problems:
          1. Hypoglycemia.
          2. Hypocalcemic tetany.
          3. Metabolic acidosis.
          4. Hyperbilirubinemia.
    2. Etiology—high circulating maternal glucose levels during fetal growth and development; loss of maternal glucose supply following birth; decreased hepatic gluconeogenesis.
    3. Assessment:
      1. Characteristics of IDM.
      2. Hypoglycemia—Dextrostix or Chem-strip to heel stick at:
        1. 30 minutes × 2.
        2. 1, 2, and 4 hours of age; before meals × 4 or until stable.
        3. Chem-strip: if less than 20 mg/dL, must draw glucose STAT.
        4. Hypoglycemia laboratory values for preterm and term infants: under 45 mg/dL.
        5. Behavioral signs—tremors; twitching, hypotonia, seizures.
      3. Gestational age, since macrosomia may mask prematurity.
      4. Hypocalcemia—usually within first 24 hours
        1. Irritability.
        2. Coarse tremors, twitching, convulsions.
      5. Birth injuries:
        1. Fractures: clavicle, humerus, skull.
        2. Brachial palsy.
        3. Intracranial hemorrhage/signs of increased intracranial pressure.
        4. Cephalohematoma.
      6. Respiratory distress:
        1. Nasal flaring.
        2. Expiratory grunt.
        3. Sternal retraction.
        4. Intercostal retractions.
        5. Cyanosis—central.
      7. Jaundice.
    4. Analysis/nursing diagnosis:
      1. High risk for injury related to CPD, dystocia.
      2. Altered cardiopulmonary tissue perfusion related to placental insufficiency, RDS.
      3. Impaired gas exchange related to RDS.
      4. Altered nutrition, less than body requirements, related to hypoglycemia, hypocalcemia.
      5. Risk for altered endocrine/metabolic processes related to hyperbilirubinemia and kernicterus.
    5. Nursing care plan/implementation:
      1. pillImageHypoglycemia—administer formula or IV glucose, as ordered (may cause rebound effect).
      2. Preterm/immature—institute preterm care prn.
      3. pillImageHypocalcemia—administer oral or IV calcium gluconate, as ordered.
      4. Inform pediatrician immediately of signs of:
        1. Jaundice.
        2. Hyperirritability.
        3. Birth injury.
        4. Increased intracranial pressure/hemorrhage
    6. Evaluation/outcome criteria:
      1. Infant makes successful transition to extrauterine life.
      2. Infant responds to medical/nursing regimen. Experiences minimal or no metabolic disturbances (hypoglycemia, hypocalcemia, hyperbilirubinemia).
      3. Infant exhibits normal respiratory function and gas exchange.
  5. HYPOGLYCEMIA
    1. Pathophysiology—low serum-glucose level → altered cellular metabolism → cerebral irritability, cardiopulmonary problems.
    2. Etiology:
      1. Loss of maternal glucose supply.
      2. Normal physiological activities of respiration, thermoregulation, muscular activity exceed carbohydrate reserve.
      3. Decreased hepatic ability to convert amino acids into glucose.
      4. More common in:
        1. Infants of diabetic mothers.
        2. Preterm, postterm infants.
        3. SGA infants.
        4. Smaller twin.
        5. Infant of mother with preeclampsia.
        6. Birth asphyxia.
    3. Assessment:
      1. Jitteriness, tremors, convulsions; lethargy and hypotonia.
      2. Sweating; unstable temperature.
      3. Tachypnea; apneic episodes; cyanosis.
      4. High-pitched, shrill cry.
      5. Difficulty feeding.
    4. Analysis/nursing diagnosis:
      1. Altered tissue perfusion (fetal) related to placental insufficiency associated with maternal diabetes, preeclampsia, renal or cardiac disorders; erythroblastosis.
