SGH Neonatal

Clinical Field Visit

Done By:

Nurlaila
Jasmine Goh
Loke Wing See
 Outline
•Introduction

•History / Events

•Clinical Problems

•Pathophysiology

•Medical Management
- Oxygen Therapy
- Blood Investigations
- Phototherapy
- PROM
- Medication
- Nutrition

•Nursing Management
 Introduction

The premature neonate (gestation 25/52 +6 days) is a 6 days old,

Chinese male and weighs 815grams at birth.

The mother has premature rupture of membrane (PROM) 5 days

before delivery, chorioamnionitis and pyrexia.

He was admitted to neonatal ICU on 18/1/08 due to apnoea at

birth, infection complications and extremely low birth weight. He
appeared jaundice and was diagnosed with G6PD.
History/ Events
Mother’s history

Age: 28 years old

Race/ Occupation: Chinese/ Housewife

Past Medical History: Nil

Past Surgical History: Left Ureter operation more

than 10 years ago

Blood Group: 0 +

Drug Allergy: Sulphur Drugs

Maternal Drugs:

•Tocolytics (Tocolytics are medications used to suppress premature labor.

They are given when delivery would result in premature birth. The therapy also
buys time for the administration of betamethasone, a glucocorticoid drug which
greatly accelerate fetal lung maturity)

•Antibiotics

•Betamethasone (Betamethasone is a cortoidsteroid used to stimulate fetal

lung maturation, and to decrease the incidence and mortality from intracranial
hemorrhage in premature neonates.)

•Vitamins
Antenatal / Intrapartum Problems:

•Premature Labour 25/52 + 6 days

•Infection

•Pyrexia (Temperature 38.3C)

•Membrane Rupture 13/1/08 @ 0300hrs

 Labour History

Onset: 18/1/08 0200hrs

Delivery Time: 18/1/08 0507 hrs

Nature of liquor: clear

Anaesthesia/ Analgesia: Entonox

Mode of delivery: Spontaneous Vaginal

Resuscitation:
•Oxygen/ Stimulation
•Bag and Mask

Apgar Score: 7 (1 min) 8 (5 min)

 Neonate Record

Sex: Male

Birth Weight: 815 gm

Head Circumference: 24 cm

Length: 34 cm

Passed Urine: No

Passed Meconium : No
 Neonate Record
Cord Blood for:

•G6PD
•FT4/ TSH
•IgM
•ABO/ Rh/ DCT

Drugs Given
•Vitamin K 1 gm ( Vitamin K is administered prophylactically
to prevent a transient deficiency of coagulation factors II, VII, IX and X.
Dosage is 0.5mg to 1 mg IM up to 1 hour after birth. )

•Gentamicin 2 mg

•Ampillicin 40 mg
 Physical Examination upon Birth
Head Normal Liver Normal
Fontanelles Normal Spleen Normal
Face Normal Kidneys Normal
Eyes Left eye fixed; Right eye partially fixed Hips Normal
Ear Normal Back Normal
Nose Normal Genitalia Normal
Neck Normal Anus Sacral Dimple
Skin Normal Limbs Normal
Mouth Normal Activity Normal
Palate Normal Posture Normal
Heart Normal Tone Normal
Femoral Pulse Normal Moro’s Normal
Reflex
Lungs Normal Grasp Normal
Abdomen Normal Traction Normal
Umbilicus/ Normal Cry Normal
Cord
Clinical Problems
 Clinical Problems

Maternal

1. Premature Ruptured of membrane (PROM) more than 24 hrs

• Placental Histology: E Coli

2. Clinical chorioamnionitis
Chorioamnionitis is a condition in which the chorion and amnion (the
membranes that surround the fetus) and the amniotic fluid (in which the fetus
floats) are infected by bacteria. This can lead to infection in both the mother
and fetus, and, in most cases means the fetus has to be delivered as soon as
possible.

