The High-Risk Newborn
Problems Related to Gestational Age and Development
Maternity nurses identify and begin care for the immediate needs of neonates with gestational complications until neonatal intensive care unit (NICU) nurses assume care. Nurses from both areas also provide information and emotional care for parents. Neonatal intensive care is a nursing specialty that requires additional education and experience to prepare them for this role.
Care of High-Risk Newborns
Nurses care for minor illness in the mother-baby unit or the normal newborn nursery, but more serious problems require care in NICUs, nurseries designed for that purpose (Figure 29-1). Approximately 9% of all newborns are sick enough at birth to require special or intensive care (Carlo, 2011a).
Late Preterm Infants
Infants born between 34 and 36 weeks of gestation are called late preterm infants (LPIs) because they have many needs that are similar to those of preterm infants. In the past, LPIs often received care similar to full-term infants because they are more stable than infants of lower gestational age. However, they are physiologically and metabolically immature and have a higher mortality and morbidity rate than full-term infants.
Incidence and Etiology
Late preterm births comprised 8.66% of all births in 2009 and comprised more than 70% of all preterm births (Martin, Hamilton, Ventura, et al., 2011). Contributing factors in late preterm birth include difficulty of accurately estimating gestational age before delivery, multifetal pregnancies, obesity, assisted reproductive technology, elective and medically indicated inductions and cesarean deliveries, advanced maternal age, and all the causes of preterm birth (Engle & Kominiarek, 2008; Jorgensen, 2008b).
Characteristics of Late Preterm Infants
Because LPIs often look like full-term infants, they may not be recognized as being preterm. They are at risk for respiratory disorders, problems with temperature maintenance, hypoglycemia, hyperbilirubinemia, feeding difficulties, acidosis, and sepsis because of their immaturity (Pappas & Walker, 2010; Ramachandrappa & Jain, 2011). They are also at risk for long-term neurodevelopmental disorders as well as cognitive and behavioral problems (Jorgensen, 2008a; Talge, Holzman, Wang, et al., 2010). They are more likely to be admitted to the NICU after birth and are at increased risk for rehospitalization after discharge.
Therapeutic management varies according to the problems presented. Many interventions are similar to those for preterm infants discussed in this chapter.
Assessment and Care of Common Problems
LPIs need closer monitoring for complications during the hospital stay than full-term infants. Nursing care is similar to that for preterm infants in many aspects.
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.
Preterm infants (also called premature infants) are born before the beginning of the 38th week of gestation. The word preterm is sometimes confused with the term low birth weight (LBW), which refers to infants weighing 2500 g (5 lb, 8 oz) or less at birth. Very-low-birth-weight (VLBW) infants weigh 1500 g (3 lb, 5 oz) or less at birth. Extremely low-birth-weight (ELBW) infants weigh 1000 g (2 lb, 3 oz) or less at birth. Although most of these infants are preterm, others are full term and have failed to grow normally while in the uterus, a condition called fetal growth restriction (FGR).
Incidence and Etiology
Scope of the Problem
Advances in technology have resulted in infant survival at much lower birth weights than ever. Although the incidence of preterm births has been increasing in the past, the rate in 2009 decreased for the third year in a row to 12.18% of all births (Martin, et al., 2011). A Healthy People 2020 goal is to reduce preterm births to not more than 11.4% of live births (U.S. Department of Health and Human Services, 2010). Disorders related to short gestation and low birth weight are the second leading cause of infant mortality, surpassed only by those from congenital anomalies (Kochanek, Kirmeyer, Martin, et al., 2012).
Preventing preterm birth is best accomplished by providing adequate prenatal care for every pregnant woman to identify and treat risk factors as early as possible. Teaching women to recognize signs of preterm labor will help them seek care when stopping labor is still a possibility (see Chapter 27).
Characteristics of Preterm Infants
Preterm infant characteristics vary by gestational age. For example, the appearance and problems of infants born at 33 weeks of gestation are different from those of infants born at 26 weeks of gestation. Some characteristics, however, are common to all preterm infants.
Preterm infants often appear frail and weak, and they have less developed flexor muscles and muscle tone compared to full-term infants. Their extremities are limp, and infants typically lie in an extended position (see Figure 21-24). The infant’s head appears large in comparison with the rest of the body.
Preterm infants lack subcutaneous or white fat, which makes their thin skin appear red and translucent, with blood vessels clearly visible. The nipples and areola may be barely perceptible, but vernix caseosa and lanugo may be abundant. Plantar creases are absent in infants of less than 32 weeks of gestation (see Figure 21-30).
