University:
American Career College
Course:
NURS-113 | Beginning Medical/Surgical Nursing
Academic year:

2018
Views:

455

Pages:

28
Author:

KillSteel

NEONATOLGY Some definitions Stillbirth - fetus born with no signs of life ≥24 weeks of pregnancy •Perinatal mortality rate - stillbirths + deaths within the first week per 1000 live births and stillbirths •Neonatal mortality rate - deaths of live-born infants within the first 4 weeks of age per 1000 live births •Neonate - infant ≤28 days old •Preterm - gestation <37 weeks of pregnancy •Term - 37-41 weeks of pregnancy •Post-term - gestation >42 weeks of pregnancy •Low birthweight (LBW) - <2500 g •Very low birthweight (VLBW) - <1500g •Extremely low birthweight (ELBW) - <1000 g •Small for gestational age - birthweight <10th centile for gestational age •Large for gestational age - birthweight >90th centile for gestational age ASSESSMENT OF THE MOTHER The optimal care of low-risk and high-risk newborns requires knowledge of the family history, history of prior and current pregnancies, and events of labor and delivery. Neonatal medicine requires a comprehensive understanding of the physiology of normal pregnancy; placental and fetal growth, function, and maturity; and any extrauterine or intrauterine pathologic events that affect the mother, placenta, or fetus Bleeding develops when the placental mass overlies the internal cervical os; this may produce maternal hemorrhagic shock, necessitating transfusions. Bleeding also may result in premature delivery. Painful vaginal bleeding is often the result of retroplacental hemorrhage or placental abruption Fetal asphyxia ensues as the retroplacental hematoma causes placental separation that interferes with fetal oxygenation. Both types of bleeding are associated with fetal blood loss. Neonatal anemia may be more common with placenta previa. Oligohydramnios (amniotic ultrasound fluid index ≤2 cm) is associated with IUGR and major congenital anomalies, particularly of the fetal kidneys. It also is associated with chromosomal syndromes. Bilateral renal agenesis results in diminished production of amniotic fluid. It also results in a specific deformation syndrome (Potter syndrome), Polyhydramnios may be acute and may be associated with premature labor, maternal discomfort, and respiratory compromise. More often, polyhydramnios is chronic and is associated with diabetes, immune or nonimmune hydrops fetalis, multiple gestation, trisomy 18 or 21, and major congenital anomalies. Anencephaly, hydrocephaly, and meningomyelocele are neurologic problems associated with reduced fetal swallowing. Esophageal and duodenal atresia and cleft palate interfere with swallowing and gastrointestinal fluid dynamics. Premature rupture of the membranes Prolonged rupture of the membranes (>24 hours) Increased risk of maternal or fetal infection (chorioamnionitis) and preterm birth. Typically, group B streptococci, Escherichia coli, and Listeria monocytogenes are associated with fetal infection. The risk of serious fetal infection increases as the length of time between rupture and labor (latent period) increases, especially if the period is greater than 24 hours. Intrapartum antibiotic therapy decreases the risks of neonatal sepsis. Multiple gestations Increased risk resulting from polyhydramnios, premature birth, IUGR, abnormal presentation (breech), congenital anomalies (intestinal atresia, porencephaly, and single umbilical artery), intrauterine fetal demise, birth asphyxia, and twinto-twin transfusion syndrome. Twin-to-twin transfusion syndrome is associated with a high mortality and is seen only in monozygotic twins who share a common placenta and show an arte-riovenous connection between their circulation Toxemia of pregnancy, or preeclampsia/eclampsia, Unknown but probably vascular etiology that may lead to maternal hypertension, utero-placental insufficiency, IUGR, intrauterine asphyxia, maternal seizures, and maternal death. Toxemia is more common in nulliparous women and in women with twin gestation, chronic hypertension, obesity, renal disease, positive family history of toxemia, or diabetes mellitus. A subcategory of preeclampsia, the HELLP syndrome (hemolysis, elevated liver enzyme levels, low platelets), is more severe and is often associated with a fetal inborn error of fatty acid oxidation ASSESSMENT OF THE FETUS Fetal growth can be assessed clinically by determining the fundal height of the uterus through bimanual examination of the gravid abdomen. Ultrasound measurements of the fetal biparietal diameter, femur length, and abdominal circumference are used to estimate fetal growth IUGR is present when fetal growth stops and over time declines to less than the 5th percentile of growth for gestational age or when growth proceeds slowly, but absolute size remains less than the 5th percentil ASSESSMENT OF THE NEWBORN Physical Examination and Gestational Age Assessment Appearance The general appearance of the infant should be evaluated first. Signs such as cyanosis, nasal flaring, intercostal retractions, and grunting suggest pulmonary disease. Meconium staining of the umbilical cord, nails, and skin suggests fetal distress and the possibility of aspiration pneumonia The level of spontaneous activity, passive muscle tone, quality of the cry, and apnea are useful screening signs to evaluate the state of the nervous system initially. Gestational Age The skin is covered with lanugo hair, which disappears by term gestation. Hair tufts over the lum-bosacral spine suggest a spinal cord defect. Vernix caseosa, a soft, white, creamy layer covering the skin in preterm infants, disappears by term. Post-term infants often have peeling, parchment-like skin. Mongolian spots are transient, dark blue to black pigmented macules seen over the lower back and buttocks in 90% of African American, Indian, and Asian infants. Nevus simplex ("salmon patch"), or pink macular hemangiomas, is common, usually transient, and noted on the back of the neck, eyelids, and forehead. Nevus flammeus, or port-wine stain, commonly is seen on the face and should cause the examiner to consider Sturge-Weber syndrome (trigeminal angiomatosis, convulsions, and ipsilateral intracranial "tram-line" calcifications). Erythema toxicum is an erythematous, papular-vesicular rash common in neonates that develops after birth and involves eosinophils in the vesicular fluid. Pustular melanosis, consists of a small, dry vesicle on a pigmented brown macular base. Milia (yellow-white epidermal cysts of the pilosebaceous follicles that are noted on the nose) and miliaria (prickly heat), which is caused by obstructed sweat glands. Edema may be present in preterm infants, but also suggests hydrops fetalis, sepsis, hypoalbuminemia, or lymphatic disorders Mongolian spot Erythema toxicum milia