Once stable, normal newborns usually have their temperature checked only once a shift. To prevent unrecognized cold stress, the temperature of the LPI should be checked every 3 to 4 hours, depending on need and agency policy (Ramachandrappa & Jain, 2011). Kangaroo care (KC), (a method of providing skin-to-skin contact between infants and their parents [see p. 705]), a radiant warmer, or an incubator may be used if the infant cannot maintain normal temperature.

LPIs may have immature suck and swallow reflexes, have shorter awake periods, and fall asleep during feedings before they have fed adequately, or they may sleep through feedings (Cleveland, 2010). They may have difficulty with latch when breastfeeding. Their low tone and weak suck may decrease the amount of milk they obtain (Walker, 2008). They have an increased caloric need and should be fed every 2 to 3 hours.

Feeding problems are common, and nurses should assess feeding sessions to ensure swallowing is occurring. Urine and stool output are monitored as indications of adequate intake. Breastfeeding mothers need special help to ensure infants are feeding well. Because LPIs are at greater risk for breastfeeding-associated rehospitalization than term infants, lactation consultants should be involved in their care (Radtke, 2011). Use of the football and cross-cradle holds are helpful in positioning these infants at the breast. Breastfeeding should be evaluated at least twice daily (Ramachandrappa & Jain, 2011). Supplemental feedings by bottle, gavage, or use of a supplemental nursing system may be necessary.

LPIs are at risk for hypoglycemia. Therefore blood glucose level measurements should be performed according to hospital protocol, especially during the first 24 hours.

In addition to the usual discharge criteria for term infants, other considerations apply for the LPI. Infants should not be discharged before 48 hours of age. Nurses should ensure that infants have fed successfully and have had normal vital signs for at least 24 hours before discharge. Bilirubin levels should also be assessed before discharge (Association of Women’s Health, Obstetric, and Neonatal Nurses [AWHONN], 2010; Ramachandrappa & Jain, 2011).

Parents should be taught signs of common complications, such as jaundice or dehydration, and what to do if they occur. A follow-up visit with the health care provider should be arranged for 24 to 72 hours after discharge (AWHONN, 2010; Dave & Campbell, 2009; Ramachandrappa & Jain, 2011).

Teaching should include the need for keeping the infant warm. The infant should be kept away from drafts and dressed with one more layer than an adult would wear. A car seat challenge should be conducted before discharge to ensure the infant can tolerate sitting in a car seat without bradycardia, apnea, or decreased oxygen saturation.

LPIs are subject to overstimulation (see pp. 698). This may occur when parents take the baby home to an environment of many different stimuli. The nurse should teach signs of overstimulation and how to minimize them.

The nurse differentiates periodic breathing from apneic spells. Periodic breathing is the cessation of breathing for 5 to 10 seconds without other changes. It may be followed by rapid respirations for 10 to 15 seconds. Apneic spells are a lack of breathing lasting more than 20 seconds, or accompanied by cyanosis, pallor, bradycardia, or hypotonia (Goodwin, 2010). They are common in preterm infants, increasing in incidence with lower gestational age. Apnea without an identified cause in a preterm infant is called idiopathic apnea or apnea of prematurity and generally improves as the infant matures. The infant may require gentle tactile stimulation, medications, or continuous positive airway pressure (CPAP).

The nurse observes the effort required for breathing and the location and severity of retractions. Retractions are particularly noticeable in preterm infants, whose weak chest wall is drawn in with each inspiration. The excessive compliance (elasticity) of the chest cage during retractions may interfere with full expansion of the lungs.

Grunting may be an early sign of RDS. It closes the glottis and increases the pressure within the alveoli, keeping the alveoli partially open during expiration and increasing the amount of oxygen absorbed.

