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Patient Assessment 3 > Neonatal Assessment > Flashcards

Neonatal Assessment Flashcards

1
Q

Neonate Definition

A

A newborn baby in the first 28 days of life

There may be some variability on the exact number of days but generally, it is the first 28/month

This does not take into consideration if the baby was a term baby or a preterm baby

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2
Q

Embryo Definition

A

Embryo: <10 weeks gestation

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3
Q

Fetus Definition

A

Fetus: 10 weeks till birth

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4
Q

Pre-Term Baby

A

Pre-Term Baby: Born between 20- 37 weeks gestation

Any baby that is born <23 weeks will tend to have a lot of issues and chances of survival are low

There are further divisions in the preterm classifications

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5
Q

Term Baby

A

Born within 38-42 weeks

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6
Q

Post Term Baby

A

Born after 42 weeks

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7
Q

Trimesters

A

1st < 12 weeks

2nd 13-28 weeks

3rd > 28 weeks

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8
Q

Gravidity

A

Number of pregnancies

If the mother gives birth to twins or multiple births it is still considered 1

An abortion will be considered a pregnancy under this definition

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9
Q

Parity

A

Number of pregnancies that where carried to viable gestation (>23 weeks)

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10
Q

Gravida/Para/Abortus

A

(charting shorthand is GPA)

G [# of pregnancies] P [# Carried to viable age] A {# of abortions]

If there are no abortions then we just drop the A

If a woman has had 2 pregnancies both that where live births it would be G2P2

KNOW this as it is a common question

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11
Q

Nullgravida

A

Never been pregnant

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12
Q

Nullpara

A

Never carried passed20 weeks

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13
Q

Primipariety

A

First pregnancy

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14
Q

Sources for Pt Information and Background

A
  • Daily report
  • Chart
    • There may be a cardex which will give you the most recent and important information, then if you need more information you can look into the fully chart
  • Bedside Nurse
  • Family (Parents)
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15
Q

The Pt Information and Background should give you a feel for

A
  • Patient and maternal history
  • Prenatal and delivery history
    • The prenatal history not always be available for us
    • If mom is addicted to drugs or alcohol the baby may come out with respiratory depression
  • Major clinical events
  • Current clinical status
    • Ex. In babies if they go apneic and have bradycardia at the same time it means that we have to improve their ventilation
  • Current orders and PCP
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16
Q

What are the PPE Precaution in the Special Care Nursery and NICU

A
  • Even before you start your shift you will begin with a 60 second hand wash
  • It is required to take off everything below the elbows such as jewelry and watches and no long sleeves
  • There will be a stethoscope that is at the bedside and specific for each patient
  • Make sure to always keep hair up and everything pulled back and not hanging into the environment
  • Make sure to wipe down your pager, ID, and everything external that you are bringing into the environment
  • Absolutely no food or drink
  • Wipe down all common surfaces
  • Neatly trimmed and cleaned nails
  • Stay home when you are sick
    • Ex. The rhino virus is a common cold in adults but can be very severe in infants
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17
Q

Labor and Delivery Isolation Precautions

A

It is a clean procedure not a sterile procedure

However a C section in the OR is a sterile procedure

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18
Q

Vap Bundles Adults

A

HOB at 30 degrees

Inline suction

Limit circuit changes

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19
Q

VAP Bundle Neonates

A
  • HOB at 15 degrees
    • Preventing oral secretion from getting pass the tube and moving the gravity dependant condensation in the heated circuits downwards
  • Inline suction
    • Decreases circuit break
    • You wont do open suction on a neonate
  • Limit circuit breaks
  • Only required when indicated or solid
  • Single use nasal catheter
  • Continuously assess for extubation
    • Majority of the time we extubate to CPAP or BiPAP in order to help prevent VAP and allow lungs to develop normally
  • Monitor sputum
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20
Q

Goals of Care

A
  • Will be the same as with adults, but you will find that in neonatal they tend to make special consideration such as resuscitation on babies we know are not viable
  • Resuscitation
    • Medical care and interventions including resuscitation followed by admittance into the NICU
  • Medical
    • Medical care and interventions not including resuscitation
  • Comfort
    • Medical care interventions with the focus on comfort
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21
Q

Initial Impression

A
  • Before you go in for your assessment make sure that you are coordinating your care with other disciplines and when they are doing their assessment in order to prevent unnecessary disruption to the baby as well opening and closing the isolette door may cause a draft and make the baby cold
  • Utilize your visual evaluation of the patient and bedside monitors as much as possible to prevent disrupting the baby
    • Perform the “inspection” of IPPA to gather an overall impression of the patient clinical status
    • With NICU remember you can not always touch a baby so you have to rely a lot on the monitor

Many clinicians prefer to do the “monitoring” of the patient before the physical exam components. This allows collection of “baseline” data before disturbing the patient.

NOTE: The initial visual evaluation may reveal that in immediate intervention is required, however! (e.g. coughing/desaturation requiring suctioning).