3. Pyrexia
• Temperature Maximum: 38.3C
• Covered with PO EES 800mg BD then IV EES
 Clinical Problems

Neonate

1. Prematurity
•IM Betamethasone X2 completed 14/1/08

2. Premature Rupture of membrane

3. Apnea of Premature
•Covered with IV Caffeine Citrate

4. Glucose-6-phosphate dehydrogenase (G6PD) deficiency

5. Early Neonatal Jaundice

•Serum Bilirubin 71 at 15 hrs of life
 Clinical Problems

6. Hyper glycaemia
•Reflo 125 158 140 ( normal range : 65 – 125 mg/ dl)
•Urine Sugar 1+
•Piggy back with ½ strength normal saline

•Hyperglycemia occur in preterm neonate who is having

total parenteral nutrition. It may also be an early sign of
sepsis
 Clinical Problems
7. Hypernatremia
•Na 152
Hypernatremia is defined as a serum sodium greater than 150mmol/L.
Newborn infants, particularly preterm ones, rapidly become dehydrated
and hypernatramia if fluid intake is reduced or abnormal losses occur
where water loss exceeds sodium loss.

6. Reduced renal excretion. The newborn kidney is less efficient at

excreting excess salt than water, and so hypernatraemia is more
likely in very immature infants than in older children.

8. Excessive water loss. The lack of keratin in the skin of very tiny
babies causes excessive transepidermal water loss.
Phototherapy and radiant warmers aggravate this loss.
Pathophysiology
 What is G6PD?
• G6PD enzyme glucose-6-phosphate dehydrogenase is one of many
enzymes that help the body process carbohydrates and turn them
into energy. G6PD also protects red blood cells from potentially
harmful byproducts that can accumulate when a person takes
certain medications or when the body is fighting an infection.

• G6PD deficiency is an inherited condition in which the body doesn't

have enough of the G6PD, which helps red blood cells (RBCs)
function normally. This deficiency can cause hemolytic anemia,
usually after exposure to certain medications, foods, or even
infections.
 What is Jaundice?
• Bilirubin is a normal pigment made when red blood cells
break down in the body. It is usually processed by the
liver, recycled and eliminated in the baby’s stool.

• Jaundice is very common in newborn babies. The baby’s

skin and whites of the eyes turn a yellow colour. When a
baby has jaundice, it means either his body is making
too much bilirubin or the liver is not eliminating.
Medical Management
 Parameters

Normal Neonatal Vital Signs

Temperature: Rectal : 35.6 C to 37.5 C

Axillary: 36.4C to 37.2C

Heart Rate: 110 to 160 beats / min

Blood pressure:
•Systolic: 60 to 80 mmHg
•Diastolic: 40 to 50 mmHg

Respiration: 30 to 50 breaths / min

 Vital signs of the Neonate
Date/Day Body Heart Rate Blood MAP Respiratory SpO2 Respiratory Support
Temperature (beats/ min) Pressure Rate (breaths/ (%) Settings
(degree (mmhg) min)
celcius)
18/1/08 35.9 164 48/36 40 30 92 – CPAP (nasal)
Day 1 98 FIO2 25%
PEEP +5
Flow Rate 6 L
19/1/08 36.4 130-166 60/44 49 25 – 48 92 – CPAP (nasal)
Day 2 98 FIO2 30%
PEEP +5
Flow Rate 6 L
20/1/08 36.1 130-162 60/36 48 28 – 41 92 – CPAP (nasal)
Day 3 97 FIO2 21%
PEEP +5
Flow Rate 6 L
21/1/08 36.4 145-174 54/43 47 25- 59 90 – CPAP (nasal)
Day 4 99 FIO2 25%
PEEP +5
Flow Rate 6 L
22/1/08 36.5 133-165 56/32 41 20 – 61 90 – CPAP (nasal)
Day 5 98 FIO2 21%
PEEP +5
Flow Rate 6 L
23/1/08 36.5 148-172 48/35 40 26 - 55 89 - 97 CPAP (nasal)
Day 6 FIO2 21%
PEEP +4
Flow Rate 6 L
 Oxygen Therapy
Precautions to note:

•Oxygen must be warmed and humidified to prevent

hypothermia and dehydration.
•High concentration of oxygen therapy over prolonged
periods can cause blindness
•Low concentration of oxygen can allow hypoxia and
central nervous system damage

Nasal CPAP

Continuous positive airway pressure (CPAP) is the application of positive pressure to the
airways of the spontaneously breathing patient throughout the respiratory cycle. Neonates
are preferential nose breathers, which easily facilitates the application of nasal CPAP.