      2. Risk for altered endocrine metabolic processes related to high incidence of morbidity associated with birth asphyxia.
      3. Impaired gas exchange related to coexisting RDS.
      4. Altered nutrition, less than body requirements, related to hypoglycemia.
      5. High risk for injury related to coexisting infection, metabolic acidosis.
    5. Nursing care plan/implementation (see IV. INFANT OF THE DIABETIC MOTHER, The Newborn Infant).
    6. Evaluation/outcome criteria (see IV. INFANT OF THE DIABETIC MOTHER, The Newborn Infant).
  6. DISORDERS AFFECTING PSYCHOSOCIAL-CULTURAL FUNCTIONS: NEONATE WHO IS DRUG-DEPENDENT (HEROIN)
    1. General aspects
      1. Maternal drug addiction has been associated with:
        1. Prenatal malnutrition and vitamin deficiencies.
        2. Increased risk of antepartal infections.
        3. Higher incidence of antepartal and intrapartum complications.
      2. Infant at risk for:
        1. Intrauterine growth retardation (IUGR).
        2. Prematurity.
        3. Fetal distress.
        4. Perinatal death.
        5. Child abuse.
        6. Sudden infant death syndrome (SIDS) (5–10 times higher than normal).
        7. Learning and behavior disorders.
        8. Poor social adjustment.
    2. Pathophysiology—withdrawal of accustomed drug levels → physiological deprivation response.
    3. Etiology—repeated intrauterine absorption of heroin/cocaine/methadone from maternal bloodstream → fetal drug dependency.
    4. Assessment—degree of withdrawal depends on type and duration of addiction and maternal drug levels at birth.
      1. Irritability, hyperactivity, hypertonicity, exaggerated reflexes, tremors, high-pitched cry, difficult to comfort:
        1. "Step" reflex (dancing)—infant places both feet on surface; assumes rigid stance—does not "step" or dance.
        2. "Head-righting" reflex—holds head rigid; fails to demonstrate head lag.
      2. Nasal stuffiness and sneezing; respiratory distress, tachypnea, cyanosis, or apnea.
      3. Exaggerated acrocyanosis or mottling in the infant who is warm.
      4. Sweating.
      5. Hunger—sucks on fists; feeding problems—regurgitation, vomiting, poor feeding, diarrhea, and increased mucus production.
      6. Convulsions with abnormal eye-rolling and chewing motions.
      7. Developmental lags/mental retardation.
    5. Analysis/nursing diagnosis:
      1. High risk for injury related to convulsions secondary to physiological response to withdrawal, CNS hyperirritability.
      2. Impaired gas exchange related to respiratory distress secondary to inhibition of reflex clearing of fluid by the lungs.
      3. Altered nutrition, less than body requirements, related to feeding problems secondary to respiratory distress and GI hypermotility.
      4. High risk for impaired skin integrity related to scratching secondary to withdrawal symptoms.
    6. Nursing care plan/implementation:
      1. Goal: prevent/minimize respiratory distress.
        1. infoImagePosition: side-lying, head dependent—to facilitate mucus drainage.
        2. Suction prn with bulb syringe for excess mucus—to maintain patent airway.
        3. Monitor respirations and apical pulse.
      2. Goal: minimize possibility of convulsions.
        1. Decrease environmental stimuli—quiet, touch only when necessary, offer pacifier.
        2. Keep warm, swaddle for comfort.
      3. Goal: maintain nutrition/hydration.
        1. Food/fluids—oral or IV, as ordered.
        2. I&O.
        3. Daily weight.
      4. Goal: assist in diagnosis of drug and drug level. Collect all urine and meconium during first 24 hours for toxicological studies.
      5. Goal: maintain/promote skin integrity.
        1. Mitts over hands—to minimize scratching.
        2. pillImageKeep clean and dry.
        3. Medicated ointment/powder, as ordered, q2–4h, to excoriated areas.
        4. Expose excoriated areas to air.
      6. pillImageGoal: minimize withdrawal symptoms. Administer medications, as ordered.
        1. Paregoric elixir—to wean from drug.
        2. Phenobarbital—to reduce CNS hyperirritability, hyperbilirubinemia.
        3. Chlorpromazine (Thorazine), diazepam (Valium)—to tranquilize, reduce hyperirritability. Note: Valium is contraindicated for the neonate who is jaundiced because it predisposes to hyperbilirubinemia.
        4. Methadone.
      7. Goal: emotional support to mother.
        1. Encourage verbalization of feelings of guilt, anxiety, fear, concerns.
        2. Refer to social service.
    7. Evaluation/outcome criteria:
      1. Infant responds to medical/nursing regimen.
        1. Maintains adequate respirations.
        2. Feeds well, gains weight.
        3. No evidence of CNS hyperirritability, convulsions; demonstrates normal newborn reflexes.
      2. Infant evidences bonding with parent(s). Responsive to mother's voice.
  7. DISORDERS AFFECTING PSYCHOSOCIAL-CULTURAL FUNCTION: FETAL ALCOHOL SYNDROME (FAS)
    1. General aspects:
      1. Maternal alcohol abuse has been associated with:
        1. Malnutrition, vitamin deficiencies.
        2. Bone marrow suppression.
        3. Liver disease.
        4. Child abuse.
      2. Infant at risk for:
        1. Congenital anomalies (FAS).
        2. Mental deficiency; learning disabilities.
        3. IUGR.
    2. Pathophysiology—permanent damage to developing embryonic/fetal structures; cardiovascular anomalies (ventricular septal defects).
