Acute Conditions of the Neonates
• Respiratory Distress syndrome
• Meconium Aspiration syndrome
• Sepsis
• Hyperbilirubinemia
• Sudden Infant Distress syndrome (SIDS)
Respiratory Distress Syndrome (RDS)
• Hyaline membrane disease
• Difficult respiration due to deficient
surfactant, leading to collapsed lungs
(atelectasis), w/c prevent adequate gas
exchange
• ETIOLOGY:
- Immature lungs w/ decreased
surfactant
• Hyaline membrane disease
• Due to immaturity of the lungs
• Decreased gas exchange
• Etiology:
• Deficient synthesis or release of
SURFACTANT
- High in lecithin and fatty protein
necessary for absorption of oxygen
in the lungs
RDS Manifestations:
• RR: 60 breaths/min or more
• Rapid respirations with grunt-like sounds,
• Nasal flaring,
• Cyanosis,
• Intercostal and substernal retractions
• Severe: edema, lassitude, apnea
Treatment / MGT:
• Corticosteroids (bethamethasone)
✓ IM, 1 – 2 before delivery
✓ Preterm Newborns: via endotracheal tube (ET)
at birth or when symptoms of RDS occur
• Improvement of lung function w/in 72 hours
• VS monitored closely
• Arterial blood gases analyzed
• Warm incubator w/ gentle or minimal handling
• IVF – nurse observes for signs of
overhydration or dehydration
• O2 therapy via hood or ventilator in
concentrations necessary to maintain adequate
tissue perfusion
Incidence
• Common in preterm newborns, especially
those weighing bet. 1000 – 1500 gms.
• Also high in babies:
✔ Of diabetic mothers
✔ Delivered by CS, and
✔ Whose mothers had antepartum
bleeding
Complications/associated problems
• Hypoxia
• Retrolental fibroplasia
• From O2 of high concentration,
greater than 40%
• Atelectasis
• Bronchopulmonary dysplasia
Assessment/Findings
• Use Silverman-Andersen Scale for scoring
difficult respiration
✔ 0 = normal respiration
✔ 10 = most difficult respiration, RDS
Major Signs:
• Expiratory grunting – major sign; late-
occuring
• Flaring of the nares – early sign
• Retractions (sternal and intercostals)
• Due to use of accessory muscles to
aid respiration
• See-saw breathing
• flattening of the chest during
inspiration w/bulging of abdomen
• Tachypnea: RR > 70/min – an early sign
Minor signs
• Cyanosis
• Tachycardia
• Falling body temperature; color: pale gray
• Dyspnea
• Decreased activity level
• Respiratory acidosis
• Auscultation: fine rales, diminished breath
sounds o Decreased urine; edema of
extremities
• Decreased muscle tone; absent bowel
sounds
• Periods of apnea
Diagnosis
• History
• Assessment findings (Silverman)
• Blood gas studies
Nursing Implementation
• Keep airway patent/promote respiration
o Suction ET 1 – 2 hours as needed
o In preterm: < 5 seconds per
suctioning
o Use sterile catheter
• Maintain and monitor O2 concentration
o Maintain humidity; maintain in
supine position w/ head slightly
 extended to improve respiratory
funtion
o Do not hyperextend the neck
• Administer prescribed O2 under CPAP
• Safety: Mouth-to-mouth resuscitation
• Frequent evaluation/monitoring:
• VS, color, breath sounds, and blood
gases
• Maintain hydration and nutrition • NPO for
tachypnea
• Monitor I&O, daily weight
• Provide for IV therapy, gavage feeding
(when infant is unable to suck or tires
easily) or hyper alimentation
• Hyperalimentation
Nursing Implementation
Prevent infection by:
• Hand washing
• Wearing proper attire
• Antibiotics as ordered
• Avoiding exposure to infected personnel
• Isolating infected Newborns
Keep warm
• Maintain in isolette w/ high humidity
✔ Incubator: 40 -70%
✔ High humidity: 55 – 65%
• Monitor temp per axilla
• Prevent heat loss
Give supportive care to parents
• Allow verbalization of feelings and concern
• Explain special procedures
• Inform of results and progress
• Encourage participation in care; provide
positive feedbacks
Meconium Aspiration Syndrome (MAS)
• Group of symptoms that occur when the
fetus or newborn aspirates meconium-
stained amniotic fluid into the lungs
• Etiology:
• prolonged labor 􏰀 fetus expels
meconium into amniotic fluid (esp.