CPAP maintains inspiratory and expiratory pressures above ambient pressure, which
should result in an increase in functional residual capacity (FRC) and improvement in
static lung compliance and decreased airway resistance in the neonate with unstable lung
mechanics.
Blood Investigations
 Immunohaematogical
Mother Blood Group O+

Antibody Negative

Baby Blood Group B+

Antibody Negative
 Full Blood Count
Date 18/01/08 19/01/08

WBC (9.0 – 30.0) 23.52 X 10 (9) / L 19.5 X 10 (9) / L

Hb (14.0 – 24.0) 15.6 G/DL 12.5 G/DL

PLT (140 – 440) 421 X 10 (9) /L 441 X 10 (9) / L

Reticulocytes (2.5 – 14.6 % 3.0%

6.5)
 Urea Electrolytes
Date 19/01/08 21/01/08

Urea (2.8 – 7.1) 11.1 mmol 11.0

Sodium (131 -144) 142 152

Potassium (4.5 – 6.8) 6.6 5.2

Chloride (102 – 112) 107 120

Bicarbonate (17.0 – 26.0) 18.9 16.1

Creatintine (35 – 88) 98 114

 Arterial Blood Gas
Date 18/01/08

pH (7.35 – 7.45) 7.331

PO2 (50 – 80) 86.6mmHg

PCO2 (35 -45) 41.7mmHg

HCO3 (19 – 24) 21.5

BE (-4 – 0) -4.2

SaO2 95.2%
 Cerebrospinal Fluid
CSF Latex Agglutination Negative For:

• Haemophilus Influenzae type B

• Streptococcus Pneumonia
• Streptococcus group B
• Neisseria Menigitidis ACY W 135
• Neisseria Menigitidis B

• Escherichia coli
Culture & Aspiration Result
Blood Culture No bacterial growth @ 48
hours

Ear Culture Swab No bacterial growth @ 48

hours

Gastric Aspiration Escherichia coli

Phototherapy
 Neonatal Jaundice
Date / Serum Bilirubin Level Interventions
Day (Doctor’s Order : to
start phototherapy if
Bilirubin level is more
18/1/08 71 mmol/L
than 70) Continue on single blue light with eye
Day 1 pads
19/1/08 88 mmol/L Continue on single blue light with eye
Day 2 pads
20/1/08 86 mmol/L Continue on single blue light with eye
Day 3 pads
21/1/08 81 mmol/L Continue on single blue light with eye
Day 4 pads
22/1/08 109 mmol/L 135 109mmol/L – Started on double blue
Day 5 mmol/L light
135 mmol/L – Increased on triple blue
23/1/08 122 mmol/L Continued on triple blue light
light
Day 6
 Photo therapy
Phototherapy (light treatment) is the process of using light to eliminate
bilirubin in the blood. The neonate's skin and blood absorb these light
waves. These light waves are absorbed by your baby's skin and blood and
change bilirubin into products, which can pass through their system.
Side effects

Babies under any type of phototherapy

treatment will have frequent and loose bowel
movements that are sometimes greenish in
color. This is normal since this is the way the
body removes the bilirubin.
PROM (Prolonged Rupture of membrane)

Rupture of amniotic membrane > 24 hrs prior to delivery of baby

Scoring System for Risk of Infection in Neonates

Gestation
•Less than 34 weeks 2 points
•34 – 37 weeks 1 point
•More than 37 weeks 0 point

Materal Clinical Amnionitis 1 point

Indicators of Infection ( one or more of) 1 point

•Maternal temperature > 38 C
•Fetal Tachycardia > 160/ min
•Polymorphs in amniotic fluid or infant’s gastric aspirate