The infant’s temperature is monitored continuously by a skin probe on the infant’s abdomen, which is attached to the heat control mechanism of the radiant warmer or incubator. The abdominal skin temperature is usually maintained at 36° C to 36.5° C (96.8° F to 97.7° F). The infant’s temperature should be recorded every 30 to 60 minutes initially and every 1 to 3 hours when the infant is stable (Brown & Landers, 2011).The axillary temperature should be compared with the heat control reading to ensure that the equipment is functioning properly.

The axillary temperature for a preterm infant should remain between 36.3° C and 36.9° C (97.3° F and 98.4° F) slightly lower than the temperature in a full-term infant (Brown & Landers, 2011). If the infant has accumulated brown fat, an axillary temperature reading may be misleading. A normal axillary temperature when the skin temperature is decreased may indicate heat from brown fat in the axillary space is being used to maintain the infant’s core temperature.

Indications of inadequate thermoregulation include poor feeding or intolerance to feedings in an infant who previously had little difficulty, lethargy, irritability, poor muscle tone, cool skin temperature, and mottled skin (Figure 29-3). Hypoglycemia and respiratory distress may be the first signs that the infant’s temperature is low. Because temperature instability may be an early sign of infection, the nurse should assess for other evidence of infection.

SAFETY ALERT

Signs of Inadequate Thermoregulation

• Axillary temperature <36.3° C to >36.9° C (<97.3° F to >98.4° F)

• Abdominal skin temperature <36° C to >36.5° C (<96.8° F to >97.7° F)

• Poor feeding or feeding intolerance

• Irritability followed by lethargy

• Weak cry or suck

• Decreased muscle tone

• Skin pale, cool to touch, mottled or acrocyanotic

• Hypoglycemia

• Respiratory distress

• Poor weight gain if chronic

Maintenance of heat in preterm infants involves the same basic nursing care principles as for the full-term infant (see Chapter 22). These principles, however, must be adapted to meet the needs of the preterm infant.

The nurse must carefully monitor intravenous (IV) fluids using infusion control devices that administer fluid with a precision of 0.1 mL/hr to help prevent fluid volume overload (Jones et al., 2011). IV medications should be diluted in as little fluid as is consistent with safe administration of the drug and should be included when measuring intake. Starting IV lines on infants with poor veins is a lengthy, difficult procedure. Infants must be restrained as necessary to prevent infiltration. If they infiltrate, some solutions cause extensive damage as a result of tissue sloughing.

IV sites should be assessed at least every hour for signs of infiltration. Many infants have central venous catheters or umbilical lines that must be assessed for infection and position changes. Small blood transfusions may be necessary to replace blood drawn for frequent laboratory tests.

Guidelines for evidence-based practice in care of the neonate’s skin have been developed by AWHONN (2007).

Adhesives should be used as little as possible. Commercial devices are available to secure tubes and catheters. Backing tape with cotton, waiting more than 24 hours to remove it, and using gauze wraps instead of tape decrease skin damage. Pectin or hydrocolloid barriers, transparent semipermeable dressings, hydrogel or silicone-based adhesive products, and barrier films are less traumatic to the skin and may be used to attach devices (AWHONN, 2007). Hydrogel and hydrocolloid dressings may be used if skin breakdown or wounds occur. These substances promote moist healing and need no adhesive (Lund & Durand, 2011).

All disinfectants have potential risks when used on neonates. Aqueous chlorhexidine gluconate solutions are commonly used at this time. Povidone-iodine may injure the skin and may have toxic effects on the thyroid in premature infants. All disinfectants should be removed with sterile water or saline. Alcohol should not be used (AWHONN, 2007; Lund & Durand, 2011).

Cleansers with a pH of 5.5 to 7 may be used for bathing infants. Infants should not be bathed more often than every other day. Warm water without soap should be used for infants less than 32 weeks of gestational age for the first week after birth. Sterile water is not necessary unless there are concerns about the safety of tap water or there is a break in skin integrity. Stable preterm infants without umbilical IV lines may be immersed in water that covers the shoulders for bathing if there are no contraindications. Emollients can help reduce fissures in dry skin and transepidermal water loss. They are safe to use under radiant warmers and during phototherapy (AWHONN, 2007).