The pinna of the ear is soft, flat, and contains little cartilage (see Figure 21-32). In the female infant, the clitoris and labia minora appear large and are not covered by the small, separated labia majora. The male infant may have undescended testes, with a small, smooth scrotal sac (see Figures 21-33 and 21-34).
Behavior varies according to gestational age. In general, preterm infants have little excess energy for maintaining muscle tone. They are easily exhausted from noise and routine activities. Their responses are varied, including lowered oxygenation levels and stress-related behavior changes. The cry may be feeble.
Assessment and Care of Common Problems
Preterm infants are prone to problems that affect all systems and body processes.
Problems with Respiration
Problems of the respiratory system are a major concern because preterm newborns have immature lungs. The presence of surfactant in adequate amounts is of primary importance. Surfactant reduces surface tension in the alveoli and prevents their collapse with expiration. It allows the lungs to inflate with lower negative pressure, decreasing the work of breathing. Infants born before surfactant production is adequate develop respiratory distress syndrome (RDS) (see p. 708). In addition, preterm infants have a poorly developed cough reflex and narrow respiratory passages, which increase the risk for respiratory difficulty.
The infant’s respiratory status must be observed constantly. The lungs are assessed for adventitious breath sounds or areas of absent breath sounds.
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.
Interventions focus on collaborating with other team members, such as the respiratory therapist, to manage technical equipment and facilitate removal of secretions.
Working with Respiratory Equipment
An oxygen hood is often used for infants who can breathe alone but need extra oxygen. The hood is a plastic dome that fits over the infant’s head or head and upper body. The infant breathes the higher levels of oxygen within the hood, and the device does not interfere with access to the rest of the infant’s body for care (Figure 29-2).
Oxygen also may be given by nasal cannula to the infant who breathes well alone. After discharge, many preterm infants continue to receive oxygen via nasal cannula at home. Oxygen must be humidified to prevent insensible water loss and drying of the delicate mucous membranes. It is warmed to maintain body temperature.
CPAP may be necessary to keep the alveoli open and improve expansion of the lungs. It can be delivered with nasal prongs, a mask, or an endotracheal tube. The infant may need conventional mechanical ventilation when respiratory failure, severe apnea or bradycardia, or other conditions are present. High-frequency ventilation may be used to provide very fast, frequent respirations with less pressure and volume. This helps decrease lung injury from pressure (barotrauma) and volume (volutrauma).
When oxygen is administered, it should be warmed and humidified. Because both too little and too much oxygen can cause problems, the level of oxygen in the infant’s blood must be monitored. Arterial blood may be drawn for testing oxygen levels. Pulse oximetry is also used. It is less invasive and provides continuous information about oxygen partial pressure (PO2) levels through sensors attached to the skin. Nurses and respiratory therapists titrate oxygen depending on the pulse oximetry or arterial oxygen levels according to agency policy.
The nurse must observe the infant’s increasing or decreasing dependence on breathing assistance and need for oxygen. Handling, feeding, and linen changes may increase oxygen need. Changes in settings on equipment may be needed during such activities.
Positioning the Infant
The side-lying and prone positions facilitate drainage of respiratory secretions and regurgitated feedings. These positions are not recommended for normal newborn infants because they are associated with an increased incidence of sudden infant death syndrome (SIDS). In the preterm infant, however, the prone position increases oxygenation and enhances respiratory control, improves lung mechanics and volume, and reduces energy expenditure (Gardner & Goldson, 2011).
Supine positioning for sleep is begun when the infant can tolerate it and before discharge so the infant can become accustomed to sleeping on the back before going home. Before discharge, parents should be taught the importance of the supine position for sleep to prevent SIDS. It is important for nurses to model SIDS prevention by placing infants in the supine position as soon as they are able, because parents are more likely to position infants as they saw them positioned in the hospital (Carrier, 2009; McMullen, Lipke, & LeMura, 2009).
The nurse checks suction equipment at the beginning of each shift to ensure it is available and functioning properly at all times. The infant is suctioned only as necessary when the need becomes apparent. Suction should be gentle to avoid traumatizing the delicate mucous membranes. Trauma could cause edema, decreasing the size of the air passages and leading to more respiratory difficulty.
