Chapter 32 THE NEWBORN AT RISK: CONDITIONS PRESENT AT BIRTH 917
CONGENITAL ANOMALIES: IDENTIFICATION AND CARE IN NEWBORN PERIOD
Congenital Anomaly Nursing Assessments Nursing Goals and Interventions Congenital hydrocephalus Choanal atresia Cleft lip Cleft palate Tracheoesophageal fistula (type 3) Assess presence of hydrocephalus: Measure and plot occipital-frontal baseline measurements; then measure head circumference once a day. Check fontanelles for bulging and sutures for widening. Assist with head ultrasound and transillumination. Maintain skin integrity: Change position frequently. Clean skin creases after feeding or vomiting. Use sheepskin pillow under head. Postoperatively, position head off operative site. Watch for signs of infection. Assess patency of nares: Listen for breath sounds while holding babys mouth closed and alternately compressing each nostril. Assist with passing feeding tube to confirm diagnosis. Maintain respiratory function: Assist with taping airway in mouth to prevent respiratory distress. Position with head elevated to improve air exchange. Provide nutrition: Feed with special nipple. Burp frequently (increased tendency to swallow air and reflex vomiting). Clean cleft with sterile water (to prevent crusting on cleft prior to repair). Support parental coping: Assist parents with grief over loss of idealized baby. Encourage verbalization of their feelings about visible defect. Provide role model in interacting with infant. (Parents internalize others responses to their newborn.) (At left) Unilateral cleft lip with cleft abnormality involving both hard and soft palates. Prevent aspiration/infection: Place prone or in side-lying position to facilitate drainage. Suction nasopharyngeal cavity (to prevent aspiration or airway obstruction). During newborn period feed in upright position with head and chest tilted slightly backward (to aid swallowing and discourage aspiration). Provide nutrition: Feed with special nipple that fills cleft and allows sucking. Also decreases chance of aspiration through nasal cavity. Clean mouth with water after feedings. Burp after each ounce (tend to swallow large amounts of air). Thicken formula to provide extra calories. Plot weight gain patterns to assess adequacy of diet. Provide parental support: Refer parents to community agencies and support groups. Encourage verbalization of frustrations because feeding process is long and frustrating. Praise all parental efforts. Encourage parents to seek prompt treatment for upper respiratory infection (URI) and teach them ways to decrease URI. Maintain respiratory status and prevent aspiration: Withhold feeding until esophageal patency is determined. Quickly assess patency before putting to breast in birth area. Place on low intermittent suction to control saliva and mucus (to prevent aspiration pneumonia). Place in warmed, humidified incubator (liquefies secretions, facilitating removal). Elevate head of bed 2040 degrees (to prevent reflux of gastric juices). Keep quiet (crying causes air to pass through fistula and to distend intestines, causing respiratory embarrassment). Maintain fluid and electrolyte balance: Give fluids to replace esophageal drainage and maintain hydration. Provide parent education: Explain staged repairprovision of gastrostomy and ligation of fistula, then repair of atresia. Keep parents informed; clarify and reinforce physicians explanations regarding malformation, surgical repair, preoperative and postoperative care, and prognosis (knowledge enhances feelings of self-worth). Enlarged head Enlarged or full fontanelles Split or widened sutures Setting sun eyes Head circumference 90% on growth chart Occlusion of posterior nares Cyanosis and retractions at rest Snorting respirations Difficulty breathing during feeding Obstruction by thick mucus Unilateral or bilateral visible defect May involve external nares, nasal cartilage, nasal septum, and alveolar process Flattening or depression of midfacial contour Fissure connecting oral and nasal cavity May involve uvula and soft palate May extend forward to nostril involving hard palate and maxillary alveolar ridge Difficulty in sucking Expulsion of formula through nose History of maternal hydramnios Excessive mucous secretions Constant drooling Abdominal distention beginning soon after birth Periodic choking and cyanotic episodes Immediate regurgitation of feeding Clinical symptoms of aspiration pneumonia (tachypnea, retractions, rhonchi, decreased breath sounds, cyanotic spells) Failure to pass nasogastric tube (continued) 918 SIX THE NEWBORN CONTINUED Congenital Anomaly Nursing Assessments Nursing Goals and Interventions Tracheoesophageal fistula (type 3) continued Diaphragmatic hernia Involve parents in care of infant and in planning for future; facilitate touch and eye contact (to dispel feelings of inadequacy, increase self-esteem and self- worth, and promote incorporation of infant into family). (At left) The