w/ cord compression)
• If Asphyxia and acidosis occur
􏰀fetus gasps 􏰀drawing meconium-
stained amniotic fluid into lungs
• 1st breath before nose and mouth is
suctioned 􏰀meconium-stained fluid
in upper airway passages is drawn
into the lungs
• Aspiration of meconium into the
tracheobronchial tree in utero or during the
1st few breaths after delivery in a term
neonate
• Etiology:
Manifestations:
• RDS s/symptoms – primary sx
• Rales and ronchi
• Tachypnea that persists for several weeks
• TREATMENT:
• Supportive care w/ warmth
• Supplemental O2
• Energy-conserving plans of care
• Intubation and mechanical ventilation
MAS Etiology:
Meconium can cause severe respiratory
distress in 3 ways:
• Causes Inflammation of bronchioles
o Because it is a foreign substance
• Can block small bronchioles by mechanical
plugging
o Ball-valve action: air is allowed in but
cannot be exhaled
o hyperinflated lungs
o 􏰀􏰀ed pulmonary perfusion
o 􏰀􏰀ed hypoxia
• Causes 􏰀 in surfactant production thru lung
trauma
Assessment
• May demonstrate signs of fetal distress during
labor and delivery
• Apgar score less than 6 @ 1 and 5 minutes o
Immediate signs of respiratory distress @
• delivery (cyanosis, tachypnea, retractions) o
Over-distended, barrel-shaped chest
• Diminished breath sounds
• Yellow staining of skin, nails, umbilical cord
Priority Dx: Ineffective gas exchange
Interventions:
• Suction oropharynx then nasopharynx after
neonate’s head is born to remove as much
meconium as possible
• Place infant under radiant warmer
• Administer O2 to maintain adequate PO2 and
• O2 saturation
• Perform chest physiotherapy routinely
Sepsis
• Systemic response to infection with bacteria o
Can also result from viral or fungal infections
• Causes SYSTEMIC Inflammatory Response
Syndrome (SIRS) due to the endotoxin of the
bacteria that causes tissue damage
• If untreated 􏰀septic shock, multi-organ
dysfunction syndrome, DEATH
Manifestations:
• Fever, chills, tachypnea, tachycardia,
neurological signs (lethargy)
• Hypotension – ominous/threatening sign
✔ Indicates body is unable to compensate
adequately
and cardiorespiratory arrest is about to occur
• Lab tests:
✔ (+) blood cultures
✔ Reduced fibrinogen and thrombocyte levels
✔ Presence of immature WBC
✔ Neutropenia (neutrophil 􏰀1000/mm3)
Nursing Responsibilities
• Monitoring neurological status and VS
• Observing for shock;
• Maintaining strict standard and expanded
precautions (masks, gowns, gloves)
• Antibiotics IV
• Immunization against H. influenzae (Hib)
bet. 2 mos. – 4 years
HYPERBILIRUBINEMIA
• HYPER - “excess”; BILIS – “bile”; RUBOR
– “red”; EMIA – “blood”
• Excessive levels of serum bilirubin greater
than 12 – 13 mg/100 mL
▪ Normal: 2 – 6 mg/100 mL, not to
exceed 12 mg/100 mL
Physiology
Pathophysiology
• Before birth – unconjugated bilirubin is
eliminated by the placenta
• After delivery – converted to conjugated
bilirubin in the liver and is excrete via bile
ducts into the intestines
• Can be reabsorbed from the intestines if
peristalsis slows
• KERNICTERUS – complication
Risk factors
• Resolution of enclosed hemorrhage
(cephalhematoma, large amount of bruising
from difficult delivery)
• Infection/sepsis
• Dehydration
• Breastfeeding – pregnanediol in breast milk
renders glucorynyl transferase ineffective in