    3. Etiology—high circulating alcohol levels are lethal to the embryo; lower levels cause permanent cell damage.
    4. Assessment:
      1. Characteristic craniofacial abnormalities:
        1. Short, palpebral fissure.
        2. Epicanthal folds.
        3. Maxillary hypoplasia.
        4. Micrognathia.
        5. Long, thin upper lip.
      2. Short stature.
      3. Irritable, hyperactive, poor feeding.
      4. High-pitched cry, difficult to comfort.
    5. Nursing care plan/implementation:
      1. Goal: reduce irritability.
        1. Reduce environmental stimuli.
        2. pillImageWrap, cuddle.
        3. Administer sedatives, as ordered.
      2. Goal: maintain nutrition/hydration.
      3. Goal: emotional support to mother.
    6. Evaluation/outcome criteria (see VI. NEONATE WHO IS DRUG-DEPENDENT [HEROIN], The Newborn Infant):
      1. No respiratory distress.
      2. Infant feeding properly.
      3. Maternal bonding apparent.
      4. Social services—home involvement.
  8. CLASSIFICATION OF INFANTS BY WEIGHT AND GESTATIONAL AGE
    1. Terminology
      1. Preterm, or premature—37 weeks' gestation or less (usually 2500 gm [5 lb] or less).
      2. Term—38 to 42 weeks' gestation.
      3. Postterm—over 42 weeks.
      4. Postmature—gestation greater than 42 weeks.
      5. Appropriate for gestational age (AGA)—for each week of gestation, there is a normal range of expected weight (between 10th and 90th percentile).
        1. Term infants weighing 2500 gm or more are usually mature in physiological functions.
        2. If respiratory distress occurs, it is usually related to meconium aspiration syndrome.
      6. SGA or dysmature—weight falls below normal range for age (<10th percentile).
        1. Preeclampsia.
        2. Malnutrition.
        3. Smoking.
        4. Placental insufficiency.
        5. Alcohol syndrome.
        6. Rubella.
        7. Syphilis.
        8. Multifetal gestation (twins, etc.).
        9. Genetic.
        10. Cocaine abuse.
      7. LGA—above expected weight for age (>90th percentile). Note: If preterm, at risk for RDS.If postterm, at risk for aspiration and sudden intrauterine death.
        1. Etiology:
          1. Maternal diabetes or prediabetes.
          2. Maternal weight gain over 35 lb.
          3. Maternal obesity.
          4. Genetic.
        2. Associated problems:
          1. Hypoglycemia.
          2. Hypocalcemia.
          3. Hyperbilirubinemia.
          4. Birth injury (e.g., fractures, Erb-Duchenne paralysis).
    2. Estimation of gestational age—planning appropriate care for the newborn requires accurate assessment to differentiate between preterm and term infants. PRETERM INFANT—Born at 37 weeks of gestation or less.
      1. Pathophysiology—anatomical and physiological immaturity of body systems compromises ability to adapt to extrauterine environment and independent life.
        1. Interference with protective functions
          1. Temperature regulation—unstable, due to:
            1. Lack of subcutaneous fat.
            2. Large body surface area in proportion to body weight.
            3. Small muscle mass.
            4. Absent sweat or shiver responses.
            5. Poor capillary response to changes in environmental temperature.
          2. Resistance to infection—low, due to:
            1. Lack of immune bodies from mother (these cross placenta late in pregnancy).
            2. Inability to produce own immune bodies (immature liver).
            3. Poor WBC response to infection.
          3. Immature liver
            1. Inability to conjugate bilirubin liberated by normal breakdown of RBCs → increased susceptibility to hyperbilirubinemia and kernicterus.
            2. Immature production of clotting factors and immune globulins.
            3. Inadequate glucose stores → increased susceptibility to hypoglycemia.
        2. Interference with elimination: immature renal function—unable to concentrate urine → precarious fluid-electrolyte balance.
        3. Interference with sensory-perceptual functions: CNS—immature → weak or absent reflexes and fluctuating primitive control of vital functions.