most frequently seen type of congenital tracheoesophageal fistula and esophageal atresia. Nurse should never ventilate with bag and mask O 2 because the stomach and intestines will become distended with air, further compressing the lungs. Maintain respiratory status: Immediately administer oxygen. May need to be intubated and ventilated. Initiate gastric decompression. Place in high semi-Fowlers position (to use gravity to keep abdominal organs pressure off diaphragm). Turn to affected side to allow unaffected lung expansion. Carry out interventions to alleviate respiratory and metabolic acidosis. Assess for increased secretions around suction tube (denotes possible obstruction). Aspirate and irrigate tube with air or sterile water. (At left) Diaphragmatic hernia. Note compression of the lung by the intestine on the affected side. Difficulty initiating respirations Gasping respirations with nasal flaring and chest retraction Barrel chest and scaphoid abdomen Asymmetric chest expansion Breath sounds may be absent Usually on left side Heart sounds displaced to right Spasmodic attacks of cyanosis and difficulty in feeding Bowel sounds may be heard in thoracic cavity Esophagus Trachea Lung Esophagus Stomach Bowel through opening in diaphragm Diaphragm Liver Chapter 32 THE NEWBORN AT RISK: CONDITIONS PRESENT AT BIRTH 919 CONTINUED Congenital Anomaly Nursing Assessments Nursing Goals and Interventions Myelomeningocele Omphalocele Gastroschisis Imperforate anus, congenital dislocated hip, and clubfoot Prevent trauma and infection. Position on abdomen or on side and restrain (to prevent pressure and trauma to sac). Meticulously clean buttocks and genitals after each voiding and defecation (to prevent contamination of sac and decrease possibility of infection). May put protective covering over sac (to prevent rupture and drying). Observe sac for oozing of fluid or pus. Cred bladder (apply downward pressure on bladder with thumbs, moving urine toward the urethra) as ordered to prevent urinary stasis. Assess amount of sensation and movement below defect. Observe for complications. Obtain occipital-frontal circumference baseline measurements; then measure head circumference once a day (to detect hydrocephalus). Check fontanelle for bulging. (At left) Newborn with lumbar myelomeningocele. SOURCE: Courtesy Dr Paul Winchester. Maintain hydration and temperature. Provide D 5 LR and albumin for hypovolemia. Place infant in sterile bag up to and covering defect. Cover sac with moistened sterile gauze, and place plastic wrap over dressing (to prevent rupture of sac and infection). Initiate gastric decompression by insertion of nasogastric tube attached to low suction (to prevent distention of lower bowel and impairment of blood flow). Prevent infection and trauma to defect. Position to prevent trauma to defect. Administer broad-spectrum antibiotics. Maintain hydration and temperature. Prevent trauma and infection to defect. Provide D 5 LR and albumin for hypovolemia. Place infant in sterile bag up to cord and covering defect. Initiate gastric decompression by insertion of nasogastric tube attached to low suction. Administer broad-spectrum antibiotics. Identify defect and initiate appropriate referral early. Saclike cyst containing meninges, spinal cord, and nerve roots in thoracic and/or lumbar area Myelomeningocele directly connects to subarachnoid space so hydrocephalus often associated No response or varying response to sensation below level of sac May have constant dribbling of urine Incontinence or retention of stool Anal opening may be flaccid Herniation of abdominal contents into base of umbilical cord May have an enclosed transparent sac covering Lateral defect in abdominal wall allowing viscera outside the body to the left of an intact umbilical cord. No sac covering. Associated with intestinal atresia, malrotation See discussion in Chapter 29, Anus and Extremities Source: Courtesy of Nancy Houck, RNC, BSN, NNP. may suffer withdrawal. In addition, the drugs the mother in- gested may be teratogenic, resulting in congenital anomalies. Alcohol Dependence The fetal alcohol syndrome (FAS) includes a series of mal- formations (identified shortly) frequently found in infants exposed to alcohol in utero. It has been estimated that com- plete FAS occurs in 5.2 live births per 1000 (AAP Commit- tee on Substance Abuse and Committee on Children with Disabilities, 2000). FAS rates are increased among Native Americans and Alaska natives and those of low economic sta- tus. Fetal alcohol effects (FAE), or alcohol-related birth defects (ARBD), are usually determined only by a positive maternal drinking history and cognitive difficulties and usu- ally do not exhibit the classic facial dysmorphology (Rosen & Bateman, 2002). The new diagnostic categories for FAS take into consideration the various clinical manifestations of FAS, the social and family environment, and, if available, the ma- ternal alcohol history.