Suctioning also provides an entry for organisms and decreases oxygenation during the procedure. The procedure causes changes in heart rate, blood pressure, and cerebral blood flow. Suction should be applied for only 5 to 10 seconds at a time, and increased oxygen should be provided before and after each suction attempt. The mouth is suctioned before the nose because stimulation of the nares causes reflex inspiration that could cause aspiration of fluids in the infant’s mouth (Gardner, Enzman-Hines, & Dickey, 2011b). Rest periods should be provided after suctioning.
Adequate hydration is essential to keep secretions thin so that they can be removed by drainage or suction. If infants become dehydrated, secretions will become thick and viscous and could obstruct tiny air passages. Fluid intake should be increased, as ordered by the physician, if secretions seem to indicate minimal dehydration.
Problems with Thermoregulation
Although heat loss can be a problem for full-term infants, it is even more significant for preterm infants. They have thin skin with blood vessels near the surface and little subcutaneous (white) fat for insulation. Less brown fat is present for nonshivering thermogenesis. Preterm infants’ body surface area in proportion to their body mass is five times that of adults (Blackburn, 2013). Their extended extremities increase exposure to the air for heat loss. The temperature control center of the brain of preterm infants is less mature and may be further impaired by asphyxia. These conditions all contribute to heat loss.
Complications of heat loss are more likely in the preterm infant than in the full-term infant. They include hypoglycemia, metabolic acidosis, pulmonary vasoconstriction, impaired surfactant production, and hyperbilirubinemia. In addition, calories used for heat production are unavailable for growth and weight gain.
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.
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.
Maintaining a Neutral Thermal Environment
A neutral thermal environment is especially important to prevent the need for increased oxygen to maintain body temperature. The delivery room should be warm to decrease heat loss at birth. Immediately after birth, the infant is dried and placed on the mother’s abdomen or a prewarmed radiant warmer for care. Infants less than 29 weeks of gestation should be placed in a polyethylene bag or wrap that covers the body from the shoulders down before the infant is dried. This prevents heat loss by evaporation during initial care and transfer to the NICU and is used until the infant is stabilized (AWHONN, 2007; Kattwinkel, 2011). It also decreases insensible water loss.
Because they produce heat less effectively and lose more heat than larger or older infants, smaller, less mature infants need more warmth to maintain body heat. Radiant warmers or incubators are used until infants can maintain normal body temperature alone. Some devices convert from a radiant warmer to an incubator and back again to eliminate the need to move the infant from one device to another.
Infants needing many procedures are usually placed under an open radiant warmer to make it easier to see them and work with equipment. However, air currents around an unclothed infant can cause heat loss by convection despite the heat generated by the warmer. Doors near the warmer should be closed and traffic kept to a minimum to decrease convective heat loss. The infant should receive only warmed oxygen, because thermal receptors in the face are very sensitive to cold. Cold oxygen could quickly lead to cold stress.
Equipment or caregivers should not come between the infant and the heat source, thus preventing heat from reaching the infant. A transparent plastic blanket over the infant allows heat from the warmer to pass across to the infant and decreases exposure to drafts and insensible water loss while maintaining visibility of the infant’s body.
Incubators are used for infants who do not need to be under radiant warmers. They have double walls to minimize radiant heat loss to the cooler outer walls. Warmed air circulating inside the incubator provides heat. Humidity may be added to decrease evaporative heat loss and insensible water loss, especially in very preterm infants. Incubators should be placed away from air conditioning ducts or windows that may affect the temperature.
When infants are in incubators, nurses should keep portholes and doors closed as much as possible. A significant amount of heat is lost every time the incubator is opened, and it takes time to build up again. When removed from the incubator for procedures or holding, the infant should be wrapped in heated blankets and a hat applied. The incubator doors should be closed while the infant is outside to maintain heat inside.
Although temperature loss is the most common concern, overheating also is a problem for preterm infants. Overheating may occur when heating devices such as radiant warmers are set too high or a skin probe is accidentally removed. Overheating leads to an increase in the metabolic rate, with increased oxygen and glucose needs, and insensible water losses. Alarms to detect high and low temperature should be turned on at all times.
Temperature regulation in preterm infants is usually provided in incubators until infants can maintain their own temperature, but warmth can also be provided when parents hold them. Adequate temperature is maintained in stable infants during KC.
Weaning to an Open Crib
Preparation of infants for moving to open cribs should begin early. When stable, infants can be dressed in a shirt, diaper, and hat while in the incubator. Clothing conserves heat and helps infants adjust to a different temperature on the face than the rest of the body. Infants who weigh about 1500 g (3 lb, 5 oz), have a consistent weight gain for 5 days, have no medical complications, and are tolerating enteral feedings (feedings into the gastrointestinal tract orally or by feeding tube) can begin gradual weaning from external heat (Brown & Landers, 2011).