      2. Etiology: often unknown; preterm labor.
        1. Iatrogenic—EDD miscalculated for repeat cesarean birth (rare).
        2. Placental factors
          1. Placenta previa.
          2. Abruptio placentae.
          3. Placental insufficiency.
        3. Uterine factors
          1. Incompetent cervix.
          2. Overdistention (multifetal gestation, polyhydramnios).
          3. Anomalies (e.g., myomas).
        4. Fetal factors
          1. Malformations.
          2. Infections (rubella, toxoplasmosis, HIV-positive status, AIDS, cytomegalic inclusion disease).
          3. Multifetal gestations (twins, triplets).
        5. Maternal factors
          1. Severe physical or emotional trauma.
          2. Coexisting disorders (preeclampsia, hypertension, heart disease, diabetes, malnutrition).
          3. Infections (streptococcus, syphilis, bacterial vaginosis, pyelonephritis, pneumonia, influenza, leukemia, UTI).
        6. Miscellaneous factors
          1. Close frequency of pregnancies.
          2. Advanced maternal age.
          3. Heavy smoking.
          4. High-altitude environment.
          5. Cocaine use.
      3. Factors influencing survival:
        1. Gestational age.
        2. Lung maturity.
        3. Anomalies.
        4. Size.
      4. Causes of mortality (in order of frequency):
        1. Abnormal pulmonary ventilation.
        2. Infection.
          1. Pneumonia.
          2. Septicemia.
          3. Diarrhea.
          4. Meningitis.
        3. Intracranial hemorrhage.
        4. Congenital defects.
      5. Disorders affecting fluid-gas transport: RDS
        1. Pathophysiology—insufficient pulmonary surfactant (lecithin) and insufficient number/maturity of alveoli predispose to atelectasis; alveolar ducts and terminal bronchi become lined with fibrous, glossy membrane.
        2. Etiology:
          1. Primarily associated with prematurity.
          2. Other predisposing factors:
            1. Fetal hypoxia—due to decreased placental perfusion secondary to maternal bleeding (e.g., abruptio placentae) or hypotension.
            2. Birth asphyxia.
            3. Postnatal hypothermia, metabolic acidosis, or hypotension.
        3. Factors protecting neonate from RDS:
          1. Chronic fetal stress—due to maternal hypertension, preeclampsia, or heroin addiction.
          2. PROM.
          3. Maternal steroid ingestion (e.g., betamethasone).
          4. Low-grade chorioamnionitis.
        4. Assessment:
          1. Usually appears during first or second day after birth.
          2. Signs of respiratory distress:
            1. Nasal flaring.
            2. Expiratory grunt.
            3. Sternal retractions.
            4. Tachypnea (60 breaths/min or more).
            5. Cyanosis—central.
            6. Increasing number and length of apneic episodes.
            7. Increasing exhaustion.
          3. Respiratory acidosis—due to hypercapnea and rising CO2 level.
          4. Metabolic acidosis—due to increased lactic acid levels and falling pH.
        5. Analysis/nursing diagnosis:
          1. Impaired gas exchange related to lack of pulmonary surfactant secondary to preterm birth, intrapartum stress and hypoxia, infection, postnatal hypothermia, metabolic acidosis, or hypotension.
          2. Altered nutrition, less than body requirements, related to poor feeding secondary to respiratory distress, ↑ caloric demand.
        6. Nursing care plan/implementation:
          1. Goal: reduce metabolic acidosis, increase oxygenation, support respiratory efforts.
            1. Ensure warmth (isolette at 97.6°F).
            2. Warmed, humidified O2 at lowest concentration required to relieve cyanosis, through hood, nasal prongs, or endotracheal tube.
            3. Monitor continuous positive airway pressure (CPAP)—oxygen–air mixture administered under pressure during inhalation and exhalation to maintain alveolar patency.
            4. infoImagePosition: side-lying or supine with neck slightly extended ("sniffing" position); arms at sides.
            5. Suction prn with bulb syringe—for excessive mucus.
          2. Goal: modify care for infant with endotracheal tube.
            1. Disconnect tubing at adapter.
            2. Inject 0.5 mL sterile normal saline (may be omitted).
            3. Insert sterile suction tube, start suction, rotate tube, withdraw.
            4. Suction up to 5 seconds.
            5. Ventilate with bag and mask during procedure.
            6. Reconnect tubing securely to adapter.
            7. Auscultate for breath sounds and pulse.
          3. foodImageGoal: maintain nutrition/hydration.