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22
Q

Noise Controls

A

Noise can affect babies hearings

Even your normal speaking voice can be too loud

Set your pager to vibrate

Turn down vent alarms and monitors

Try to be as quiet as possible when closing the isolette door

In all NICU there will be a period of silence for 2 hours

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23
Q

Neutral Thermal Enviroment (NTE)

A
  • We have to be very concerned about babies maintaining a normal temperature
    • If they do not maintain a normal temperature it will affect oxygen demand
  • Neonates are very susceptible to hypothermia due to their decreased surface area and body fat
    • Premature babies will not have produced brown fat which would keep them warm
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24
Q

What are the Different Types of Heat Loss

A

Conduction

Evaporation

Radiation

Convection

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25
Q

Mechanism of Heat Loss-Conduction

A

What: Body heat loss to a cooler contact surface

Prevention: Avoid placing the baby on a cool surface

Devices: Use a warmed dry blanket, use preheated radiant warmers

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26
Q

Mechanism of Heat Loss-Evaporation ​

A

What: Removal of heat from a body that occurs as the liquid evaporates

Prevention: Increase room humidity, dry the baby, wrap the baby, bag the preemie, and humidify the inspiratory gases

Devices: Use warmed blankets to dry and wrap the baby and use humidifers

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27
Q

Mechanism of Heat Loss-Radiation ​

A

What: Heat loss to a cooler surface not in contact with the body

Prevention: Keep incubators heated or heat shielded, keep the room temperature high

Devices: Use a heated shielded incubator, use bonnets to cover the babies head

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28
Q

Mechanism of Heat Loss-Convection

A

What: Heat loss to cooler surrounding air

Prevention: Keep room temperature high, avoid drafts, and keep the baby covered

Devices: Use a radiant warmer or isolette

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29
Q

Radiant Warmer

A
  • Used for overhead warming
  • Body temperature can be maintained via servo mode, with a skin probe which is normally attached to the abdomen
  • The giraffe isolette is the radiant warmer and does not have closed sides
    • Used for older premature and term babies
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30
Q

Closed Isolette

A

Use for low birth weight infants with temperature instability (hypothermia)

Maintains a constant body temperature by using either a servo-controlled skin probe, air temperature control device, or air temperature probe

Should be double walled or heat shielded (will look almost cloudy which makes assessment more difficult)

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31
Q

What are the basic assessments and physical examination for CNS

A

PIPP

General Neurological State

Activity Level and Ability to Settle

Fontanel

Tone/Reflex

Head Circumference

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32
Q

Premature Infant Pain Profile (PIPP)

A
  • As baby will not show pain in typical ways we use these scores (can desat with scores)
  • Minimum score of zero and maximum score of 21
  • The higher score correlates with the greater pain
  • Lower gestational age will have a higher PIPP
  • Done at admission to NICU (will determine how often done after), before and after procedures
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33
Q

Non Pharmacological Ways to Help Babies with Pain

A
  • Rocking
  • Re positioning
  • Diaper change
  • Decreasing environmental stimuli
  • Skin to skin
  • Prone positioning
  • Breastfeeding
  • Giving the baby sucrose (not available for intubated patients)
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34
Q

State of the Baby

A
  • Undisturbed/Disturbed
  • Crying
  • Active awake
  • Quiet alert-Not moving around a lot but still aware of you
  • Drowsy-Touching them and they are slow to wake up it can be very similar to deep sleep which is why it is difficult to assess
  • Active asleep-Moving around in their sleep
  • Deep sleep
  • Sedated
  • Comatose-Babies may be comatose when they are very sedated (ex. Therapeutic hypothermia, massive head injury or brain bleeds)
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35
Q

Activity Level and Ability to Settle

A

Appropriate -Are they acting appropriately for their gestations age (term babies will have more tone and strength compared to preemies)

Jittery May indicate pain, repositioning, diaper change

Lethargic

Unresponsive

Paralyzed-It is rare that we will actually paralyze a baby

Intolerant of Handling

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36
Q

Fontanel

###

A

The fontanel is the non-ossified part of the skull and we will gently feel them for assessment

Soft & Flat

Depressed

Overriding Sutures-Will happen normally and will resolve quickly but if it is an early or late fusion it can lead to distorted skulls

Full/Bulging-Could mean we are giving them too much fluid or that there is a bleed

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37
Q

Tone and Reflex

A
  • Appropriate
  • Flaccid
  • Hypertonic
    • Bring in the extremities
    • Baby in pain or cold
  • Hypotonic

Check tone right away

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38
Q

Head Circumference

A
  • Chest circumference ~ head circumference
  • Term infant:
    • Occipitofrontal circumference: around the front of the head above the brow and the occiput (occipital area)
    • Above the ears
    • Normally 32-37 cm at term
  • Accessing development at birth & trending growth
    • Head circumference, weight & length percentiles are recorded and trended
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39
Q

EEG

A

Used to assess seizure activity

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40
Q

CT Scan

A

Looks for bleeds or fluid in subdural or subarachnoid space

Assesses parenchyma

Skull #s

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41
Q

MRI

A

Myelination

Ischemic or hemorrhagic lesions

Agenesis of corpus callosum

AV malformations

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42
Q

Ultrasound

A

Performed at the bedside to check for intracranial and intraventricular hemorrhage