Each NICU has its own protocol for the weaning process. The incubator temperature is usually decreased gradually. It is increased if the infant’s temperature falls below the desired range. If the temperature remains stable, the process can continue.
When the infant is ready for transfer to an open crib, double-wrapping with warm blankets at first helps insulate body heat. The temperature is assessed at gradually increasing intervals until the infant is on a routine schedule. A blanket is added for a low temperature, but if the temperature does not rise to normal, the infant is returned to the incubator. Nurses should observe infants carefully during the first few days after transfer to an open crib.
Problems with Fluid and Electrolyte Balance
Preterm infants lose fluid very easily. The rapid respiratory rate and the use of oxygen increases fluid loss from the lungs. Their thin skin has little protective subcutaneous white fat and is more permeable than the skin of term infants. The large surface area, in proportion to body weight, and lack of flexion further increase transepidermal water losses. Radiant warmers heighten insensible water losses by 40% to 50%, compared with water loss in an incubator (Brown & Landers, 2011). Heat from phototherapy lights causes more fluid loss through the skin.
The ability of the kidneys to concentrate or dilute urine is poor, causing a fragile balance between dehydration and overhydration. The fluid needs of preterm infants vary according to size, gestational age, insensible water loss, and medical needs. Normal urinary output is 2 to 5 mL/kg per hour for preterm infants (Jones, Hayes, Starbuck, et al., 2011). After 24 hours of life, output less than 0.5 mL/kg per hour is oliguria (Blackburn, 2013).
The kidneys’ regulation of electrolytes also is a problem. Preterm infants need higher intakes of sodium because the kidneys do not reabsorb it well. If they receive too much sodium, however, they may be unable to increase sodium excretion adequately and are susceptible to sodium overload.
Monitoring intake and output of fluids is important in determining fluid balance. The infant’s intake and output by all routes are carefully calculated. Parenteral, feeding tube, medication, and oral fluids are included when measuring intake. Output from regurgitation, drainage tubes, stools, and urine should be measured. The nurse must also keep track of the amount of blood taken for laboratory tests because the loss can be substantial.
There are several methods of measuring urinary output. Plastic bags that adhere to the perineum are not suitable for the preterm infant because they may damage the fragile skin. Weighing diapers is less invasive. The weight of dry diapers is subtracted from the weight of wet diapers to determine the amount of urine excreted. One gram is equivalent to 1 mL of urine. Humidification may add moisture to the diaper, and a radiant warmer may cause evaporation of urine on the diaper. When precise measurement is essential, diapers can be fastened instead of placing them open under the infant.
Specific gravity should be checked to determine if urine is more concentrated or dilute than expected. Urine is collected by placing cotton balls at the perineum. The specific gravity should range between 1.002 and 1.01 (Jones et al., 2011).
Changes in the infant’s weight can give an indication of fluid gain or loss, especially if the changes are sudden and greater than would be expected. The undressed infant should be weighed at the same time each day with the same scale. Very small infants are often placed in a bed with a scale so that they are not disturbed for daily weighing. They may be weighed two or three times a day to monitor their fluid status more closely.
Signs of Dehydration or Overhydration
The nurse should observe for signs that indicate the infant has received too little or too much fluid. Early signs of dehydration include decreased urine output (less than 2 mL/kg/hr) and increased specific gravity. Weight loss may exceed that expected for the infant’s age and general condition. Dry skin or mucous membranes, sunken anterior fontanel, and poor tissue turgor are late signs. Changes in the blood include increased sodium, protein, and hematocrit levels resulting from decreased plasma volume.
Signs of overhydration include increased output of urine (more than 5 mL/kg/hr) with a below-normal specific gravity. Edema and weight gain occur from retention of fluids. Bulging fontanels, moist breath sounds, and decreased blood sodium, protein, and hematocrit levels also are present. Complications of excess fluid may include patent ductus arteriosus and congestive heart failure.
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.
Problems with the Skin
Preterm infants have fragile, permeable, easily damaged skin. They often have endotracheal tubes, IV lines, electrodes, and other equipment that must be maintained in place, but standard adhesive tape can be very damaging to the skin, especially during removal. Preparations used to disinfect the skin before invasive procedures can be harmful to fragile skin and may be absorbed.
The nurse should frequently assess the condition of the infant’s skin and record any changes. The infant’s response to products used for cleansing and disinfection should be noted.
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.