            1. Administer fluids, electrolytes, calories, vitamins, minerals PO or IV, as ordered.
            2. I&O.
          4. Goal: prevent secondary infections.
            1. Strict aseptic technique.
            2. Hand washing.
          5. Goal: emotional support of infant.
            1. Gentle touching.
            2. Soft voices.
            3. Eye contact.
            4. Rocking.
          6. Goal: emotional support of parents.
            1. Keep informed of status and progess.
            2. Encourage contact with infant—to promote bonding, understanding of treatment.
          7. Goal: minimize possibility of iatrogenic disorders associated with oxygen therapy (see F.and G., below).
        7. Evaluation/outcome criteria:
          1. Respiratory distress treated successfully; infant breathes without assistance.
          2. Infant completes successful transition to extrauterine life.
      6. Iatrogenic (oxygen toxicity) disorders: retinopathy of prematurity
        1. Pathophysiology—intraretinal hemorrhage → fibrosis → retinal detachment → loss of vision.
        2. Etiology—prolonged exposure to high concentrations of oxygen.
        3. Assessment—only perceptible retinal change is vasoconstriction. Note: Arterial blood gas (PaO2) readings less than 50 or more than 80 mm Hg.
        4. Nursing care plan/implementation: Goal: prevent disorder. Maintain PaO2 of 50 to 70 mm Hg.
        5. Evaluation/outcome criteria:
          1. Successful recovery from respiratory distress.
          2. No evidence of retinopathy.
      7. Iatrogenic (oxygen toxicity) disorders: bronchopulmonary dysplasia (BPD)
        1. Pathophysiology—damage to alveolar cells result in focal emphysema.
        2. Etiology—positive-pressure ventilation (CPAP and positive end-expiratory pressure [PEEP]) and prolonged administration of high concentrations of oxygen.
        3. Assessment—monitor for signs of:
          1. Tachypnea.
          2. Increased respiratory effort.
          3. Respiratory distress.
        4. Nursing care plan/implementation: Goal: prevent disorder.
          1. Use of positive-pressure devices.
          2. Maintain oxygen concentration below 80%.
          3. Supportive care.
          4. Wean off ventilator, as possible.
        5. Evaluation/outcome criteria:
          1. Successful recovery from respiratory distress.
          2. No evidence of disorder.
      8. Intraventricular hemorrhage
        1. Pathophysiology—rupture of thin, fragile capillary walls within ventricles of the brain (more common in preterm).
        2. Etiology:
          1. Hypoxia.
          2. Respiratory distress.
          3. Birth trauma.
          4. Birth asphyxia.
          5. Hypercapnia.
        3. Assessment:
          1. Hypotonia.
          2. Lethargy.
          3. Hypothermia.
          4. Bradycardia.
          5. Bulging fontanels.
          6. Respiratory distress or apnea.
          7. Seizures.
          8. Cry: high-pitched whining.
        4. Nursing care plan/implementation: Goal: supportive care to promote healing.
          1. Monitor vital signs.
          2. Maintain thermal stability.
          3. Ensure adequate oxygenation (may be placed on CPAP).
        5. Evaluation/outcome criteria:
          1. Condition stable, all assessment findings within normal limits.
          2. No evidence of residual damage.
      9. Disorders affecting nutrition
        1. Pathophysiology—underdeveloped feeding abilities, small stomach capacity, immature enzyme system, fat intolerance.
        2. Etiology—immature body systems associated with preterm birth.
        3. Assessment:
          1. Weak suck, swallow, gag reflexes—tendency to aspiration.
          2. Signs of malabsorption and fat intolerance (abdominal distention, diarrhea, weight loss, or failure to gain weight).
          3. Signs of vitamin E deficiency (edema, anemia).
        4. Analysis/nursing diagnosis:
          1. Altered nutrition, less than body requirements, related to poor feeding reflexes, reduced stomach capacity, inability to absorb needed nutrients.
          2. Impaired gas exchange related to aspiration.
        5. Nursing care plan/implementation: Goal: maintain/increase nutrition.
          1. foodImageFrequent, small feedings—to avoid exceeding stomach capacity, facilitate digestion.
          2. Frequent "burping" during feeding—to avoid regurgitation/aspiration.
          3. pillImageSupplement vitamin E (alpha-tocopherol) intake, as ordered, in infants who are formulafed. (Note: intake adequate in infants who are breastfed.) Vitamin E actions:
            1. Antioxidant.
            2. Maintains structure and function of smooth, skeletal, and cardiac muscle.
            3. Maintains structure and function of vascular tissue, liver, and RBC integrity.
            4. Coenzyme in tissue respiration.
            5. Treatment for malnutrition with macrocytic anemia.
          4. Encourage parent/family participation.
        6. Evaluation/outcome criteria:
          1. Feeds well without regurgitation/aspiration.
          2. Maintains/gains weight.
          3. No evidence of malabsorption, vitamin deficiency.
      10. Disorders affecting nutrition/elimination: necrotizing enterocolitis (NEC)
        1. Pathophysiology—intestinal thrombosis, infarction, autodigestion of mucosal lining, and necrotic lesions; incidence increased in preterm.
        2. Etiology—intestinal ischemia, due to blood shunt to brain and heart in response to:
          1. Fetal distress.
          2. Fetal/neonatal asphyxia.
          3. Neonatal shock.
          4. After birth, may result from:
            1. Low cardiac output.
            2. Infusion of hyperosmolar solutions.
          5. Complicated by action of enteric bacteria on damaged intestine.
        3. Assessment—early identification is vital.
          1. Abdominal distention or erythema, or both.
          2. Poor feeding, vomiting.
          3. Blood in stool.
          4. Systemic signs associated with sepsis that may need temporary colostomy or iliostomy:
            1. Lethargy or irritability.
            2. Hypothermia.
            3. Labored respirations or apnea.
            4. Cardiovascular collapse.
          5. Medical diagnosis:
            1. Increased gastric residual.
            2. X-ray shows ileus, air in bowel wall.
        4. Analysis/nursing diagnosis:
          1. Altered nutrition, less than body requirements, related to inability to tolerate oral feedings, and gastrointestinal dysfunction secondary to ischemia, thrombosis, or necrosis.
          2. Constipation related to paralytic ileus with stasis; diarrhea related to water loss.
          3. High risk for injury related to infection, thrombosis, metabolic alterations (acidosis, osmotic diuresis, dehydration, hyperglycemia) due to parenteral nutrition.
          4. Altered parenting related to physiological compromise and prolonged hospitalization.
          5. Impaired skin integrity when colostomy is necessary.
        5. Nursing care plan/implementation:
          1. Goal: supportive care.
            1. Rest GI tract: no oral intake—to achieve gastric decompression.
            2. pillImageIV fluids, as ordered—to maintain hydration.
          2. pillImageGoal: prevent infection. Administer antibiotics, as ordered.
          3. Goal: prevent trauma to skin surrounding stoma.
        6. Evaluation/outcome criteria:
          1. Tolerates oral feedings.
          2. Demonstrates weight gain.
          3. Normal stool pattern.
          4. Parents are accepting and knowledgeable about care of infant.

POSTTERM INFANT—Over 42 weeks of gestation.

  1. General aspects
    1. Labor may be hazardous for mother and fetus because:
      1. Large size of infant contributes to cephalopelvic disproportion; obtain estimate of fetal weight (EFW) by ultrasound.
      2. Placental insufficiency → fetal hypoxia; diagnosis by:
        1. Contraction stress test.
        2. Nonstress test
        3. Amniotic fluid index (AFI).
      3. Meconium passage (common physiological response) increases chance of meconium aspiration.
  2. Assessment:
    1. If postmature skin: dry, wrinkled—due to metabolism of fat and glycogen reserves to meet in utero energy needs.
    2. Long limbs, fingernails, and toenails—due to continued growth in utero.
    3. Lanugo and vernix—absent.
    4. Expression: wide-eyed, alert—probably due to chronic hypoxia (oxygen hunger).
    5. Placenta—signs of aging.
  3. Analysis/nursing diagnosis: High risk for injury related to high incidence of morbidity and mortality due to dystocia or hypoxia.
  4. Nursing care plan/implementation:
    1. During labor:
      1. Goal: emotional support of mother—may require cesarean birth due to CPD or fetal distress.
      2. Goal: continuous electronic monitoring of FHR. Report late decelerations immediately (indicate fetal distress).
    2. After birth:
      1. Goal: if born vaginally, prompt identification of birth injuries, respiratory distress. Continual observation.
      2. Goal: early identification/treatment of emerging signs of complications.
        1. Hypoglycemia—Dextrostix readings and behavior.
        2. pillImageAdminister oral or intravenous glucose, as ordered.
  5. Evaluation/outcome criterion: successful transition to extrauterine life (all assessment findings within normal limits).