If there is a hemorrhage we can grade them based off of the CT scan (Grade 4 being the worse) and then take the baby to CT and MRI for more information

Most common is germinal matrix hemorrhage and is more common in the premature infants and they might be getting ultrasounds daily in order to assess for this

Can also be used to find hydrocephaly

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43
Q

Lumbar Punctures

A

Obtain CSF for diagnosis [meningitis, encephalitis, intracranial hemorrhage], check response of CNS infections to ABX, administer intrathecal meds

Specimen can be sent for: gram stain, C&S, glucose, protein, CBC & differential, or rapid testing for specific pathogens

Lumbar puncture will be inbetween the 4th and 5thlumbar vertebra in order to avoid the spinal cord which ends at about the L2 level

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44
Q

CNS Pharmacology-Sedation

A

Lorazepam- This is a benzo and an antianxiety medication

Phenobarbital- This is a barbiturate that is stronger than a benzo and is commonly used for seizures

We try to not over sedate in babies in order to avoid side effects (not as worried about delirium like we are worried about in adults)

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45
Q

CNS Pharmacology-Analgesia

A

Remeber that analgesic are used to help decrease the sensation of pain

Fentanyl-Less depressant effects than morphine

Morphine- Causes chest wall ridigity

Tylenol

Pain meds can be given intrathecal but as a last resort

​

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46
Q

CNS Pharmacology-Paralytics

A

Pancuronium

Vecuronium

Paralytics are not commonly used in neonates

A side effect of paralytics is the result of third spacing where we will them have to give them more volume to draw the fluid out of the 3rd space

Paralytics are commonly used with therapeutic hypothermia

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47
Q

Therapeutic Hypothermia Used For

A

Used to treat hypoxic-ischemic encephalopathy (HIE) at birth (perinatal asphyxia) in order to try and prevent/minimize the long term consequence of brain injury

Cerebral Palsy (CP), cognitive and visual impairments

If a baby is breach or has the vocal cord around their neck they may lose oxygenation

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48
Q

Therapeutic Hypothermia Mechanism of Action

A
  • Reduces
    • swelling, bleeding & infection
      • edema, hemorrhage & neutrophil infiltration
    • Excitatory neurotransmitters
    • Free radical production
      • protects cells from oxidative damage during reperfusion
    • Cerebral tissue injury
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49
Q

Infant undergoing hypothermia may exhibit

A
  • Reduction of HR and Elevation of BP
  • Clotting Disorders
    • ​Lower platlet counts and long prothrombin time
  • Worsening Acidosis
  • ​Possible worsening oxygenation secondary to pulmonary hypertension
    • ​When PPHN occurs with HIE we are compounding the problem
  • Abnormal EEG
  • Skin Breakdown
    • ​Secondary to decreased perfusion and lack of movement
  • Hyponatremia and Hypokalemia
    • Will do blood work every 6 hours to check for this
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50
Q

Clinical Neurological Examination

A

All infants should undergo a brief neurological assessment (tone & reflexes) as part of the an initial examination

posture, movement, muscle tone, reflexes, cranial nerve and oromotor function, sensory responses, and behaviour

The normal full term infant will assess in a particular way

High risk infants require a more in-depth neurodevelopmental assessment

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51
Q

High Risk Infants

A
  • Prematurity
  • Intrauterine Growth Retardation (IUGR)
    • We see this in moms who smoke which will make the baby hypoxic and have a growth retardation
    • It can also occur if there is a placenta deficiency
  • Asphyxia
    • Very low APGAR score (0-3) for > 10 mins
    • Associated with high mortality >50%
    • If the baby survives only 25% will have a major handicap (Gomella)
  • TORCH Infections
  • Meningitis
    • Tested through LP
  • Hypoglycemia or Polycythemia
    • Will be associated with neurological disability
  • In utero exposure to drugs
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52
Q

TORCH Infections

A

Toxoplasmosis (Protozoan)-Cat Feces, raw meat

Other (syphilis)

Rubella

Cytomegalovirus

Herpes simple virus/hepatitis/HIV

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53
Q

CVS Basic Assessment and Physical Exam

A

Perfusion

Edema

Peripheral Temperature

Colour

Precordial

Heart Sounds

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54
Q

Perfusion (Central/Peripheral)

A
  • Central (core)
  • Peripheral (extremities)-Temp, blood volume, CO, BP, Acid-base balance
  • Capillary refill will be done on stoach or foot
  • Newborns have a low systemic output and high vasoconstriction
    • This is completely normal for the 1st 24 hours
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55
Q

Changes in Perfusion can Come From

A

Change in environmental temperature

Circulating catecholamines which contribute to vasoconstriction

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56
Q

Transcutaneous Monitoring

A

Transcutaneous monitoring probes are put on the stomach and are commonly used in neonates when they are peripherally shut down.