Infants and their equipment should be positioned to avoid undue pressure on the skin. Frequent position changes are important but should be based on the infant’s ability to tolerate changes.

The nurse should be alert for signs of sepsis at all times (see Chapter 30, p. 727).

Early signs of infections should be identified and reported so that treatment may begin immediately. The nurse carefully notes the infant’s response to treatment because some organisms become resistant to antibiotics. Other nursing care for infections is discussed in Chapter 30.

The nurse performs pain assessment whenever vital signs are taken. In addition, the nurse must assess the infant’s response to painful stimuli and to pharmacologic and nonpharmacologic interventions. Assessment tools are available to evaluate physiological and behavioral responses to pain in term and preterm infants. One example is the Premature Infant Pain Profile (PIPP), designed for use with term or preterm infants. The tool assesses gestational age and behavior states, heart rate, oxygen saturation, brow bulge, eye squeeze, and nasolabial furrow (lines from the edge of the nose to beyond the corners of the mouth) to assign a pain score (Walden & Gibbins, 2008).

Physiologic changes may be unpredictable and cannot be used alone to assess pain. Behavioral responses must also be assessed (see Nursing Quality Alert: Common Signs of Pain in Infants). Behavioral changes include high-pitched, intense, harsh crying. Infants who are intubated or too weak to cry have a “cry face,” a facial expression of crying without the sound of a cry. Less than half of preterm infants experiencing painful stimuli respond with crying (Gardner, Enzman-Hines, & Dickey, 2011a). Infants who have been exposed to prolonged or repeated pain may no longer be able to show behavioral changes even though they are experiencing pain. Critically ill or very immature infants may also not show pain responses in the same way that older, less sick infants do. Therefore a lack of response to a painful situation should not be perceived as an absence of pain. Because parents often spend many hours with their infants, the nurse should involve them in helping to assess their infant’s pain.

Nurses should prepare infants for potentially painful procedures by waking them slowly and gently and using containment. Containment simulates the enclosed space of the uterus and is comforting to infants. It involves keeping the extremities in a flexed position and midline by swaddling, positioning devices, or the nurse’s hands. At least one of the infant’s hands should be near the mouth for sucking. Containment is also called facilitated tucking (Fernandes, Campbell-Yeo, & Johnston, 2011). KC and breastfeeding are also used to reduce pain.

The infant should be allowed to rest before and after procedures. The infant is often hypersensitive after a painful stimulus and may perceive other activities as painful (Walden & Gibbins, 2008). Comfort measures help the infant cope with short-term, mild pain and reduce agitation. They include using a pacifier for nonnutritive sucking. Sucrose placed on the pacifier or given by mouth 2 to 3 minutes before a painful stimulus increases pain relief. However, sucrose may not be appropriate for very young preterm infants. Talking softly, holding, rocking, or prone positioning are other methods of pain relief that may be used alone or with sucrose. Measures should be adapted according to infants’ responses. Methods may be combined such as skin-to-skin contact with a sucrose-dipped pacifier (Academy of Breastfeeding Medicine, 2010).

Comfort measures alone are not enough for moderate to severe pain. The nurse should discuss the infant’s pain with the primary care provider to ensure that medications are available when necessary. Opioids, such as morphine and fentanyl, can be tolerated by preterm infants. Nonnarcotic analgesics such as acetaminophen may also be used. Topical anesthesia can be used to reduce pain during some procedures. Sedatives are effective for agitation, but they are not effective for pain. Regional or general anesthesia is used during surgery.

The nurse gives ordered medications before painful procedures and when the infant demonstrates signs of pain. The infant’s response is assessed frequently to determine the need to increase or decrease the dosage. Analgesics may be given continuously or on an as-needed basis.

A nursing diagnosis appropriate for preterm infants having difficulty enduring the multiple stimuli in their environment is: