Ateneo de Zamboanga University

College of Nursing
NCM 109j – PEDIA

ACUTE CONDITIONS OF THE NEONATES:

Respiratory Distress syndrome

Meconium Aspiration syndrome
Sepsis
Hyperbilirubinemia
Sudden Infant Distress syndrome (SIDS)

Respiratory distress syndrome (RDS)

Hyaline membrane disease
Due to immaturity of the lungs ➔decreased gas exchange
Etiology:
Deficient synthesis or release of SURFACTANT
High in lecithin and fatty protein necessary for absorption of oxygen in the lungs
Incidence:
Common in preterm newborns, especially those weighing bet. 1000 – 1500 gms
Also high in babies:
Of diabetic mothers
Delivered by CS, and
Whose mothers had antepartum bleeding

Complications/associated problems
Hypoxia
Retrolental fibroplasia
From O2 of high concentration, greater than 40%
Atelectasis
Bronchopulmonary dysplasia

Assessment/Findings
Use Silverman-Andersen Scale for scoring difficult respiration
0 = normal respiration
10 = most difficult respiration, RDS
Major Signs:
Expiratory grunting – major sign; late-occuring
Flaring of the nares – early sign
Retractions (sternal and intercostal)
Due to use of accessory muscles to aid respiration
See-saw breathing
flattening of the chest during inspiration w/ bulging of abdomen
Tachypnea: RR > 70/min – an early sign
Assessment/findings
Minor signs
Cyanosis
Tachycardia
Falling body temperature; color: pale gray
Dyspnea
Decreased activity level
Respiratory acidosis
Auscultation: fine rales, diminished breath sounds
Decreased urine; edema of extremities
Decreased muscle tone; absent bowel sounds
Periods of apnea
Diagnosis
History
Assessment findings (Silverman)
Blood gas studies

RDS Manifestations
RR: 60 breaths/min or more
Rapid respirations with grunt-like sounds,
Nasal flaring,
Cyanosis,
Intercostal and substernal retractions
Severe: edema, lassitude, apnea

Nursing Implementation
Keep airway patent/promote respiration
Suction ET 1 – 2 hours as needed
In preterm: < 5 seconds per suctioning
Use sterile catheter
Maintain and monitor O2 concentration
Maintain humidity; maintain in supine position with head slightly extended to
improve respiratory function
Do not hyperextend the neck
Administer prescribed O2 under CPAP

Treatment/ Management :
Corticosteroids (bethamethasone)
IM, 1 – 2 hrs. before delivery
Preterm newborns : via endotracheal tube (ET) at birth or when sx of RDS occur
Improvement of lung fxn w/in 72 hours
VS monitored closely
arterial blood gases analyzed
 Warm incubator w/ gentle or minimal handling
IVF – nurse observes for signs of over hydration or dehydration
O2 therapy via hood or ventilator in concentrations necessary to maintain adequate tissue
perfusion
Frequent evaluation/monitoring:
VS, color , breath sounds, and blood gases
Maintain hydration and nutrition
NPO for Tachypnea
Monitor I&O, daily weight
Provide for IV therapy, gavage feeding (when infant is unable to suck or tires easily) or
hyperalimentation)
Prevent infection by:
Handwashing
Wearing proper attire
Antibiotics as ordered
Avoiding exposure to infected personnel
Isolating infected newborns
Keep warm
Maintain in isolette w/ high humidity
Incubator: 40 -70%
High humidity: 55 – 65%
Monitor temp per axilla
Prevent heat loss

Meconium Aspiration Syndrome (MAS)

Group of symptoms that occur when the fetus or newborn aspirates meconium-stained
amniotic fluid into the lungs
Etiology:
prolonged labor ➔ fetus expels meconium into amniotic fluid (esp. w/ cord
compression)
If Asphyxia and acidosis occur ➔fetus gasps ➔drawing meconium-stained amniotic
fluid into lungs
1st breath before nose and mouth is suctioned ➔meconium-stained fluid in upper
airway passages is drawn into the lungs
MAS Etiology:
Meconium can cause Severe Respiratory Distress in 3 ways:
Causes Inflammation of bronchioles
Because it is a foreign substance
Can block small bronchioles by mechanical plugging
Ball-valve action: air is allowed in but cannot be exhaled ➔hyper inflated
lungs ➔Decreased pulmonary perfusion ➔Increased hypoxia
Causes decreased in surfactant production through lung trauma.