It is a little more complex and comes with more risk but sometimes it has to be done

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57
Q

Cause of Inability to Maintain a Stable Temperature

A

Skin Temperature (36-36.5)

  • Prematurity
  • Shock
    • Will be more pronounced in neonates
    • In shock you can get more vasoconstriction or dilation which can affect temperature
  • Decreased perfusion
  • Cardiac abnormalities
    • They will either have persistent fetal circulation or are structurally abnormal
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58
Q

Why are all babies at risk for temperature instability and heat loss

A

All babies even term babies are at a risk for temperature instability it is just that pre mature babies are at more of a risk. Babies require entirely on the metabolism of brown fat which makes up 5%

They rely entirely on the metabolism of brown fat (easily metabolized fat that accumulates prior to birth to assist baby in keeping warm) and glycogen for heat production

Premature babies are more susceptible to temperature because if they are below 26 weeks they have no brown fat

When the baby is peripherally very cold and unable to warm up we can give vasodilators and fluid

When measured rectally core temperature should be 36.5-37.5

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59
Q

Low body weight and preterm babies have additional risks

A
  • Little Sub q fat
    • Preemies born prior to 26 weeks have no brown fat
  • High body surface area to weight ratio
    • Pediatrics have this too
  • Reduced glycogen stores
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60
Q

To help promote normal temperature in babies

A

Keep room warm

Be quick with your assessment when you are opening isolette

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61
Q

Cold Stress

A

Cold Stress: Any environment where a newborn baby is not warm enough

In the presence of mild cold stress, the normal newborn will respond by peripheral vasoconstriction

This will increase the amount of norepinephrine and in turn metabolize brown fat

Norepinephrine will break down brown fat into fatty acids which hydrolyze into glycerol and nonesterified fatty acids which are oxidized to produce heat to increase body temperature

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62
Q

Non-Shivering Thermogenesis

A
  • Glycogen will be converted to glucose to generate energy
    • This requires increased metabolic and O2 demands that can be met through normal fat stores and feedings
      • Which is why for a baby that is cold their sats may drop
  • This means that is glycogen stores are low babies are unable to warm themselves
  • Glycogen store may be low when they have an inability to feed (ex. Delayed sucking response) or a premature GI tract
  • When the baby is cold they may start to use anerobic glycolysis will lead to metabolic acidosis
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63
Q

How to Prevent Cold Stress

A
  • A bonnet for the head
  • A closed environment with heat and humidity (isolette, heated circuit)
  • Clothing or swaddling if more than a kilo
    • If they are less than a kilo the skin is so delicate that they will not be wearing clothing besides a bonnet
  • Temperature regulation devices like warmers, or an enclosure like a house or incubator
  • Sufficient nutrition to meet metabolic demands
  • A stable thermal environment
  • All neonate will get heated circuits·
64
Q

Hyperthermia

A
  • Hyperthermia: Temp > 37.5 [normal core]
  • Causes
    • Environmental-Heating them up too much
    • Infection {bacterial or viral}-Will mostly be bacterial
    • Dehydration- Will occur from not getting enough breast milk
      • This is a common cause
    • Maternal fever in Labour: A common bacterial infection is GBS which can be very harmful to premature babies. So the mom may be put on antibiotics
    • Drug Withdrawal:
      • Increased metabolic rate & oxygen consumption [tachycardia, tachypnea, irritability, acidosis, brain damage & death]
65
Q

Pink Color

A

Good perfusion, want to see pink warm and dry

66
Q

Pale/Pallor Color

A

Baby washed out, anemia, birth asphyxiation, shock, infection, poor perfusion

67
Q

Ruddy/Plethora Color

A

Polycythemia (this is common in babies until they transition to extrauterine life), hyperthermia infant

68
Q

Dusky or Blue Color

A

Dusky is a common term for cyanosis and is a greyish blue tone,

69
Q

Jaundiced

A

Normally wont see at birth and only occur after 24 from birth

We treat jaundice through UV light and phototherapy

70
Q

Mottled

A

Sign of shock, hypovolemia

Looks like a marbling of the skin and it can be normal but it can be a sign of shock

71
Q

Cyanosis

A

The baby can have peripheral (acroyanosis) or central cyanosis

Peripheral/Acrocyanosis is the extremities of the body and is more

Central cyanosis is determined from the lips/tongue and is an indication of low sats or a pulmonary problem or heart defect and will reflect desaturated hemoglobin of <5g/dcl

72
Q

Cyanosis in Anemic Babies

A

these babes are pale and don’t look as hypoxic as they are – reflects the amount of Hgb

This can be difficult to detect by observation

73
Q

Cyanosis in Babies with high Hematocrit Levels

A

these babes may look blue but are not hypoxic at all – reflects the amount of Hgb

74
Q

Edema

A
  • Caput succedaneum
    • Edema on the scalp secondary to delivery; accompanied by bruising; it crosses the midline of the scalp and is outside the periosteum
    • Face & eyes may be swollen & bruised
  • Generalized edema may be indicative of fluid balance [renal] issues
75
Q

Apex/Precordium

A

Apex: PMI/HR where is it?

