VII.

INTRAVENTRICULAR HEMORRAGE (IVH)

A. Definition/Pathophysiology
Bleeding within the lateral ventricles of the brain. The fragile blood
vessels contained within the ventricles have thin walls that are easily
damaged. Graded I – IV. Can lead to hydrocephalus and/or permanent
brain injury

Predisposing Factors

B. Clinical Manifestations

C. Diagnostics
Routine and prn neuroultrasound testing
CAT - MRI

D. Nursing Nursing Dx: High Risk for Injury (Neuro) R/T capillary fragility

Intervention(s)
Preventive measures to avoid hypoxia, fluid overload, increased intracranial
pressure, hyperosmolarity, cold stress. (Refer to CRIES neonatal pain scale)

Supportive measures: vs, ^ HOB, close monitoring of fluids, lab values

(H&H, ABG’s, BS) dilute IV meds, pain control, maintain temp, cluster care,
pain/agitation control, measure head circumferences, monitor for ^ ICP.

Expected Outcome: Infant will have normal ICP with no evidence of IVH
VIII. Retinopathy of the Premature

A. Definition/Pathophysiology
Immature retinal vessels constrict & occlude due to incomplete
vascularization. New vessels are weak, rupture -> vitreous hemorrhage &
scarring. May resolve spontaneously or progress to retinal detachment

B. Predisposing Factors

C. Nursing Care

D. Treatment
Routine eye exams for premature infants on O2
Laser surgery.

IX. Brochopulmonary Dysplasia (BPD)

aka Chronic Lung Disease (CLD)

A. Definition/Pathophysiology
A chronic condition noted by epithelial edema, thickening and fibrous
changes of alveolar walls.

B. Predisposing Factors

C. Clinical Manifestations

D. Diagnostics
CXR; ABG’s

E. Medical Tx.
Prevention
Wean respiratory support prn.
Diuretic therapy
Nutrition – normal growth will develop healthy lung tissue

F. Nursing Dx: Impaired gas exchange r/t cellular damage secondary to RDS and
tx. modalities.
 Intervention(s)

Expected Outcomes: Infant exhibits adequate oxygenation; respiratory pattern

WNL.

X. SEPSIS NEONATORUM

A. Definition/Pathophysiology
Presence of microorganisms or their toxins in the blood or other tissues

B. Predisposing Factors
Maternal systemic or genital tract infections. May be bacterial or viral.

C. Clinical Manifestations

D. Diagnostics
(Septic workup) Cultures: blood, urine, CSF, tracheal, lesion or eye
drainage; CXR.

E. Nursing Dx: Risk for infection transmission r/t contagious nature of organism

Interventions(s)

Expected Outcome: Infant exhibits no evidence of infection.

XI. Necrotizing Enterocolitis (NEC)

A. Definition/Pathophysiology

B. Predisposing factors – as above

C. Clinical Manifestations:
Abdominal distension, ^ residual (+/- bile stained), vomiting, decreased
bowel sounds, bowel loops present (visual or palpation), guiac + stools,
generalized worsening of condition.

D. Diagnositics
Abdominal x-ray (left, lateral oblique) to check for free air in peritoneum.

E. Nursing Dx: High Risk for Injury (Peritonitis) r/t poor tissue perfusion,
microbial colonization

Interventions:

Expected Outcome: Infant exhibits stable weight gain and growth, free of
complications

XII. Transient Tachypnea of the Newborn (TTN)

A. Definition/Pathophysiology
Self-limiting tachypnea of term infants due to retained amniotic fluid in
the lungs

B. Predisposing Factors
Shallow breathing; weak cry; delayed clearance of fetal lung fluid
 C. Clinical Manifestations

D. Diagnositics
CXR

E. Nursing Dx: Ineffective breathing pattern r/t retained amniotic fluid in

alveolar spaces.

Interventions:

Expected Outcome: Infant will exhibit effective breathing pattern

XIII. Meconium Aspiration Syndrome

A. Definition/Pathophysiology

B. Predisposing Factors
Function of fetal hypoxia: with hypoxia, the anal sphincter relaxes and
meconium is released; reflex gasping movements draw meconium and other
particulate matter in the amniotic fluid into the infant’s bronchial tree,
obstructing the airflow after birth.

C. Clinical Manifestations

D. Diagnostics
CXR

E. Nursing Dx: Ineffective Gas Exchange r/t aspiration of meconium

 Intervention (s)

F. Expected Outcome: Infant with normal oxygenation and ventilation pattern.

XIV. Neonatal Abstinence Syndrome

A. Definition/Pathophysiology
Group of signs and symptoms (CNS, metabolic, vasomotor, respiratory
and GI) associated with drug withdrawal in the neonate.

B. Predisposing Factors
Exposure in utero to harmful effects of drug us by the mother.

C. Clinical Manifestations:

D. Diagnostics
Urine or meconium for toxicology screen

E. Nursing Diagnosis: Risk of injury (seizure) r/t maternal substance abuse

Interventions:

Expected Outcome: Infant will exhibit no sign of seizure activity.

XV. Fetal Alcohol Syndrome

A. Definition/Pathophysiology
Multifactorial chromosomal disorder directly related to maternal
alcohol ingestion during pregnancy. The disorder is characterized by
growth deficiencies, CNS alterations and facial abnormalities. A leading
cause of mental retardation.

B. Predisposing Factors
Exposure to alcohol in the prenatal period.

C. Clinical Manifestations of FAS

Common characteristics:
Size

Head:

Cognition:

D. Diagnostic
Genetic evaluation and testing

E. Nursing Process: See above NAS

168HRNB_2St
168HRNB_2