Problems with Infection
The incidence of infection in preterm LBW infants is 3 to 10 times greater than that in full-term normal-birth-weight newborns (Stoll, 2011). Many preterm infants have one or more episodes of sepsis during their hospital stays. Factors contributing to the high rate of infection include exposure to maternal infection, lack of transfer of immunoglobulin G (IgG) from the mother during the third trimester, and immature immune response to infection.
Preterm infants are often exposed to situations that may cause infection. They are subject to many invasive procedures such as insertion of IV lines leading to catheter-related bloodstream infections. A prolonged stay in the hospital increases the likelihood of acquiring an infection from multiple exposures to organisms.
The nurse should be alert for signs of sepsis at all times (see Chapter 30, p. 727).
Hand hygiene is the most important factor in preventing nosocomial infections. Nursing care involves scrupulous cleanliness and maintaining the infant’s skin integrity. Even the normal flora on the hands of caretakers may cause sepsis. Therefore, parents and staff members should thoroughly wash their hands and arms before handling infants. Exposure to family or staff members who have contagious diseases should be prevented.
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.
Problems with Pain
Infants in the NICU undergo many painful procedures each day. Caregivers once thought that newborns, particularly preterm infants, were neurologically too immature to feel pain. It is now recognized preterm infants do feel pain, and pain stimuli cause physiologic and behavioral changes in infants.
Pain can have numerous untoward effects. For example, increases in intracranial pressure resulting from pain may elevate the risk for intraventricular hemorrhage. Other risks include hypoxia, changes in metabolic rate, and adverse effects on growth and wound healing. Stress and pain in the newborn may alter pain thresholds and cause permanent changes in neural pathways (Blackburn, 2013). The long-term effects of pain in the neonate are not yet fully understood. The American Academy of Pediatrics and the American College of Obstetricians (AAP & ACOG, 2007) and the National Association of Neonatal Nurses (Walden & Gibbins, 2008) recommend that pain be routinely assessed, painful procedures be minimized, and environmental and pharmacologic interventions be used to prevent, reduce, or eliminate pain in neonates.
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.
The Preterm Infant
Preterm infants commonly have difficulty with environmental stress and obtaining adequate nutrition. Their parents may have difficulty with bonding.
Environmentally Caused Stress
The effects of environmental factors on the preterm infant have led to developmentally supportive care. Developmental care keeps stressors in the environment to a minimum based on the infant’s physiologic and behavioral responses.
In the past, preterm infants were often exposed to bright lights and a noisy environment without understanding of the effect on infants. Improvements have occurred, but noise continues to be a problem. Although the recommended noise level in NICUs is below 45 decibels, levels may range between 38 and 90 decibels or higher (Gardner & Goldson, 2011). Noise levels tend to be loudest during report and caregiver rounds and in areas where staff congregate such as at entrances, sinks, and computer areas. The sounds of alarms, ventilators, incubators, doors, and people create a noise level that increases the risk of hearing loss and other complications. In addition, stimulation of any kind can cause increased energy expenditure by the preterm infant. Noise and even routine handling and nursing interventions are often accompanied by changes in heart rate, oxygen saturation levels, and behavior states.
Preterm infants undergo multiple assessments, procedures, and treatments that may cause frequent interruptions of sleep and may interfere with the development of normal sleep-wake cycles. Sleep disruption alters neuronal maturation and secretion of growth hormone and interferes with growth and development (Gardner & Goldson, 2011). Energy used to cope with an overstimulating and stressful environment may be unavailable for normal growth and development.
Although touch is generally thought to be comforting to infants, it is often associated with painful events for preterm infants. This can cause infants to develop touch aversion, a negative response to touch of any kind. They may cry, squirm, and recoil when touched, expecting that touch will lead to pain.
Assess the amount of noise to which the infant is exposed. Determine how often interruptions occur and how the infant responds to different types of care. Assess the infant’s ability to tolerate activity and noise. Overstimulation results in changes in oxygenation and behavior.
Nursing Diagnosis and Planning
The infant will show decreasing signs of overstimulation during routine activity, as evidenced by fewer respiratory and behavioral changes during handling and increased periods of relaxed behavior or sleep.
Interventions are focused on providing developmentally supportive nursing care that meets the preterm infant’s ability to tolerate stimulation.
Schedule periods of undisturbed rest to allow the infant to recover from treatments. Avoid waking the infant during the short quiet sleep phase. If the infant must be awakened for care, try to wait until the infant is in an active sleep phase and more easily aroused with quiet talking and gentle touch. Arrange routine care to correspond with the infant’s awake periods and avoid disturbing rest.