Precordium: Active or not active

76
Q

Heart Rate in Babies

A
  • Term Infants
    • HR: 120 to 170 beats/minute while awake
    • HR: 80 or 90 beats/minute while asleep
  • Transient tachycardia [>200 b/m] with stimulation or agitation
  • Neonates older than 35 weeks of gestation have greater variability in heart rate than an infant born at 27 to 35 weeks of gestation
77
Q

Blood Pressure in Neonates

A
  • Systolic/Diastolic
  • Adequate MBP = gestational age ( weeks ) + 5
  • Pulse pressure: Difference between systolic & diastolic; widen may indicate a PDA in term infants
  • Preemies
    • To calculate an adequate MABP take gestations age and add 5
    • 26 weeks should have a MABP of at least 31 mmHg
  • Term Neonates
    • 75/50 mmHg (~60 for MBP)
    • 42 week MABP should be at least 47 mmHg
78
Q

RR in Neonates

A
  • Preemies
    • 30-60
  • Term Neonates
    • 40-60
79
Q

Slow HR Benign Reasons

A
  • Pooping
  • Feeding
  • Barfing
  • Suctioning
80
Q

Slow HR Pathological Reasons

A

Hypoxia

Seizures

Airway

Acidosis

Hypothermia

Drug

81
Q

Fast HR Benign Reasons

A

Stress

Pain

82
Q

Fast HR Pathological Reasons

A

Fever

Shock

Anemia

Sepsis

Cardiac Abnormalities

Drugs

83
Q

Heart Sounds [Murmurs]

A

Murmurs: “rushing” sound heard on auscultation

Most are normal and resolve with closure of patent ductus arteriosus (PDA)

Some murmurs are heard at specific spots on the chest wall & may be indicative of a heart defect/malformation

84
Q

Weak Pulses

A

Low cardiac output states such as shock or hypoplastic left sided heart syndrome

85
Q

Bounding Pulse

A

PDA

L to R shunt

86
Q

ECG Monitor

A

High incidence of arrhythmias in first few days

1-5% have some disturbance in HR or rhythm

Dropped beats (PAC); benign

87
Q

UAC

A

UAC: 5 and 7 o’clock for arteries [2]

High [T6-T8/9] below ductus arteriosus & above celiac artery

Low [L3-L4] above the inferior mesenteric and below the renal artery aorta intersection

88
Q

Pre/post-ductal SpO2

A

Pre: R arm will have a higher O2 saturation

Post: L arm & lower extremities will have a lower O2 saturation

89
Q

Echo/Functional Echo

A

Functional echocardiography- ductal and atrial shunting, pulmonary artery pressure, right and left ventricular output and superior vena cava flow as well as myocardial function

90
Q

CO/ SVR Pharmacological Interventions

A

Dopamine [hypotension]

Dobutamine [hypotension]

91
Q

Rate & Rhythm Pharmacological Interventions

A

Bradycardia -Atropine

Narrow complex SVT - Adenosine

Tachys: Na channel blockers, beta blockers [propranolol], K channel blockers [amiodarone], Ca channel blockers [verapamil]

92
Q

Pulmonary vasodilators [PPHN] Pharmacology

A
  • iNO
  • Sildenafil (phosphodiesterase type inhibitor)—other name?
  • Prostacyclins/prostaglandins:
    • Iloprost
    • Treprostinil
    • Epoprostenol (flolan)•
93
Q

Anti-thrombotics Pharmacology

A

Low molecular weight heparin [NP]

Unfractionated heparin [P]

The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies

94
Q

Blood Products

A
  • Blood products [N blood volume 80mL/kg]
  • PRBC: O Rh neg; to get hematocrit to 50% [maintenance of 02 carrying capacity]
  • FFP [fresh frozen plasma]
  • Albumin
  • EPO
95
Q

Other Pharmacological Interventions

A

Iron: needed for growth and development; anemia; breast milk or fortified formulas

Folate

Vitamin E

96
Q

ECMO

A

Both the heart and lung supported

Blood taken from RA

CO2 removed, O2 added

Rewarmed to body temp & returned right common carotid artery

97
Q

CVS Electrical Therapy

A

Circulatory collapse with a tachycardia whether broad or narrow complex requires cardioversion, which should be synchronised

98
Q

PDA Closure

A

Indomethacin + ibuprofen

Ligation

Intravascular “coils”

99
Q

IPPA of Neonates-Inspection

A

General appearance

Gestational age

Malformations

Colour

Tone

Chest excursion: Symmetrical or Asymmetrical

WOB: retractions, nasal flaring, grunting

Precordium – apical pulse

100
Q

IPPA of Neonates-Palpation

A

Skin-perfusion, temperature, capillary refill

Compare central and peripheral pulses

Abdomen

Fontanels

101
Q

IPPA of Neonates-Percussion

A

DONT DO IT

102
Q

IPPA OF NEONATE-AUSCULTATION

A

Can be difficult due to the high level of transmission of breath sounds throughout the neonatal chest

Equality of breath sounds from side to side

Decreased breath sounds equally means under ventilation

Presence of adventitious breath sounds

Wheezes and crackles can both be heard with experience

103
Q

Assessment of Artifical Airway

A
  • Invasive
  • Tube size
  • Tube position
    • ATG
    • Off the carina
  • Cuffed vs uncuffed
  • Securing
    • Tapes
104
Q

