NURSING TOOL BOX SERIES

  BIRTH INJURIES Birth injuries refer to trauma that a foetus sustains during birth. The structures commonly involved are muscles, nerves, bones, visceral organs and skin. types of birth injuries   1. Internal organ injuries – spleen, liver, adrenal glands 2. Nerve injury –mostly brachial plexus leading to Erb’s palsy 3. Soft tissue injury –intracranial haemorrage, skull fractures 4. Extracranial injuries –cephalohaematoma,caputsuccadenium. predisposing factors Ø Prematurity Ø Large for dates Ø Cephalo pelvic disproportion Ø Malpresentation Ø Congenital malformation e.g. hydrocephalus CAPUT SUCCADENIUM AND CEPHALOHAEMATOMA Caput succadenium – is an oedematous swelling due to accumulation of serum fluid under the foetal scalp. It results from pressure between the foetal skull and pelvic bones during delivery that leads to reduced venous blood and lymphatic drainage and part of the serum escapes into the tissues. The swelling is self – limiting and disappears within 36hours of life. Ceph

  HAEMORRHAGIC DISEASE OF THE NEWBORN This bleeding occurs during the first fews days of life due  tovitasmin K deficiency. Vitamin K is synthesized by the bowel normal flora and its role is to convert clotting factors such as prothombin, thrombokinase, thromboplastin. To prevent HDN the neonates are given vitamin K 0.5-1 mgi.m.  predisposing factors · Hereditary factors- clotting factor defect e.g. haemophilia · Prematurity · Birth trauma · Treatment with antibiotics · Respiratory distress syndrome · Disseminated intravascular coagulopathy (DIC) · Birth asphyxia · Mothers who are on drug such as warfarin, heparin and Phenobarbital Clinical features · Continuous oozing of blood from the umbilical cord · There is a spontaneous bleeding from various parts of the body · Bleeding in the mucous membrane of GIT and may present with maleana stool or haematemesis · Continuous bleeding from any punctured blood vessel or injection site thus when looking for venous access avoid puncturing femoral

  PROTOPORPHYRINS These are hemeoxygenase inhibitors which are administered to inhibit the breakdown of heme thus reduce bilirubin production. They are usually used in combination with phototherapy and/or blood exchange transfusion.  Nursing diagnosis of children undergoing phototherapy v Deficient fluid volume v Imbalanced nutrition less than body requirements v Impaired skin integrity v Risk for injury v Ineffective thermoregulation

  BLOOD EXCHANGE TRANSFUSION This is a treatment in which the baby’s blood is gradually removed and replaced by donor’s blood. It is used as a definitive treatment when bilirubin concentrations are approaching toxic levels. The baby has haemolyticdisease  or low Hb. The transfusion has the following benefits -it helps in increasing the baby’s Hb -excessive bilirubin and unwanted antibodies are washed from the babys circulation. The donor’s blood used for the transfusion should be rhesus negative so that it does not alter the babys blood group and to ensure that no antigen ios introduced into the baby’s circulation that may lead to antibodies production. It should also be fresh and ABO compactible. Indications ü Infants with haemolytic disease. ü Preterms with bilirubin levels of 300 -400 mol/l ü Babies whose birth weight was less than 1500g and have bilirubin levels of 255mol/l ü Term babies with bilirubin levels above 100 mol/l at birth or later 400 -500 mol/l Care of the baby post tr

  NEONATAL JAUNDICE This is condition in neonates characterized by yellow discoloration of the skin, sclera and mucous membrane. It develops when there is an excessive bilirubin level in the blood stream. When there is increased rate of haemolysis of RBC or decreased conjugation, there are high amounts of free bilirubin in circulation leading to jaundice. BILIRUBIN METABOLISM When RBC’s are broken down by haemolysis, they produce heme and globulin. The heme part produces bilirubin and iron. Unconjugated (indirect) bilirubin is fat soluble hence has to be converted to water soluble form (conjugated/ direct bilirubin) by process of conjugation for it to be excreted. Conjugation of bilirubin occurs in the liver and thus it has to be transported to the liver by binding to transport protein, albumin. On arrival to the liver, bilirubin detaches itself from the albumin. Conjugation is done by glucoronlytransfares in which bilirubin is added to glucoronic acid to become bilirubinDiglucoronide