Assessment
May demonstrate signs of fetal distress during labor and delivery
Apgar score less than 6 @ 1 and 5 minutes
Immediate signs of respiratory distress @ delivery (cyanosis, tachypnea, retractions)
Over-distended, barrel-shaped chest
 Diminished breath sounds
Yellow staining of skin, nails, umbilical cord

Priority Dx: Ineffective gas exchange

Interventions:
Suction oropharynx then nasopharynx after neonate’s head is born to remove as much
meconium as possible
Place infant under radiant warmer
Administer O2 to maintain adequate PO2 and O2 saturation
Perform chest physiotherapy routinely

Sepsis
Systemic response to infection with bacteria
Can also result from viral or fungal infections
Causes SYSTEMIC Inflammatory Response Syndrome (SIRS) due to the endotoxin of the
bacteria that causes tissue damage
If untreated ➔septic shock, multi-organ dysfunction syndrome, DEATH

Manifestations:
Fever, chills, tachypnea, tachycardia, neurological signs (lethargy)
Hypotension – ominous/threatening sign
Indicates body is unable to compensate adequately and cardiorespiratory arrest is
about to occur
Lab tests:
(+) blood cultures
Reduced fibrinogen and thrombocyte levels
Presence of immature WBC
Neutropenia (neutrophil 1000/mm3)

Nursing Responsibilities
Monitoring neurological status and VS
Observing for shock;
Maintaining strict standard and expanded precautions (masks, gowns, gloves)
Antibiotics IV
Immunization against H. influenzae (Hib) bet. 2 mos. – 4 years

HYPERBILIRUBINEMIA
HYPER - “excess”; BILIS – “bile”; RUBOR – “red”; EMIA – “blood”
Excessive levels of serum bilirubin greater than 12 – 13 mg/100 mL
Normal: 2 – 6 mg/100 mL, not to exceed 12 mg/100 mL

Physiology
Pathophysiology
Before birth – unconjugated bilirubin is eliminated by the placenta
After delivery – converted to conjugated bilirubin in the liver and is excrete via bile ducts into
the intestines
Can be reabsorbed from the intestines if peristalsis slows
KERNICTERUS – complication

Risk factors
Resolution of enclosed hemorrhage (cephalhematoma, large amount of bruising from difficult
delivery)
Infection/sepsis
Dehydration
Breastfeeding – pregnanediol in breast milk renders glucorynyl transferase ineffective in
conjugating bilirubin
Poor meconium/stool passage

Assessment
Pathologic jaundice
Occurs in the 1st 24 hours
Duration: lasts more than a week
Dangerous levels @ w/c kernicterus may set it:
Full-term: 20 mg/100 mL or above
Preterm: 15 mg/ 100 mL or above
Assessment: Kernicterus
Signs of kernicterus:
Sluggish-to-absent Moro reflex
Opisthotonus
Severe lethargy
Projectile vomiting
Tense, bulging fontanel; high-pitched cry
Apnea
Convulsion – late sign
Irritability
Increasing serum bilirubin
Nursing Diagnoses :
Fluid volume deficit r/t decreased intake, loose stools, and increased insensible water loss
Impaired parenting r/t interruption in bonding between infant and parents secondary to
separation

Interventions and management

Phototherapy
Transports bilirubin from skin to the blood, then to bile where it is excreted and
passed out thru the stool
Light tubes 16 inches (42 – 45 cm) away from baby
Prepare for phototherapy:
Undress newborn
Cover eyes and genitalia
Phototherapy
Provide continued care during the treatment
Feed regularly (Q 2 – 3 hours) to prevent metabolic acidosis
Remove infant from under the light, remove eye shield, then cuddle him
during feeding
Turn q 2 hours for maximum exposure of skin surfaces
Increased fluid intake; give fluids in between feedings
Monitor temperature q 2 hours
Assess for S/S, and manage as necessary
Bronze skin (explain to parents: temporary)
Dark, concentrated urine (Increased fluids; sterile water between regular milk feedings)
Bright, green, loose stools from excess bilirubin excretion (explain: not diarrhea)
Priapism (turn to prone)
Retinal damage (prevent by shielding eyes)
Dehydration
Elevated temp/fever (monitor temp; provide adequate hydration)

SUDDEN INFANT DEATH SYNDROME (SIDS)

Clinically defined as:
Sudden, unexpected death of an apparently healthy infant bet. 2 weeks & 1 year of age for
which routine autopsy fails to identify the cause
“Crib death”
Peak incidence: bet. 2 & 4 months of age

Clinical features
Death occurs during sleep, and
 Infant does not cry or make other sounds of distress
How it happens?
Current theories focus on neurologic immaturity related to the infant’s inability to
sense and regulate oxygenation status ➔ultimately leading to respiratory arrest

Risk factors for SIDS

Infant risk factors
Prematurity
Low birth weight
Twin or triplet
male
Age bet. 2 – 4 mos
Passive smoke exposure
Hx of respiratory compromise
Hx of a sibling who died of SIDS
Maternal risk factors
Age under 20 years
Smoking or illicit drug use
Anemia
Multiple pregnancies w/ short intervals bet. them
Low socio-economic status, crowded living conditions
Poor prenatal care and limited weight gain during pregnancy
Preventive measures
Put infant on his back to sleep
Not smoking anywhere near an infant
Remove pillows, quilts, stuffed toys, or other soft surfaces that may trap exhaled air from crib
or sleeping environment
Use firm mattress w/ snug-fitting sheet
Make sure infant’s head remains uncovered while sleeping
Keep warm while sleeping but not overheated
Nursing Care
Assist parents in the grieving process
Stay calm and let parents express their feelings
May express anger or blame others
Reassure them that disease cannot be predicted nor prevented, and “they are not
responsible” for the death
Allow them to say goodbye to the infant:
Let them touch, hold and rock the infant
May assist in burial preparations