Apgar Score
Less than 6 at 5 minutes 1 point
More than 6 at 5 minutes 0 point

Sex
Male 1 point
Female 0 point
PROM (Prolonged Rupture of membrane)
Management

If infant does not appear ill

• Score 0 – 1 Observation only

• Score 2 Culture gastric aspirate, ear and blood
• Score > 3 as above + CSF cultures and start antibiotic therapy with
ampicillin and gentamicin

If Infant has any signs and symptoms

• Early respiratory distress

• Apnoea, seizures
• Feed Intolerance, vomiting, abdominal distention
• Early hyperbilirubinaemia, increased bands on peripheral smear, motting , poor
perfusion

Proceed to full septic workup and antibiotic treatment

Important Points

Combination of maternal clinical or pathological amnionitis, male infant and gestational

age less than 37 weeks projects the highest infection risks, therefore this group
requires full septic workup and antibiotic treatment
 Medication
Date Route Drugs Name Dosage Frequency Discontinued

18/01/08 IM Gentamicin 2 mg 24 hours

19/01/08 IV Caffeine Citrate 4 mg 24 hours

(caffeine citrate 10mg/ml, 0.4ml
dilute with N/S 0.6ml to make
up
1ml and run over 30 min).
18/01/08 IV Ampicillin 40 mg 12 hours 21/01/08

21/01/08 IV Ampicilin 20 mg 12 hours

22/01/08 SC Eprex 75 unit (Stat Dose) 22/01/08

(0.09ml)
 Gentamicin
• Indications: Severe systemic infections of CNS,
respiratory, GI, urinary tract,soft tissues caused
by susceptible strain of Escherichia Coli

• Side effects: nephrotoxicity

• Precaution: mild renal disease

• Dosage Range:
for neonates less than 30 weeks 2.5 mg/kg/dose
 Caffeine Citrate
• Indication:
used for the short-term treatment of a breathing problem (apnea) in premature
infants.
Caffeine blocks certain proteins (adenosine receptors) which lead to improved
breathing in these infants.

• Side effect:
lack of energy (lethargy), severe vomiting

• Dosage range:
– Loading 20 mg/kg
– Maintenance 5 mg/kg/d om
– For IV – give over 30 mins
– Day 5 – 7 caffeine levels
 Ampillicin
• Indication: effective for gram- positive cocci,
gram negative cocci, gram negative cocci, gram-
negative bacilli

• Side effects: Rash, bone marrow depression

• Dosage range:
– High: 50mg/kg/dose 12 hr
– Normal 25 mg/kg/dose 12 hr ( when culture negative)
 Eprex
• Erythroproietin

• At birth, the infant moves from a relatively

hypoxic fetal state to become relatively
hyperoxic. This suppresses erythroproietin
secretions for the first 7 – 8 weeks
Nutrition
 IV Fluid
Date Route Drugs Name Frequency Discontinued

18/01/08 IV ½ Strength 24 hours 19/01/08

N/S
19/01/08 IV ½ Strength 24 hours 20/01/08
N/S
20/01/08 IV ½ Strength 24 hours 21/01/08
N/S
21/01/08 IV ½ Strength 24 hours 22/01/08
N/S
22/01/08 IV ½ Strength 24 hours 23/01/08
N/S
23/01/08 IV ½ Strength 24 hours
N/S
 IV TPN
Date Route Drugs Name Frequency Discontinued

18/01/08 IV D 5% 53ml over 19/01/08

24hrs
19/01/08 IV D 3.75% 43ml over 20/01/08
24hrs
20/01/08 IV D 3.75% 48ml over 21/01/08
24hrs
21/01/08 IV D 3.75% 48ml over 22/01/08
24hrs
22/01/08 IV D 3.75% 48ml over 23/01/08
24hrs
23/01/08 IV D 3.75% 72ml over
24hrs
 Diet
Date

21/01/08 Breast Milk or Full Strength (Premature Formula)

@ 4 ml, 3 hourly X 8 per day

22/01/08 Breast Milk or Full Strength (Premature Formula)