  OPTHALMIA NEONATORUM This is a condition that occurs in neonates within 21 days of life and is characterized by purulent discharge from the eyes. It is common in infants of mothers who had vaginal discharge e.g. gonnorrhoea during pregnancy. Syphilis does not predispose an infant to opthalmianeonatorum but it causes congenital syphilis that is characterized by gross congenital malformation.   CAUSATIVE ORGANISMS   ü neisseriagonorrhoeae ü chalmydiatrachomatis ü staphylococcus aureus ü Escherichia coli ü Haemophilus influenza ü Streptococcus pneumonia ü Pseudomonas .spp ü Klebsiella  CLINICAL FEATURES ü Eyes have sticky watery discharge ü Eyes are slightly red ü Oedematus eyelids ü Yellow purulent discharge if the infection is by N.gonorrhoeae ü Inflamed conjunctiva  NURSING MANAGEMENT ü All perinatal mothers presenting with vaginal discharge suggestive of gonnorrhoae should be treated before delivery. ü Correctly swab the baby’s eye at birth. ü Instill 1% tetracycline ointment (TEO)

  NEONATAL HYPOTHERMIA  This is a condition in which the neonates body temperature falls below 36*C .the baby losses heat through radiation,conduction, convection and evaporation.  PREDISPOSING FACTORS ü  Prematurity ü  Asphyxia neonatorum ü   Maternal diabetes mellitus ü  Respiratory distress syndrome ü   Cold environment CLINICAL FEATURES ü Rectal temperatures is below 36*C ü Baby feels cold on touch ü Paleness of extremeties and face ü Very weak cry ü Low respiration rate ü Baby not eager to feed (poor feeding) NURSING MANAGEMENT ü Nurse the baby in a warm environment in a resuscitaire or wrap it in warm clothings ü Feed the baby with expressed breast milk via NG tube ü Give the baby extra glucose e.g. dextrose ü Closely observe the baby for signs of hypoglycaemia and if present, give 10% dextrose ü Check for and treat convulsions with anticonvulsants  PREVENTION ü Delivery  should be conducted in a room temperature ü Put the baby on resuscitaire or in incubator to compensate heat l

  HYPOGLYCAEMIA This is a metabolic disorder in which the blood glucose level falls below 2.6 mmol/L. At term, the baby’s glucose level is almost equal to that of the mother but gradually drops within 3-4 hrs after birth. This is why the baby has to be fed within four hours of life. The baby’s maintain their energy requirements as long as they are kept warm. This condition is common in infants of diabetic mothers. Due to excess glucose, the large babies (macrosomia). At birth the glucose level falls rapidly while insulin levels remain relatively high so the baby is at risk of hypoglycemia .this is why such babies are admitted to the NBU. Prolonged hypoglycaemia can lead to mental retardation, permanent neurological damage anddeath due to respiratory and metabolic acidosis. PREDISPOSING FACTORS Ø  Low birth weight Ø  Prematurity Ø   Birth injuries Ø  Maternal diabetes mellitus Ø   Asphyxia Ø   Septicaemia Ø   Respiratory distress syndrome CLINICAL FEATURES v  Low blood glucose less than

  RESPIRATORY DISTRESS SYNDROME This is a condition that occurs due to lack of or inadequate surfactant in the lung tissue. Mature lungs have adequate surfactant factor that lower the surface tension in the alveoli, stabilizes the alveoli and prevents them from adhering together and collapse. This leads to breathing with ease. Surfactant is produced slowly from 20 weeks gestation and reaches a surge at 30- 34 weeks gestation and another surge at onset of labour. The premature infant lack this function thus the alveola walls pressure rises as he breaths out and alveoli collapse leading to severe difficulty in breathing. Other names are: · Hyaline membrane disease · Pulmonary syndrome of the newborn · Developmental respiratory distress It is a disease of prematurity and self limiting with recovery phase or death. PREDISPOSING FACTORS v  RDS may be a complication of asphyxia and develops within 48 hrs of birth v  Prematurity due to inadequate surfactant factor v   Perinatal hypoxia e.g du

  ASPHYXIA NEONATORUM This is a term which refers to a condition in which the baby fails to breath at birth. TYPES OF ASPHYXIA          The degree of asphyxia is determined by Apgarscorein which the following features are observed and score 0-2 ·  Appearance (colour of the body) ·  Pulse (heart rate) ·  Grimace (response to stimuli) ·  Activity (muscle tone) ·  Respiration /respiratory effort A score between 8- 10 does not show asphyxia. There are three types of asphyxia namely: 1. Mild asphyxia – Apgar score is 6-7. It requires clearing of the airway and application of external stimuli to in initiate breathing 2. Moderate asphyxia – Apgar score is 4-5. It requires resuscitation, administration of oxygen and drugs to initiate breathing. 3. Severe asphyxia – Apgar score is 0-3. It requires intensive resuscitative measures and intubation to survive. PREDISPOSING FACTORS   ü  Any condition causing foetal distress e.g. cord prolapse, prolonged labour,APH, intrauterine hypoxia due to placen