Coordinate diagnostic tests and care given by other health care workers to ensure the infant is not stressed. Decrease the frequency of taking vital signs and performing other routine care as soon as possible. Even the handling involved in routine sponge bathing may cause stress in small infants. Routine daily baths are unnecessary and should be avoided. Bathing every fourth day does not increase skin flora or pathogen counts. Bathing should be postponed until infants are physiologically stable (Gardner & Goldson, 2011).
Cluster or group care so that several tasks are performed at one time to allow for more rest between care activities. Keep clustered care short and be alert to the infant’s signs of stress. Too many activities may be more than the infant can tolerate. Clustered care may not be appropriate for preterms less than 28 weeks of gestational age (Gardner & Goldson, 2011).
Provide short rest periods within grouped activities or during long or painful procedures. Do not include painful procedures in a cluster of other care activities. Rest is needed before and after painful procedures.
Keep noise around the infant as low as possible. Place incubators away from traffic and congestion areas, and avoid talking near the incubator. Use incubator covers to help lower sound inside the incubator. Set alarm volumes on low, and respond quickly when they sound. Open and close incubator portholes and doors and cupboards quietly. Do not place objects on top of the incubator or use it as a writing surface because it increases the noise inside. Teach parents and others to avoid tapping on the incubator. Soft classical music is sometimes used to help promote rest.
Lights that are on 24 hours a day in the nursery may interfere with the development of sleep cycles. Position the incubator so the infant is not facing bright lights, and drape blankets or incubator covers over the back and ends to decrease light, as well as noise, further. Use dimmer switches to vary the intensity of lights as needed. Reduce lighting at night to as low as possible to help promote rest and conserve energy for growth.
Some NICUs have single rooms for each infant. This reduces noise and allows environmental stimuli to be adapted to each infant’s individual needs. It also provides more privacy for visiting family members and may reduce nosocomial infections.
When possible, schedule “quiet times” when lights and noise in the unit are kept to a minimum to promote rest. Only emergency procedures should take place during rest times. Rest periods should be at least an hour long to allow preterm infants to complete a sleep cycle (Gardner & Goldson, 2011).
Scheduled naps when infants are disturbed as little as possible may help decrease waking and lead to longer uninterrupted sleep. Naps also may help the infant begin to differentiate day and night sleeping patterns. Lights lowered at night can help develop circadian rhythms.
Contain the infant’s arms and legs to promote flexion of the joints and reduce energy loss from flailing extremities. Containment is used to promote quieting, enhance physiologic stability, and reduce stress (Gardner & Goldson, 2011). Provide boundaries with rolled blankets or commercial positioning devices placed around the infant.
Stroking and gentle massage may be calming for stable preterm infants. It may help increase weight gain and improve development. It can also help involve parents in care of the infant. However, it may not be appropriate for smaller, more fragile infants (Carrier, 2010).
Promoting Motor Development
Preterm infants may have musculoskeletal and developmental problems from prolonged immobilization and the effects of gravity on their immature neuromuscular system. Because the extensor muscles mature before the flexor muscles, the infant tends to remain in an extended, “frog-leg” position. Shoulder retraction, abduction and external rotation of the lower extremities, lateral flexion of the arms, neck hyperextension, and flattening of the sides of the head may be prevented with correct positioning.
Reposition the infant every 2 to 3 hours or when other care is provided. Change the position slowly as it may be stressful. When possible, position the infant with the extremities flexed and the hands positioned in midline and near the mouth to allow the infant to suck the hands for comfort. Use swaddling, blanket rolls, or commercial positioning devices to maintain flexion.
When possible, the same nurse or several nurses should be assigned care for an infant to provide consistency in care and handling techniques. This allows the nurse to learn the infant’s unique responses and to individualize nursing care. It is also very helpful to parents to relate to a small number of nurses who know their infant well.
The ability to tolerate stress varies with each infant. Adapt general care according to the infant’s ability to tolerate it. Even positive stimuli, such as soft music or soft talking, can overstimulate some infants.
Infants often require extra energy to adjust to changes in care. Observe how well they tolerate changes such as moving from assisted to more independent breathing or introduction of new feeding methods. Increase rest periods during these times.
Communicating Infants’ Needs
Use the nursing care plan, Kardex, and shift reports to inform other caregivers of techniques that are especially effective for certain infants. Tape notes at the bedside as reminders of each infant’s needs. Explain all techniques to parents so they can participate in care appropriately.