@ 4 ml, 3 hourly X 8 per day

23/01/08 Breast Milk or Full Strength (Premature Formula)

@ 5ml, 3 hourly X 8 per day
Date 18/1/08 19/1/08 20/1/08 21/1/08 22/1/08 23/1/08
Postnatal Age 1 2 3 4 5 6
Weight (g) 815 710 710 700 700 732
Dextrose Volume 53 43 48 48 65 72
% 5 3.75 3.75 3.75 3.75 3.75
Gram 2.7 1.6 1.8 1.8 2.4 2.7
Gram/Kg 3.3 2.3 2.5 2.6 3.5 3.7
Calories 10.6 6.4 7.2 7.2 9.8 10.8
Amino Acids % 1 1.5 1.5 1 1.5 1.5
Gram 0.5 0.6 0.7 0.5 1 1.8
Gram/Kg 0.7 0.9 1 0.7 1.4 1.5
Calories 2.1 2.6 2.9 1.9 3.9 4.3
Lipids Volume 2.4 2.4 2.4 4.8 4.8 4.8
% 20 20 20 20 20 20
Gram 0.5 0.5 0.5 0.96 0.96 0.96
Gram/Kg 0.6 0.7 0.8 1.4 1.4 1.3
Calories 4.3 4.3 4.3 8.6 8.6 8.6
Milk Frequency 8 (PF) 8 (PF) 8 (PF) 8 (PF) 8 (PF)
Volume NBM 2x8 2x8 4x8 4x8 5x8
Calories 12.8 12.8 25.6 23
Volume/day 53 73 90 109 126 129
Volume/kg/day 65 90 111 133 155 158
Calories/day 9.8 2.6 2.7 4.3 4.6
Calories/kg/day 12 37 38 62 65
Intake & output Intake 40 57.3 92 107.5 100
Output 38ml 32ml 40ml 45ml
PU 3X PU 3X
Asp: 0.8 Asp: 0.2 Asp: 1.3 Asp: 0.5 Asp: 0.6
BNO BO: 1X BO: 1X BO: 5X BO: 4X
 IV TPN
Indications:
It is used as a supplement to enteral feedings when adequate
nourishment cannot be achieved by the enteral route

Hyperalimentation can cause many alternations in biofunction. Therefore it is essential

to do laboratory monitoring.

Complications of TPN for neonate:

•Infection due to contamination of the line

•Malposition of the catheter leading to collection of the pleural fluid, causing
hydrothorax.
•Metabolic complications such as hyperglycaemia
 Nursing Management
Neonatal Jaundice

• Initiate phototherapy as ordered by doctor

• Explain the purpose and procedure to parents
• Obtain required blood investigations – FBC and ABO
• Position the phototherapy lamp to illuminate the neonate at a distance of 36 to 40 cm
• Nursed the neonate naked under phototherapy light
• Place a shaded plexiglass heat shield over the entire body
• Protect the neonate’s eyes with eye pads and access his eyes 3 to 4 hrly for infection or
inflammation
• Reposition the neonate every 2 hrs to expose all body surfaces to the light and to prevent head
molding and skin break down from pressure
• Feed 3 hrly as ordered by doctor
• Observe for hypothermia/hyperthermia, skin rash, conjunctivitis, lethargy, green projectile stools.
• Monitor elimination and weight neonate daily. Watch for signs of dehydration
• Monitor Serum bilirubin levels as ordered by the doctor/ protocol
 Nursing Management
Respiratory Problem

• Prepare appropriate requisites for setting oxygen therapy.