ETT Size for <1000

A

Gestation Age <28

ETT 2.5

Suction 5/6

105
Q

ETT Size for 1000-2000

A

Gestation Age 28-34

ETT 3.0

Suction 6 or 8

106
Q

ETT Size for 2000-3000

A

Gestation Age 34-38

ETT 3.5

Suction 8

107
Q

ETT Size for >3000

A

Gestation Age >38

ETT 3.5-4.0

Suction 8 or 10

108
Q

Non-Invasive Ventilation

A
  • NIV
    • CPAP
    • SiPAP
  • Monitor: machines & pt
  • Skin break down
    • Changing from nasal mask to prongs
      • Schedule
      • Patient specific
      • Nasal care & instillation
    • Barrier creams/salves
109
Q

Bronchopulmonary Hygiene

A
  • “Suctioning”; clearing airway of secretions
  • In a spontaneous breathing patient
    • Flexible catheter ~10F
    • With 80-100mmHg
  • Artificial Airway
    • Flexible catheters for ETT size
  • 80-100mmHg if open, 100-120 mmHg closed [AHS P&P2010])
  • Rarely on a schedule
  • Rarely after surfactant-Why not?
    • Because it will suck out the surfactant
  • Assess regularly via auscultation & vent wave forms [resistance] if intubated
110
Q

Term (40 Weeks) ~24 Hours ABG

A

pH 7.35-7.45

PaCO2 35-45

PaO2 50-70

HCO3 18-22

SpO2 92-96%

111
Q

28 Week-Term (40 Weeks) ABG

A

pH ≥ 7.25

PaCO2 45-55 (Permissive Hypercapnia)

PaO2 50-70

HCO3 18-20

SpO2 85-92%

112
Q

< 28 Week Old ABG

A

pH ≥ 7.25

PaCO2 45-55 (Permissive Hypercapnia)

PaO2 45-65

HCO3 15-18

SpO2 85-92%

113
Q

CBG Expected Values

A

pH 7.32-7.42

PaCO2 35-45

PaO2 30-40

HCO3 20-24

SpO2 85-88%

114
Q

Quality Control

A

A systematic process used to monitor, document and regulate the accuracy and reliability of a procedure or a laboratory measurement

  • Components of quality control are:
    • Performance validation (testing new instrument)
    • Preventative maintenance & function checks
    • Automated calibration& verification
    • Internal statistical quality control
    • External quality control (proficiency testing)
    • Remedial action (to correct errors)
    • Record keeping (policies & procedures)
115
Q

Non-Analytical Errors

A
  • Pre:
    • during sample draw [not removing air bubbles, venous admixture] handling or transport
    • Wrong patient poked, or correct patient, but mislabeled sample [results to wrong chart]
    • Status or therapy not recorded or assessed
  • Post:
    • Error in transcription phone report of critical values to someone not familiar with data, or a test run by someone who doesn’t know what the critical values are, so doesn’t report it
116
Q

Analytical Error

A

Occurs during analysis, often equipment although improper mixing is the fault of the operator

117
Q

Internal Quality Control

A

Scheduled analysis & recording of specific samples

Comparison between machines

Routine P&Ps to detect inconsistencies

An accreditation requirement

118
Q

External Quality Control

A
  • Labs compare results
    • Sample sent to Calgary labs compared with labs elsewhere in province
  • Independent agency
119
Q

Supplemental Oxygenation

A
  • Too much oxygen can be just as harmful in a newborn as too little oxygen, as free radial will form from hyperoxgenation leading to cell death in the brain and poor long term developmental outcomes
  • Acceptable oxygenation saturation levels range from 87-95%
  • When the neonate experiences a desaturation episode the following can be used to resolve the episode
    • Observe the infant to see whether they self recover
    • Stimulation
      • Stable infants will oftn respond well to tactile stimulation
    • Increase FiO2
      • If you do need to increase FiO2 try to increase it in small 2-3% intervals
    • Bag mask ventilation
  • When we increase FiO2 it has been discovered that the cerebral oxygenation levels increased higher than what was needed and this could be harmful to the nwborn babies brain
    • In adults there is a respiratory mechanicm that when cerebral oxygenation increase higher than what is needed there will be vasoconstriction, but this mechanism is not well developed in the newborn and will not occur leading to white matter damage
120
Q

Chest X-Ray General

A
  • A/P View
    • ​Heart appears larger
  • Inspiration
    • ​Want to see 8 ribs
  • The right side of the diaphram will be higher than the left and 60% of chest diameter
  • Enlarged lung vessels
  • Tracheal narrowing during E is normal
  • Good film: chin neutral, centered
  • Tubes and lines:
    • ETT- halfway between the medial end of the clavicles and the carina (T2/T3/T4)
121
Q

CHest X Ray-ETT with Flexion and Extension

A

When the neck is flexed the ETT will move down

When the neck is extended the ETT will move up

122
Q

Position of the Carina

A
  • The carina is situated higher than in adults
    • neonate – level of third vertebrae
    • 10 years of age – level of the fifth vertebrae
123
Q

Chest X Ray Thymus Gland

A
  • triangular shaped
  • called the “sail sign” when identified on x-ray
  • largest at about 2 years of age
  • may be mistaken for
    • heart border
    • upper lobe atelectasis
124
Q

Hyperaeration

A

Hyperaeration or hyperinflation is where the lung volume is abnormally increased, with increased filling of the alveoli. This results in an increased radiolucency on X-ray, a reduction in lung markings and depression of the diaphragm. … It causes one form of overexpansion of the lung.

125
Q

Transient Tachypnea of the Newborn

A

Transient tachypnea of the newborn (TTN) is a parenchymal lung disorder characterized by pulmonary edema resulting from delayed resorption and clearance of fetal alveolar fluid .

126
Q

Transient tachypnea of the newborn (TTN) CXR

A
  • Common cause of respiratory distress in newborns
    • Retention of fetal lung fluid
  • Infiltrated in the hilar region
    • Engorged veins and lymphatic vessels
  • Hyperaeration
    • Increased Raw due to fluid in the airway
  • Clear 24-48 hours
127
Q

Transient tachypnea of the newborn (TTN) Pulmonary Compliance

A
  • The excess lung water in TTN results in decreased pulmonary compliance.
  • Tachypnea develops to compensate for the increased work of breathing associated with reduced compliance.
  • In addition, accumulation of fluid in the peribronchiolar lymphatics and interstitium promotes partial collapse of the bronchioles (increased resistance) with subsequent air trapping.
  • Continued perfusion of poorly ventilated alveoli leads to hypoxemia, and alveolar edema reduces ventilation, sometimes resulting in hypercapnia.
128
Q

Respiratory Distress Syndrome

A
  • Most common lung disease in premature neonates
  • To lessen the likelihood and/or severity of RDS, surfactant will be administered.
  • Often an improvement in compliance post surfactant will be seen quite quickly with the infant requiring supportive measures (ventilation/oxygenation).
  • What the baby ends up on is not just dependent on the administration of surfactant, as very premature babies will require respiratory support longer!
129
Q

Respiratory Distress Syndrome CXR

A
  • Reticulograndular “ground glass” appearance”
    • Aerated alveoli are surrounded by areas of increased density
  • Lack of aeration
    • Causes a white out in the lung fields
    • Increased opacification throughout the lung fields.
  • Not likely to see pleural effusion as that would be more indicative of an infectious process
  • Lungs will clear over a few days. Apices & periphery first, followed by more central and basal lung units.
130
Q

Meconium Aspiration CXR

A
  • In mild cases the CXR may seen normal
  • In Severe cases you will see
    • Bilateral infiltrates
    • Air trapping
    • Air leak syndrome
      • Pulmoanry intersitial emphysema (PIE)
      • Pneumomediastinum
      • Pneumothorax
    • Atelectasis
    • Inflammation
      • Chemical irritation from meconium
    • Pleural effusion
131
Q

Pneumonia CXR

A

Variable pattern difficult to distinguish

Diffused lung markings

Pleural fluid may be present

Looks like RDS

132
Q

Pneumonia

A

Can occur just before, during, or after birth

Common source-Group B hemolytic streptococcus

133
Q

Pneumothorax CXR

A
  • The lung is displaced away from the chest wall by a dark band of air
  • The dark air space will have no lung markings
  • Border of the lung may be seen as a sharp white line
  • Tension pneumothorax
    • Depressed diaphragm on affected side
    • Widening intercostal spaces
    • Mediastinal shift to unaffected side
    • Rapid deterioration of neonate
134
Q

Congenital Diaphragmatic Hernia

A
  • May occur in utero or at birth
  • in utero will cause a hypoplastic lung
  • usually ccurs on left side (80-85% of time)
  • Stomach and bowel are present in the chest
  • Mediastinal shift away from affected side
135
Q

UAC

A

High UA - between thoracic vertebrae 6 and 8

Low UA - lumbar L3 and L4

136
Q

Respiratory Pharmacology

A
  • Inhaled meds
    • Bronchodilators
    • Steroids
  • Systemic meds
    • Dexamethasone
    • Stimulants
      • Caffeine
      • Theophyline
  • Specialty gases
    • Nitric oxide
137
Q

Transillumination

A
  • The preferred diagnostic test for a pneumothorax would be a Chest X-Ray, but if there isn’t time you can use Transillumination of the chest to help with your diagnosis
  • Place light source (otoscope, transilluminator) on infant’s chest. Ensure it isn’t hot.
  • A normal chest will have a small glowing “Halo” around the light source. Usually it extends less than 1 cm from the light source and is symmetric.
  • If the chest “lights up like a jack-o-lantern or ET’s chest” (large area of redness that is often asymmetric), then ptx should be HIGH on your DDx list..
  • You should compare to the other side if you are unsure.
138
Q

Respiratory Therapeutic Interventions

Chest Tubes

A

Emergent needling

Chest tubes

Heimlich valves

139
Q

Respiratory Therapeutic Interventions

Vent Strategies

A

P & Ps/Algorithms

Normal targets

Lung protective

Persistent pulmonary hypertension newborn (PPHN)

Meconium aspiration syndrome (MAS)

Cyanotic heart defects (CHD)