conjugating bilirubin
• Poor meconium/stool passage
Assessment
• Pathologic jaundice
✔ Occurs in the 1st 24 hours
✔ Duration: lasts more than a week
✔ Dangerous levels @ w/c kernicterus may set
it:
• Full-term: 20 mg/100 mL or above
• Preterm: 15 mg/ 100 mL or above
Assessment: Kernicterus
✔ Signs of kernicterus:
• Sluggish-to-absent Moro reflex
• Opisthotonus
• Severe lethargy
• Projectile vomiting
• Tense, bulging fontanel; high-pitched cry •
Apnea
• Convulsion – late sign
• Irritability
• Increasing serum bilirubin
Nursing Diagnoses :
• Fluid volume deficit r/t decreased intake,
loose stools, and increased insensible
water loss
• Impaired parenting r/t interruption in
bonding between infant and parents
secondary to separation
Interventions and management
• Phototherapy
▪ Transports bilirubin from skin to the
blood, then to bile where it is excreted
and passed out thru the stool
▪ Light tubes 16 inches (42 – 45 cm)
away from baby
▪ Prepare for phototherapy:
✔ Undress newborn
✔ Cover eyes and genitalia
Phototherapy
• Provide continued care during the
treatment
✔ Feed regularly (Q 2 – 3 hours) to prevent
metabolic acidosis
• Remove infant from under the light, remove
eye shield, then cuddle him during feeding
✔ Turn q 2 hours for maximum exposure of skin
surfaces
✔ Increased fluid intake; give fluids in between
feedings
✔ Monitor temperature q 2 hours
Assess for S/S, and manage as necessary:
• Bronze skin (explain to parents: temporary) o
Dark, concentrated urine (Increased fluids;
sterile water between regular milk feedings)
• Bright, green, loose stools from excess bilirubin
excretion (explain: not diarrhea)
• Priapism (turn to prone)
• Retinal damage (prevent by shielding eyes)
• Dehydration
• Elevated temp/fever (monitor temp; provide
adequate hydration)
SUDDEN INFANT DEATH SYNDROME (SIDS)
• Clinically defined as:
• Sudden, unexpected death of an
apparently healthy infant bet. 2 weeks & 1
year of age for which routine autopsy fails
to identify the cause
• “Crib death”
• Peak incidence: bet. 2 & 4 months of age
✓ Multiple pregnancies w/ short intervals bet.
them
✓ Low socio-economic status, crowded living
conditions
✓ Poor prenatal care and limited weight gain
during pregnancy
Preventive measures
• Put infant on his back to sleep
• Not smoking anywhere near an infant
• Remove pillows, quilts, stuffed toys, or other
soft surfaces that may trap exhaled air from
crib or sleeping environment
• Use firm mattress w/ snug-fitting sheet
• Make sure infant’s head remains uncovered
while sleeping
• Keep warm while sleeping but not overheated
Nursing Care
• Assist parents in the grieving process
• Stay calm and let parents express their
feelings
• May express anger or blame others
• Reassure them that disease cannot be
predicted nor prevented, and “they are not
responsible” for the death
• Allow them to say goodbye to the infant:
• Let them touch, hold and rock the infant • May
assist in burial preparations

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

Risk factors for SIDS

Infant risk factors
✓ Prematurity
✓ Low birth weight
✓ Twin or triplet
✓ Male
✓ Age bet. 2 – 4 mos
✓ Passive smoke exposure
✓ Hx. of respiratory compromise
✓ Hx. of a sibling who died of SIDS
Maternal risk factors
✓ Age under 20 years
✓ Smoking or illicit drug use
✓ Anemia