• Check oxygenation system and ensure tubings are connected correctly before use.
• For CPAP:
– Choose the appropriate size cannulae.
– Adjust the appropriate oxygen concentration as required.
– Adjust oxygen flow as prescribed.
– Adjust appropriate water pressure to be delivered.
– Fill humidifier with the correct amount of sterile water and set the appropriate temperature.
• Ensure the CPAP system is in place by checking and recording hourly.
• Position the tips of nasal cannulae into infant’s nares.
• Use Velcro tapes to secure nasal cannulae in-situ.
• Secure tubings with safety pins and small rubber bands.
• Check the position of the nasal cannulae, and to ensure there is no direct pressure on the nasal septum.
• Observe for redness or signs of skin breakdown on areas that are in content with nasal cannulae.
• Check for abdominal distension
– Insert oro-gastric (OG) tube for release of abdominal air.
– If the infant is on feeding, release OG tube 1 hour before the next feeding.
 Nursing Management
Nutrition (IV Therapy)
• Prepare IV drip infusion as prescribed by doctor.
• Prepare and assist doctor in IV cannulation.
• Administer parenteral fluid as ordered.
• Observe inserted site hourly for signs of phlebitis / infiltration:
– Redness
– Swelling at the IV site
– Leakage from IV site
• Check and record the amount and rate of infusion at hourly interval.
• Test urine for specific gravity and sugar every shift.
• Pass oro-gastric (OG) tube for aspiration hourly.
• Record amount and nature of aspiration content.
• Observe for urine output and bowel movement.
• Weight infant as required.
• Respiratory Problem
 Nursing Management
Nutrition (Feeding)

• Give correct amount of milk feeds as ordered by doctor.

• Perform tube – feeding if infant is unable to suck orally.
• Pass oro-gastric (OG) tube.
• Check tube position before each feeding.
• Change OG tube weekly.
• Observe for feed intolerance.
• Observe urine output and bowel movement.
• Weight infant as required.
 Nursing Management
Parental Education
• Accompany the parents the first time upon their visits
• Talk to parents and create supportive atmosphere.
• Explain ward orientation and visiting policy.
• Explained procedures and treatment needed and reasons for them.
• Arrange for doctor to speak with parents about baby’s new development.
• Keep parents well informed of baby’s progress and each new development.
• Encourage parents to visit infant regularly.
• Encourage and provide opportunities for the parents to have contact with their infant.
• Give the parents tasks to perform for their infant.
• Reinforce parenting skills.
• Facilitate verbalization of concern.
• Monitor and record parent – infant interaction and visits.
 References
• Engle, W.A., Trautman, M.S., & Applengate, K.E. (2005). Nonsurgical causes of
respiratory distress. in Hertz, D.E.(ED.). Care of the newborn: A handbook
for primary care. Philadelphia: Lippincott Williams & Wilkins.

• Greenough, A., & Roberton, N.R.C. (1999). Acute respiratory distress in the newborn.
In Rennie, J.M., & Roberton, N.R.C. (ED.). Textbook of neonatology (3rd ed.).
Edinburgh: Churchill Livingstone.

• Harold, C.E., & Priff, N. (ED). (2008). Springhouse nurse’s drug guide 2008 (9th ed.).
Philadelphia: Lippincott Williams & Wilkins.

• Kelnar, C.J., Harvey, D., & Simpson, C. (1995). The sick newborn baby(3rd ed.).
London: Bailliere Tindall.

• Kenner, C., Amlung, S.R., & Flandermeyer, A.A. (1998). Protocols in neonatal
nursing. Philadelphia: W.B. Saunders.
 References
• Kenner, C., Lott, J.W., & Flandermeyer, A.A. (1998). Comprehensive neonatal
nursing: A physiologic perspective (2nd ed.). Philadelphia: W.B.Saunders.

• Merenstein, G.B., & Gardner, S.L. (2006). Handbook of neonatal intensive care (6th
ed.). St. Louis: Mosby Elsevier.

• Vargo, L.E., Trotter, C.W. & Freda, M.C. ( n.d.). The premature infant: Nursing
assessment and management (2nd ed.) [On-line slides]. Available:
http://72.14.235.104/search?q=cache:3xiYF8fn3JsJ:www.marchofdimes.com/n
ursing/modnemedia/othermedia/premature_infant_blue.ppt+treatment+of+RDS
+in+preterm+infants&hl=en&ct=clnk&cd=73 (2008, 01,18)..

• Yeo, H. (1998). Nursing the neonate. London: Blackwell science.