Advanced Modes of ventilation [HFO, HFJV, ECMO-VV]

Weaning*

140
Q

GI Assessment

A
  • Weight (actual vs dosing)
  • Abdominal girth/distension
    • Necrotizing Enterocolitis
      • NEC~10% of babies <1500 g
        • More common in prems, but does occur in term infants
      • 50% mortality rate in severe cases
  • Bowel sounds
    • Not continuous
  • Bowel movements
    • Meconium
141
Q

GI Monitors

A
  • BM frequency
    • 99% of term infants within the first 24hrs
    • 99% of preterm infants within the first 48hrs*
      • *really premature infants are not fed because the colon is not developed
  • Weight trends
    • ~10-15% of birth weight is lost during first week of life
    • Weight gain begins in second week of life [~1-3% of body weight/day; Prems do not regain as quickly as term]
    • FYI: Length ~0.75 cm/week term & almost 1 cm/week for preterm infants
142
Q

GI Diagnostics

A
  • Residuals/Aspirates
    • Gastric aspirates are performed before feeding to determine feeding tolerance and rate of digestion (avoid over or under feeding)
  • Calorimetry
    • Resting Energy Expenditure (REE)
    • Direct Measure: Heat produced and lost by the body. Requires specilized equitment and personale (expensive)
    • Indirect Measure: Measure O2 consumption and CO2 production
      • Partial pressures inspired [control] vs exhaled [sample]
  • Abdominal x-rays
143
Q

GI Pharm and Interventions

A
  • Feeding
    • Colostrum [antibodies and immunoglobulins]
    • Breast
    • Bottle [EBM & formulas]
    • Tube [EBM & formulas]
    • Total Parenteral Nutrition [TPN]
  • H2 blockers
    • Decrease stomach acid production
      • Ranitidine (Zantac®)
      • Cimetidine (Tagament®)
  • Proton pump inhibitors (PPIs)
    • Inactivates the pumps that produce stomach acid
      • Pantoprazole (Pantaloc)
      • 2012 FDA reviewing PPI use in <12 mos, as no benefit shown
  • Drains/colostomy
144
Q

Colostrum

A
  • Thick, yellowish milk
    • Immunoglobulins
    • Lipids
    • Proteins
    • Beta carotene
    • Leukocytes
  • Coats the GI tract with a protective barrier to decrease permeability & prevent pathogens from adhering
  • Laxative effect-helps with the passing of meconium
    • Decreasing the amount of bilirubin and aid in jaundice prevention
145
Q

Renal Assessment

A
  • Fluid balance
    • 100% of all healthy infants (prems, terms & posts) void within 24 hrs
    • Decreased urine output, no urine output or edema - “red flag”
  • Diaper weight
146
Q

Urine Output

A
  • 1-3 mL/kg/hr in the newborn
  • Normal newborn kidneys do not concentrate urine well
  • Renal failure leads to volume overload, hyperkalemia, acidosis, hyperphosphatemia, and hypocalcemia
  • ~25% of infants have some form of renal failure with 75% of those having pre-renal causes
  • Prerenal causes are due to poor perfusion of the kidney:
    • dehydration [poor feeding or environmental]
    • perinatal asphyxia
    • hypotensive states [septic shock, hemorrhagic shock, or cardiogenic shock secondary to congestive heart failure]
147
Q

Urine Analysis

A
  • Blood urea nitrogen [BUN]
    • >15-20 mg/dL suggests dehydration
  • Creatinine
    • Levels drop from birth to < 0.6 mg/dL by 1 week of age
    • Higher level suggest renal disease
148
Q

Urine Cultures

A

Blood and Infections

149
Q

Diuretics

A

Chlorothiazide with spironolactone-chronic management

Furosemide {lasix}-potent and good for rapid diuresis

Side effects: ototoxicity, electrolyte abnormalities, interference with bilirubin-albumin binding

150
Q

Foley (in/out)

A

Check to see if poor output secondary to obstruction

Collect adequate sample for labs, cultures

151
Q

Signs of abnormalities seen in 1st 24 hrs form Lab data

A

Sepsis

High or low RBC levels

RBC isoimmunization

Problems in glucose regulation

WBC are significantly higher in the neonate

152
Q

Sepsis

A

Often diagnosed on clinical presentation and acted upon before lab results come back

Pale, mottled, floppy

Not feeding well

Irritable

Unresponsive (ominous)

153
Q

Some Important lab values

A
  • The presence of either of the below may occur with infection
    • Leukopenia <3500/mm3
    • Leukocytosis >25,000/mm3 … though not unusual in the “immediate” newborn period
  • Compare immature granulocytes/total granulocytes [>0.2:1 implies infection]
  • Low platelet levels <150,000/mm3 also implies infection or a clotting disorder
154
Q

Lab Tests

A

Bilirubin

  • Conjugated
  • Unconjugated

Blood cultures/infection markers

155
Q

Catheters and Lines

A

UVC [umbilical vein catheter]

PICC [peripherally inserted central catheter]

Peripheral IVs

156
Q

Other Medications that can be given

A

Acetate

Tham

Bicarbonate

Patient Assessment 3 (12 decks)

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